PVAI and Protocol

I am scheduled with Natale in June for a touch up ablation. Index ablation done in Lex, KY 2 yrs ago.
When asking travel questions to the facility I was sent immediately information on LAA ablation and consequences from the procedure. I have never discussed LAA ablation or anything to do with that area. So im just curious. Now-a-days is it just auto assumed by the care provider that there will be a good possibility there may be attention given to that area? From what I read after any work done there a TEE is performed to basically determine the success and the remaining functionality of the LAA and if its cooked you are stuck on blood thinners. Just wondering if that is a risk to take or just protocol. Also anyone with experience does the ablation of that area and results outweigh the possibility of being on bloodthiners???

thanks
Tim

I'll start with that last question first which answers all the rest. YES, the results of achieving durable NSR are more than worth the possibility of having to deal with anti-coagulation which, if you do need full LAA isolation because that is the prime remaining source driving your arrhythmia ( which is the only reason you would get full LAA isolation in the first place) then you actually give yourself your very best odds then of actually staying off life long OAC too as anyone whose disease process has evolved to the point where the LAA/CS (coronary sinus) companion structure is the main remaining culprit WILL not be free of arrhythmia without addressing this elephant in the room. Up until fairly recent years LAA activity was mostly overlooked outside of all but a very few top centers like Natale's centers as the prime pioneers of this area of work and Bordeaux who does a significant amount of LAA work now too in light of the more challenging case loads both top centers largely address.

You stand about a 60% to 70% chance of needing to address the OAC issue after a successful LAA isolation if your LAA emptying velocity is too low (below 40mm/sec) and/or your Doppler A-Wave measured into the mitral valve inflow is not robustly consistent enough, or there is the presence of any SEC (spontaneous echo contrast or 'smoke' seen during the 6 month post LAA isolation TEE scan. Keep in mind too that while very complex and advanced paroxysmal cases can have LAA triggering , it's actually pretty rare for LAA ablation to be needed in the large majority of typical paroxysmal cases (another motive not to beat around the bush too long in the face of continued lack of full success at achieving total remission of AFIB via any or all of the various self-directed natural-based protocols alone.

Note, that this still gives you a net 30% to 40% chance of not only ending all Arrhythmia for the long term but also ending all need for anti-coagulation and essentially being done with this battle for good once it's all buttoned down.

Should your long term battle with the beast have evolved now to include principal LAA involvement and you do not address the LAA by rendering it silent, there is essentially ZERO chance you will escape inevitable life-long OAC ... And on top of that you will still be in the life long slugfest with ongoing AFIB/Flutter with all that that entails including increased risk for silent cerebral ischemia continuous accumulation due to the constant AFIB/Flutter which is now a huge focus of AFIB management research the last 8 years or so when it was never considered, or really understood prior to that when the now very out of date idea that just slowing your rate under 100beats and staying on OAC would render AFIB a nuisance but not really dangerous, which has now been overthrown by the recognition of a clear increase in early onset dementia and Alzheimer's for those with high long term ongoing AFIB burden.

So this is not really a choice Tim at all ... It's very important that you digest this reality metric to see the big picture more clearly.

First of all, Dr Natale will only address the LAA at all when, after addressing and silencing all other source of triggering, he discovers that the LAA and often its connection to the CS are the last remaining drivers of this challenging saga all of us afibbers have experienced to one degree or another as a key influence over our lives. He will first do everything he can to control the LAA triggering via delaying the amplitude of these LAA trigger electrograms seen without full isolation.

If after the isoproterenol challenge part of the ablation when this adrenaline like drug is infused in at around 20mcg/minute rate for 10 to 15 minutes to try and ferret out any remaining active triggering that requires ablation, and he carefully observes that the delay he has made to your LAA triggering is holding steady and consistent and is not suddenly jumping all over the place in the same chaotic fashion as LAA triggers appear on electrograms prior to at least being delayed, then he will leave it at that and see how well you hold steady in NSR, which in some cases is indefinitely though it's not uncommon for at some point down the road for a good number of delayed LAA to need to return once more for what would then amount to a very small target touch up to only finish isolation of the LAA at that time.

If that attempt to delay the LAA successfully does not pass this isoproterenol challenge and the LAA triggers break open again, then the only option is to fully isolated the LAA in that index or follow up procedure knowing that this will give the patient not only his very best chance for true long term freedom from the three headed beast of AFIB/AFlutter/ ATachy but also will give him or her their best odds of not needing to deal with OAC issues long term.

A 30% to 40% chance of not needing OAC ever again after going through full succssful LAA isolation in the hands of a maestro at doing these procedures, once the 6 month TEE confirms they still have robust enough blood flow velocity in and out of the LAA, is far better odds than basically zero chance which is what not addressing an LAA trigger amounts too. Again, if a person with LAA involvement and/or CS involvement that makes the poor choice of selecting an EP who not only is not well trained and experienced in addressing and isolating both the LAA and CS structures, but as is so often the case, does not even know how to reliably detect true LAA triggering and would not attempt ablation there even if they did recognize it, they are highly likely to be doomed to either ongoing ablations of the same known areas over and over long term, or just throw in the towel.

These EPs will usually tell the patient they have done all they can do and that they will have to stay on OAC for life and take likely a cocktail of rate control and possibly an AAR drug in some cases for life... Usually a rate control combo to keep the AFIB, or more likely AFlutter at this latter stage, low speed.

One thing you can take to the bank is that's Dr Natale will absolutely NOT isolate or even delay your LAA unless your heart and body demands it as the last and remaining key driver of your misery, by presenting this to him as the end stage of your own evolution of this very lousy cardiac condition.

Dr Natale or any other EP has no control over what we present to them at the time of ablation on that table. But this is why it is so important, especially for longer term cases of arrhythmia that have progressed over time, to be very discriminating in making sure you partner up with a highly experieced EP that is fully comfortable and very well vetted at recognizing and successfully addressing whatever degree of difficulty your case of arrhythmia presents to them.

The fact that so many EPs are not capable of consistently addressing more challenging cases of the beast in this fringe frontier areas of the left atrium ( and right atrium for the CS), is reflected in the overall rather mediocre long term outcomes of ablations when excluding the stats and experience of the top elite operators of the world.

The whole field is now moving much more quickly toward accepting and embracing the need to learn and perfect LAaisokation in their own practices if they are going to improve the success rates beyond the 70% or so maximum without addressing these more complex structures to which AFIB Flutter almost always migrate over time if the arrhythmia is allowed to progress and remodel without addressing these key areas for truly long term success in so many folks.

I hope this helps open your perspective on what this is about some Tim. The reason St Davids sends out a letter describing the benefits and the high odds or needing to sea with long term OAC or add in a Watchman or ligation device, is to fully inform all patients that LAA iso might be needed since over 75% of St Davids cases are on complex cases like persistent and long standing persistent AFIB which are all far more likely to have some LAA involvement.

All the more reason not to mess around for years once one has aggressively adopted all life style risk factor reduction protocols they might need and embraced with dedication the Strategy electrolyte restoration and improved high quality eating and diet as well as appropriate exercise, and if AFIB is still making even a mild moderate frequency of appearance even with still short episodes in your life, then by all means go for an expert ablation earlier rather than later... Trying to out think yourself after a certain point of a past a full year of earnest effort at all the life style RFM (risk factor modifications) plus strategy efforts, is most often a losing game long term. There will be very occasional exceptions, but the vast majority will find out within 6 months to a year if the natural route ALONE is going to be successful for them.

But if breakthroughs are still happening inspite of a full year of real effort on your own, time to join forces with the best EP you can and really start putting this behind you sooner rather than later for you own long term good.

Best wishes,
Shannon



Edited 2 time(s). Last edit at 04/28/2016 09:49AM by Shannon.