Left atrial appendage

I am so confused about this. Can the LAA be ablated or is a closure done and no ablation is involved? Is it always necessary to have a watchman implanted if you have an LAA procedure?

There is a Medscape article that makes me very concerned about this.

[a-fib.com]

I found Dr. Jais comment of interest. He has been noted here as another expert.

Quote
Pixie
I am so confused about this. Can the LAA be ablated or is a closure done and no ablation is involved? Is it always necessary to have a watchman implanted if you have an LAA procedure?

The LAA can be ablated. Mine was, and there are others in this group who also had theirs ablated. If the LAA is a source of afib or flutter, simply closing it would make you safer from strokes but it probably wouldn't eliminate the arrhythmia.

It's common for the LAA to be involved with persistent afib and so ablating it may be necessary to stop the afib. It can also be involved with flutter, which was my situation. I had paroxysmal flutter that hit rates of 230-250 bpm. My LAA was the source of that flutter and it stopped immediately when Natale ablated it.

It is not necessary to have a Watchman if your LAA has been ablated. For about 40% of patients who've had an LAA isolation, the LAA continues to pump adequately so nothing needs to be done. It's possible for those 40% to stop anticoagulants. For the other 60%, they must either remain on an anticoagulant for life or have their LAA closed.

Prior to the last year or two, it was very difficult to get insurance to pay for a Watchman at all. You had to have a documented inability to tolerate any of the anticoagulants. That has changed now as Medicare and insurance companies have realized the cost reduction the Watchman provides for them and the patient.

If the article you read was written by John Mandrola, stop now and discard that article. It is entirely wrong, as are all his writings on this subject. You might want to read the rebuttal written by Shannon instead. (Yes, THAT Shannon.)

Carey, thank you for the thorough explanation. The article was written by John Mandrola and that did put up a red flag for me. Is the rebuttal written by Shannon one of the comments to the article?

As Carey stated the LAA can be a source for afib.

During my first ablation with Natale he did some work on my LAA. He then moved on to another trigger focal point. While he was working there (coronary sinus) I had an organic episode that originated in my LAA. So I got a 2fer that day on my LAA.

My following 2 procedures with him focused mostly on the LAA and Coronary Sinus. The LAA is a different animal to work with as it's structure makes ablating more difficult. I add to that difficulty due to the size of mine.

If my Aflutter is on the left side it is harder to ablate than on the right. I need to keep my stress down, but this is not helping.

Quote
Pixie
Carey, thank you for the thorough explanation. The article was written by John Mandrola and that did put up a red flag for me. Is the rebuttal written by Shannon one of the comments to the article?

No, I linked to Shannon's article directly so maybe you didn't notice the link. Here it is again https://www.medscape.com/viewarticle/853571

Very (very) basically, the EP world can be broken down into 3 broad categories.

A. Ep’s who don’t do ablation at all
B. Ep’s who only do PVI (pulmonary vein isolation) ablations
C. Ep’s who ablate beyond the pulmonary veins (includes LAA)

Category B could further be broken down into two

B1. PVI using cryoballoon
B2. PVI using RF (radio frequency) catheter

B1 is a way to get EPs through fellowships a bit faster as the cryoballoon technique is an easier skill to master than the RF. It’s also less effective in my opinion, but that’s just me. Plenty of folks have had cryos and they worked. I just wouldn’t choose it for myself.

It’s important to determine where on the spectrum any practitioner lies. You’ll find yourself having to ask a lot of questions while at the same time being diplomatic about it to figure it out. Or ask around here, maybe someone knows. Decoding “doctor speak” is also a skill one has to learn. Hearing something like “The a-fib ablation procedure won’t help you” might be true but it might also mean your doctor is in category A and is really saying “I don’t know how to do an a-fib ablation”, or he/she is in category B and personally has dismal success rates with ablations and is saying “I could try it but I’m really not great at it.”

This is why second and even third opinions are hugely important. It’s your life.

Pixie,

I believe it really depends on the facts and circumstances of your (or a person's) case. Are you early in your afib "career" with infrequent paroxysmal (converts on its own) afib? Are you longstanding persistent (afib only converts with cardioversion and may not stay in NSR long after)? What is your overall health? What is your CHA2DS2-VASc?

I'm a strong advocate for lifestyle risk factor management, however this likely has the greatest probability of a positive on afib "early" in your afib career. If this is the case, then aggressively try it for 6 months and see what you can accomplish. I also advocate controlling with non-drug means any controllable factor in the CHA2DS2-VASc score. This is a way to keep stroke risk low. For example, a couple of years ago my systolic blood pressure was creeping into the 120's mmHg. I went after this with a variety of non drug approaches and now consider anything above 110 elevated. This morning my BP was 102/58. If you are longstanding persistent, then lifestyle risk factor management is unlikely to materially impact afib, though could help your overall health.

In my opinion, there is an optimal time to choose an ablation and that is way before it gets close to longstanding persistent. If you see frequency & duration increasing, despite risk factor management, then go for an ablation. And WolfPack's sorting is correct. I'd choose an EP in the "C" category, even if my case did not require LAA work. I'd pick someone who'd done in the 10's of thousands of cases.

On the lifestyle risk factor management, a childhood friend recently was diagnosed with afib. He's relatively early in progression. He's obese and has hypertension. I offered to coach him on lifestyle and I'm guessing it would have had a decent chance of helping. He acknowledged that I'm very healthy and have been successful for 17 years keeping afib in the early progression stage. He said my lifestyle was 6 standard deviations from normal and he did not have interest in pursuing that. I'm still coaching on the afib, not the lifestyle, and right now his EP has recommended medical management. I have strongly suggested that if it comes time for an ablation, he go to Austin.