Subtle Post-Procedural Cognitive Dysfunction after ablation

The 2013 J Am Coll Cardiology contains a rather disturbing study entitled:

"Subtle Post-Procedural Cognitive Dysfunction After Atrial Fibrillation Ablation".

Summary: 12%-20% of patients who had afib ablation had significant cognitive deficits, 90-days after the procedure.

Everyone knows that anesthesia can leave one a bit out of sorts for a day or two, but this study measured the results 90-days post procedure, and found significant cognitive deficits still present.

I'm aware that Natale is the best... and he didn't do the ablations in this study, but I'm curious... if there is a more concrete reason... why one might expect a better outcome than the 12%-20% cognitive deficit for a Natale ablation? In other words, are there any problems with the ablation techniques or equipment used in this study? (I can't find any...)

Before answering, keep in mind that the fact that you might know lots of people who have had Natale ablations and seem fine does not mean they really are. The cognitive deficits in this paper are not gross defects, such as unsteady gait, speech problems, limb palsy, etc. Rather, they were cognitive deficits which were only detected by targeted tests.

One example of such a test: patient is read a list of 10 words, then 15 minutes later asked to recall as many of the words as they could. 90 days post-ablation, 12-20% did a lot worse on this test. There are 9 other tests... Unless one has taken these tests before (and after) their Natale ablation, we cannot say that the Natale ablations don't also have this problem. Thus, I'm looking for a more watertight argument for why Natale ablations might avoid this drawback. For example, does Natale use an arterial line filter? (That's one of the suggested methods in the paper for avoiding the cognitive deficit).

---- more details ----

The entire paper is available, free, from here. (Click "Download PDF" in the upper left)

Rather than just using MRI, they actually gave a series of cognitive tests to 4 groups of people:
a) those with persistent afib (n=60)
b) those with paroxsymal afib (n=30)
c) those with supraventricular tachycardia (n=30)
d) control group (no heart issues), (n=30)

Let's ignore category (c), because in this forum all we care about is afib.

Everyone in categories (a) and (b) had a very low CHADS2 score: 0 or 1.
Mean age was relatively young: 58

The tests appear to be quite through. There were 9 tests, covering memory recall, verbal fluency, visual-motor coordination, etc (see Table 1 for exhaustive details of the tests).

The tests were given at 3 timepoints:
1) pre ablation
2) 2 days after ablation
3) 90 days after ablation

The control group was not ablated, but were given the tests at the same 3 timepoints.

Test results were performed using a statistics technique called RCI (Reliable Change Index).
All ablations were performed with irrigated catheters (full details of all catheters used are in the paper).

The test results were grouped into two categories: POCD, or no POCD
POCD (Post-Operative NeuroCognitive Dysfunction) was defined as "a severe deterioration in a few tests, or a less severe deterioration in many tests relative to baseline functioning."

As expected, at 2 days after ablation, many of those who were ablated had POCD (statistically worse test results).
So far, no big deal. They'll get better, right? Wrong.

At the 90-day mark, 13% (parox afib) and 20% (persistent afib) ablation patients still had POCD.
It would be nice if the paper tested farther out (180 days, 360 days), but they didn't.

In the discussion section, the only correlation the paper authors were able to draw was that the patients with the most left atrial access time had the worse results.

They also referenced a paper where (during cardiac surgery), patients randomized to have an arterial line filter had a significantly lower number of cerebral microembolic events and were significantly less likely to have POCD at 8 weeks followup. Is an arterial line filter even possible in an afib ablation, and if so, does Natale use one?

So, aside from the fact that Natale is better than everyone else, is there anything specific that one can point to that would account for Natale having better results (if indeed he does) w/r/t the 90-day cognitive deficit? Ideally, that would be in the form of a study Natale himself did to assess this. I haven't found such a paper yet, but that doesn't mean it doesn't exist.

Second best would be if someone noticed something different about Natale's tools/techniques, vs those described in the paper. But AFAICT, the tools and techniques seem essentially equivalent.

I'm hoping to be proved wrong.

Your thoughts?



Edited 1 time(s). Last edit at 08/04/2015 12:26AM by apache.

After just skimming through the study, and thinking off the top of my head, it seems to me that unless there was some serious complication from an inexperienced Ablationist, then this effect would be similar across the board for all Ablationists that used similar tools. Maybe Dr's that used techniques that had less burn lines, would have less of this effect. It's a good question though. Does Dr. Natales skill level have a way of negating this occurrence?

This study looked at Endocardial Ablation, and not Epicardial Ablations right? Might be a difference there. Has there been any research comparing that?

Also, This study makes you wonder about the people that have had 6-7 Ablations? They should be studied from the angle of possible cognitive loss.



Edited 1 time(s). Last edit at 08/04/2015 02:02PM by The Anti-Fib.

My understanding is that Dr. Natale is totally aware of the stats on possible cognitive decline in connection with ablations. In fact he has ongoing research going on right now on this topic. I am enrolled in one aspect of this research.

My understanding is that one of the key factors in keeping the micro emboli down to an absolute minimum is the very stringent anti coagulation protocol Dr. Natale uses for his ablation patients.

Perhaps one of our members will chime in on the details of the extra stringent protocols Dr. Natale uses to achieve low, low micro emboli events.

JohnB

I've had three ablations by Dr. Natale. Is PPCD something I should be worrying about long term? I've been "off" after the ablations but wrote it off to the drugs and lack of exercise quality and quantity. No end of things to worry about.

My anecdotal observations and comments are these:

First Natale ablation - age 67.... and for the next 11 years ... no memory problems...

Age 78 - Second Natale ablation 8/2013.. and using Eliquis since 5/2013... annoying short-term memory lapses. During the time leading up to the 2nd ablation... at least 4 ECVs.. maybe more. I'd have to look up the exact number. I contend that isn't good for one's brain either.

Age 79 - Third Natale ablation 4/2013 - still using Eliquis and now both short and long-term memory... impairment.

My hope is that once off Eliquis, there will be improvement. But, the fact that 2 ablations done within 7 months of each other and in an elderly patient, who is otherwise, basically healthy, may make a difference with the memory deficit factor... along with taking the NOAC, Eliquis.

If this happens in younger patients as well, then the link is likely due to the procedure's impact and potentially, also the effect of Eliquis in some. As listed in the Eliquis post a while back, I have numerous ongoing symptoms also reported by others which I highlighted in bold. [www.afibbers.org]

Time will tell if I am able to stop the Eliquis and if the symptoms resolve.

Jackie

Just to be clear, I too have experienced some short term memory loss, especially around remembering names. This is more of an embarrassment than anything else. I will be 70 years old this December.

* I was in untreated persistent afib for 3 years before I was cardioverted and placed on Amiodarone for 8 years.

* I have been cardioverted about 6 times in the last 10 years.

* I have had 3 ablations, so far. The 4th is coming up later this month. This will be the second by Dr. Natale, a touch up for a flutter circuit.

* I have been on Eliquis for several months with no noticeable side effects.

Just exactly why I am experiencing short term memory loss is not known to me. I have not as yet consulted any physicians about this.

I am grateful to be one of Dr. Natale's patients. He and his team are above and beyond, imho. I will run this issue past Shirley or Dr. Natale himself, when I see him.

John

John - I'm grateful, as well, for a calm heart in NSR and I have the highest regard for Dr. Natale and his team.

Just hoping that once off the Eliquis, things resolve.

Jackie

Prior to my recovery to NSR, which did not include an Ablation, I also had issues related to memory, and feeling a little "off". All of the sudden going on 4 medications, having a multiplicity ECV's, and enduring all of the AFIB, most certainly had an negative impact. The waters were muddied as how I could know exactly what is going on with responding to multiple medications taken for the first time, as well as going through the AFIB, etc.

I'm thinking that there is going to need to be more long-range studies on this, and there will be, in order to definitavly prove that this is going on. I have spoken about this before, but when I spoke with Dr Sirack (5-Box Dr.), I think this is what he was trying to warn me about in regards to an traditional Endocardial Ablation. The way I understood it, as the burn lines are being made, microscopic particles (debris) are released into the bloodstream, and then since in is already right there in the Heart, then these little particles are shot straight up to the Brain. In an Epicardial Ablation (done outside the Heart) there would be much less of this.

Well - I'm not blaming the ablation, but rather the Eliquis since I had 8 years prior to the first ablation with turbulent bouts and long standing... many lasted 24 hours and often only 4 hours break and back in Afib again and no memory or other problems. I wasn't using an anticoag during those years...managed the clotting risk with natural blood thinners and Nattokinase...as I've reported in my history. (except for 6 weeks prior and about 6 weeks post ablation.)

I had none of the symptoms I've experienced since going the NOAC, Eliquis....and definitely no memory decline. So my total was 8 years before plus the 11 years after (for 19) and no memory decline.

What changed is... taking Eliquis, the second ablation followed by the third; and, of course, the obvious... definitely older.

Time will tell.

Jackie

Quote
JohnB
My understanding is that Dr. Natale is totally aware of the stats on possible cognitive decline in connection with ablations. In fact he has ongoing research going on right now on this topic. I am enrolled in one aspect of this research.

Hi JohnB,

Could you please elaborate on this? Did they give you a cognitive test (and/or cereberal MRI) before and after your ablation?

Thanks,
-Ted

Ted,

As part of Dr. Natale's ongoing research, I received an MRI in February of this year. I am returning in a week to Austin for a touch up ablation with Dr. Natale. Perhaps I will have another MRI at during that visit.

Unfortunately cognitive decline is part of life for many of us as we age, especially after age 65. The risk factors are many.

Here is a link to an article in Wikipedia on silent stroke that describes the ailment and its risk factors:

[en.wikipedia.org]

Afib and ablation are among the more than dozen risk factors described.

Personally, I do all I can to maintain a healthy mind, body and spiritual experience. We each have our own paths...

John

Hi JohnB,

Quote
JohnB
As part of Dr. Natale's ongoing research, I received an MRI in February of this year. I am returning in a week to Austin for a touch up ablation with Dr. Natale. Perhaps I will have another MRI at during that visit.

Unfortunately cognitive decline is part of life for many of us as we age, especially after age 65

Thanks for the additional info. Unfortunately, I'm confused by your answer. If the MRI was part of a study, I would've thought... they would've given you specific details/dates on the number of MRI's needed for the study (eg, "we'll take 3 MRI's: the first will be pre-ablation, the second will be 3 months later, and the third will be 12 months later" ).

Or are you saying that because you need a follow-up ablation next week... it's before the regularly scheduled follow-up MRI... so it's not clear if Natale will do an MRI at that point in time since it doesn't fit the study parameter timeline (is "too early" )?

--------------- cut here for rant about cognitive decline caused by the corporate world, not age -------------

Regarding the cognitive issues after age 65, not only do I agree with you, but I'd back it up to age 35. That's around the age at which engineers in my company started joking about getting old and coming down with CRS ("Can't Rember Sh*t" ). My theory is the CRS syndrome has more to do with dealing with too much multi-tasking and corporate BS than it does with age. After a few years in the corporate R&D env, where too much is managed by other teams (with their own objectives), one realizes that there's often no point in remembering specific details, because some random person will change something and make the prior knowledge invalid.

If I had a nickle for each time some short-sighted person changed an API or process (not making it better, just changing it so they had something to put on their quarterly accomplishments, and were able to say they "improved" something), I'd be a very rich man. A wise old engineer once told me that "standard is better than better". Meaning if you're going change something, the benefit had better be huge, otherwise the net effect will be negative, due to all the ripple-down changes required. Sort of like the butterfly effect. These days, where we often have lower-cost "coders" instead of properly trained engineers, the problem is much worse. Any monkey can be taught to code. An engineer not only knows how to code, but more importantly understands how to design, and properly analyze all the tradeoffs and consequences of any particular design or process, to come up with a solution that improves the "big picture" rather than just their own tiny ecosystem.

Getting back to CRS, I would argue that those lucky few who are independently wealthy (and can thus ignore arbitrary changes in their work env, initiated by others outside their span of control) do not suffer from CRS. Or experience CRS to a much lesser degree.

-Ted

I read and don't remember where, maybe PubMed, that anytime a person usually a person over 50 under goes an operation and is put
to sleep it affect the brain cells somehow causing them to be less affective. I have not done a lot of studying on this. Just picking my
operations. If not needed I won't have it done. Of course sometimes it is unavoidable.

This is a response by Shannon to Apache... he asked it be copied and pasted here as it relates as well to the cognitive function aspect

Shannon [ PM ]
Re: Cryoablation Procedure
August 05, 2015 01:13PM Admin
Registered: 2 years ago
Posts: 1,784
Hi Researcher,

Good summary of Natale's long standing persistent and regular persistent approach as he narrated in the video.

Many EPs less sure and experienced ... And yes he has at least 8,000 right and left atrial ablations since he began helping to pioneer focal AFIB approaches and worked in concert with the Bordeaux team as they developed and published the blueprint for PVI ablation with their seminal paper describing how more than 85 % of paroxysmal AFIB triggering was found to be from the pulmonary veins which launched the entire catheter ablation for AFIB world. Natale has been at the forefront of innovation in this field ever since pioneering many techniques, tools and methodologies such as the uninterrupted preiprocedural anti coagulation method that is now the standard method after recent large multi-center international randomized controlled trials have definitively proven this method of continuous unbroken OAC foopr several weeks at a minimum prior to ablation as well as unbroken all the way through to the ablation itself with either Warfarin, Xeralto or Eliquis (but not Pradaxa) and then combed with using IV full weight heparin just BEFORE using a double transeptal puncture to allow both the ablation catheter and lasso mapping Cather to be inserted one time across the septal wall within the sheath and avoid possible multiple transfers of catheters in and out from the RA to the LA which increases risk of micro emboli and micro bubble formation and dislodge meant into the LA when only one sheath is used and two catheters have to be exchanges a few times (not a good idea at all!) .

Next they discovered that insuring that the ACT time is maintained from 300sec to 350sec starting again just before LA access is established helps not only reduces stroke and TIA risk compared with using interrupted and bridged warfarin with enoparin (low molecular weight heparin which has different properties and actions than does either Warfarin, and NOAC or full IV heparin), and then switching back to warfarin only after the procedure has been found to even more dramatically increase risk of Peri-procedural SCI creation by a significant margin over using the now much preferred Continous unbroken procedural anticoagulation for most every procedure involving left atrial access across the septal wall.

Please note: Apache and Anti AFIB who inquired about this after Apache posted that valid and important topic though from in this case a rather marginal study from down under on neuro-cognitive impact of these SCI caused during an ablation, I've not had the time to address the onslaught of one paper after another here recently Apache, but this one must be addressed as I will later attempt to after returning home from Phoenix where my wife is getting her biopsy as I type this on my IPhone.

But hearin lies your answers ... Right up front you can toss a large percentage of that Aussie studies number on cognitive impact with the longer AFIB ablations compared to the shorter SVT ablations used as controls, not only because of the different time components under anesthesia for each group, but far more importantly because they used a broken INTERRUPTED anticoagulation protocol for the AFIB Ablation procedures as well, not unlike with those right sided only shorter SVT ablations that didn't always include LA access.

A number of far more robust multi center studies by top tier groups in this field from the likes of Thomas Deneke, Gaita, Natale, Pierre Jais etc etc have underscored now the large superiority of unbroken peri procedural anticoagulation in sharply reducing AFIB ablation related SCI creation which is obviously p a key important goal that all the heavy weights have been working on non stop since the first indication of this phenomenon was first noted over 10 years ago and really caught everyone's attention about 6 years ago.

Combining properly used irrigated catheters. Unbroken periprocedural Anti-coagulation with assured ACT times in the LA above 300sec up to 350sec from just before LAaccess until protamine partial reversal of the IV heparin bolus is applied only AFTER all instrumentation is removed from the LA and the Continous warfarin, Eliquis or Xeralto is maintained unbroken as before the rate of SCI creation drops to the range of 1 to 2 ..3 max tiny white SCI lesions noted the first DE-MRI 24 to 48 hours post ablation and which almost always resolve and disappear after 48 hours to the point where it is not common to detect much, if any, Flare weighted MRI evidence of glial scar remnants which would indicate some possible lingered brain cell injury.

In contrast with interrupted anticoagulation schemes and/or when singke sheath and multiple Cathyer transfer in and out of the LA is used and/or when ACT is not maintained above 300 secs ... All bets are off as the rate of SCI generation jumps to from around 12 up to close to 70 such SCI lesions noted on early DE MRI in typical patients and with a significantly greater number potentially remaining visible days and months later on FLARE MRI as glial scar remnants...

Not surprisingly, this Aussie study Apache dug up used an interrupted anticoagulation scheme... It wasn't entirely clear if each AFIB ablation patient had been on warfarin before the procedure or not and then had it interrupted for the 4 to 5 days that is typical with interrupted schemes during which they switch to enoxaparin up until Transeptal puncture at which time typically the IV Heparin is infused often at high 10,000 to 13,000 unit doses and after the procedure enoxaparin is used again to bridge back to warfarin in light of the slow uptake rate of warfarin of around 5 days for INR to stabilize again....

That is a Lot of variability in anticoagulation status over this key period of time and what contributes to the excess generation of SCI and thus by logic and inference the Modest increase in subtle post procedure cognitive function decline that appears mostly temporary and a good part of which was also acknowledged to be from early anesthesia recovery effect for the first large 24% number vs 13% for the later period of either 30 or 90 days I can't recall at the moment.

The single most important thing for you and others to grasp, Apache, is that leading centers are already greatly reducing the degree of potential SCI creation during an ablation. We are not at zero yet, and may never be, but great consolation is there when you realize that the very procedures Dr Natale uses (since he is the doc you were asking about) have very low rates of SCI in their carefully screened patient pool ..

Thus, if you ever really do decide to get an ablation and decide that perhaps he gives you a good balance of odds stacked in your favor, you then could request to be apart of any ongoing study of SCI as they have done quite a few so far, and then will get pre and post DeMRI and FLARE MRI to determine how much SCI burden you already have accumulated from the years of ongoing AFIB which is ... BY FAR ... The single greatest generator of these micro brain lesions and that continues to accumulate indefinitely the longer even subclinical asymptiomatic AFIB continues.

And even more important to digest, is the fact that the comparatively larger SCI burden (relative to the very low levels when all best ablation practices are used) even from the worst catheters and most out of date interrupted anticoagulation schemes, still pales in comparison to the much larger burden over time from ongoing living without consistently stable NSR!! Your brain while still contending with ongoing AFIB either paroxysmal or persistent is far more likely to accumulate more micro emboli or impact from micro bleeds from variable levels of oral anti-coagualtion including the NOACs as well long term, or so seems to indicated the more and more research ... Thus the emphasis on gaining and maintaining as much pure NSR in ones life as possible as the true goal of this game, by whatever means you need to achieve that to the best of your ability.

To be sure, these studies on this issue are all valuable and important, but the take home message is largely the same. DO everything you can in your power to improve your own good health by learning about and adopting better life style choices and better dietary and nutritional repletion ,, and when needed choose the most experienced EP you can who is also very SCI savvy and uses all the known best practices for minimizing risk of stroke, TIA AND SCI creation in the peri-procedural time frame.

When that fact sinks in, you will quickly realize the importance not only of partnering with an EP who has been at the forefront of SCI reduction research from its first recognition, but from the reality that any successful ablation process will be the single biggest weapon you can employ to reduce your long term SCI burden and thus greatly reduce early dementia likelihood related to ongoing paroxysmal or persistent AFIB/Flutter.

It's like the old Indian proverb about how it often takes a small thorn to remove a much larger thorn and then you cast them both aside and get on with your life.

Cheers!
Shannon

PS George or Jackie, can either of you please copy and past this reply into the thread Apache started related to the study about the neuro-cognitive impact of ablations. Magdalena and I won't be home until tomorrow and I wanted to get this info out about this important topic.

Also, for those who don't read THe AFIB Report , I have covered this key issue three times in the last year and a half and will be featuring the largest and most comprehensive and up today's international Multi center review of the subject in the Next issue (Aug/Sept) of The AFIB Report once again.

Many thanks
Shannon



Edited 3 time(s). Last edit at 08/06/2015 04:35PM by Shannon.

Also Anti AFIB this effect of Increased SCI burden is not unique to catheter ablation as far as primary causes, it is also found in CABG operations , PCI coronary artery stenting valve replacement operations and a number of other medical procedures.

Again, the good news is great strides have been made to significantly lessen these peri-procedural causes of added SCI burden during AFIB/Flutter ablations which, in turn, present vanishing lower burden causes than does unaddressed and still active paroxysmal and persistent AFIB over time that remains the single biggest danger we know of for promoting this unwanted phenomenon.

Be well,
Shannon



Edited 1 time(s). Last edit at 08/06/2015 04:21PM by Shannon.

The Taurine update post starts with news that Taurine Grows New Brain Cells... so continued use of the Essential Trio is still important for former afibbers...

I'm going to increase my daily intake to be sure that my brain cells have good support from taurine.



In light of my recent complaint about memory issues, this is timely:

Regarding brain function, the Sept. 2015 issue of Life Extension Magazine contains a report stating that Taurine Grows New Brain Cells and includes 79 study references. This should be good news for those who follow the nutritional support recommendation for helping to reverse Afib… called the Essential Trio… (magnesium, potassium and taurine).

Here’s the summary from the LEF 2015 report:

Taurine, a little-known amino acid, can do the seemingly impossible: stimulate new brain cells to grow in adult brains. This capability creates an entirely new paradigm for the ways we think about age-related cognitive decline and even major neurodegenerative diseases like Parkinson’s and Alzheimer’s.

Taurine levels fall as we age, leaving our brains relatively unprotected. Taurine levels are low in people with age-related brain disorders. Animal studies reveal that supplementation can not only restore youthful taurine levels, but also improves deficits in memory and cognition.

Taurine also has a fundamental connection with longevity, particularly related to cardiovascular disorders. Animal studies demonstrate protection against heart disease with taurine supplementation, and human studies show that supplementation produces dramatic improvements in heart and blood vessel function.

People with metabolic syndrome have lower taurine levels than their healthy peers; again, taurine supplementation drives down the detrimental effects of metabolic syndrome while inducing changes that reduce the syndrome’s long-term impact on cardiovascular risk.

A balanced supplement program should aim at restoring youthful levels of nutrients known to counteract the chemical stresses, inflammatory changes, and toxic exposures we experience through life. The evidence for the amino acid taurine suggests that it be included in such a regimen. [www.lifeextension.com]



Jackie

Thanks Shannon for the detailed reply, much appreciated!

Since we covered some of these topics via PM, I'll only comment on the items which were not covered in PM...

Quote

Right up front you can toss a large percentage of that Aussie studies number on cognitive impact with the longer AFIB ablations compared to the shorter SVT ablations used as controls

Actually.. I did toss out the SVT data. The control I used was their group of non-ablated patients. Who (as expected) had 0% cognitive decline at Day 90. In contrast, the parox/persistent afib ablation patients had 12%-20% cognitive decline at Day 90.

Quote

Unbroken periprocedural Anti-coagulation with assured ACT times in the LA above 300sec up to 350sec

Actually... the paper I referenced used the same ACT times.

Quote

Thus, if you ever really do decide to get an ablation and decide that perhaps he gives you a good balance of odds stacked in your favor, you then could request to be apart of any ongoing study of SCI as they have done quite a few so far, and then will get pre and post DeMRI and FLARE MRI.

Excellent suggestion, thanks!

Quote

to determine how much SCI burden you already have accumulated from the years of ongoing AFIB which is ... how much SCI burden you already have accumulated from the years of ongoing AFIB which is ... BY FAR ... The single greatest generator of these micro brain lesions and that continues to accumulate indefinitely the longer even subclinical asymptiomatic AFIB continues.

Fortunately this does not apply in my case. The SCI burden I currently have is zero (more on this below).

Quote

And even more important to digest, is the fact that the comparatively larger SCI burden (relative to the very low levels when all best ablation practices are used) even from the worst catheters and most out of date interrupted anticoagulation schemes, still pales in comparison to the much larger burden over time from ongoing living without consistently stable NSR!! Your brain while still contending with ongoing AFIB either paroxysmal or persistent is far more likely to accumulate more micro emboli or impact from micro bleeds from variable levels of oral anti-coagualtion including the NOACs as well long term, or so seems to indicated the more and more research

That may well be true statistically speaking, for the general population of people with afib (many/most of whom are not aware of it), but I'm very self-centered and only care about my brain. And the odds in my case seem to be different, thus making a Natale ablation in my case seem more risky than not-ablating.

Some people have subtle or "silent" afib. I'm not one of them. I always know immediately when I go into afib, and when I do, I start Xeralto. The two EP's I've asked (not Natale, yet...) assert that if one goes into afib there is a 24- 48 hr where one can be cardioverted w/o worry of SCI (and no TEE needed), because that's how long it takes for a clot to form. And now that we have a NOAC, Xeralto, which ( becomes clinically effective in 2 to 4 hours) , there is no SCI burden at all, for me. In fact, I can schedule my cardioversion 4 or 5 days in the future, with no SCI burden.

So unless I'm missing something (which is possible), it seems to me that in my case, the choice is between 0% SCI risk by not having an ablation, versus a non-zero chance of SCI (Silent Cerebral Infarct) if I do have an ablation.

Am I missing something here? I'd love to be proven wrong, as getting cardioverted all the time and avoiding triggers is growing ever more inconvenient.

(In the meantime, I'll go back and reread the 9 issues of the newsletter).

Cheers,
-Ted



Edited 1 time(s). Last edit at 08/07/2015 05:52AM by apache.

Hi, Ted,

I don't believe anyone with AF—or anyone, for that matter—has a risk of zero for SCI, and I'm not sure that knowing that you are in AF (always the case for me, too, thus far) provides you with protection other than the obvious awareness that you are, indeed, in AF and can take steps that you otherwise wouldn't take. From everything I read, there is a vulnerable period with anti-coagulants when you start and stop them, so, again, I'm not sure that you aren't at some small risk every time you start and stop Xeralto. The "pill in pocket" approach to anti-coagulation is an area that seems to be less than fully clear at present, although it also seems that many EPs recommend starting anti-coagulation with NOACs when you have an AF episode. The 24-48 hour window has also been narrowed, as well, I believe. I know that I've read more recently that there are examples of stroke within 5 hours and also after one has converted back to NSR. My local doc told me that the most vulnerable time is the time around the conversion from AF to NSR.

And there are people on this list and other accounts who have had a stroke when they were in NSR and were in "perfect" INR range with warfarin. I don't think it's as black and white as we might wish these things to be. I don't get the sense that these risks are big if you are otherwise healthy, but they are not non-existent. I think the main thing is that life is a risk factor. :-)

At a certain point, recognizing that you can minimize your risk only so far, even if you pursue every avenue, and then getting on with life has definitely lowered my stress level. I expect that stress may be the bigger risk factor, in any event.


Rob



Edited 1 time(s). Last edit at 08/07/2015 03:53PM by rob50.

..... "if you are otherwise healthy." Good point, Rob.

On this topic, frequently not mentioned as a consideration for clotting risk are the factors that bring about the "thick, sticky blood" factor mentioned in many of my posts on that topic....with silent inflammation working behind the scenes to contribute initially to the hyperviscosity.

Certainly, when preparing for ablation, Rx anticoagulants are prescribed which remain in place for a requisite period of post-procedure time.... but those who go into the procedure having managed the hyperviscosity factors long before ablation was considered, logically have to be in a more healthy viscosity range to start with. It would be reasonable, therefore, to assume the various clotting risks during the procedure are still present but are apt not to cause as much of a problem where blood was already flowing well and long-standing inflammation wasn't part of the scene.

Afibbers are smart to clean up the many initiating factors that contribute to hyperviscosity and which can be evaluated by testing the individual markers, changing diet and lifestyle to eliminate the potential for one's tendency for blood to clot abnormally fast... so that if and when ablation time does roll around, then the formal NOACs work very efficiently for the period of time prescribed. Once off the Rx anticoags, all the good preventives such as the natural anticoags and anti-inflammatories, curcumin, fish oil, enzymes, and so forth can continue to keep blood in a healthy, non-sticky range.

Once you have good test results on your Viscosity markers, it helps remove a lot of the stress and worry.

Viscosity markers include: High sensitivity C-reactive protein, (HS-CRP), Fibinogen, Ferrrin, Homosteine, Hemoglobin AlC, Lipoprotein(a), Oxidized LDL, Interleukin 6 ... and are indicators or promoters for thick, sticky blood so elevations out of the norm should be managed immediately. Keep in mind many factors including silent inflammation drive the stickiness.

Once off the OACS, if these markers aren't managed, you're still at risk clot formation even if the Afib is now gone.


Jackie

References:

Sticky, thick blood - risk of stroke or MI [www.afibbers.net]
Sept 6 2012

Discussion on fibrinogen – one of many
[www.afibbers.net]

Red Flags
[www.afibbers.net]

Jackie

Why would a person run for the presidency when their health records say that this person had a problem with blood clots affecting legs, brain on past occasions, suffered a transverse sinus venous thrombosis in the brain. Had blood clots in 1998, 2009 and 2012, takes Coumadin to help prevent new blood clots. Isn't this a serious condition?

L

Who has all this? Dick Cheney had Heart issues and AFIB.

I don't think Cheney had AF, he did have a heart transplant----the person that has the blood clot problem, which was released by her doctor who said she was in good health, gee, I don't think so, its Hillary and the blood clotting is bothersome, most people don't seem to know anything about health issues, I think it is scary, am I wrong?

L

Dick Cheney did have AFIB, but that was mild compared to all the other stuff he had going on with 5 Heart Attacks.

[www.doctorzebra.com]

You are right about Hillary, it is an issue that's not given enough attention. I thought she should have just stayed as Senator from NY. She was tired, and kind of got pushed along into running for President, and accepting the Secretary of State job.

Oh, I didn't know he had AF, I knew he had a lot of heart problem issues.

Liz