Ablation causing surface changes to atria increasing chances of pooling and clots?!

Saw this on a UK forum from a well-respected poster

BobD
BobDVolunteer
a day ago
If anticoagulation was one of the meds then I agree wholeheartedly. There is plenty of evidence that even successful ablation does not remove stroke risk. In fact the ablation itself can cause the internal surface of the atrium to change allowing pooling to occur . More and more people are advised to remain on anticoagulation post ablation. Since you have not mentioned what other drugs you have re-started further comment is inapropriate.

Thoughts?

A mix of facts with a bit of confusion. Yes, people with afib have an elevated stroke risk even after controlling their afib with drugs or ablation. It won't be as high as it was when they had active afib, but it will be higher than someone with the same CHADS-Vasc score who has never had afib. Where the confusion comes in is the explanation of why. It's not that changes to the atrial surfaces allows pooling to occur; it's the reduced pumping action that does that. Since an ablation blocks electrical signals in the atria, the pumping action can be impaired. This is why you'll sometimes hear people say the "atrial kick" is lost. How much kick is lost depends on how extensive the ablation was.

So he's right, but his explanation is off. Or maybe it's just his wording and he didn't mean exactly how it sounds to me.



Edited 1 time(s). Last edit at 12/19/2019 07:50PM by Carey.

Carey, so you are saying ones heart doesn't pump as strongly after an ablation? Does this affect ones ej rate when one gets an echo?

The atria may not pump as strongly as before an ablation, but the ventricles will be unaffected and they're the main pumping chambers. The EF won't change because the ventricles will still pump the same percentage of the blood they contain. If you had an EF of 65% before the ablation, you'll have an EF of 65% afterwards. The only change may be that the ventricles don't fill quite as fully as before, so the overall blood volume pumped might fall slightly. It's generally such a slight loss that the only person who might notice it would be an elite athlete who's competing in races decided by fractions of seconds.

Quote
susan.d
Carey, so you are saying ones heart doesn't pump as strongly after an ablation? Does this affect ones ej rate when one gets an echo?

Susan, I think the specific worry is the pumping in the left atrial appendage. That is why, when LAA work has been done, follow up TEE's are necessary before allowing someone to reduce or quit anticoagulation.

If I understand @mcwf correctly, his LAA was not touched in his Bordeaux ablation from Aug? 2018. Hence should not be a worry for him.

George

Thanks for the clarification Carey.

George, whilst I'd take a little loss in atrial kick in exchange for no or greatly reduced AF, any higher stroke risk where only a PVI (and little more than that) had been done would get my attention a little. Prof Jais said with my CHADs of 0 I did not need to continue AC indefinitely so I do not take it. But having read the post that I did and as per my original post as per above, I thought it worth raising here. The chap Bob D from the UK forum who posted opining as he did is a very longstanding and respected poster on (and a mod of) the forum in question.

Mike F

Quote
GeorgeN

Susan, I think the specific worry is the pumping in the left atrial appendage. That is why, when LAA work has been done, follow up TEE's are necessary before allowing someone to reduce or quit anticoagulation.

If I understand @mcwf correctly, his LAA was not touched in his Bordeaux ablation from Aug? 2018. Hence should not be a worry for him.

It's not just LAA isolation. Extensive ablation can reduce the pumping action of the entire atria even when the LAA hasn't been touched. The LAA might still be where a clot forms (and probably will be), but it's because of reduced pumping action of the entire atrium, not just the LAA. This is specifically why Natale recommended I remain on 1/2 dose Eliquis despite having a Watchman.

So if a person is in permanent AF and isn't bothered too much by their AF they might be better off just taking a blood thinner/drugs, reduced pumping action can cause fatigue, can't it? Perhaps that is why Mayor Bloomberg and Biden didn't get an ablation, at least I havn't read that they have done so. If one would get a Watchman and not an ablation, their pumping action should be ok, unless they have some problem right?

Liz

Reduced atrial kick doesn't cause fatigue. You can't even feel it. The only physical effect someone might notice is an elite athlete who might see a slight drop in performance. Normal athletes wouldn't even notice it.

Plain vanilla PVI shouldn’t reduce atrial kick very much if at all.

Quote
wolfpack
Plain vanilla PVI shouldn’t reduce atrial kick very much if at all.

Agreed. That's why I've been saying "extensive ablations." I'm an example of that and the end result is definitely reduced atrial kick. I don't feel any different, but it can be seen as an obviously diminished P wave on ECGs and reduced A wave on TEEs. The latter gives me a high E:A ratio that led my PCP to mistakenly think I had diastolic dysfunction.

There's a hill near where I live that I've long used as a measure of my cardio fitness level. I ride up it at 10 mph and note my heart rate at the top. It's a pretty good objective measure and it never changed due to ablations. (The thing that changes it is being lazy and gaining 10 pounds.)

Quote
Carey
(The thing that changes it is being lazy and gaining 10 pounds.)

Yeah. Damn gravity!