left appendage ablations

Dear Friends,
I had my second ablation three years ago in Austin, Texas by Dr. Natale. After Natale looked at my TEE six months after the procedure, he advised me to continue Eloquis. My local cardiologist believes my risk factor of bleeding is higher than stroking and thinks I just need to take an aspirin and monitor my blood pressure.
Can someone explain to me the function of the left appendage and even when you are not in afib is there a possibility of a clot forming. I am truly hoping in the future there is a blood thinner developed that can be reversed immediately. I am 60 years old.
Thanks n advance,
Pamela

Hi Pamela,

If Dr. Natale isolated your left atrial appendage (LAA) during your ablation and then told you to continue anticoagulants after seeing your TEE at six months then you should believe him. If he said that, that means the TEE showed that you don't have adequate blood flow within your LAA to prevent blood from pooling and clotting there. The LAA is the source of 90% of all afib strokes so this is something you have to take very seriously. Taking your blood pressure and aspirin aren't nearly enough and demonstrates that your cardiologist doesn't fully understand the consequences of LAA isolation.

Unfortunately, many (most?) cardiologists aren't familiar with LAA isolation and its special risks. If your cardiologist firmly believes you're at high risk of a bleed, you should ask him to consult with Dr. Natale and iron it out between them. You absolutely should not follow his advice until the two of them have spoken.

Also, Eliquis can be reversed. I don't know what you mean by "immediately" but a reversal drug does exist and works as fast as it gets in medicine. But the thing is, it's extraordinarily unlikely you would ever need that drug. Virtually no one ever does because, like all the NOACs, Eliquis has a very short half-life. They can almost always deal with a bleed by simply stopping the Eliquis, and by giving you plasma if it's truly serious. The risk of life-threatening bleeds from anticoagulants is more of a fear of patients than a reality.

Good advice and explanation from Carey. I'm curious to why your cardiologist thinks you're such a high risk for a bleed.

I also have LAA isolation and am on eliquis. I'm an avid cyclist an neither Dr Natale or my local EP have ever shown any real concern about it.

Hi Pamela, good to hear from you! I what to strongly second Carey’s excellent summary above! Your no doubt well-meaning cardio is unfortunately misinformed. As Carey emphasized above, he simply doesn’t understand the risks, or the options. Did he define your added bleeding risk? Also, a good solution, even if you do have an actual elevated risk for bleeding, is a Watchman FLX, which you could easily get approved should their be an actual elevated bleeding risk in your case.

Besides, the added bleeding risk for Eliquis is roughly in the same ballpark as an aspirin to begin with, and that is why Eliquis is ranked as having significantly lower bleed risk among all the NOACs and Coumadin, as it is.

Please, you absolutely must talk to Dr Natale and don’t follow your cardios advice and stop Eliquis until you get your LAA closed, or Dr Natale agrees that you aren’t at an elevated bleed risk with your cardio. As Carey noted, Dr. Natale can speak to your cardio and enlighten him. I’m sure your cardio is a good doc, it’s understandable he could make this mistake as there is a concerted effort now to better inform Cardios and GPs around the world as to the nuances of LAA-iso management.

I recruited Carey and Andy B. from our forum, both of whom have Watchman FLX installed post their own LAA isolations, and who kindly flew to Austin last week to participate in a project sponsored by Boston Scientific, maker of the Watchman/WatchmanFLX, in which they had Dr. Natale and Dr Horton do a series of six interviews with a select group of ablation patients who also have LAA closure with the Watchman installed.

Boston Scientific will be showing these videos repeatedly on many large LCD screens stationed all about many of the major cardiology and EP conferences throughout 2020 calendar year, as well as at key internal medicine conferences too, in order to educate cardiologist and GPs around the world about the advantages of LAA closure in ablation patients ... especially for folks who required LAA isolation in order to end their battles with atrial arrhythmia.

Cheers!
Shannon

I actually had to “depart ways” with my local Cardiologist over my LAA being isolated and other disagreements my Cardiologist had with Austin. I did not get into a big knock down with my Cardiologist but IMO he is way out of his league.
I need to find me a EP in my area but that is difficult in this rural area. I am doing great but I need somebody locally who does not take it personally when I make a decision whom I pick to do my Ablations.

Thanks so much for all the support and advice. I spoke with my cardiologist and he is going to call Dr. Natale. I asked him if my left appendage works correctly when I am not in afib. He said he did not know the answer and he wanted to speak with Dr. Natale to understand the left appendage better. Will Dr. Natale speak with him?

He did suggest having me purchase an Apple Watch 5 to monitor if I am ever back in afib. Anyone have success wearing an apple 5 watch to monitor heart rate?

I did purchase an Omron blood pressure cuff to monitor my pressure. My cardiologist in Michigan said I have a CHAD score of 1 because I am a woman and that is part of his idea of thinking to stop my Eloquis.

I have to say I am happy to hear that Eloquis is as safe as an aspirin. It has always been my fear taking Eloquis that if I was in an accident it would be dangerous bleeding out.
thanks again for all your suggestions,
Best,
Pamela

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pamela
I asked him if my left appendage works correctly when I am not in
My cardiologist in Michigan said I have a CHAD score of 1 because I am a woman and that is part of his idea of thinking to stop my

Pamela, after your ablation your LAA is not as efficient and there are various parameters that Dr. Natale looked at after your TEE. In your case he has determined that because one or more of these parameters is not in range, you have a higher risk of a clot forming even when you are in NSR.

Shannon has described these factors in detail before. They include emptying velocity, “smoke’ and others. If you do an advanced search, for all dates with Shannon as the author on these two terms and LAA it should come up.

{edit} here is the search <[www.afibbers.org]
George



Edited 2 time(s). Last edit at 10/31/2019 09:32PM by GeorgeN.

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pamela
Anyone have success wearing an apple 5 watch to monitor heart rate?

The Series 5 would work great, as would the slightly older Series 4 or even 2 or 3.

I you want to take single lead EKG's, you'll want a Series 4 or 5.

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Shannon
Post LAA Isolation 6 month TEE parameters that must be passed in order possibly be able to stop OAC drugs (Assuming your systemic stroke/TIA risk factors that do not include LAA function (like CHA₂DS₂-VASc) nor anything directly regulated to AFIB/Flutter are:

1. LAA Emptying Velocity - the LAA emptying Velocity measured just inside the ostium (mouth) of the LAA must be >/= 45cm/sec

2. Doppler A-Wave into the Mitral Inflow - the doppler A-Wave of blood flow measured at the mitral valve inflow from the LAA outflow directly above and vertically perpendicular to the horizontal oriented mitral valve opening ... must show a Consistently Robust A-Wave amplitude beat by beat ... it is not okay to stop a blood thinner if the A-wave is largely absent or with an irregular A-wave amplitude that includes some mitral inflow measured A-wave heart beats that indicate less than robust and consistent mechanical function through the full LA/LAA through Mitral valve flow pattern with every heart beat

3. The Absence of any 'Smoke' or SEC (Spontaneous Echo Contrast) seen anywhere in the left atrium or left atrial appendage.

<[www.afibbers.org]



Edited 3 time(s). Last edit at 10/31/2019 09:33PM by GeorgeN.

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GeorgeN

1. LAA Emptying Velocity - the LAA emptying Velocity measured just inside the ostium (mouth) of the LAA must be >/= 40cm/sec

Very useful post, George. Thanks. Since the time Shannon posted that info, Natale & Co. have upgraded their criterion to 45 cm/sec.

2. Doppler A-Wave into the Mitral Inflow - the doppler A-Wave of blood flow measured at the mitral valve inflow from the LAA outflow directly above and vertically perpendicular to the horizontal oriented mitral valve opening ... must show a Consistently Robust A-Wave amplitude beat by beat ... it is not okay to stop a blood thinner if the A-wave is largely absent or with an irregular A-wave amplitude that includes some mitral inflow measured A-wave heart beats that indicate less than robust and consistennt mechanical function through the full LA/LAA through Mitral valve flow pattern with every heart beat




Could someone elaborate on this requirement above in Layman’s language? This is the reason I am on a blood thinner. I have no A wave at mitral valve.
Thank you

The A wave is the flow of blood from the left atrium into the left ventricle caused by the atrium contracting. If you've heard the term "atrial kick" that's what the A wave is. That's in contrast to the E wave, which is just the flow of blood that's passive and caused by gravity. If the A wave is reduced, that means the atrium isn't contracting effectively. The atrial kick only contributes about 5% to the heart's output so losing it doesn't usually have any clinical significance and it wouldn't be noticeable to most athletes, it does mean blood is pooling and more prone to clotting in the left atrium. Therefore, if you don't have a robust A wave, you need blood thinners to prevent clots from forming.

That is all interesting since my velocity was 34cm/sec but Natale said i was OK because it was "contracting". I am not even sure in this case how to understand "must be > 45cm/sec"

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dartisskis
That is all interesting since my velocity was 34cm/sec but Natale said i was OK because it was "contracting". I am not even sure in this case how to understand "must be > 45cm/sec"

Quite often when the LAA is isolated it no longer contracts effectively, and that's why he has to measure flow velocity, E:A wave ratio, etc, but apparently your LAA is still contracting effectively so that's even better. For the rest of us, our LAA doesn't contract effectively or maybe at all.

Lucky you. I got the 5 and it never alerted me I had af. It notifies me of low hr but not high. I called up and Apple told me the Apple Watch is not legally developed for patients who has been diagnosed with af and he was not allowed to give me tech support. I then said I would give away the watch to my daughter but wanted to know why I didn’t get high hr alerts “to help my daughter set it up” (lie) . It seems you have to have high hr for 30 minutes..making my watch worthless because before my ablation I had hours of high hr and af without alerts. However if I took a reading when in af it did say I was in af. I was hoping the watch would alert me to silent af when asleep.

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dartisskis
That is all interesting since my velocity was 34cm/sec but Natale said i was OK because it was "contracting". I am not even sure in this case how to understand "must be > 45cm/sec"

Hi dartisskis,

What is interesting is that the long term line of demarcation consider the borderline of ‘safe’ LAA emptying velocity has been in the past set at 25cm/second.

However no respectable EP or Cardio will allow a patient to operate right on the knifes edge of reasonable safe margin. They will always build a heathy buffer zone above which the treaty EP or Cardio is totally confident the patent is highly unlikely to ever drift into a long term unsafe LAA emptying velocity zone.

Because of Dr Natale vast experience with LAA isolation and LAA issues in general, he has raised his ‘extremely safe’ zone to be just at/or above 45cm/sec over the last year or so.

However , because he doesn’t look at each of the three metrics one must pass with solid safety margins to earn a possible reprieve on needing a blood thinner, based only in the separate numbers but rather evaluated the combined LAA mechanical function capacity indicated by all three values combined proving a very robust LAA mechanical pumping capacity, is why you will occasionally see patients like yourself with a still strong LAA emptying velocity but perhaps a bit shy of optimal Emptying velocity numbers when evaluated solely in isolation. This due to the combined pumping strength and consistency of your LAA emptying velocity, your very robust Doppler A-Wave pumping capacity measurements and the absence of any signs at all of ‘smoke’ in the LA or LAA.

You should be very well protected for sure from an LAA-based embolic event, as long as you remain very vigilant in not missing any Eliquis doses at all! However, for Super-Duper ultimate protection also including LAA Closure for folks with LAA isolation is hard to beat and is what I chose to do. I
additionally for some folks who also have a high Chads Vasc score above 2, talking to your EP about possible continuing on a half dose of Eliquis could make sense on an individual case by case basis, even with a Watchman in place, solely to help minimize to the maximum any non-AFB /non-LAA sourced systemic embolic risks the patient might have as well.

P.S. for those with a lower CHADS-VASC below 2 or even below one, and who have a fully closed LAA after having had confirmed electrical isolation of the LAA, you likely do not absolutely need to do anything else, but if you are like me, you might be willing to try a high quality of Nattokinase twice a day which ‘might’ also confer some degree of protection from systemic risks as well.

Though we as yet don’t have overwhelming scientific evidence of a consistent level of protection, some of the more recent research on nattokinase is encouraging and worth following, though the evidence dose not yet rise to a truly definitive confirmation as yet.

For what it’s worth, I do take two 100mg soft gel caps/ day of a high quality Nattokinase, and I also eat the food Natto quite regularly, and have for many years after acquiring a taste for it (believe it or not!) while living in Hawaii for 38 years of my adult life.

Cheers!
Shannon



Edited 1 time(s). Last edit at 11/13/2019 12:07PM by Shannon.

Thanks Shannon for the answer. I was a bit hesitant in the beginning to withdraw from Eliquis but i do trust Natalie's conclusions that it is safe to do so. It has been over a year since my second Natale ablation (first was in 2008 in SF) and so no AF episodes. I hope it stays that way.

Shannon, what would be a acceptable number indicating robust Doppler A-Wave ?