Coronary Sinus isolation

I had an afib ablation (2nd ablation with Dr. Natale, 1st was in 2010) with Dr. Natale last week.
He stated he isolated the Coronary Sinus and then the LAA became isolated. He said this only happens with about 7% of patients.
Can anyone comment on the mechanism involved and how it relates to isolating the LAA?
Can anyone comment on how this will effect the likelyhood of LAA blood velocity being lo and what that indicates going forward.
Also I started having occular migraines (some with pain some without) after the ablation. This also happened after the first ablation and then went a way after a week.
Thank you!

Hi gmperf,

First off, the ocular migraines do happen on occasion four some people from the transeptal puncture but as you noted in your first ablation when you experienced that it was self-limiting and so too will this occurrence resolve on its own before long.

The coronary sinus (CS) runs along the bottom border of the left atrium and upper border of the left ventricle passes close to the circumflex artery and at the base of the left atrial appendage. On the opposite end it is connected to, and drains blood coming from, the great, middle and small cardiac veins into the inferior vena cava (IVC) and has a junction within the right atrium as well.

Electrophysiologically there is a close connection between the CS and LAA, as noted in your case, as in my case and Jackies as well where our LAA too were isolated with the distal CS isolation.

These are probably the two key non-PV structures, after the posterior wall, that sustain AFIB/Flutter triggers once all the other usual suspects are ablated successfully and made quiet. The CS and LAA are often the key culprits in more challenging cases and are often the only remaining sources of trouble even after the PVs and posterior wall as well as Superior vena cava have all been rendered quiet with confirmed entry and exit block as yours very likely were in the first procedure with Dr Natale.

What Dr Natale almost certainly did, knowing his process, was after confirming all your original ablation is still good with all PVs still sealed shut and no leaks of any previously ablated spots, which is almost always the case with Dr Natale patients, especially for those first ablated in the irrigated catheter era, ( circa 2008 to present), then after trying then to stimulate the AFIB, if you did not come to the EP lab in AFIB, he will via adding in pacing programs and perhaps short dose of Isoproterenol reveal the trigger sources, he will then typically go to the LAA if there are any signals there which is very likely in your case also with an active CS signal, and he will try to reduce or delay the LAA signal but stop short of full isolation at that point,

He will then check the CS signals and if they are active, either before or after the full dose isoperterenol challenge of 10 minutes to 20 minutes duration, he will often go ahead and isolate the CS. In your case he likely did that along an anterior branch of the CS which become the last electrical conduit between the LAA and LA, thus effectively isolating the LAA.

Im not sure if LAA isolation achieved more distally from an anterior branch of the CS would be more or less likely to delay emptying velocity from the LAA at 6 months TEE? Will try to remember to ask Dr Natale when I see him in three weeks for my follow up TEE after the Amplatzer Duct Occluder plug I have installed just over 6 weeks ago to fix my LAA leak after the Lariat suture loosened a bit.

At least I hope this helps explain how that process worked. He would almost certainly have had to isolated your LAA even if it had not do so while isolating your CS due to him no doubt finding an LAA trigger and having to delay it prior to going after the CS signal. Only if the LAA signal was very well behaved and low amplitude under the full duration isoproterenol challenge might he have not isolated the LAA, but he usually will forgo that on a first ablation, but on a second procedure when all else ablated in the first procedure is still quiet and its clear your only triggering is coming from these CS and LAA signals he will almost certainly address those in hopes of making this your last visit to his table.

Cheers!
Shannon

Thank you very much Shannon!
Very good explanation.

Yes please ask if you remember. (Im not sure if LAA isolation achieved more distally from an anterior branch of the CS would be more or less likely to delay emptying velocity from the LAA at 6 months TEE? Will try to remember to ask Dr Natale)

LAA velocity is my concern going forward. Along with if in three months I will need a touch-up.
NSR so far after 4 days (A few minor PACs). Sore swollen chest. Almost no bruising in the groin, wow!

Don (gmperf)

Sounds like you are doing real good Don,

Let it all settle down the next two months and odds are high you will be home free and hopefully wont need what would be no more than a very small touch up of the LAA isolation circuit, if you should. That particular structure is a challenging anatomy with the many pectinate muscles and relative thin LAA tissue in some spots, so he has to go at it with that in mind and as such its there are maybe e 30% ( though it seems to be less than that over the last year or so,) that may need a quite touch up and then are done for the long haul but the large majority after this first procedure are all buttoned down already and so far so good so just relax and enjoy each day getting even better!

Cheers!
Shannon