Undesired LAA work

Reading a different thread here about waking up with a pacemaker unexpectedly, I am reminded of a question I had and still have when considering a PVAI ablation for my paroxysmal afib. My understanding is that possible LAA involvement is neither screened for (using imaging) nor is LAA isolation beneficial in the paroxysmal afib population. In fact, there may be concerns about increased stroke risk. This was my understanding when I did some research several years ago, and things may well have changed. In any case, is it possible to insist that no LAA isolation (or perhaps only very partial isolation) is to be done during the PVAI procedure, even if challenge testing suggests a benefit? I am not willing to be on OACs indefinitely at this time for various reasons. Instead, if the PVAI is unsuccessful and the opinion is that LAA needs a lot of work, I would rather come back at a later date when the new Watchman is available and hopefully covered by insurance.

Are you saying that if they do LAA ablation that you have to be on OACs indefinitely?

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safib
My understanding is that possible LAA involvement is neither screened for (using imaging) nor is LAA isolation beneficial in the paroxysmal afib population.

There's no way to screen for LAA involvement using any type of imaging. That can only be determined during the procedure by actually mapping the source(s) of the afib.

I don't know where you read that LAA isolation isn't beneficial in the paroxysmal population but that's not an accurate statement. If you consider freedom from afib beneficial and your afib is originating in the LAA, then you would consider isolating it beneficial. Yes, it might come at the price of dependence on anticoagulants, but at least among the several people I know who've had their LAA isolated, not a single one of them regrets it. In my case, I absolutely positively don't regret it in the least. I would have Natale isolate that SOB a thousand times over if necessary. And I would say the same whether I had a Watchman or not. I came out of that procedure having no idea I would ever receive a Watchman and I was grateful beyond words that I was no longer experiencing both afib and flutter with rates well over 200.

But that's a personal choice. If you'd rather live with afib (which will require anticoagulants) than have an isolated LAA (which will require anticoagulants) then that's your choice. Sure, you can tell your EP not to isolate your LAA even if he finds it to be the source of your afib. But that means knowingly accepting a failed ablation, living with afib and anticoagulants, and then requiring another ablation at some time in the future and requiring an additional Watchman procedure. Your choice but I don't see the benefit.

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Not necessarily. I don't know the most recent figures, but I thought about 60 % did need require OACs indefinitely, unless a surgical procedure of some type was used to close off the LAA. Also, lacking such a procedure, one had to be extremely diligent about not missing dosages. Others here know a lot more about this than I do.

The 60% figure is about right. So if your afib originates in the LAA, here are your choices:

1) Isolate it, be free of afib, and have a 40% chance of also coming off anticoagulants.

2) Don't isolate it and have a 100% chance of afib continuing and remaining on anticoagulants indefinitely.

My LAA was isolated on my second Ablation by Dr. Natale. I am on Eliquis for life. It is the smaller dosage of 2.5 mg 2x a day. There are negatives to being on anticoagulants for life but like Carey said I would have been on Eliquis if I chose to remain in AFIB. I have been in NSR since my second Ablation and I would choose this way again. I just have to find a work a round for procedures, surgeries, RF burning of the facet nerves in my back which all require being off Eliquis for 72 hours. One of these procedures requires 48 hours but all Physicians have there guidelines and will not waiver.
Being in NSR is such a blessing compared to Persistent AFIB.

You don't need to find a workaround yourself. Natale has a bridging protocol for times when you need to come off Eliquis. Ask his office to send it to your doctor.

I would still be in afib today if it weren't for LAA work done by Dr Natale. I had a organic afib occurrence while in the LAB that originated at my LAA. The trade off is Elequis for now. However, I would be on it anyway.

I agree with Safib about the isolation of the left Atrial Appendage and then having to be on blood thinners the rest of your life. I have thought about an ablation but I am sure I would have to have the above procedure done as well. What I will do is to eventually try to get the new Watchman and either stay in AF (which isn't too bad), try to stay in NSR but forego an ablation, most have to get more than one procedure to ablate, at my age nothing I want to look forward to.

At a younger age I would probably get an ablation and if they had to ablate the LAA than I would get a watchman, I would find out before if I could get a watchman and if not then I would not get an ablation and the LAA ablated. That's just me, everyone has to decide what is best for them and how AF is affecting them.

I was not very clear in what I wrote. Some further explanations are below

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Carey


There's no way to screen for LAA involvement using any type of imaging. That can only be determined during the procedure by actually mapping the source(s) of the afib.

What I meant was that imaging can play a role in screening not for whether afib originates in the LAA, but rather for the stroke risk associated with the morphology (structure) of the LAA in the presence of afib. This type of imaging and risk stratification is not usually carried out in the paroxysmal population from what I can tell.

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Carey

I don't know where you read that LAA isolation isn't beneficial in the paroxysmal population but that's not an accurate statement. If you consider freedom from afib beneficial and your afib is originating in the LAA, then you would consider isolating it beneficial. Yes, it might come at the price of dependence on anticoagulants, but at least among the several people I know who've had their LAA isolated, not a single one of them regrets it. In my case, I absolutely positively don't regret it in the least. I would have Natale isolate that SOB a thousand times over if necessary. And I would say the same whether I had a Watchman or not. I came out of that procedure having no idea I would ever receive a Watchman and I was grateful beyond words that I was no longer experiencing both afib and flutter with rates well over 200.

What I should have said is that LAA isolation isn't generally as beneficial in the paroxysmal population, because there is a higher prevalence of PV triggers compared with the nonparoxysmal population. Clearly, the results would depend on the relative amount of afib originating in the LAA for the individual case, which I guess could be measured during the procedure. So this would be part of the discussion with the surgeon.

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Carey

But that's a personal choice. If you'd rather live with afib (which will require anticoagulants) than have an isolated LAA (which will require anticoagulants) then that's your choice. Sure, you can tell your EP not to isolate your LAA even if he finds it to be the source of your afib. But that means knowingly accepting a failed ablation, living with afib and anticoagulants, and then requiring another ablation at some time in the future and requiring an additional Watchman procedure. Your choice but I don't see the benefit.

Your points are well-taken. However, my afib is rather less severe than yours was, and there are some other tradeoffs involved (bleeding, cost, compliance, side-effects) which affect people differently, both physically and psychologically.

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safib
What I meant was that imaging can play a role in screening not for whether afib originates in the LAA, but rather for the stroke risk associated with the morphology (structure) of the LAA in the presence of afib. This type of imaging and risk stratification is not usually carried out in the paroxysmal population from what I can tell.

Despite having undergone an MRI with contrast, a CT with contrast, and multiple TEEs, I still don't know the morphology of my LAA. It's not in any of the reports (I have them all), and I kept asking and I kept getting shrugs and blank looks. When I asked around, what I found was that EPs don't consider it all the important. Yes, there were studies that showed that certain morphologies were more likely to form clots than others, but I don't think anybody is stratifying risk by that measure. Nobody is going to tell you that you don't need to worry about clot formation because your LAA is chicken wing.

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What I should have said is that LAA isolation isn't generally as beneficial in the paroxysmal population, because there is a higher prevalence of PV triggers compared with the nonparoxysmal population. Clearly, the results would depend on the relative amount of afib originating in the LAA for the individual case, which I guess could be measured during the procedure. So this would be part of the discussion with the surgeon.

While it's true that the LAA is more often involved in patients with persistent afib, there are more than enough paroxysmal patients who also have LAA sources. Every single person I know of who's had their LAA isolated was paroxysmal.

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Your points are well-taken. However, my afib is rather less severe than yours was, and there are some other tradeoffs involved (bleeding, cost, compliance, side-effects) which affect people differently, both physically and psychologically.

The good news is it's unlikely an EP will need to isolate your LAA in the first place. And unless you go to an elite EP, it's even more unlikely they would know how or be willing to do so. You can definitely refuse that in advance. All you need to do is have the discussion with your EP and say no. But your choices will still be the same: you can refuse isolation, possibly have a failed ablation and remain on ACs, or you can let the EP decide and possibly come off ACs. If being on ACs is your deciding factor then your best chances of coming off them is allowing LAA isolation if necessary.

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Carey

But your choices will still be the same: you can refuse isolation, possibly have a failed ablation and remain on ACs, or you can let the EP decide and possibly come off ACs. If being on ACs is your deciding factor then your best chances of coming off them is allowing LAA isolation if necessary.

I am not currently on ACs since my CHA2DS2-VASc is zero, and also according to the latest research my AF burden does not incur significant additional stroke risk. So the choice seems to be short term ACs as part of the PVAI protocol, or potentially indefinite ACs with LAA isolation. Of course things can change change depending on what is found, for example, very high percentage of AF originating in the LAA. But generally, I am not prepared to be on ACs indefinitely at this time.

No regrets about my LAA being isolated or occluded.

Perhaps the biggest concern with an isolated LAA is the potential consequences from just one missed dose of AC. I had phone timers set and I never left the house w/o 2-3 days supply with me. It just becomes an important part of your life that you accept as a result of not having afib anymore, until/if you have the LA occluded.