First EP Visit-Long Post

Hello,
My husband's first EP visit is with Dr. Brett Gidney in Santa Barbara is scheduled for March 28. I am trying to prepare myself with extensive knowledge to help both of us navigate this problem successfully. I, like many others, have been impressed with the amount of information to be found on this website.

He was DX'd with Afib by an EKG in the ER in October 2017. His previous EKG in May 2017 was OK. ER visit was for very severe gastritis that was later determined to be probable food poisoning. He has been in persistent Afib since then. He is 73 (74 in May), nonsmoker, moderate drinker (2 glasses of wine per day), exercises regularly, golfs a lot and spends multiple days each week in our extensive gardens. ChadsVasc score of 1 (over 65) and we visited a cardiologist after his stress test showed no further problems. His heart rate is normal, except when he was in the ER and freaking out. Of course, the cardiologist wanted him on Eliquis immediately and continuously. He did explain that cardioversion only has a success rate of about 30% and wasn't the best choice. No other options were offered and we called the EP on our own after a friend recommended him.

Our problem with the NOAC is that my husband also suffers from dry AMD (age related macular degeneration). There is no treatment for the dry form of AMD and 10 to 15% of folks with dry AMD progress to the wet form which causes more potential blindness. The wet form of AMD is caused by blood vessels leaking in the macula of the eye. Wet AMD can be treated with monthly injections of a VEGF (vascular endothelial growth factor) inhibitor into the retina. Many of our food choices and nutritional supplements are designed to increase the pigments found in the macula and to increase the strength of the blood vessels. So far his dry AMD has been stabilized and he has not had any progression. My concern with the NOAC is that they could cause intraocular bleeding and possibly advance his AMD to the more serious wet form. His retinal specialist has not personally seen any problems with the NOACs, but has remarked that it would be best if he could avoid the blood thinners.
There are few reports online about AMD and NOACs, especially Eliquis, since it is the newest. I do understand that blood thinners would be necessary both before and after an ablation, but we would like to avoid long term usage.

I have the following questions about how to proceed and would be grateful for any input:

1. The term "LAA isolation" refers to the electrical burns done during a catheter ablation around the PV? And "LAA occlusion" refers to a device (Watchman, Lariat) to completely close the LAA? Is my understanding correct?

2. Even if he has a successful ablation and has a ChadsVasc score of 2 (once he is age 75) he would still need to be on NOAC for life? According to the new Afib guidelines.

3. The only way to avoid blood thinners for life with a ChadsVasc score of 2 would be a plug or device(Watchman, Lariat) to close the LAA?

4. Dr. Gidney is part of the AMAZE study (www.amazetrial.com) which is a combo of the Lariat first and then ablation. Are there any AMAZE participants on this forum? I know that Shannon has had the Lariat procedure, anyone else with a Lariat? I've been reading about some
serious complications, including death!

5. Finally, on DrJohnM's site he states "If your AF heart rate is not excessive, it’s unlikely that you will develop heart failure. Likewise, if you have none of the 5 risks for stroke, or you take anti-coagulant drugs, AF is unlikely to cause a stroke. In these cases, you don’t have to take
an AF- rhythm drug(s) or have an ablation. You can live with AF. You might not be as good as you were, but you will continue to be."
Doesn't long standing persistent AF cause remodeling of the heart or is it long standing excessive rate that that causes the changes?

Thanks in advance for reading this long story. I would appreciate your thoughts on the above.
Vicky

Quote
wineandroses
1. The term "LAA isolation" refers to the electrical burns done during a catheter ablation around the PV? And "LAA occlusion" refers to a device (Watchman, Lariat) to completely close the LAA? Is my understanding correct?

2. Even if he has a successful ablation and has a ChadsVasc score of 2 (once he is age 75) he would still need to be on NOAC for life? According to the new Afib guidelines.

3. The only way to avoid blood thinners for life with a ChadsVasc score of 2 would be a plug or device(Watchman, Lariat) to close the LAA?

4. Dr. Gidney is part of the AMAZE study (www.amazetrial.com) which is a combo of the Lariat first and then ablation. Are there any AMAZE participants on this forum? I know that Shannon has had the Lariat procedure, anyone else with a Lariat? I've been reading about some
serious complications, including death!

5. Finally, on DrJohnM's site he states "If your AF heart rate is not excessive, it’s unlikely that you will develop heart failure. Likewise, if you have none of the 5 risks for stroke, or you take anti-coagulant drugs, AF is unlikely to cause a stroke. In these cases, you don’t have to take
an AF- rhythm drug(s) or have an ablation. You can live with AF. You might not be as good as you were, but you will continue to be."
Doesn't long standing persistent AF cause remodeling of the heart or is it long standing excessive rate that that causes the changes?

Long post but one of the most well thought out posts I've seen in a while.

1. No, LAA refers to the left atrial appendage, which is a small structure that protrudes from the left atrium where the vast majority (>90%) of blood clots form in the atria. The Watchman device is used to occlude the LAA, which seals it off and therefore prevents those clots from occurring.

2. Maybe yes, maybe no. It might be possible to stop anticoagulants after an ablation, but that depends on whether the ablation was fully successful and whether the EP needed to isolate the LAA during the procedure, which is not common. If the LAA was isolated, he would need to be on anticoagulants for at least six months, at which time a trans-esophageal echocardiogram (TEE) would be performed. The purpose of the TEE is to measure the blood flow in and out of the LAA. If the flow rate is adequate, he could come off anticoagulants forever (assuming his CHADS score remained low). However, if the flow is inadequate, he would have to remain on anticoagulants indefinitely or have a LAA closure device implanted.

3. Not necessarily. A CHADSVasc score of 2 is borderline. It's a judgement call that would be decided by other factors such as his risk factors (his AMD, for example), whether he still has active afib, and so forth.

4. All invasive procedures have serious complications, including death. That even applies to things like tonsillectomies and root canals. The question you should be asking is how likely are those complications and is the risk worth the benefit? More recent studies on closure devices have revealed that as operator experience has increased, adverse events have decreased significantly. A closure device might be a good option for your husband, but what's of utmost importance is that the person doing the procedure has extensive experience with it.

5. First off, I would suggest taking Dr. Mandrola with a grain of salt. He's prone to minimize the effects of afib, blame patients for their lifestyles, and intentionally stir controversy with his WebMD articles. The more I read of what he writes, the less I respect him. That said, what he's saying there is sure, you can live with permanent afib as long as the rate is controlled and you're on anticoagulants (he's on a crusade against anti-LAA closure devices). Yes, afib does cause remodeling of the heart. What that means is the longer you're in afib, the more likely you'll become to remain in afib. "Afib begets afib" is the common expression. So if you don't mind taking beta blockers and anticoagulants for life, then simply ignoring afib is an option.

I concur with Carey's response.

The 30% Cardioversion success rate your Dr. quoted you is misleading. Successfull treatment with Anti-Arrythmic Drugs is about 30%. Electrical Cardioversion is successful over 90% of the time, at least initially. People often do go back into AFIB later on. Maybe long-term success from a single Electrocardioversion is only 30%. Still why not try right away and see, and stop the degeneration associated with ongoing AFIB? Your Dr. may have had his reasons based on your Husband's situation, but I would ask the EP about this.

As for getting an Ablation, I think most Patients try at least one or two Cardioversions, before getting an Ablation. A ElectroCardioversion is a simple out-patient procedure. I am in and out of the Hospital in 3 hours, when I have done mine.



Edited 1 time(s). Last edit at 03/20/2018 04:11AM by The Anti-Fib.

Vicky - I can offer some encouragement on the ARMD when taking Eliquis.

I've had that diagnoses for a very long time... first it was sloughed off as 'drusen' being watched or I'd have had benefit early on using nutritional aids to help slow the progress much earlier. However, after changing retinal specialists about 7 years ago, I was overjoyed to learn that the new doctor officially prescribed nutritional supplements for eye health.

Following his recommendations and along with what I had been using, my last tomography assessment indicated I had actually improved by two categories... or whatever the measurement was called. We both were thrilled. This was more than great news because I had been on full dose Eliquis for almost 2 years and then was able to reduce to half dose after the waiting period with the last ablation procedure but I'm still required to take the Eliquis.

It's obviously an enormous concern when you read that Eliquis and similar can promote interocular bleeding.

Jackie

Jackie

You said that Eliquis and similar can promote interocular bleeding" My doc. called today and I am going to go for some testing this week to see If I can take Eliquis, When I did take Coumadin many years ago the blood showed up in my eyes, they are all blood thinners, doubtful that I will fare any better.

liz

Thank you, Carey, for your detailed answers to my questions.Your comments have increased my understanding of the whole process.

Anti-Fib, I will definitely ask the EP next week about cardioversion.

Jackie, it's encouraging to know that someone has successfully dealt with the Eliquis and AMD issue. May I PM you if the need arises?

Thanks again,
Vicky

Vicky - Yes, certainly...you can send me a PM any time for any reason.

Jackie

Liz - I'll be interested to know what tests the doctor does for you to determine if it's safe for you.
No testing was done for me and it's definitely noted as a precaution that those with ARMD can have
intraocular hemorrhages while on blood thinners. Catch 22 not being addressed very well by the
medical community.

Jackie

Jackie;

A script is held for me at whichever U of M facility I go to have the blood draw, I know my doctor was a little concerned about how low my platelets are, I don't think they are too low. I will let you know.

isn't it strange that the medical community revised he Chad for blood thinners, a point for over 75, and a point for being a woman, that is already 2 without even trying, so with those revisions millions of people should to be on blood thinners. Now isn't that a coincidence 3 new blood thinners on the market, somebody has to pay for them.

l

With a score of 2, how many people have to take the anti-coagulant in order to safe one person from a blood clot?

Jackie;

I went this afternoon and got my blood drawn for 3 tests that my Doctor ordered, they are as follows;

CBC, INR and PROTIME

So, what do you think, will those tests solve my problem as to whether I can tolerate a blood thinner. I am doubtful, I am very leery to take a blood thinner, if I have to stop it, last time when I was on a blood thinner and had to stop, a couple of weeks passed and I coughed up some blood clots, I was lucky that time, but my luck could run out.

liz

Quote
Carey

5. First off, I would suggest taking Dr. Mandrola with a grain of salt. He's prone to minimize the effects of afib, blame patients for their lifestyles, and intentionally stir controversy with his WebMD articles. The more I read of what he writes, the less I respect him. That said, what he's saying there is sure, you can live with permanent afib as long as the rate is controlled and you're on anticoagulants (he's on a crusade against anti-LAA closure devices). Yes, afib does cause remodeling of the heart. What that means is the longer you're in afib, the more likely you'll become to remain in afib. "Afib begets afib" is the common expression. So if you don't mind taking beta blockers and anticoagulants for life, then simply ignoring afib is an option.

Quoted for truth.

Certainly read the good doctor’s posts to enhance your understanding of Afib and it’s treatment options. But when it comes to making a decision with regards to yourself, you must apply a coefficient to all of that.

I’d suggest ZERO.