TEE and another Austin visit?

When I left Austin in March, after my ablation, I was under the impression that I would only have to be on eliquis for about 3 months and that I probably would not have to return if everything is ok. Today I received an email from one of Natale's "Nurse Navigator." (In response to a question I emailed asking to confirm how long I would be on eliquis). She mentioned that I would have to be on it at least 6 months, especially since Dr Natale isolated/ablated the left coronary sinus. She also said that it's recommended that I come back to Austin near the end of the 6 month mark for a TEE, which will determine if I can stop the eliquis then.

I guess I was kind of surprised by (1) the length of time I'll have to be on eliquis (2) that I'd need to go back to Austin and (3) that I'll need a TEE.

Do you think she made a mistake? Or is her recommendation typical?

Thanks for your input!

That's the standard protocol if he isolated your left atrial appendage (LAA), not the CS. You sure you read the email right? If he did isolate your LAA, do not under any circumstances stop the Eliquis until they do that TEE. And that means not even for a single day.

That's what I thought!

She wrote, "During your ablation Dr. Natale isolated/ablated an area of the heart called the coronary sinus that can decrease the function/squeeze of the left atrial appendage, which puts you at higher risk for blood clots during this time even if you are in sinus rhythm."

I think she used somewhat confusing terminology in her email, but it's not exactly easy to explain heart anatomy to patients, especially in an email. The bottom line is I think your LAA has been isolated so you need to follow their advice carefully.

You can have a TEE done locally, but the reason they ask you to come back to Austin for it is they've had poor results from other centers doing them for this purpose. They have very specific criteria for taking you off anticoagulants after LAA isolation (LAAI) and centers not trained to deal with LAAI often don't provide what they need, leading to a second TEE being required. So yeah, I spent $ on a trip to Austin for that six-month TEE and it showed I wasn't even close to being able to come off anticoagulants. I figured the $1000 or so in travel expenses was a small price to pay for keeping myself out of a nursing home drooling on a bib and bankrupting my wife.

You drove to Austin if I remember correctly? So I don’t think the travel expenses would be that high if you drove again. A night at a hotel before driving back. I agree with Carey. it’s better to get the TEE by someone N trusts.

Carey does your post means Dr Natale keeps his patients generally on Eliquis for 6 months? I don’t have a clue how long I will be in it.,My local EP wants me on it indefinitely while I told Natale’s NP of his comment and her response was it shouldn’t be indefinitely. Maybe because today was my scheduled second ablation date (I postponed due to Covid19) and the clock would had reset for another 6 months??

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susan.d
Carey does your post means Dr Natale keeps his patients generally on Eliquis for 6 months?

No, not at all. The protocol Cirene describes is for patients who have had their LAA isolated.

Thanks. Carey, my primary nurse educator responded:

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We will send out a 7 day monitor at the 6 month mark to eval for arrhythmias. If clear and no further treatment is indicated (like a TEE or an additional procedure is sometimes) you are often told after then by the provider that it is okay to discontinue the Eliquis. You did not have treatment to your Atrial appendage which is often what leads to a TEE.

Not sure why there were conflicting messages. But, that sounds more reasonable.

Also, I thought I would be on eliquis only 3 months. But maybe I was mistaken.

Well they responded: "the protocol for coronary sinus isolation is the same as the LAA isolation because isolation of the coronary sinus can affect the function of the LAA." So it appears I need a TEE. I didn't know this. Bummer!

Interesting and good to know. Thanks!

I did not know, nor is it obvious scanning the literature, that the protocol for coronary sinus isolation and LAA isolation were the same. What are the statistics for coronary sinus isolation versus LAA isolation in terms of the need to be on OAC's indefinitely? Are they also the same? What other variations have the same protocol and perhaps the same need for OAC's indefinitely?

I would like to be fully informed about the parameters of the ablation to be performed, and the resulting statistics for lifelong OAC's barring a Watchman. This discussion should take into account medical as well as financial and personal preferences which may not be evident or compelling while the ablation procedure is actually taking place.

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safib
I would like to be fully informed about the parameters of the ablation to be performed, and the resulting statistics for lifelong OAC's barring a Watchman. This discussion should take into account medical as well as financial and personal preferences which may not be evident or compelling while the ablation procedure is actually taking place.

I don't know how that would be possible unless you divided the ablation into two procedures: a mapping procedure first to discover what needs to be ablated and the actual ablation later. And that, of course, would nearly double the cost and risk.

And even then I don't think it would be 100%. When I read my own ablation report from Natale, he discovered and ablated my fast flutter source in the LAA, but once that stopped I went to a slower flutter emanating from the right atrium. I'm not sure he could have found that one until he stopped the other.

To give you the full context of the message...

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the protocol for coronary sinus isolation is the same as the LAA isolation because isolation of the coronary sinus can affect the function of the LAA. Because the coronary sinus was isolated (fully ablated) you will need to stay on the Eliquis for at least 6 months and have a TEE following your 7-day monitor, if no additional arrhythmias occur between now and September.

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Carey

I would like to be fully informed about the parameters of the ablation to be performed, and the resulting statistics for lifelong OAC's barring a Watchman. This discussion should take into account medical as well as financial and personal preferences which may not be evident or compelling while the ablation procedure is actually taking place.

I don't know how that would be possible unless you divided the ablation into two procedures: a mapping procedure first to discover what needs to be ablated and the actual ablation later. And that, of course, would nearly double the cost and risk.
.

I thought you said before that one could leave instructions not to ablate the LAA. What I am saying here is that I would like to add to that other areas which have similar outlook for lifelong OAC's. If that means nothing gets ablated at that time, so be it. I would like to be fully informed and to have that choice.

Indications are that I will be on eliquis for 6 months, not the rest of my life. If it was the later I would've hope that they would've warned me of this possibility before I got the ablation.

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safib
I thought you said before that one could leave instructions not to ablate the LAA. What I am saying here is that I would like to add to that other areas which have similar outlook for lifelong OAC's. If that means nothing gets ablated at that time, so be it. I would like to be fully informed and to have that choice.

Well, you can, but I wouldn't tie a doctor's hands like that (or blow $40K on a do-nothing procedure). If you've got AF and you're a CHADS 1 or more, you're probably going to be on anticoagulants for life anyway unless you do something to stop the AF.

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Ciren
Indications are that I will be on eliquis for 6 months, not the rest of my life. If it was the later I would've hope that they would've warned me of this possibility before I got the ablation.

You might wanna check with those who have had their LAA isolated to see how many have been able to get off DOACs without getting a Watchman.

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Daisy
You might wanna check with those who have had their LAA isolated to see how many have been able to get off DOACs without getting a Watchman.

I believe the stats are a 40% chance of getting off OAC for LAA isolation. I don't know if that applies to coronary sinus isolation.

I do have a friend who had a Natale LAA isolation. He was initially marginal to go off OAC, but negative enough. As I recall, he improved enough in two years he is now off all meds. He's extremely happy. He's 68, so not a spring chicken.

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GeorgeN
I believe the stats are a 40% chance of getting off OAC for LAA isolation. I don't know if that applies to coronary sinus isolation.

That number is correct (source: Natale).

As for why ablating the coronary sinus (CS) needs the same protocol as LAA isolation, I talked to Shannon about that and he talked to Natale. The reason is that the distal end of the CS is so close to and intimately involved with the LAA that some ~15% of patients with CS isolation will have some degree of LAA isolation as well. So following the LAA protocol is out of an abundance of caution. But I expect the percentage with CS isolation who can come off NOACs after their 6-month TEE will be much higher than 40%.

Great info. Thanks. I hope this means at after six months I’ll be able to stop the eliquis.

So is it recommended to state before procedure not to ablate the LAA? I'm heading down for my first ablation in June with Natale. Or does Natale automatically not ablate the LAA for 1st timers.

My Afibb always self terminating 1 episode over 24 hrs in 10 years. Most episodes under 1 HR. (a little history)

No, it's not recommended and please don't ever mention that I said you can refuse it because I think that's being misinterpreted.

Natale ablates only what needs to be ablated to solve your problem. He doesn't automatically ablate anything. This notion of refusing LAA isolation is something I wish I'd never mentioned. You shouldn't be telling your heart surgeon how to do your bypass and you shouldn't be telling your EP how to do your ablation.

If you're concerned about LAA isolation, discuss it with your EP. If they're trained and experienced in doing that if needed, then congratulations, you found a highly trained, competent EP. My advice would be to take their advice.



Edited 1 time(s). Last edit at 05/02/2020 12:29AM by Carey.

Got it.

What cases or types of afibb are likely to have the LAA ablated?

To update everyone: I just got an informative call from Shannon D. He spoke with Dr N and confirmed that CS isolation does not require a TEE. I guess there was just some misunderstanding. He said he'll post the details here later.

A hug shout out to Shannon D too! He is so awesome!

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Driver
What cases or types of afib are likely to have the LAA ablated?

The more long standing persistent the case is, the more likely the LAA is likely to be involved, from my understanding.

There was a poster here, maybe around 2012. His situation was similar to mine. He'd had a multi month episode in the first few months of his afib journey. Then he'd managed to keep the afib mostly in remission with very long times between short episodes. Unfortunately the remission did not last forever and his afib burden increased. He decided on an ablation. He lived in Boston, and the EP's in the area told him he'd be a "simple" case. He checked with Bordeaux and they said he'd be "complex." He ended up going to Bordeaux for his successful ablation and he reported that he was a "complex" case. I can not tell you the definitions of simple and complex, but I assume simple would imply a PVAI only ablation would suffice. I always remember his case as I had a 2.5 month episode at the end of the first four months of my afib career (which started nearly 16 years ago), hence I'd likely be "complex" as well.



Edited 1 time(s). Last edit at 05/02/2020 03:11PM by GeorgeN.

Hi Folks,

Apparently, there was a mistaken choice of words used that inadvertently conveyed the wrong impression to Cienepurzalot implying that he was required to return to Austin for a TEE at 6 months after his index ablation. As it turns out, Robert does NOT have to return to Austin for a 6 mo. TEE to evaluate his LAA mechanical function after all.

It's easy to see how by inadvertently using a couple of misplaced words, a relatively new NP conveyed the mistaken impression that Robert would have to return to Austin at the 6 month mark after his index ablation.

I spoke with Dr. Natale this morning, and I also re-read Roberts ablation report confirming what I had remembered from reading his ABL report to him after his ablation this past march. Confirming that he did not have any ablation work done to his LAA, and thus there is no requirement for him to return to Austin for the 6 month TEE to evaluate residual LAA mechanical function and determine whether or not he can safely stop an anticoagulant drug thereafter.

Robert did require coronary sinus isolation, but isolation of the CS alone with no additional work being required to the LAA eliminates the need for a follow-up TEE and it does not require a person to stay in long term anti-coagulant use, in and of itself, so long as the Afibber does not have a CHADS-VASc score at 2 or above.

The only two scenarios that require returning for a 6 month post ablation TEE scan of one's LAA and LA is:

1. If the Afibber required full LAA isolation then the 6 month TEE is essential.

2. Or, in a relatively small number of patients who require Coronary Sinus Isolation, but who also have a relatively rare anterior branch extending from the distal aspect of the CS close to the LAA ... (7% to 10% of patients have this anterior branch from the distal CS). In such patients, the EP may delay activation of the left atrial appendage without fully isolating the LAA. In such cases, the EP may then want to evaluate the status of the LAA delay at 6 months thereby confirming whether or not residual LAA mechanical function remains sufficient?

I hope this helps clear up the confusion in the thread above from a well-meaning and very good new NP simply misplacing a few words.

When you look at option '2' above and then re-read her comments sent to Cirenepurzalot, it's easy to understand this innocent mistaken choice of words.
Dr. Natale said he would certainly clarify the issue with the newer staff on Monday morning so that they can better convey the proper nuance around this issue.

And for you, Driver, regarding your up-coming ablation with Dr Natale this June in Austin, I can assure you there is essentially ZERO chance you will need LAA isolation at your young age and relatively moderate history with paroxysmal AFIB. I have never seen any one near your age group (in their 40's), and who did not have established persistent or long-standing AFIB, who then required LAA isolation at all! Indeed, out of the many many hundreds of Afibbers I've helped usher through their expert ablation process I've only seen two who were respectively 45 yrs old and 49 years old, that required both CS-Isolation and LAA-Isolation. However both of these folks had at least several years of advanced LSPAF prior to their index ablations.

Plus, even if by some extreme long-shot outlier case in which a mid-40s PAF patient showed some degree of triggering from the LAA during their index procedure with Dr Natale, he would surely only delay, at most, the LAA and not fully isolate it during the first ablation. In any event, you will not have to even address this issue as it is so no need to spend any time on it now. Enjoy your drive from Washington state to Austin and I'm sure you will do just fine!

Cheers!
Shannon

Thanks Shannon! Excellent and thorough explanation, as always! I think if anything ever happens to Dr Natale you should start performing ablations. I think you know more than most EPs!

Shannon as always thanks for easing my ever racing mind! Between you and Carey along with many others here at affibers, really are a God send in navigating the sometimes muddy waters



Edited 1 time(s). Last edit at 05/02/2020 06:00PM by Driver.

Hi Cirenepurzalot and Driver,

You are both more than welcome! And like you both, I'm also very grateful for Carey's many regular contributions to the forums ... which has been a big help for me as well. As is true for all you 'Old-timer' regulars here that make this such a special place for Afibbers from all parts of the world!

Cheers!
Shannon

Yep, Carey is a Rock Star as well! Kudos!!!

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cirenepurzalot
Well they responded: "the protocol for coronary sinus isolation is the same as the LAA isolation because isolation of the coronary sinus can affect the function of the LAA." So it appears I need a TEE. I didn't know this. Bummer!

On my second Ablation by Dr. Natale, My LAA was isolated. I had to stay a Eliquis for 6 months then We drove 9 hours back to Austin to have the Tee. Everything was great except no P wave detected. Bummer because that means Anticoagulant for life.
Blood thinners stink except for the part of it could save your life.
No one has ever gave me a layman’s explanation why I have to stay on a blood thinner but I am faithful and take Eliquis as directed. I will admit I had No Idea that a blood thinner for life was possible until after the second procedure. It was not explained to me but I am happy; just bruise and skin seems easy to tear.

This thread brings out two important points in regard the ablation process.
The procedures are complex and the supporting staff (say Natale's at St. DAvid) are multi tiered, busy and ever changeing.
You cannot count on being fully, accurately updateded on your particular case, especially once you have departed and its "routine"
followup. St. DAvids strives for excellent support, and appears to be about as good as it gets. It was "not made clear" to me, as well,
that, post ablation, a 6 month TEE (in Austin !) and possible lifelong Eliquis was looming. Only after multiple inquiries and then referring back
to discharge notes, etc. was it evident that this had been prophesized! Good thing too: I was one of those persistent AF cases, with a "difficult"
ablation requiring LAA isolation, who nonetheless was allowed off Eliquis (and in NSR ever since).

Lesson #1: you can never learn enough, pre-ablation about the procedure, its options, variations and nuances. If you could then you would know most of the post procedure protocols likely and know what questions to ask. I tried to do this and learned a lot (much thanks to this excellent blog).
But, in hind sight I realize that I was still naive and wasn't in a well enough educated position to ask the right questions while in Austin. Had to keep prying out details from them and this blog, post-Op.

Lesson #2 You do have [at least] two emensely valuable opportunities to fully understand your case and its ramificattions, follow up, etc while at St David's. They are when you consult with Dr.Natale pre and post Op. You really must prep for these (take notes, review questions, follow ons, etc), because he is a busy guy and wont stay around giving you an individual seminar on your case! But there will always be: " do you have any questions". These are the very best chances to have your situation and prognosis explained. Its fleeting (you'll never get him subsequently on the phone) so you must be prepared to take advantage of the opportunity. To even begin to be able to you need #1 above.

As well: in the end I came to appreciate (as this thread mentioned) that I could have had the crucial 6 Month TEE done locally (for me a major convenience, being 2000 Miles from Austin). Worth a try? In the end I opted to travel to Austin after carefully establishing (again not at all made
routinely clear!) that I would personally consult with Natalie post TEE regarding its implications. Just the oportunity to go over my case with him was reason enough for the trip.

Second to Natale himself, this blog (with special thanks to Shannon) is invaluable for the necessary education and to resolve ambiguities.
Many thanks to all!