Saw Dr. Natale Yesterday

My thanks to the LAF Forum braintrust for nudging me in the direction of Dr. Natale.

P.S. Smackman, glad your wife is on board with pursuing Dr. Natale. I got in to see Dr. Natale six weeks early on what I assume was a cancellation (I was set for Jan. 14 but I called and as luck would have it, one opening on Dec 3). Flying down from Virginia on short notice, I could have flown to Europe twice on what the airfare cost me, but I have no regrets.

Anyway, I went into the visit with Dr. Natale fearing I might be in a precursor or early stage of CHF based on a recent echo, which showed both atria moderately enlarged, right ventricle mildly increased, but left ventricle normal size with good ejection fraction (63%). (Also mild valvular disease been there 10 years.)

Dr. Natale identified what he termed a "big discrepancy" between the Left Atrium volume of 56.2 (cm3/m2 from 2D view) and Left Atrium long axis diameter of 3.3 cm from 1D view. He said that with a LA volume of 56 he would expect the LA diameter to be more like 4.5. He recommended a repeat echo with the technician being more careful in doing the volume measurement.

Dr. Natale did not feel I have CHF at this time or that there was necessarily irreversible damage to my heart from my long history of AF. He also estimated my CHA2DS2VASc score to be in the 0-1 range.

So, I'll ask for a re-do of the echo locally and hope for a better result but sounds like a potential HUGE CATCH on Dr. Natale's part in spotting some echo values that would be unlikely to co-exist if valid.

As may have already been pointed out in other posts, Dr. Natale is comfortable with either Coumadin or Xeralto as AC's. I asked him about the lack of antidote for Xeralto and I didn't quite get it all, but he said something about frozen plasma or factor 7 as being adequate reversal agents for the most likely scenarios (again, I'm fuzzy on the details here).

Another item: for AF patients who fail anti-arrhythmics, he would definitely prefer to proceed to ablation after the first failure rather than try a different anti-arrhythmic and then fail that one too, because according to the data there is a much better ablation success rate after just one failure. So my flec gave me four really good years, then a relapse then a remission, now a difficult relapse, and my local EP probably ought not to be suggesting a trial of a different anti-arrhythmic among the options he presented to me.

A final item: I have a script for dessicated thyroid. Older brother has had his own tough relapse of LAF this year but was diagnosed with hypothyroidism and started on meds recently which seemed to bring an abrupt halt to his AF. I have some of the clinical symptoms of hypothyroidism (low basal temp etc.) but normal lab tests (by conventional not functional cut-offs) and was considering a trial of dessicated thyroid as a diagnostic tool and hopefully release from my own AF relapse. However, Dr. Natale advised against it prior to ablation because he said thyroid meds can "change the way things fire" and apparently complicate his surgical efforts.

Did you have to have a referral to see Dr. Natale?

Smackman, I was initially told I did need a referral by Dr. Natale's admin assistant Rachelle Thomas (maybe for insurance purposes?), but the way it played out I sort of referred myself (there was no referral letter or any contact from my local EP).

I told Dr. Natale's clinic that my EP couldn't formally refer me because he was able to offer me the ablation himself through my govt health insurance (Tricare). I didn't want my local EP to do it, I only wanted Dr. Natale.

Dr. Natale's clinic sent me the information packet to complete and they offered me a consult date and somehow it worked.

Randy - that's great. So glad you were able to move up in the wait line. You won't be disappointed.

Best to you,
Jackie

Good News Randy,

You made the right choice, and Smackman, dont worry too much about the referral, tell them you were referred by an army of his patients from this site ... Just call and set up a consult. If you must, use your Cardios name and then tell him about it too of course .. at some point when you see him next... he should be thrilled and pleased to have thought of it himself!

Just insist that you want only Dr N working inside your heart and it will get done.

And Randy, regarding the desiccated thyroid, what dose are you taking and what was your last Free T3, Free T4 and TSH readings 'prior' to starting desiccated thyroid? Also if you have the latest FT3, FT4 and TSH while on your normal dose of Desiccated that could help shed some light on where you stand with it now.

Too low a Free T3 as well as too high Free T3 are both major triggers for AFIB so its wise to keep it in the broad more optimal range.

With AFIB its also wise to err on the side of caution and stay under treated rather than overtreated, At least until after a good solid year of quiet post ablation .. even then dont overdo it.

I totally understand Dr N's concern, yet his experience is almost entirely with Synthroid which is solely T4 ( T4 is a thryoid storage hormone that has to be converted through enzymatic processes in the body to the cellularly active thryoid hormone T3) and Synthroid is a less effective form of thyroid replacement and easier to either overdo it or underdo it with and more apt to swing in too broad of a range.

I agree with him that its best to either reduce to a very low dose .. perhaps as low as 7.5mg to 15mg and at the very most 30mg, or a half grain of desiccated thyroid, leading up to the ablation and for as much as a 9 months to a year after the ablation.

Shannon

Shannon,

Thanks for the helpful info. I should clarify, I haven't actually taken the dessicated thyroid yet (I just have it). I held off pending the consult with Dr. Natale and now won't take it, maybe indefinitely.

The only data points I have is an FT4 of .99 and a TSH of 2.23, totally WNL by conventional standards. Not sure why FT3 wasn't ordered as part of the thyroid panel. I may not have hypothyroidism type 2, don't know, but am reading Mark Starr's book on type 2, definitely have some of the clinical symptoms and the family history, but conventional doc wouldn't even refer me to endocrinology based on the FT4 and TSH. I then went to a functional med physician who wasn't convinced but said it was worth a trial of dessicated thyroid as a test of whether I might have it.

So I'll stay on the undertreated side, in this case the untreated side for the foreseeable future respecting the timeframes you mentioned relative to ablation.

Randy

Hi Randy, really too bad no Free T3 but that is par for the course for most conventional docs who tend to be more or less clueless when it comes to proper thryoid treatment and how to interpret labs in conjunction with paramount clinical signs and symptoms.

Your Free T4 is lousy, and along with the mild to moderately elevated TSH ( you need at least three or four TSH reading to derive a decent average) and along with your history of AFIB , I would bet you might run a borderline high normal to even high FT3 which would be the classic pattern of "low T4 syndrome' which is a classic thyroid/adrenal dysfunction scenario in which a low adrenal/cortisol output results in too rapid conversion of an already borderline low normal T4 level into too much T3 too quickly and thus further suppresses your Free T4 level as he has now to only 0.99.

Forget the much too broad reference ranges for these thyroid hormones. the Optimal range for Free T4 in a good sized male is from 1.6 to 1.8 , optimal Free T3 is from 3.7 up to 3.9 or 4.0 and some people need even a slightly higher T3 to feel their best.

Anyway, I totally agree with Dr N and your decision to put all that on the back burner for now as your levels aren't critically out of whack yet .. though the FT4 is much too low ... until you get the ablations well within your rearview mirror. First things first!

Best wishes,
Shannon

Shannon, do you take visa or mastercard or can I work off my debt to you? Your analysis of my thyroid numbers is eye opening. I'll push for a few more thyroid readings from my conventional docs to begin to build up a more reliable data base for future use but as you said, first things first. I also want to proceed with Jackie's advice to check out my adrenals since this current relapse, which is persisting and nosedived to daily episodes sort of abruptly, was preceded by substantial prolonged life stress of various kinds (which I could have managed better). For adrenal eval, I'm looking at the 24 urine test offered by Meridian Valley labs at the moment.

Thanks again,
Randy

The 24 hour steroid urine profile by Meridian Valley Labs is an excellent test to start with. Im reviewing one right now that came in today for another patient ( not AFIB related) I work with in conjunction with his functional medicine MD. It's very comprehensive and covers all anabolic hormones and metabolites as well as all adrenal hormones and metabolites and includes urinary free T3 and T4, Aldosterone, urinary Sodium and Potassium and you can add urinary Growth Hormone testing as well. The full kit also includes urinary Melatonin and 6-Sulfatoxy-Melatonin as well as Oxytocin measures for a very complete overview of your entire endocrine system.

For an initial eval its a good idea to add a Diurnal 4x/day Saliva Adrenal Stress profile with added saliva DHEA- Sulfate measure to help correlate with the 24 hour urine collection on the same day as the Saliva collection adds valuable circadian Cortisol release info that, in conjunction with the overall full 24 hour cortisol and other adrenal metabolite measures really helps give a more complete picture of your adrenal reserves and how you process and metabolize the catabolic side of the adrenal hormone cascade.

Let me know Randy about a week before you are going to do that Test .. I suggest getting the ZRT Labs Diurnal Adrenal Stress Profile and add the DHEA-Sulfate to it so you have that kit with you to do at the same time as the urine collection. If you send me your phone number then with at least 5 days in advance before doing the sample collections, I will call and walk you through how to prepare and carry out both tests in order to get very accurate test results.

Cheers!
Shannon

Shannon, thanks once again. I'll add the saliva adrenal stress profile kit w/ DHEA (ZRT) to the Meridian Valley urine profile. I had a first visit two weeks ago with the only FM I've been able to find in my area but he's older, scaling his practice "way back" as he said and taking an extended holiday so won't be able to do the Meridian Valley profile until Dec 23 at the earliest. I don't know if he has the ZRT kit. But wondering...I'm a doc but not a physician...any idea whether one or both labs would send me the kits directly or do they only do business with medical practices? Guess I can scour their website and/or give them a call to see what the degrees of freedom are.

Randy

What kind of Doc are you Randy, if you'd rather not say publically you can PM me.

Shannon

Hey Randy,

Do you have Dr. Natale's office direct line in Austin? I was consulting with him in NYC and after he left St. Luke's I've been having trouble getting in touch with him.

Thanks,
Robert

Robert, I'm not sure, but Shannon may already have given you a batline # to his clinic in another post. Just in case, though, I use 1-512-807-3210 to reach his appointment person Rachelle Thomas.