Dr. Natale

I visited my very humble cardiologist this week to discuss my current situation, including the possibility of a future ablation (I've recently written here about stopping magnesium and wondering about the impact of corticosteroid use). I live in the SF bay area, and he has had many patients go to Dr. Natale for ablation. He noted his understanding that Dr. Natale is somewhat alone in believing it is important to ablate the left atrial appendage (LAF), and that one consequence of doing so is an increased likelihood of having to stay on blood thinners (since apparently the LAF is the primary spot where pooling and clotting occurs, and it becomes somewhat compromised when ablated).

He told me that the results he has seen from Dr. Natale have not been noticeably better than with other experienced EP's (need for multiple and sometimes unsuccessful ablations), and he has seen this particular LAF complication of needing to remain on bloodthinners has appeared on multiple occasions.

I've appreciated much of the posting on this site over the past few years - especially the obvious caring and goodwill conveyed by regulars like Jackie and GeorgeN and Shannon, etc. However, I have noticed what has felt to me a cult-like belief in both the unique expertise and results of Dr. Natale and the benefits of Magnesium. I am finding the Magnesium mantra doesn't ring true for me (as I've recently written about). I am now wondering about the Dr. Natale mantra. Any thoughts about Dr. Natale's approach with the LAF vs. other EP's? Is my cardiologist correct that Dr. Natale is more focused on ablating this area than other EP's. Thanks, Ralph

Ralph,

Great to ask and to try to poke holes in the conventional wisdom - we can't learn if we don't challenge our understanding.

I asked about Dr. Natale's methods and what I had "heard" was a more aggressive approach than other EPs. I was told that he does what needs to be done, no more and no less. However, between the lines is the idea that he is able to find and fix more than your average EP, therefore it follows that he is going to do more work than the average EP. All I can say about the LAA is that he didn't touch mine - Shannon is probably a good resource re his thinking and approach there.

All the best,

C

Hi Ralph - I spent some time looking over your posts spanning the last 5 years to present. I didn’t see your comments about managing your Life Style Risk Factors, your age or fitness level, and pre-existing medical conditions or what Rx drugs you may take that could be contributing factors that support arrhythmia tendencies.

If you are young and healthy, then after five years or so of tinkering to reverse the AF trend without consistent success, and if the events are become more prolonged and frequent, it seems reasonable to consider an ablation with a well-known and experienced EP who has a track record of safe and successful ablations and virtually zero negative results. Shannon has a list of those EPs considered to be in that top-tier or elite category.

I’m sure Shannon will emphasize that Dr. Natale does not automatically ablate the LAA unless it’s needed. The problem with many less experienced and confident EPs is that they do not even investigate the LAA’s involvement and if there are signals there needing ablation but are not addressed, you’re not going to be satisfied with the results. I knew going into my second ablation, that it was probably a given to have the LAA isolated. I was right. But, the sense of peace that comes the relative assurance that I’ll stay in NSR is priceless and I’m so very grateful that I was able to benefit from his expertise once again.

You can call it a ‘cult’ to be a strong proponent of Dr. Natale, but I joined this forum in 2002 and then shared with members the accolades that were being circulated back then about Dr. Natale’s successes when he was at the Cleveland Clinic here in Ohio. Those results for members back then when ablations weren’t nearly as commonplace as today, were far more reassuring than many less fortunate who joined in to share their unfortunate, often tragic, stories about ablations gone awry.

A few examples include: Pete, who died on the table and had an out of body experience and “came back” to tell his horror story and then, his subsequent successful ablation not by Dr. Natale but with another skilled EP well known at the time. Pam’s story is published in a book by her husband, Dan Walter, that documents her ablation tragedy: Collateral Damage. A young man with a busy construction business wanted a fast ablation and opted for getting in quick. He sustained a burn/perforation in the heart wall (tamponade) and spent many months in severe pain from pericardial effusion. The solution was to have open-heart surgery to strip the pericardium from his heart… both painful, debilitating and lots of lost time. Fortunately, today, he is well and functional. While researching solutions and reliable cardiac surgeons, he met another person on the other side of the country who also experienced a similar error during ablation and also had to endure the stripping of the pericardium. Over the years, there have been many new members reporting the lack of success with their ablations, often numbering 3, 4 and 5 procedures who eventually managed to consult with Dr. Natale and finally, are enjoying restored NSR.

Experience counts as does an innate skill set and the 'magic touch' of an extremely-gifted ablationist.

Obviously, I’m partial to Dr. Natale because he was my first and only choice for my ablation (2003) at age 68, after which I enjoyed 11 years not worrying about my heart going into Afib. When I had the recurrent flares, I knew I’d go to Texas to take advantage of his expertise once again. I’ve always been somewhat in awe that he could do that to my heart and I wouldn’t feel as if I’d been run over by a truck the next day. Totally amazing. But, after three of them, I know it’s his gifted, magic touch and experience that makes all the difference.

So, yes, you could call it a cult following… but I like to think it’s just common sense to choose an EP with the best track record in the world for safe and successful ablation procedures. Am I biased? You bet! (And not only that, he’s a kind, caring, ‘angel’ of human being.)

I wish you well with your decision.

Best to you,
Jackie

I've been interested in this for quite a while. There was a poster a number of years back who'd had an early long episode followed by years of good control (similar to my story). Then his control diminished. All the EP's local to him told him all he'd need was a simple PVAI. He contacted the group in Bordeaux and they said the early long episode (some months) meant he'd be a complex case. He went' and had his ablation in Bordeaux. This stuck with me, because very likely if I ever need an ablation I'd likely be a complex case.

My understanding is that complex cases usually require multiple ablations and likely need LAA work to solve the problem.

For people I know personally that have gotten a local ablation, only one has been successful. None have had the horror stories that Jackie describes, just an ablation that didn't work. I've recommended a number of friends and family go to Natale or a protegee, all have had successful outcomes. Last week,I saw one, my best friend from childhood, who needed two Natale ablations, with LAA work & is on Eliquis. He tied or beat Shannon for the longest ablation time Shannon knew of - a very complex case. He was effusive in his praise of Natale and thanked me again for the recommendation and is ecstatic with continued NSR.

In 2008 or 9, my cousin went to a local EP, My cousin had both afib and flutter. The EP suggested doing just a flutter ablation. I knew the odds of that fixing his afib was about 5%. I suggested he go to Sergio Pinkski, a Natale protogee, for a second opinion. Pinski told him he needed to fix both problems at once. My cousin was very impressed with Pinski and chose him for the procedure. It was successful and he's been in NSR since.

Shannon was in Amsterdam some years ago when his sister had an ablation with the best EP in a large city. Unfortunately the outcome for her was a tamponade and now needing to spend her life in a nursing home.

My advice to others is to always go to the best. For people outside the US, this would be the Bordeaux team.

George



Edited 1 time(s). Last edit at 07/10/2017 08:27AM by GeorgeN.

When a LAA is performed and Dr. Natale appears to perform quite a few of them, a person then has to remain on blood thinners the rest of their lives, is that correct? What happens if a person cannot take blood thinners, what happens then?

Liz

Hi Liz,

After a successful LAA isolation, there is a 58% average risk of having to either stay on a OAC drug long term or go for LAA closure via an occlusion device like the Watchman or Amulet, or a ligation procedure like an Atriclip or LARIAT. If the person does not have a CHADsVASc of 2+ or higher then they can often stop all OAC after a successful LAA Closure so long as they are free from all Atrial arrthymias as well, as is usually the case after successful LAA isolation process is completed with an expert like Dr Natale.

Now consider Liz, that means there is a 42% chance of potentially not needing to stay on an OAC drug after LAA isolation and even without needing LAA Closure too, though this is determined only on a case by case basis and not by a general rule of thumb ... obviously.

In fact, for a person who has LAA triggering ... which is the ONLY circumstance under which Dr Natale will even do an LAA Isolation on the person ... having an LAA isolation is the only chance such a person will ever be free of OAC drugs (approx. 42% chance) and free of all arryhthmia as it is. Keep in mind, that any EP seeing a person still in persistent AFIB after doing every other process in their tool kit for addressing persistent and LSPAF, unless the EP recognizes that the remaining remnant triggers leftover that are driving their arrhythmia is almost certainly from the LAA and/or Coronary Sinus (once all other active sources have been rendered non-inducible) one's EP must be experienced enough in both recognizing and then successfully addressing these last two frontier areas of the left and right atria that so often mark the final atrial structures capable of sustaining atrial arrhythmia once all the other more typical suspects have been durably silenced, to achieve a long term durable freedom from the beast in such cases!

The result of accepting ongoing AFIB/Flutter due to either not recognizing the person remains in arrhythmia due to an LAA trigger source, or they do not feel confident in performing an LAA isolation, is dooming such advanced patients to living with persistent, or what surely will soon become LSPAF before long, and be relegated to medical drug management until eventually many EPs might then recommend AV-node ablation for more symptomatic LSPAF patients just so they do not feel their arrhythmia even though they remain in permanent AFIB, will require a life long pacemaker installed that makes the patient truly pacemaker dependent for life and insures lifelong OAC drugs as well

And Liz, it is not a choice whether or not to get an LAA isolation ... not really ... as not going for LAA isolation when the person needs one will almost certainly condemn that person to unbroken long standing persistent AFIB.

Shannon

PS Ralph, I will also address both your questions too, although Jackie and George already did so, but it may not be until this coming weekend when I have the time to revisit your inquiry above in more depth on this thread, as I have to drive down to Scottsdale from my home in Sedona on early Tuesday and returning on Thursday evening for a few appointments. Will try to reach you by phone in the interim as I'm in transit too and from Scottsdale/Phoenix and Sedona.

Shannon



Edited 2 time(s). Last edit at 07/14/2017 02:34PM by Shannon.

Hi Ralph.

Like you I live in the SF bay area. When it came to choosing an ep I consulted with Dr Natale and ep’s from UCSF, Stanford and Silicon Valley Cardiology. Based on my evaluation criteria I decided on Dr Natale. I had a 90 minute ablation, no LAA isolation, 3 years ago and have been afib free since.

I would take issue with some your cardiologist’s statements based on my research and consultations. Firstly, Dr. Natale’s results for being afib free for 5 and 10 years (which is what mattered most to me) were the best I found. Secondly, Dr Natale is not the only ep that does LAA isolation. You may want to do some research into the BELIEF Trial and I have also included a link that discusses this in more detail.
LAA Isolation

In my discussion with Dr N’s office it was made it clear to me that LAA isolation and long-term OAC was a possibility.

Like Clay I heard that Dr Natale is aggressive and this partially stems from a Dr John Mandrola post at the 2011 Boston AF symposium. Ep’s and cardiologists are like the rest of us and have egos and are prone to the same jealousies and envy that pervade our society so you need to objectively evaluate these subjective statements.

Your description of a cult-like view of Dr Natale is something I initially felt when I started my research. However, after meeting with Dr Natale several times I would more accurately describe it as admiration and love by those that he has treated. Dr Natale is also the most humble person I have ever met so even if you decide not to go with him I would recommend that you have a consultation with him.

Good luck

Thanks everyone for your input - that includes a long phone call with Shannon. If or when I have an ablation it will be with Dr. Natale. I'm still in afib about 1% of the time, and am still cautiously hopeful that I can stay there or better for the forseeable future. I'm aware that conventional wisdom says I won't, and if I were able to bet on it, I'd bet against it also. But my overall computation of this leads me to hold off until there is a noticable downslide (knowing that a downslide would make an ablation somewhat more complicated as George points out - but then again I've heard of an EP who can deal with that type of thing : )

I had a similar response from a local EP I went to about 6-7 years ago. He didn't do Ablations, and had had to go through the process of referring out patients for this procedure. He was trying to tell me that if I did it, I should just get it done by the best guy locally.

I never got an Ablation, but based on my research, it is worth going to a high volume center that specializes in this procedure, for the simple reason that the complication rate is lower.

It would make a good survey for our Forum members to embarq upon, that is to all ask our local Dr's to compare their success rates of patients who have been referred out to a top level Ablationist, versus having it done by their own Dr, or local Ablationist. By local I mean in the nearest major city.

As for the issue with Natale and the ablating the LAA, I am wondering if a patient could just tell Natale to leave the LAA alone.

For those seeking an ablation, but haven't found this forum, how do they find a top level ablationist with a high success rate? Even of one finds this forum, it seems that Dr. Natale is the only one around. Also, how is "a high success rate" defined? What is Dr. Natale's success rate?

In my case, not having found this forum before my a-fib, my cardiologist knew of a good local abationist, but felt that he needed more experience before sending me to him. I waited, as I recall, two years for him to "develop his technique", then I went in. One ablation, and now 10.5 years a-fib free. He spent 3.5 hours with me with 60 burns to get it right. No a-fib during the "blanking period" and only on Warfarin for two weeks, then nothing else, and it's still that way today.

So, is Dr. Kevin Wheelan in Dallas a great ablationist? How does one figure that out? I tried to find more about him, but online research doesn't generate much detail such as one would find on sites like Healthgrades.

I suspect that there are other excellent ablationists out there, but trying to find them seem to be an issue?

It seems to me that there are a few pieces to this puzzle. One is that there is very little comparative data that is available to patients. Another is that the work required and level of complexity/difficulty vary by patient, and no one really knows what they're going to find until they get in there.

If you knew ahead of time that you were paroxysmal and that all of your activity was in the PVs, then you have a lot of options for EPs who can get the job done. However, if the activity goes beyond your PVs, then your chances of success with an average EP diminish, because they probably have not been trained or had a lot of experience in more complex cases.

I was technically paroxysmal when I called Dr. Natale's scheduler. And she told me in a very nice way, "Well, you really don't need to see Dr. Natale", meaning, "... please, a lot of people can handle this". But she scheduled me anyway, which turned out to be fortunate, because I had activity outside the PVs that I would probably still have if I hadn't gone to TCAI.

I just saw Dr Natale yesterday in San Francisco. I had an ablation for persistent afib in September 2016 and have been in NSR since waking from the procedure. He gave me the all clear to stop xarelto, the only med I am on. I cannot say enough good things about him and the procedure. I asked him last September how many ablations he had done. He told me he stopped counting 2 years prior at over 8,000. I believe that experience is crucial in an ablation.