LAA Morphology Article

I was intrigued by the article "Left Atrium Appendage (LAA) Morphology and Physiology 'The Missing Piece of the Puzzle'" in the most recent Afib Report, June/July 2015.

I am wondering if this additional diagnostic, LAA morphology classification, would apply to CHA2DS2 patients who have been successfully ablated, such as myself. I have a CHA2DS2 score of 0 and was recently ablated—2.5 months out now and all is going well. I will hear from Dr. Natale soon whether I can stop my OAC, Eliquis.

As well, I recently had a CT of the heart for my ablation. Would Dr. Natale be able to determine my morphology, Chicken Wing or not, if I asked him?

As a corollary, when does the stroke risk of a patient who has had a successful ablation return to the risk level of a non-afib person?

Many thanks in advance
Q

Last question first, the stroke risk for former AFIBBers who have had a successful ablation process that restored full time unbroken NSR, has been shown in a number of studies (most recently in large study at Intermountain Utah) to fall to that of those of the same age/sex matched population control group who have never had AFIB.

Next question, LAA morphology applies, of course, as this just classifies the shape/variegation/volume of your LAA, but the implication is entirely different in NSR than it is in ongoing AFIB or with a too reduced pumping and flow velocity of the LAA either from being in persistent AFIB for so long that scarring and structural remodeling has passed the tipping point where little to no reverse remodeling can be recovered even after gaining NSR long term after a successful ablation, or far more commonly mainly from ongoing AFIB itself.

In NSR without an acquired reason for reduced LAA functioning, there is no increased stroke risk, per se, though I suspect the very tiny overall odds (about 0.1%) of having an embolic ischemic stroke or TIA originating in the LAA while in long time NSR of many months or longer duration, would be some what higher in the Non-Chicken wing morphologies, but there is likely no way to tell for sure as the numbers would be so small to work with in any event that its likely impossible to get a statistical confirmation of that.

Plus, even going there would just be looking for things so vanishingly unlikely to occur, on the order of being hit by lightening on your birthday, and thus needlessly be looking for things to worry and fret about.

The LAA morphological classifications have their most practical meaning for folks with ongoing AFIB, either paroxysmal or persistent, or for those who have had an LAA isolation and are now in NSR but who then demonstrate a too low LAA emptying velocity ( below 40mm/sec) and an inconsistently over all weaker Doppler A-Wave reflecting the Mitral Valve inflow coming out of the mouth of the LAA , which is discovered during the same TEE as the empty velocity figure is recorded. This later scenario is either from the outcome of a successful LAA isolation ablation, or from the aforementioned waiting too long to re-establish permanent NSR after a long time dealing with persistent or very long standing and active persistent AFIB to the point where the impact on LAA mechanical function has rendered it permanently impaired.

And keep in mind all those who still think is no big deal to stay in asymptomatic AFIB for the rest of a long life when at a relatively young age...this very likely long range scenario along with the related increased risk of SCI ( silent cerebral ischemia) increased burden over time contributing to possible early onset dementia are both compelling reasons why that old view is rapidly falling from favor in the EP and Cardio world as the underlying nuanced and details of living with AFIB continue to be uncovered and clarify.

If both of those conditions are not met in the positive, then one would have to either stay on blood thinners for life or get an LAA ligation with the Atriclip preferably, or a Watchman LAA occlusion device if they feel confident that their LAA electrical isolation is durable and holding well.

The advantage of an Atriclip is instantly achieving total electrical and vascular isolation of the LAA which then is completely resorbed by the body just distal, or above the clip and thus preventing any risk of LAA-sourced embolic event at all for life, while eliminating any blood thinner need based on the concern for LAA-based ischemic clot formation.

In other words, instantly eliminating roughly 95% of all possible AFIB related stroke risk in one shot, while also giving extra reassurance to an already done LAA isolation ablation that the LAA wont act up again as an AFIB/Flutter source in the future as there literally is no LAA any longer.

One of our long time readers, BillK, just had a minimally-invasive Atriclip installed this past Monday in Austin and will be sharing his experience with us before long. It was a resounding success, with a good deal less discomfort than some might have expected. He didn't require any pain meds at all on his flight back home on Thursday after just 2.5 days in the hospital at St David's south.

Most encouraging too was the siginificant advances that have been made in this minimally-invasive procedure, with use of the 4th generation of robotic surgical tools which are leaps and bounds more capable with each new generation over the previous generation and now allowing incredible precision in placement of such a device as the Atriclip. Plus use a new contrast agent called Firefly to illuminate the LAA and smaller veins and arteries around the LAA, such they these structures can more easily be avoided nicking or pinching closed inadvertantly during the clipping of the LAA itself. Use of Firefly contrast also allows the positioning and seating of the Atriclip to be done in deliberate confirmed steps with the ability to readjust the seating, angle and proximity to the LAA/LA mouth prior to actuating the spring-loaded clip permanently.

Anyway, Bill will share more of these very welcomed details of his experience with Dr Hoenicki, the cardiac surgeon at St Davids that Dr Natale works with in Austin for the patients he refers to Dr H for Atriclip installation who came to Austin for their procedure(s) with Dr Natale. For his San Fran patients who need an LAA ligation he recommends Dr Dunnington in Napa Valley who has trained with Dr Hoenicki in Austin too in the nuances of this evolved minimally-invasive Atriclip surgical procedure.

It's all really good news for those who may now, or in the future, be in need of LAA ligation.

Shannon



Edited 1 time(s). Last edit at 07/26/2015 12:46PM by Shannon.

Shannon,

Thanks much, very good information. I talk to an NP at CPMC about scheduling a TEE next week which will let me know whether that procedure is in my near future. I look forward to BillK's report. Great news about no pain meds 2.5 days after! I'd heard a month on pain meds: a bit daunting.

Mike Erickson

Ok, that sums it up well.

Thanks kindly Shannon!

Q