LAA and stroke risk

I do not have much knowledge about the LAA but I am aware that there are differing opinions in the EP community regarding the safety of left atrial appendage isolation (increased stroke risk).

I know my EP has some issues with this.

Looking for comments on this, please.



Edited 1 time(s). Last edit at 08/16/2021 11:44AM by Pixie.

Statistically, LAA isolation carries a 60% chance of needing lifetime anticoagulation or the installation of a device like the Watchman. This risk is stated going in. That being said, the only way to solve afib for some folks, especially with longstanding persistent cases, is with LAA isolation. Many fellowship programs do not train EP's to isolate the LAA.

A recent example. Tom Poppino, (who posts as Poppino) went to Austin to see Dr. Natale after several ablations with another EP. Natale was very complimentary of the other EP's work. The other EP had told Tom to go to Natale. Natale isolated the LAA to solve Tom's problem. It will be 6 months or so before Tom will know whether he is in the 60% or 40%. In any case, he is on anticoagulation for the time being.

You can also look at it another way. If you don't solve your afib problem, you also have the stroke risk issue.

George is correct. My afib had morphed into atypical flutter. Left sided flutter. I had asked Dr Natale: what determines wether or not you ablate/isolate the LAA? Dumb question: his answer: wether its producing electricity to cause the flutter ! So yes mine was. 9 days ago was my procedure and i am on eliquis until dec or jan then i would gladly do the Watchman should i fall into the 60%. Then after a period of time maybe no meds. I have a great EP here in Charlotte Dr Holshouser but hes not gonna do LAA nor cornary sinus
Im still early out of the procedure and getting a few tachy episodes a day

After Dr. Natale isolated my LAA on the 2nd procedure, I went back to Austin 6 months later. My LAA had a emptying velocity of 55-60%. LAA was normal in size. Everything was great except I HAD NO A WAVES. Tall E waves are noted. This was at the Mitral Valve..
Because of this, I am on Eliquis for life.
It’s not always just about flow. I am no EP but I follow Dr. Natale orders.

Thanks Sackman interesting although i dont grasp but like u ill do what Natale says. Did you get a watchman? So i guess what happens at Mitral is reason for eliquis not LAA?
T

I did not get the Watchman. This was summer 2016 so the Watchman I believe was still “ sorta experimental “. I wish I had the Watchman or newest device that is used. Some lucky posters got in on the Watchman trial but I knew Zero about a trial so it was given to certain individuals with some pull IMO. That’s okay; It’s Life. I wish I could have got it for free but life goes on and I stay on Eliquis. It’s a bitch just to get a Colonoscopy etc.
Anyway Life is good. Getting Medicare to approve was a nightmare 18 months ago. Anyway……..

Nobody had any pull. It was just being at the right place at the right time to be able to get into the last few slots open in the trial, and meeting the criteria for being accepted. It also required paying for multiple trips to Austin, and then undergoing a bunch of followup exams.

It's likely you could qualify for a Watchman now. The criteria in 2016 were hard to meet. You had to be unable to take any of the anticoagulants, and I've never met a single person like that. But now Medicare and most insurers will approve a Watchman if your LAA has been isolated and you don't meet the criteria for stopping anticoagulants, which describes you. If I were you I would look into it. It's no longer the experimental procedure it was considered to be in 2016. Just look around locally and find a center doing them. As long as the EP has done a few hundred that should be sufficient. It doesn't require maestro-level skills like an ablation does. Or you can always call Natale's office if you prefer.

GeorgeN, you mention that many fellowship programs do not train EP's to isolate the LAA. Do you think that is because of what my EP said about differing EP opinions in the community because of the risks?

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Pixie
GeorgeN, you mention that many fellowship programs do not train EP's to isolate the LAA. Do you think that is because of what my EP said about differing EP opinions in the community because of the risks?

I'm not connected enough to give an opinion. Someone like our moderator Shannon could give a better answer to that.

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GeorgeN

GeorgeN, you mention that many fellowship programs do not train EP's to isolate the LAA. Do you think that is because of what my EP said about differing EP opinions in the community because of the risks?

I'm not connected enough to give an opinion. Someone like our moderator Shannon could give a better answer to that.

I base this comment during a conversation I had with one of my local EP's Fellows back in 2018 when I was in the hospital following a failed 2nd ablation with my local EP. Who BTW I have the utmost respect for and was vary favorable towards Dr. Natale.

In some circles the LAA and Coronary Sinus are outlier's, at least they were in 2018. And in their opinion aren't necessarily points of interest when it comes to afib. My guess is that that may no longer be the case in this particular circle as my local EP follows my case with great interest.

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Carey
Nobody had any pull. It was just being at the right place at the right time to be able to get into the last few slots open in the trial, and meeting the criteria for being accepted. It also required paying for multiple trips to Austin, and then undergoing a bunch of followup exams.

It's likely you could qualify for a Watchman now. The criteria in 2016 were hard to meet. You had to be unable to take any of the anticoagulants, and I've never met a single person like that. But now Medicare and most insurers will approve a Watchman if your LAA has been isolated and you don't meet the criteria for stopping anticoagulants, which describes you. If I were you I would look into it. It's no longer the experimental procedure it was considered to be in 2016. Just look around locally and find a center doing them. As long as the EP has done a few hundred that should be sufficient. It doesn't require maestro-level skills like an ablation does. Or you can always call Natale's office if you prefer.

IF I would have known there was a trial going on, I would have applied or whatever it took to maybe get accepted. You cannot apply if you are not in the know about the trial. Anyway that’s Life. You win some, You lose some and also strikeout.
I did look into it and it still is not easy at all to acquire approval for the Watchman. In all Honesty, The individuals I talked too at Austin led me to believe it was a big process to get approval. I worked with them for at least 2 weeks on and off but I was told I would not be approved as long as I could handle a NOAC like Eliquis.

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smackman
I worked with them for at least 2 weeks on and off but I was told I would not be approved as long as I could handle a NOAC like Eliquis.

How long ago was this? I know of several people who've received a Watchman in the last 12 months who were doing just fine on Eliquis. They had an isolated LAA and inadequate function, and that was sufficient for approval. I believe all were on Medicare.

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Carey

I worked with them for at least 2 weeks on and off but I was told I would not be approved as long as I could handle a NOAC like Eliquis.

How long ago was this? I know of several people who've received a Watchman in the last 12 months who were doing just fine on Eliquis. They had an isolated LAA and inadequate function, and that was sufficient for approval. I believe all were on Medicare.

Sorry for the late post. Lot going on…… Anyway I think it was summer of 2018. I was basically told I was not qualified for a watchman because I could tolerate a NOAC. Maybe they have relaxed on the requirements. I was having to get all this information together from my Cardiologist at home and it was not free to get the material from my Cardiologist. It was a cluster crap to say the least. I finally got a answer of No; I did not meet the protocol.
My biggest fear is colonoscopy or any procedures that need or may need to be done. This watchman NOW in 2021 should be used on anyone who wants it if there LAA is isolated.
It’s all good. I will cross them bridges when I get to them. Here is a possibility for a man later in life. A prostrate biopsy. So many procedures require being off the NOAC for 3-4 days depending on which Specialist you need to use.

Those are exactly my reasons for wanting a Watchman. Expecting to live another 20 years without ever needing to stop an anticoagulant for medical reasons is obviously unrealistic. And then there are all the other possibilities such as losing or forgetting your meds when you're somewhere they can't be promptly replaced, being seriously injured, being unable to communicate to doctors who don't understand the risks of LAA isolation, and so forth. So many doctors don't understand the LAA issue that even a medic alert bracelet might not help. It's not a question of "if" but "when" you'll find yourself missing one or more doses.

I got mine in 2018, and at that time Medicare and insurance companies were definitely not paying for them if you could tolerate any of the anticoagulants. But that has changed since then. I think you'll likely meet the criteria now.

And for future reference, you shouldn't have to be getting records from anyone or contacting your insurer. The center doing your Watchman will handle that, and you should let them. They know what they're doing and it will be much smoother if you just let them handle it.

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Pixie
GeorgeN, you mention that many fellowship programs do not train EP's to isolate the LAA. Do you think that is because of what my EP said about differing EP opinions in the community because of the risks?

That's part of it, but it's primarily because isolating the LAA is a fairly new procedure that's limited by a relatively few number of EPs qualified to train other doctors, many of whom don't work at teaching hospitals. They've got to train the trainers before they can train students.

Isolation of the LAA is often the key to successfully treating persistent afib, and also complex patients with multiple failed ablations (I'm an example), but new procedures with significant risks aren't adopted rapidly in medicine. That's often both a good and a bad thing.

But it will happen, and is happening. LAA isolation is an entirely new window of opportunity that enough EPs recognize to justify a worldwide conference devoted solely to the subject. The last one was held in Kansas City in 2019, which Shannon and I attended, and we would have attended the one in 2020, but we all know what happened to in-person conferences in 2020.

So LAA isolation being adopted slowly isn't solely because of the risks, but more because of the logistics of training 10s of thousands of doctors with only dozens of trainers to begin with, and even now probably only a few hundred. I think the fact that the payers (government and private health plans) are now beginning to recognize the benefits and pay for it, along with things like the Watchman, will accelerate the process.

I would love to get the watchman. However, last I spoke with Dr. Natale I was not eligible under current criteria. I only have 1 point and believe I need 3 for insurance.

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Carey
Those are exactly my reasons for wanting a Watchman. Expecting to live another 20 years without ever needing to stop an anticoagulant for medical reasons is obviously unrealistic. And then there are all the other possibilities such as losing or forgetting your meds when you're somewhere they can't be promptly replaced, being seriously injured, being unable to communicate to doctors who don't understand the risks of LAA isolation, and so forth. So many doctors don't understand the LAA issue that even a medic alert bracelet might not help. It's not a question of "if" but "when" you'll find yourself missing one or more doses.

I got mine in 2018, and at that time Medicare and insurance companies were definitely not paying for them if you could tolerate any of the anticoagulants. But that has changed since then. I think you'll likely meet the criteria now.

And for future reference, you shouldn't have to be getting records from anyone or contacting your insurer. The center doing your Watchman will handle that, and you should let them. They know what they're doing and it will be much smoother if you just let them handle it.

Back then, I had no choice but to “chase down” records. This was Austin’s call not mine. The center at TCA in Austin had me to do this. I would never volunteer or anything of that nature but they were not going to do this back then. It was a bad experience that went on for weeks.

Ok here s an off the wall question: if paid outa pocket whats the approx cost? Ill assume youd or id get a lower number as they would not have to deal with insurance
So anesthesiologist procedure the Watchman itself one night all in???

I'm going to take a guess and say somewhere in the neighborhood of $20K, but I could be way off. I'll see if I can find out. St. David's can usually quote the out-of-pocket cost of procedures because they do a lot of procedures for non-Americans who are paying out-of-pocket.

I think thats a fair estimate as i was guessing 15-25 k. What complicates it is: would they require a TEE velocity test first even done elsewhere? Am sure
In my case im to wear a 7 day monitor at 6 months. Im told that determines their next move. So lets say zero arrhythmias then ill assume a TEE is next then a Watchman if im in the 60% but not sure if thats all one visit or 2? Thanks Carey

They'll want to do both a monitor to see if you're reliably in NSR and also a TEE to assess your LAA function at six months. If you're reliably in NSR but your LAA isn't pumping adequately, you become a candidate for the Watchman. The TEE can't easily be done in one trip with the Watchman procedure itself simply because results don't come back immediately, so there's no way to schedule you for "maybe a Watchman." The TEE doesn't have to be done in Austin, but they've had difficulty getting the results they need from other providers, even those who say they understand the requirements. So getting a TEE done locally is a bit of a gamble and it might have to be repeated. Ask Natale's staff who they recommend in your area if you want to go that way.

Ok great that helps alot. I have a 9/8 virtual with Dr Holshouser so ill get his take. He and i have a good open relationship He conquered my afib just not left flutter thus Natale