True risk from LAA blood flow reduction

It seems to have been shown that the LAA is a source for @ 90% of clots formed from atrial fibrillation caused by non-valvular caused afib.
Many of us who have had ablations that may have slowed blood flow in the LAA are now faced with deciding if LAA occlusion is the best choice for us going forward.

I am wondering if anyone can shed some light on the following questions:
(1) Is the current thinking on what the minimum blood flow in the LAA based on any hard science, or are they very conservative guesstimates?
(2) Since most of us never had the LAA blood velocity measured prior to an ablation that may have slowed the LAA blood flow, how do we know what our "normal" LAA blood flow was before the ablation procedure.
(3) Is the velocity of LAA blood flow minimum standard for discontinuing ant-coagulation very established based on well established science? Would it be prudent to perhaps wait a year or two to see if this minimum number is revised after there is more time to evaluate what is the true risk based on LAA blood flow (and LAA shape)?
(4) It would seem logical that not only is blood flow part of the risk of clot profile, but also the shape of the LAA. It seems that the shape is not mentioned in the evaluation of if a patient can go off ant-coagulation therapy after LAA isolation. Only blood flow velocity and associated wave action. Is this because LAA shape hasn't been adequately evaluated in the decision of risk of stroke profiling?

I understand that LAA isolation to stop Afib is controversial. It is also relatively new approach. It would seem to follow that some of the LAA blood flow ideas are also new, and perhaps not well studied.

I will be making the decision in the next few months whether to proceed with LAA occlusion.

(This post is an addition to my original post.)
Here is a study by Dr. Luigi Di Biase entitled "Can the shape of the left atrial appendage affect stroke risk?"


https://www.einstein.yu.edu/departments/medicine/divisions/cardiology/news/shape-of-heart-and-stroke-risk.aspx

In patients with atrial fibrillation, stroke risk is managed with oral anticoagulants (blood thinners such as warfarin or the newer oral anticoagulants such as pradaxa, rivaroxaban and apixaban) or occlusion devices (WATCHMAN, LARIAT, AtriClip, and many others), which divert the blood flow by closing off the LAA to prevent pooling and clot formation.

The CHADS2 score and more recently the CHADSvasc score represent the most utilized classifications to identify patients at higher risk for stroke and the decision on oral anticoagulation. "Identification of patients at higher risk for stroke is key. Although these scores have an important predictive value, we still have patients with low scores who experience stroke," said Dr. Di Biase, MD, PhD, FACC, FHRS, Associate Professor of Medicine (Cardiology) at Albert Einstein College of Medicine/Montefiore Medical Center and Senior Researcher at Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, Texas, USA.

Patients who had Chicken Wing morphology were found to be four times less likely to have had a prior stroke/TIA than patients with Cactus morphology, five times less likely than those with Windsock morphology, and eight times less likely than those with Cauliflower morphology. The Chicken Wing morphology was concluded to be protective.
"If confirmed by further studies, these results could have a relevant impact on the oral anticoagulation management and occlusion device management of patients with an intermediate risk for stroke, because we will be able to identify patients with low stroke risk who might benefit from oral anticoagulation," said Dr. Di Biase.

Don

Excellent LAA q's.

On a related note, the new OAC Rx's available (Xeralto, etc) have essentially zero side-effects and/or lifestyle impact (vs. Warfarin), so it would seem that just staying on Xeralto... would be a safer and more conservative route... than going for a Watchman/Lariat surgery. Yet people in this forum seem to be leaning towards the surgical approach for low-velocity LAA (vs. staying on Xeralto). Why is that?

I've heard the argument that it is dangerous to be on an OAC if one is in an accident, but it seems like the medical opinion on that is changing. For example, Natale now keeps people on OAC's up to and through the ablation procedure (instead of the previous practice of stopping the OAC 3 days before the operation, and bridging them to low molecular weight heparin).

Don,

I have discussed this issue and other related issues with Shannon and he is probably the only one who can speak with any authority here. However, I will tell you that Dr Hoenicke, the heart surgeon that did my Atriclip on Dr Natale's referral, told me that there are no "standards of care" in this area yet as the procedures are new. If there were rock solid studies there would be standards of care.

Dr Hoenicke also told me that since he has been using contrast to light up the LAA during his surgeries he has noticed that the flow rate inside the LAA is quite variable and that it is common to find that some of the contrast does not penetrate some regions of the LAA for many minutes. That knowledge would cause me some concern if I was told my flow rate was only modestly adequate.

As your questions imply there is room for improvement in the science that will certainly come as more of us have the LAA isolated. My advice is be cautious, be conservative. I grimace when I read someone who has had the LAA isolated say they are going off anti-coag because they passed a TEE.

My decision was easy as my flow rate was 15, well below the minimums cited be Natale as being adequate. I chose the most conservative option, the Atriclip. I could have stayed on Eliquis as I tolerated it well but did not want the long term bleeding risk. The Atriclip terminated the LAA as a source of 92% of the emboli that are said to cause strokes in AF patients. And, it terminates errant signaling from the LAA as an added bonus. This bonus protects me from arrhythmia caused by a break through of the lesions that isolate the LAA so I think I am at less of a risk of needing a touch up ablation later. I don't believe either the Watchman or the Lariat offer that bonus.

Your questions are good ones but are best directed to Dr N or your surgeon - ask them how confident they are in their advice.

Bill

Good information Bill. Thanks for the reply. This was helpful.

I will be meeting with Dr. Natale in the next month or two to discuss my options. My LAA flow was rather low also, so that may make the decisions easier.
I recently had an injury were I need ibuprofen for a few weeks. Being on a blood thinner can complicate simple things.

Don

Hi Bill,

I won't be able to answer more fully for the next few days as we just returned from
A week out of town and are busy catching up
The next few days.

However, I did want to let you know that a fully Lariat ligated LAA that either never had a late leak and whose LAA Ostium is fully sealed and endothelialized as the large majority of Lariat cases are... And those cases like mine, that did develop a late leak large enough to require plugging and that are then successfully plugged with full endothelial covering of said plug in the center of the Lariat pucker seal due to its 'gunny sack' type epicardial suture synching down on the proximal LAA neck ... in both these two classes of successful LARIAT procedures they do provide the same kind of both electrical AND vascular isolation of the LAA from the rest of the heart and vascular system.

Just like the Atriclip dose too Bill.

One advantage of Atriclip is its spring loaded clip and linear seam-like closure that is extremely unlikely to spring a leak of any kind going forward.

But a successful LARIAT procedure either standalone or if requiring an additional leak plugging procedure that is fully successful itself, will certainly convey both protection against future LAA-based triggering and provides the same degree of vascular closure or ligation to the full LAA up to the proximal epicardial suture or the LARIAT which functions very much, in this case, as does the Atriclips epicardial spring-loaded clip in place of the LaRIATs epicardial suture.

I'll come back in a couple days to add more thoughts on the Lariat. Atriclip and Watchman .. The later of which is the only one of the three that only provides vascular isolation or occlusion alone, but does not provide the reinforced electrical isolation too that the LARIAT and Atriclip share in common.

Be well,
Shannon



Edited 2 time(s). Last edit at 12/17/2015 04:59AM by Shannon.

Thanks for the information Bill and Shannon.
Shannon a while back your generously offered to speak with me about this when the time came. I will try to take you up on that offer in the next month or two before I meet with Dr. Natale.

Questions about the Atriclip -
The body doesn't reject it as a foreign object? Inert material?
This clip is bouncing around with each heart beat, does it cause any friction problems from its constant movement?
Long term, does the clip tend to stay in its original placement and condition? Or disintegrate, fall off, etc?

I cant seem to find this information online.

Don

Don,

I can't answer your questions but you should know that over 50,000 Atriclips have been implanted without incident. Most of those were done as part of open-heart surgeries generally as part of a MAZE surgery. So there are many years of history with the clip, much more history than with other devices.

Bill

Quote

Questions about the Atriclip -
The body doesn't reject it as a foreign object? Inert material?
This clip is bouncing around with each heart beat, does it cause any friction problems from its constant movement?
Long term, does the clip tend to stay in its original placement and condition? Or disintegrate, fall off, etc?

Another Atriclip question... does the body always cause the clipped tissue to shrink and scar down? Or does it sometimes necrotize (rot), as can happen with other areas of the body which have blood flow removed?

And since they need to gain surgical access to insert the clip, wouldn't it be "cleaner" to just suture that area and amputate the LAA instead of using an Atriclip? That would remove the concerns about clip bouncing around, friction, rejection, clip migration or mechanical failure, etc.

As you know, I may eventually need to consider a clip procedure or whatever is the recommendation of the day....since I have another 6 months to go before another TEE assessment.

My current thought now is that so far I find the dose of Eliquis much more tolerable than the full dose, and rather than face another procedure, I may leave it alone. However, I may change my mind in a few more months.

At this point in time, if I were to have a procedure, I'm leaning toward the AtriClip as it doesn't involved invading the heart again. Since it's done from the outside, there is no need to puncture the septum again or access through the femoral artery ... since my old femorals are showing signs of some scarring and creating Bruits sounds that may indicate something is not right. The vascular surgeon who is evaluating is not saying much at this point.

In time, the Clip becomes completely covered with reparative tissue in the natural "walling off response" so the clip can't come apart. Then eventually, the appendage, itself, will atrophy since the blood source is eliminated and the body's natural resorption process takes care of that. I believe it's a titanium clip so the concerns about rejection are low if any?

It's my understanding that if the LAA were to be surgically removed, that would require open heart surgery. So obviously, that wouldn't be easy or hardly a choice.

Time will tell. I'm glad to see these discussions so that if and when I need to choose, I'll have had some time to mull it over.

Thanks,
Jackie

Jackie,

Hopefully your next 6 month TEE will show good blood flow and no need to have to make this decision. It is looking good for you so far!

I was planning on maybe waiting a year or two to decide what I should do. Then I had an injury a few weeks ago. I was on a high dose of ibuprofen for 3 weeks, against the doctors recommendation. This was an old injury, re-injured, so I have dealt with the condition before and know what works to get me back to functional. The doctors (most) are afraid of blood thinner and their liability if they treat you. I have run into dentists that won't do a teeth cleaning if you are on a blood thinner.
Because of being on a blood thinner, basically this time I couldn't get the treatment that has worked in the past and had to self treat.

The new blood thinners are easy to take, with not many side effects for most of us. They seems to not be too disruptive to our lives. That is until some other health issue occurs. Then they can be very limiting and the risks can increase fairly quickly.

Don

Thanks, Don, for your comments. In a previous post, I listed all of the side effects I notice from using Eliquis. I found a blog where people were contributing all of their symptoms and I was not surprised that I had more than a couple that matched theirs. There were too many matches to be 'coincidental.'

While I like the convenience of the NOACs, I really don't like the limitations should anything come up... as you mention in your case or the worst, fall or be in an auto accident. But overall, I liked Eliquis a whole lot better than warfarin.

I also notice that the cost has gone up considerably from the time I started taking it and this year, I nearly topped out on my prescription plan because of that.

Take care and keep us posted.

Best to you,

Jackie

Quote

Then I had an injury a few weeks ago. I was on a high dose of ibuprofen for 3 weeks, against the doctors recommendation.

I've asked multiple MD's about OAC's and ibuprofen, and they said that... as long as I had no stomach upset with the ibuprofen (meaning no possibility of stomach ulcers), then I could take it arbitrarily long (eg, 600-800 mg, 3x/day, for months and months).

Apparently the key is to always take ibuprofen with food, so as to buffer it's effect in the stomach (and thus avoid ulcers). The concern about ulcers is that ulcers + OAC could cause significant bleeding which may not be easily noticed.

Quote

It's my understanding that if the LAA were to be surgically removed, that would require open heart surgery. So obviously, that wouldn't be easy or hardly a choice.

Really? It seems that if they have the access to insert the Atriclip, then they would have enough access for surgical removal for LAA. Consider the following: they've created the thorasic incision and inserted the Atriclip. Couldn't they then... suture a thin section of the LAA border (b/n the Atriclip and the heart), and then cut off the portion of the LAA which has been Ariclip'd? They would then remove the severed LAA and Atriclip. And then for good measure, cauterize the incision to ensure a tight seal. I'm not an MD, but from an engineering perspective this seems reasonable.

Apache... That could be true about excising the LAA ...without the open heart access..... I haven't formally investigated the latest on that technique.. but if that's the case then obviously removing it would eliminate the concern over leaks or foreign objects implanted in the body.

Also:

Be aware that long term use of NSAIDs including ibuprofen carry an FDA safety warning now.
[www.fda.gov]

Jackie

My apologies for not being able to finish up addressing some of these issues above until now, but Ive just now finally got the time to address a few of the questions and comments on LAA ligation and the Atriclip and LARIAT from above. Several of these questions, though certainly good questions and logical sounding speculations, are simply not a concern at all on any level, and thus I hope not too many folks following this thread have taken away some mistaken concerns about LAA ligation and ATRICLIP in particular based on the impression that is might bounce off the LAA and float away to do some harm elsewhere in the body.

1. Apache and Don both asked about excising the LAA via surgical means and why not do that in a minimally invasive way?

Answer:Surgical amputation is not as well suited for a true minimally invasive procedure like used with the ATRICLIP which needs less space for clear and clean access than does full surgical access for amputation of the LAA. Also, there is a much greater risk of bleeding and complications arising such bleeding from LAA surgical ligation .. even with staples too ... both which, in this context of a minimally invasive LAA Ligation, are less desirable overall that a well-placed ATRICLIP ( well placed meaning the ATRICLIP is placed as proximal as possible to the mouth of the LAA before the spring is sprung so to speak in which the clamp under tension is set). The fact that this is true is borne out by the huge preference for using the ATRICLIP by Cardiac surgeons now when doing either on-pump open heart surgery where AFIB is a concern and LAA ligation is warranted, or off-pump minimally invasive LAA ligation via ATRICLIP.

Most cardiac surgeons will jump at the chance to use the ATriCLIp to ligate the LAA in either of these two scenarios as the data shows more robust results with less complications and solid long term efficacy with the ATRICLIP.

With both Staples and with surgical amputation it helps to be on bypass, but both methods can be done without bypass.

However, there is often a bit of a pouch formed in surgical suture or staple ligation with a saw tooth inner seam formed by the suturing pattern with amputation that may, or may not, form little nooks and cranny's along that inner seam that is now somewhat recessed. This could allow small emboli to form in this irregular inner seal of the former LAA mouth. Such emboli could then possibly break off traveling into the LA and thus gaining full access to the left sided vascular system and thus can travel to parts unknown and largely unwanted. A clean on-pump surgical amputation likely can be done with smoother seams and proximal seal, but there is still a good deal more bleeding risk than with an ATRICLIP.

The speculative fears of the Atriclip 'bouncing loose' or 'mechanically breaking' and then migrating to some dangerous place; are all entirely unfounded fears and concerns.

Once in place at a very proximal point near the LAA mouth from the epicardial access to the LAA, and the spring is sprung, the Atriclip is going nowhere .. period!

The longest part of the procedure is carefully coaxing the wider LAA body through the opening of the open Atriclip to the point where the full LAA is tugged through the clip itself .. even if they 'forgot' to spring the clip which I cant imagine ever happening ... there is just no way the clip will ever slide of drift off of the LAA body.

And once the clip is sprung and seated around the LAA mouth, there is instant mechanical and electrical isolation and ligation of the LAA in which necrosis starts to occur instantly ... within minutes. Over a period of several weeks the LAA tissue will be entirely resorb by the body and form a cap-like scar tissue encasing and enveloping the atriclip entirely and that is very hard to distinguish from the surrounding epicardial LA tissue..

At the same time, from inside the LA viewed from the endocardial perspective where the LAA mouth is now replaced by the ATRICLIPs linear seam or seal, very quickly endothelial overgrowth begins within days after the clipping procedure and is largely complete within a few weeks to a couple months maximum such that there is no open seam or scar from the inside but smooth overgrowth of the LA endothelial tissue as if there were never an opening there at all.

Looking at multiple CT and MRI scans, as well as some autopsy photos, done both pre and post ATRICLIP, it is clear in all cases that the LAA essentially disappears into a barely visible small lump as seem from the outside of the heart almost as if it never existed ... this is true too with the fate of the LAA after successful LARIAT Ligation too as seen in a few autopsy photos from folks who died some months to a year or more after the LARIAT from caused not related to the LARIAT procedure .. there is truly barely any evidence at all of he LAA ever having been there at all and the LARIAT suture is fully endothelialized and thus entirely embedded within the outer epicardial Left atrial tissue.

Keep in mind too that only a small window is cut in the pericardial sack that surrounds the heart and LAA area to allow direct access to the LAA in these minimally invasive 'Atriclip-only' procedures. The Cardiac Surgeon will typically re-suture that small opening window with a single suture placed across the center of this pericardial window.

Thus, the Atriclip once attached to the mouth of the LAA is largely trapped within this narrow and very snug pericardial space as well! So you can see there is just no realistic mechanism for the clip to either break free or drift anywhere ... even if that were possible for it to become dislodged from the LAA which is not a real world issue.

2. Answer: Again for emphasis, you will rarely see a cardiac surgeon who has the option of placing an ATRICLIP around the LAA that will opt for a surgical approach as a preference .. that tells us pretty much all we need to know about this issue. There are certainly some instances where the surgical approach is warranted, especially in some open heart procedures, but even in the vast majority of on-pump open heart surgeries, any LAA ligation planned is most often done now with the Atriclip by preference as an easier and effective procedure with less risk of complications than going the surgical route.

3, Regarding long-term non-steroidal anti-inflammatory (NSAID) use,

Answer: An increasing number of recent, and not so recent, studies have shown a strong association between long-term NSAID use and incident AFIB in multiple population-based studies. Most Cardios and EPs who understand this strongly caution their patients NOT to make NSAID use a long term regular habit.

NSAIDS are generally okay for short term use, such as post ablation and other such surgical procedures, if it is well tolerated. But this issue is not only about GI bleeding risks at all .. especially true for afibbers with this strong connection between long-term NSAID use and AFIB episodes... a few recent such studies including one I summarized earlier this year (or maybe it was toward the end of last year) in THE AFIB REPORT ... showed this association with increased risk for AFIB held true for even shorter term use of NSAIDS.

Shannon



Edited 4 time(s). Last edit at 12/21/2015 04:02PM by Shannon.

Thanks, Shannon - Excellent summary.

I'm copying to a file for reference in case I need to make a decision after the next TEE.

Jackie

Thanks Shannon.
The more information we as patients can get, the better we can be at peace with our decisions.

Don