Ablated but still on Meds

It seems in my research of ablation it is reported with varying successes and failures. The successful ones seem to depend greatly on those holding the blade. Any afibber in the know these days realizes there are still but a chosen few who have mastered this technique. I was of the belief that meds and medical devices ended with a successful ablation, and only the difficult ones enabled meds to work again. However reading most reports here and other blogs, that seems to be an exception more than the norm. Am I expecting too much from this procedure that hopefully keeps all in NSR, even with meds afterward?

After my 1st Ablation in Jan. 2014, I stayed on Multaq and Eliquis for 3 months or the blanking period. I never went back into AFIB until approximately 18 months later. I stopped multaq and Eliquis after the 3 month blanking period.
I was “warned” that I would probably need a touch up Ablation in the Future. In July 2016, I had my 2nd Ablation. My LAA was isolated but I left the Texas Arrhythmia the next day only taking Eliquis. No Multaq etc. I was in Persistent AFIB before my Ablations. Since July 2016, NSR has been “sweet”.

I do not think you are expecting to much but the Heart has to mend after a Ablation. I had plenty of Arrhythmias for approximately 6 months and I still have some now but no AFIB. I use Dr. Natale and only Dr. Natale. His resume speaks for itself.
Fear will cause you pain, unnecessary Anxiety etc.

What you should expect is NSR after the blanking period without any drugs and that should last for many years if not indefinitely. I'm now 3 years post ablation and haven't experienced so much as a stray PAC since 3 weeks after the procedure when I stopped the Multaq a week ahead of schedule. That's the results an expert ablation should produce. The trouble with reading forums and blogs is that the people who have successful ablations don't go online and talk about it. They just go on with their lives and never visit places like this, so by reading about people's experiences online you're getting a very biased sample.

But it is true that the results you can expect depend heavily on the operator. You always want to find the EP with the most experience doing AF ablations that you can find. They should have a minimum of many hundreds of ablations, and preferably many thousands. And if they routinely put their ablation patients on drugs other than anticoagulants beyond the blanking period, that's not the EP you want regardless of how many procedures they've done. If they depend on drugs to make their ablations successful, their ablations are not successful.

So basically what Carey and Smackman are saying is, a successful ablation is one that, after the initial blanking period, should not require meds? I guess I was confused by all the posts about WM devices to eliminate the use NOACs of some here who were ablated. By the way, great reports from you and most who visit that facility. None of the EPs I presently use have little success to report.

I am b on a low dosage of Eliquis for life. 2.5 mg 2x a day. My LAA was isolated on the 2nd ablation and my TEE after 6 months basically showed I had no A wave. The Eliquis is a small issue to deal with compared to being in Persistent AFIB. That is the only medication I take after my successful Ablations by Dr. Natale. My wife Tammy will never forget how this forum lead me to the place to go. Shannon was a Godsend and we are forever grateful to Shannon and this team of excellent men and women whom care so much for individuals who struggle with Arrhythmias such as AFIB. 😀 We actually got to meet Shannon and he reassured my Wife that I had landed in the right place. Shannon was 100% right.

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hwkmn05
So basically what Carey and Smackman are saying is, a successful ablation is one that, after the initial blanking period, should not require meds? I guess I was confused by all the posts about WM devices to eliminate the use NOACs of some here who were ablated. By the way, great reports from you and most who visit that facility.

Two categories of meds - rhythm and anticoagulation. A successful ablation should not require rhythm meds. For some (and this is not typically on a first or "index" ablation) anticoagulation meds may be required. Commonly this is required for people with longstanding persistent afib, though it may also be required for others. This is normally the result of needing work around the left atrial appendage (LAA). Work in this area can slow the LAA emptying velocity, as well as negatively other parameters such that there is a requirement for continued anticoagulation. About 60% of patients who have LAA work will have a requirement for ongoing anticoagulation or the placement of a device such as the Watchman.

It is common and not rare the touchup ablation can include the LAA isolation. There is a higher af risk for women (Doesn’t exclude men) that the LAA could be the reason the first ablation doesn’t result in permanent nsr and thus require a touchup ablation that could or possibly could not include a LAA isolation. Carey, Shannon like others on this forum has had multiple prior ablations with various EPs before being helped by Dr Natale (or other gifted EPs) by getting their LAA isolated.

There are cases where the LAA cannot be completely isolated with af free success on the first attempt due to the safety of the thin LAA tissue that takes extra care during the LAA ablation to avoid risking damage. Jackie has documented her history on this forum by needing a second LAA ablation. I am very happy she has since remained in nsr.

A good question to ask your EP is the % of a successful ablation the first time around. Obviously the doctor doesn’t have a crystal ball on your chances but you can ask general questions his success % of index first ablations, a ballpark time frame average he has seen once the ablation before af returns and in your EPs experience, what % of LAA requires a second LAA touchup of his/her patients. I believe in transparency when making decisions. It beats being in the dark and being disappointed when an ablation is not successful.

In keeping with full transparency and doing your homework, I suggest you read the following, especially the section of the 2020 AF convention and Dr Jais remarks. I believe he is considered and respected by many in the AF community:
[a-fib.com]



Should the LAA be routinely cut out, stapled shut or closed off in all A-Fib patients?
The rationale for closing off the LAA is that, in case the operation fails which happens occasionally, the patient is still protected from having an A-Fib stroke. 90%-95% of A-Fib strokes come from clots which originate in the LAA. In A-Fib, blood stagnates in the LAA and clots tend to form.

VIDEO: See our library of videos about Atrial FibrillationWatch an endoscopic view of stapling and removal of the Left Atrial Appendage (1:34 min.) Go to video->

Another important consideration, even if a person is no longer in A-Fib, is that closing off the LAA may still prevent a stroke. The LAA is where most clots originate. If a surgeon is already working on the heart, why not close off the LAA and reduce the patient’s chance of having a future stroke? (If a surgeon didn’t close off the LAA, they could be sued if a patient later had a stroke, even if the patient was no longer in A-Fib.) Life (no stroke) is more important for most people than a possible reduced exercise intolerance.

In the future even people without A-Fib may have their Left Atrial Appendage closed off if it prevents or reduces the risk of a stroke. This may become a way to prevent stroke in older people, particularly women, who are more at risk of stroke as we age. There are currently a variety of devices, surgical and non-surgical, which can do this. LAA closure may become an important new way to reduce strokes, particularly in the elderly.

Functions of the Left Atrial Appendage
Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib. For a patient made A-Fib free, would their heart function better or more normally if they still had their LAA? In the words of Dr. Pierre Jais of the Bordeaux Group at the 2020 AF Symposium, “We have ablated too much…Those patients when they have the (Left Atrial) Appendage taken out, they have very poor residual LA (Left Atrium) function. I don’t want that to happen anymore. If we can avoid it, I think we should.” Dr. Jais later added, “Sinus rhythm is by definition superior to persistent A-Fib. But the best ablation strategy is the one that restores sinus rhythm at the least tissue cost, thereby preserving as much as possible the LA function.”

LAA Functions Like a Pressure Release Valve
Also, the LAA functions like a reservoir or decompression chamber or a surge tank on a hot water heater to prevent surges of blood in the left atrium when the mitral valve is closed.4 Without it, there is increased pressure on the pulmonary veins and left atrium which might possibly lead to heart problems later.

Losing the LAA Reduces Blood Pumped by the Heart
Cutting out or stapling shut the LAA also reduces the amount of blood pumped by the heart and may result in exercise intolerance for people with an active life style. (In dogs the LAA provides 17.2% volume of blood pumped.5) This is usually not a problem for patients with Persistent (Chronic) A-Fib, whose LAA has stopped contracting along with the fibrillating atrium. Cutting out or stapling shut the LAA won’t affect their cardiac output.

But this may not be the case for patients with Paroxysmal A-Fib who still have large amounts of normal rhythm and whose LAA still functions normally.

But would a non-functioning LAA return to normal when someone with, for example, longstanding persistent (Chronic) A-Fib becomes A-Fib free?

I’m not aware of any surgeons (or EPs) who do pre- and post-LAA closure measurements of exercise ability, heart pumping function, etc. with and without the LAA.

Losing the LAA May Worsen Blood Pressure
The LAA also has a high concentration of Atrial Natriuretic Factor (ANF) granules which help to reduce blood pressure.6 Some preliminary research indicates that when the LAA is closed or cut off, the Right Atrial Appendage produces more ANF to compensate for the lost of the LAA.



Edited 1 time(s). Last edit at 08/12/2020 03:12PM by susan.d.

Some people gets PACs and ectopics after ablation, and I don't think it's due exclusively to the skill of the operator. Some people just get them and they can persist for months or forever. I'm confident many of Natale's patients have had post ablation ectopics. So clearly it's not all in his hands. Those who have none are lucky. Drugs can keep them at bay as they do for me. I think some people also need meds to stop afib episodes post ablation. If that's the case, then I would be disappointed with that part of it.



Edited 1 time(s). Last edit at 08/14/2020 03:25PM by keeferbdeefer.

Ditto keeferbeefer.

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It is common and not rare the touchup ablation can include the LAA isolation.

I'm afraid this is not quite accurate. Most EPs don't do LAA isolation at all. First, it's a procedure practiced only by EPs at the elite level who have received the necessary training and learned how to do LAA isolations properly. Second, for paroxysmal patients it's unusual that LAA isolation is necessary. It's more common with persistent AF, which quite possibly explains the low success rates of ablations with persistent patients (ie, most EPs don't do LAA isolation and consequently can't cure persistent AF).

LAA isolation is a relatively new technology, having become more common only in the last few years. Most of the concerns about it have now been dispelled with proper education and improved techniques. About 40% of all LAA isolation patients will have adequate blood flow in the LAA to stop anticoagulants altogether. For those who don't fall into that lucky 40%, they must remain on anticoagulants for life or receive an LAA occlusion device. There are several LAA occlusion devices on the market, some of which are placed internally via catheters and others that are placed externally through minimally-invasive surgery.

Seems like every time I think I understand a concept I read something else only to find out I don’t understand squat. I would like to get off needing to take a NOAC in the hopes of being able to take some anti inflammatory meds which would greatly improve my QOL. But, if I understand this discussion correctly, that may not be possible even following an ablation or something type of LAA isolation procedure including a watchman. Say it ain’t so.

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walt
Seems like every time I think I understand a concept I read something else only to find out I don’t understand squat. I would like to get off needing to take a NOAC in the hopes of being able to take some anti inflammatory meds which would greatly improve my QOL. But, if I understand this discussion correctly, that may not be possible even following an ablation or something type of LAA isolation procedure including a watchman. Say it ain’t so.

It ain't so.

LAA isolation is an unusual procedure practiced only by the elite category of EPs. The vast majority of paroxysmal patients who undergo ablations will never need LAA isolation. And even those who do need it still have a 40% chance of being able to come off anticoagulants entirely without any sort of closure device.

Anyone looking at a first ablation for paroxysmal AF should just put the LAA out of their mind. It's really premature to be talking about it, much less worrying about it.