Setback (minor) after 1 year LAA ablation

Today was a setback, although minor to most afibbers. As a reminder, I underwent a LAA isolation performed by Andrea Natale just a year ago in Austin. I did the 6m post-op TEE in Austin, and all the metrics (ejection rate and others) were good enough that Dr. Natale was OK to let me drop thinners and swich to baby aspirin. However, my EP at Mt Sinai in NYC wanted to be more cautious and ordered a LINQ implant and wanted to perform another TEE, which was today.
Well, apparently, he detected something that he is not comfortable with, which has to do with the fact that the left atrium (not just the LAA, the entire atrium) is ejecting, but not in sync with when the electrical impulse would dictate that it does. He showed me on the monitor where I could see spikes showing the ejection from the LA, but out of phase with the electrical impulse. He worries that this may lead to some risk of clot forming in the LA/LAA as the flow of blood is not 100% optimal given anomaly observed.
I was given a CD of the recording and my EP very much intends to discuss it with Dr. Natale.

So this is my status; unless something/somebody convinces my EP (I have followed him for 15y so I respect his conservative stance) then I have to remain on Xarelto for life, which is really not great news at 53y of age.

I am curious to see if others have had the same experience and whether some different views might be known.

Regards

Hi Phillipe,

I would not lose too much sleep over the issue quite yet PH, as we just don't know yet if you do or do not have to go back on blood thinner until your new CD and TEE report are thoroughly evaluated by Dr Natale.

As we discussed on the phone just now, please send the actual CD copy of the TEE and the TEE report of this mornings TEE to Dr Natale as he will definitely want to see the actual CD and not just the written report as we just discussed on the phone.

You have had three prior ablations at Bordeaux , none of which addressed the LAA and then one with Dr Natale last year in which he found that the LAA was the your main remaining culprit that caused you to have to see him at all, even after 3 prior ablations at Bordeaux.

Since Dr N isolated your LAA just at a year ago, as you noted today, you have been free of arrhythmia ever since which is very good news for sure. Since without that freedom from arrhythmia courtesy of the LAA isolation, you would have been certainly still be permanently on blood thinners in any event plus the misery on-going dealing with the beast.

With LAA isolation, there is around a 70% chance of needing to be on blood thinner in any event either for life or one can now choose either the newly FDA approved Watchman or go for a ligation with he Lariat or Atriclip to prevent LAA based stroke risk without blood thinners, though the Watchman is now easiest to get approved for faster. ( though that will surely change as the field is very likely to open up now that the watershed event of Watchman approval has been finally breached.) PH you have so far won the full lottery of not only ending your arrhythmia to-date but being able to stop the blood thinners so far. We just have to see now whether some other issue has developed that might change that last part of the total lottery win so far... I hope not and I can understand your concern after having already been off OAC drugs for 6+ months now but let's just investigate this thoroughly with Dr Natale and see if this is something new going on in your case or just a higher conservative judgment call by an EP who might be prone to putting most of his patients on blood thinners for minor cardiac anomolies that other very experienced EPs feel is overkill?

Especially since your arrhythmia has been silent now for over a year, that is a good sign with LAA isolation that the odds are now a great deal less of needing more LAA touch up to finally put your arrhythmia to sleep long term.

But in any event, lets first see what the real story is. I don't know your EP at Mt Sinai though you noted both above and on the phone how conservative and ultra cautious he is.. That can be a good thing and a not such a good thing. depending on the real world experience versus some theoretical '100% ideal' target that in your note above you indicated that the mild dysyncrony he noted in you LA ( not your LAA) fell a bit short of being "100% ideal".

I ask this question, as there are many EPs who feel that every person with even the faintest cardiac anomaly should all be placed on blood thinners immediately. While many other very experienced in the field do not feel at all that way from years of personal experience that the risk/benefit is not worth it.

First off, get Dr Natale's input and if you want a third opinion too then ask Dr David Rubenson at Scripps La Jolla to review and discuss between him and Natale and you will get what the verdict should be. Dr Rubenson is a real TEE pioneer and leader with a Natale-like stature in the TEE world.

I do know that many otherwise excellent Cardiologists are not real experts in TEE interpretation from all the reports Ive read and heard of on post LAA isolation TEE exams by local cardios who see very few of these in daily practice. Some are good and some miss the mark at times with TEE interpretation.

Also, in my own experience even good TEE docs sometimes get it wrong. It was Dr Natale who first ferreted out the accurate diagnosis of my LARIAT leak that caused my modest stroke last May. This was right after the first 2D TEE in Austin with St DAVIDs very experienced TEE cardio after Dr Natale had me rush there the day after my stroke to check my Lariat sealed LAA as he felt that may well be my culprit as it was. But their main TEE cardio at first did not think I had a leak and thought it just an artifact.

Dr Natale disagreed and said after examining it closely over night that "I definitely see what looks like a small plume into the LAA pouch" and thus he sent me to Scripps Ls Jolla and their renowned imaging center where they clearly proved that Natale was right and almost certainly spared me from another stroke or TIA had I taken the first diagnosis and stopped the Eliquis that Dr Natale put me on immediately as soon as I left the ER in Arizona after my stroke when I called him directly.

In any event, PH, try not to be e too overly concerned right now , even though I fully understand that is easier said than done, as your heart is NOT in any crisis mode in any event. This sounds like a basic issue of interpretation here over what may well be slight variables, and you are doing fine from your report on the phone today. Just think if you had not successfully stopped your arrhythmia and were dealing still with that plus certainly being on blood thinners for good in any event all this time as well.

I'm trying to finish up the last part of the AFIB Report tonight and tomorrow Phillpe and don't have any more time at the moment to devote to this, so lets leave it for now until you can get the data and CD of the TEE to Dr Natale and then see what he thinks from there. I do want to follow up though so we know what is going on with your situatiion. I still have high hopes you can stay free of the OAC, but lets see what Dr N says on the matter. I know from experience in working with him that he will go to great lengths to avoid putting any patient at risk, and that includes both risk of ischemic emboli and excess bleeding risk too from unnecessarily over aggressive anti-coagulation recommendations too, but if there is something newly seen in your scan that he too agrees needs treatment he will be the first to agree.

Be well,
Shannon



Edited 2 time(s). Last edit at 04/29/2015 05:40PM by Shannon.

PH - My recent experience is this: Last August, I had a second ablation procedure (Natale) as I began to experience numerous ongoing A-flutter events that had to be cardioverted... this was after the initial 2003 ablation (also Natale). The August 2014 procedure did isolate the LAA and I was scheduled to have the requisite TEE to determine if I could go off Eliquis. The TEE was scheduled on 3/24 with a local cardiologist instead of traveling to Austin.

Unfortunately, right before that date, I began having breakthroughs of tachycardia-like events which I recorded so Austin could evaluate. Dr. Natale said to come Austin for a 'touch up' ablation as soon I could get a date. Fortunately when I called there were two cancellations and I chose April 3. The procedure is detailed in the 4/20 post "How I spent my Spring Vacation"....

I was soooo ready to get off the Eliquis and now I'm waiting again. Of course, if this next TEE indicates inadequate clearance velocity, then I'll have more decisions. At the moment, going for a third procedure to close off the LAA does not seem appealing but time will tell. I'm not thrilled with being on Eliquis for life either....however I'm considerably older (79) that you are, PH... and if I were younger, facing that decision, I'd be studying all of the pros and cons of the next step, in case it comes to that.

However, I'm currently thinking positive thoughts that we can both be off the OAC safely and forever.

Best to you,
Jackie

I had my ablation at the CClinic under Dr. Saliba 2.5 years ago. I also hoped to go off the Xarelto. My local EP suggested the LINQ implant , which we did. He found a few short self correcting AFIB episodes over a 4 month period and refuses to let me go off Xarelto. I am 80.

I can appreciate the age factor. I'm 79 so just being female and 79 puts my CHADS/VASC score at 3 so odds are slim but not impossible. Still, I'd prefer not to be on Eliquis if at all possible.

Best to you,
Jackie