How many of you had a second ablation and needed a watchman because the LAA was isolated?

I’m curious if I am among the rare few...I appreciate your vote.



Edited 1 time(s). Last edit at 05/24/2020 06:24PM by Carey.

I wouldn’t put it quite like that, but that roughly describes my circumstances. And not that rare I don’t think. Many people unnecessarily, including me, go through more than one ablation because the 1st or 2nd or more operator didn’t know how to find and eliminate the origins of the errant electricity. And need is described/defined differently depending which side of the fence you are coming from. If you’re an EP advocating or a patient wanting because of AC issues or just don’t want to take AC for life there’s a real need, if you’re most insurance companies, good luck to you.

I don’t mind being on Eliquis for life. I found at Eliquis website their $10 co pay card which my pharmacist will honor. It’s not the end of the world.

I was told today if I have my LAA burned and did not have a watchman then I could never go off of Eliquis for a surgery or procedure.

I am allergic to titanium and nickel. I had to get screws (broken bones) and clips removed. The surgeon wrote his observation that mirrors my statement I am allergic. Forget about if I wear a white gold earring with nickel my earlobe hole will start to pus...or if I wear a 14k white gold ring with nickel the metal and my hand will tarnish. This is ones heart.Even the company doesn’t recommend it: “. Nickel in Occlusion Devices
Watchman occlusion device (Boston Scientific): The Watchman contains Nitinol, a metal that is approximately 50% nickel and 50% titanium. The manufacturer states that individuals with a nickel allergy are ineligible for a Watchman implant.Apr 22, 2019”

So I am asking if those who read this if they Had a touchup second ablation did it include burning the LAA be the norm? I’m asking about %.

This news is worst than finding out I have a rare and aggressive cancer. I am lost in words how I took the news. I’m allergic to nickel and titanium. The watchman is 50% nickel and 50% titanium. I don’t want to be in permanent AF. I restarted Multaq today. Let’s see if it works so I don’t have to go to the hospital tomorrow.

Btw I was scheduled for a cardiovert today. I didn’t eat since last night only to go to the cath lab and be told they won’t cardiovert me today because I need a covid19 test. I asked 3 nurses how often they get tested? They laughed and said never. I made such a big sacrifice to be a prisoner at home so I won’t catch the virus because of my age and health.

So I have to expose myself without social distancing and repeat this tomorrow while my heart is in AF after being home for 65 days so I know before today I was corona free.

So please, if your second ablation, both by excellent EPs resulted in your LAA burned, please reply. I’ve been reading this forum for 16 years and never heard of this. I thought a touchup involved new renegade AF cells popping up after a successful ablation and a few zaps will fix it.

You would tell Natale about your allergies to the Metals, and you could just tell him to leave the LAA alone.

I got an ECV yesterday with just the silliness of having my temp taken (the ultimate dog and pony show) then witness the nurse wanting to take my blood - enter the room ungloved (doorknob) then leaving the room with gloves, coming back in and not changing gloves that just touched doorknob touched by dozens of others. And we wonder how hospitals make sick people even sicker???

As to being covid free - no one can guarantee that - I have read hundreds of stayed at home ultra safe practices being circumvented by this virus. It is sneaky and persistent. One would have to really be locked in a bubble to have certainty.

And like Micky Rourke said in Body Heat - "any time you try a decent crime, you got fifty ways you're gonna f' up. If you think of twenty-five of them, then you're a genius... and you ain't no genius."

The virus has been more clever than all of humanity so far.

Quote
susan.d
I found at Eliquis website their $10 co pay card which my pharmacist will honor.

If you look, I don't think the discount is available for Medicare patients.

From the Eliquis site:

"Co-pay Card
ELIGIBILITY REQUIREMENTS:
You may be eligible for the Co-pay Card for ELIQUIS® (apixaban) if:

You do not have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), or Department of Defense (DOD) programs; patients who move from commercial plans to state or federal healthcare programs will no longer be eligible;"

I believe the statistic for requiring OAC (or a Watchman type device) after LAA isolation is 60%.

Quote
GeorgeN

I found at Eliquis website their $10 co pay card which my pharmacist will honor.



"Co-pay Card
ELIGIBILITY REQUIREMENTS:
You may be eligible for the Co-pay Card for ELIQUIS® (apixaban) if:

You do not have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), or Department of Defense (DOD) programs; patients who move from commercial plans to state or federal healthcare programs will no longer be eligible;"
60%.

$10 Co-pay Eligibility and Terms of Use
ELIGIBILITY REQUIREMENTS:
You may be eligible for the Co-pay Card for ELIQUIS® (apixaban) if:
You are insured by commercial insurance and your prescription insurance coverage does not cover the full cost of your prescription, that is, you have a co-pay obligation for ELIQUIS;
You do not have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), or Department of Defense (DOD) programs; patients who move from commercial plans to state or federal healthcare programs will no longer be eligible;
You are 18 years of age, or older; and
You are a resident of the United States or Puerto Rico.

I don’t have part D.

Hi Susan,

With RF being used as the energy source for all RF ablation, it is technically correct to say that burns are made in the ablation process ... but in describing : "one's LAA as having been burnt" as if the entire LAA had been cooked or torched, the choice of words inadvertently conveys a more destructive impression than what actually occurs during a full LAA isolation. In fact, the only area around the Left atrial appendage that is subject to RF lesions in the ostium ... or around the mouth of the overall much larger appendage itself that is not even touched by a Natale-trained Ostial Isolation of the LAA.

If you could see how tiny the lesions really are in an ostial (or mouth of the LAA) isolation with a rough maximum 3mm diameter catheter tip contact area as the lesions are laid down in a circular fashion to achieve complete isolation of the most proximal part of the LAA mouth, it might inspire a different view with a much less burnt appendage. Especially relative to the dramatically larger and totally untouched areas of the remaining complete appendage that is left just as it has always been, untouched.

The so-called lips forming the mouth or ostium of the LAA look almost like the lips seen on a Betty Boop WWII bomber art on the nose of a B17 bomber. The top and bottom parts of the 'lip' of the LAA ostium are thick and exaggerated while the sides of the upper and lower thick lips are much thinner as they transition to the two corners of the 'mouth'.

Also, the thicker parts of the ostium/mouth has a very rubbery-like consistency, not unlike Calamari Squid, which can be challenging to durably isolate in one shot as any one who has ever tried chewing on raw Calamari Squid can well imagine it might be a bit tough :-). Dr Natale is by far the most experienced LAA isolation maestro anywhere, but occasionally it takes even his great skill a second shot to achieve permanent electrical isolation of the mouth of the LAA and thus achieve permanent electrical disconnection of the LAA from the rest of the heart.

But this does not at all mean that the full LAA itself is now toast or fully dysfunctional after the very small encircling lesion is burned around the mouth of the appendage to achieve permanent electrical isolation of the appendage. The full LAA still produces Atrial Natriuretic Peptide hormone and B-Type Brain Natriuretic Peptide hormone as well , on demand, and most often will still retain some degree of mechanical function as well.

Although, in approx. 58% of patients who must undergo an LAA Iso at the end of one's ablation in order to achieve durable freedom from all Atrial Arrhythmia, those 58% will have reduced enough mechanical pumping action to only the LAA itself that will require them to either stay on life-long anti-coagulation, and/or under LAA closure via an endocardial Watchman Occulsion device installation or via an epicardial applied LAA Ligation option such as the LARIAT that I had done (well before the Watchman had been FDA approved), or via the epicardial ATRICLIP ligation system typically installed by a Cardiovascular Surgeon.

One of the advantages of epicardial LAA Ligation over Endocardial LAA Occlusion with the WATCHMAN (older gen. or FLX) is that through ligation you kill two birds with one stone being able to insure elimination of LAA-sourced embolic events while also insuring zero chance of the remnant LAA being a source of any future arrhythmo-genesis, meaning not more triggers from the LAA creating future arrhythmia. But thus freedom from future arrhythmia is always achieved too via an LAA electrical isolation by Dr Natale or one of his protégés trained in LAA Iso.


The endocardial Watchman is a simpler and quicker procedure with next to no real recovery issues at all for the vast majority of patients! For sure, taking no more than a half hour tops by a highly experienced operator, to install a WATCHMAN FLX, while both the LARIAT and ATRICLIP are definitely more invasive with the LARIAT requiring often two EPs with one EP doing the endocardial phase of the LARIAT procedure while the second EP handles the Epicardial phase of the procedure. The epicardial-only ATRICLIP is installed by a cardiac surgeon and requires 4 to 5 small punctures (the number of punctures being the surgeons preference) on the left side of the rib cage and require a temporary partial deflation of the left lung.

Both ligation-based LAA procedures require a longer recovery than the Watchman which is pretty much a Breeze for everyone I know who has had a Watchman, though everyone I know also made the wise choice to partner only with an elite level Watchman installer with vast experience as well.

One very significant advantage for you, Susan D., would be with the new LARIAT PLUS, since that system uses only a pre-tied adjustable diameter strong surgical suture to seal off the proximal neck of the LAA immediately behind the ostium of mouth and all done from the outside (epicardial access) of the left atria!

Therefore, with a new and improved LARIAT PLUS you can achieve full electric isolation of your LAA plus full ligation of the LAA such that after a successful LARIAT Plus install you could potentially stop all blood thinners (assuming you're systemic CHADS VASc score was under 2.0) and you would not be exposed to any endocardial placement of any nickel or titanium material whatsoever!

You get the same overall advantages as with an ATRICLIP, but Alas, in your case your nickel allergy prevents you from considering the ATRiCLIP since that device uses a spring loaded clip made with 'Nitinol' a combination metallic fusing a very small amount of nickel plus a larger amount of titanium. Regarding the nickel content in the Watchman a good number of patients with a documented history of nickel allergy proves not to trigger an allergic response when used with this Nitinol combination and relatively low exposure to nickel. Thus, they often use a test device like a pacemaker shell taped to your arm for a period with a similar nickel exposure to elicit any likely nickel allergy responses should you have such a reaction, meaning it's quite possible you might be able to use a Watchman after all ... it could be worth giving the test a try ... otherwise talk to Dr. N. or Kelley about possibly using a LARIAT-Plus to eliminate your LAA as a source of future embolic events and insure that your LAA will never trigger any further atrial arrhythmia as well.

There is more to discuss and explore about these various options Susan, but you can PM me if you wish to discuss these options in more detail over the phone.

Cheers!
Shannon



Edited 1 time(s). Last edit at 06/02/2020 11:58AM by Shannon.

Shannon, you rock! Great education. I am finally in nsr. 2 days of AF. I never had af this long. I had an appointment yesterday to be converted but when I signed in to the cath lab they insisted I take a corona test and to come back today. Which was an advantage because Dr Natale stopped by before my cardiovert to chat today. I had some unanswered questions I didn’t get to yesterday during the exam. I’m allergic to nickel so it is agreed the watchman is not an option. The Lariat 2 does contain Nitinol but it is gold plated. The gold plating acts like a barrier to nitinol/nickel exposure.

I’m very concerned of getting AF again before my next ablation, especially with the virus lurking in hospitals and the 2 day of exposure with testing the first day and cardiovert the second. They didn’t have me remove my n95 mask (10 years old) which was a plus but none of the staff practiced social distancing or ever got tested. Still it’s way better than the ER. No comparison. They put an oxygen face mask over my mask and I was good to go. I had a cardiologist convert me.

I took 3 doses of multaq since yesterday. How many doses before I am protected?

Quote
susan.d
I took 3 doses of multaq since yesterday. How many doses before I am protected?

There's not really a good answer to that question other than "now."



Edited 1 time(s). Last edit at 05/21/2020 11:45PM by Carey.

Quote
Carey

I took 3 doses of multaq since yesterday. How many doses before I am protected?

There's not really a good answer to that question than "now."

Dr Natale asked how many doses I had taken prior to the cardiovert. It was 2 and one since the cardiovert. I’m really hoping multaq will protect me.

4-8 days, you should take Multaq with a high-fat meal.

From the Official Multaq Rx Information [products.sanofi.us]

Absorption

"Because of presystemic first pass metabolism the absolute bioavailability of dronedarone without food is low, about 4%. It increases to approximately 15% when dronedarone is administered with a high fat meal. After oral administration in fed conditions, peak plasma concentrations of dronedarone and the main circulating active metabolite (N-debutyl metabolite) are reached within 3 to 6 hours. After repeated administration of 400 mg twice daily, steady state is reached within 4 to 8 days of treatment and the mean accumulation ratio for dronedarone ranges from 2.6 to 4.5".



Edited 1 time(s). Last edit at 05/21/2020 10:53PM by The Anti-Fib.

Quote
Shannon
Although, in approx. 58% of patients who must undergo an LAA Iso at the end of one's ablation in order to achieve durable freedom from all Atrial Arrhythmia, those 58% will have reduced enough mechanical pumping action to only the LAA itself that will require them to either stay on life-long anti-coagulation, and/or under LAA closure via an endocardial Watchman Occulsion device installation or via an epicardial applied LAA Ligation option such as the LARIAT that I had done (well before the Watchman had been FDA approved), or via the epicardial ATRICLIP ligation system typically installed by a Cardiovascular Surgeon.

This should be ablation 101 education given to those considering the procedure so they can make a fully informed decision. Before my ablation I new nothing of LAA isolation or the probability of reduced a pumping action.

Quote
Leo J
This should be ablation 101 education given to those considering the procedure so they can make a fully informed decision. Before my ablation I new nothing of LAA isolation or the probability of reduced a pumping action.

To be clear, isolating the LAA doesn't reduce your heart's pumping capacity. What it can do in about 60% of patient is reduce the LAA's ability to pump effectively, so blood will tend to stagnate there and clot. That's the reason for the lifelong anticoagulants or occlusion device.

Quote
Leo J
This should be ablation 101 education given to those considering the procedure so they can make a fully informed decision. Before my ablation I new nothing of LAA isolation or the probability of reduced a pumping action.

I didn’t know ablation of the LAA affects ones heart’s pumping capacity! Does it lower ones ventricle ej rate %? Shannon or Casey or George can you give me some info?

I’m on edge right now worrying my af will return. Just very carefully what I eat or do if it will trigger AF. I need to weigh the pros and cons of living a life of af vs with having a hopefully successful LAA ablation where my pumping function will be affected as the price of remaining in nsr. Also I need my gallbladder removed soon and potentially (unfortunately) the odds in my lifetime for God forbid cancer returning that requires more surgeries..something to be concerned about with bridging. It’s not the bridging that bothers me...it’s getting a surgeon on board to agree to the bridging if he has a different protocol. They are so finicky. I wanted my gallbladder out by a top tier surgeon and a desperate colonoscopy done by someone else (head of dept) in January and both refused because I had PVCs. I can’t imagine them agreeing if I have to remain on blood thinners and use bridging.

Plus if I get my LAA ablated and later on my PVCs return and I need a pvc ablation , one must be off blood thinners because they cut through the artery instead of the groin. There are a lot of examples of needing to be off of blood thinners.

Quote
susan.d
I didn’t know ablation of the LAA affects ones heart’s pumping capacity! Does it lower ones ventricle ej rate %? Shannon or Casey or George can you give me some info?

Please read my response to Leo right before the post you're getting alarmed about.

Quote
Carey

I didn’t know ablation of the LAA affects ones heart’s pumping capacity! Does it lower ones ventricle ej rate %? Shannon or Casey or George can you give me some info?


Please read my response to Leo right before the post you're getting alarmed about.

I did beforehand. “ What it can do in about 60% of patient is reduce the LAA's ability to pump effectively”.
Thus my post. I’m getting pac often since the cardiovert. Always happens after a cardiovert. Then I have to use my watch ekg for 5-7 beats to see if I am in nsr. That’s why I’m on alert and sometimes alarmed with AF, hospitals and covid19.

Friday this arrived.
[www.ebay.com]
It’s made well and hopefully will help protect me further the next time when medical staff don’t wear a mask. I would need to go twice to the hospital (covid19 testing is first step, second day for future cardiovert) if an when AF returns. So yeah I’m jumpy after being isolated for 65 days and now have to think about AF, ablation and hospitals where social distancing is not practiced. I hope multaq works.

Quote
susan.d
I did beforehand. “ What it can do in about 60% of patient is reduce the LAA's ability to pump effectively”.
Thus my post. I’m getting pac often since the cardiovert. Always happens after a cardiovert. Then I have to use my watch ekg for 5-7 beats to see if I am in nsr. That’s why I’m on alert and sometimes alarmed with AF, hospitals and covid19.

But you understand that the LAA's pumping ability doesn't affect cardiac output, right? It's common practice for surgeons to remove the LAA entirely when doing open heart surgery for other things. It has no affect whatsoever other than reducing your stroke risk.

Hans wrote a good article about the LAA

[www.afibbers.org]

Thank you anti-fib!

With high blood pressure and family history (both parents and brother) of heart failure, it seems like the LAA shouldn’t be touched. Of course that means living a life of AF.

The LAA has several important physiological functions[1-3]:
• As it is more distensible than the left atrium itself it can act as a decompression chamber when left atrial pressure is high. Animal experiments have shown that eliminating access to the LAA results in an increase in the size and mean pressure in the left atrium.
• The LAA is known to mediate thirst (at least in animals). Thus people without a LAA might have a greater tendency to become dehydrated.
• Removal of the LAA has been shown to reduce stroke volume and cardiac output and may thus promote heart failure. Its removal could be particularly detrimental in patients with existing heart failure as it would further reduce their cardiac output and perhaps promote pulmonary congestion.
• The LAA is a major endocrine organ and is the main producer of ANP (atrial natriuretic peptide) in the human heart. The ANP concentration is 40 times higher in the LAA walls than in the rest of the atrial free wall and in the ventricles. A study of patients having undergone the maze procedure and associated LAA removal found a significantly lower ANP secretion and a commensurate increase in salt and water retention. Whether this could eventually lead to hypertension is not known.

Isolating or even removing the LAA does NOT reduce stroke volume or cardiac output, it does not cause heart failure, it does not affect thirst, it does not cause hypertension, it does not cause salt or water retention.

When I find time I'll go through your list of alarming stuff that is almost all incorrect and answer in detail. Take a look at the citations in Hans' article. They're all almost 20 years old, with some of them being much older. MUCH more is known about the LAA today than when Hans wrote that article.