Re-ablate LAA after watchman ?

Just curious if the LAA becomes the source of flutter or AFIB again after the LAA was ablated and the watchman installed can the area be ablated again?
Or is reoccurrence never the case?

Thanks,
Tony

Yes, it can be ablated again. The ablation creates a barrier around the LAA, not in it.

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Tony in Boston
Just curious if the LAA becomes the source of flutter or AFIB again after the LAA was ablated and the watchman installed can the area be ablated again?
Or is reoccurrence never the case?

Thanks,
Tony

Does the scar tissue formed by ablations, either regular or a LAA isolation, begets future flutter? In a sense then more burn scar tissue being formed by additional ablations to treat atypical flutter ending up resulting in a cycle of scar tissue-ablation-new scar tissue-repeat?

[academic.oup.com]

I never had one single flutter before any of my ablations.



Edited 1 time(s). Last edit at 01/06/2022 03:17PM by susan.d.

Any ablation can create flutter. Flutter is created when an electrical barrier in the atria has a gap in it. The barrier can be scar tissue from a prior ablation, fibrosis that developed naturally due to atrial myopathy, or scar tissue caused by something else (prior infection, etc). The gap allows a normal signal to go through the barrier, and if that signal goes all the way around the atrium and comes back to where it began, it can trigger another signal that then does the same thing. So flutter is actually a self-perpetuating signal going around and around the atrium. That's why it's regular, unlike afib, and also why it can reach very high rates (the smaller the circle, the faster it is).

It's also possible to have more than one flutter circuit. I had two, one originating in my LAA on the left side and the other originating in the coronary sinus (CS) on the right side. The LAA circuit produced rates of 230-250 while the CS circuit produced rates of 125-130.

“ The gap allows a normal signal to go through the barrier”

Then how can atypical flutter be fixed if the gap(s) are encapsulated in scar tissue?

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susan.d
Then how can atypical flutter be fixed if the gap(s) are encapsulated in scar tissue?

By gap I mean a gap in the scar itself. An ablation line should be a row of burns with each burn slightly overlapping its neighbor burns so it forms a solid line of scar tissue. But if two burns are accidentally spaced too far apart, they don't overlap and a gap is created. That gap is living, conductive tissue when it should be non-conducting scar tissue.

During my ablation with Natale he also found a small gap in my PVI. He closed that gap with a single burn.

Here is a good diagram of what ablation lines look like. See how if one of those burns was a little too far from the one next to it there would be a gap?

Thanks.

Carey, this is very instructive. Thanks for having made it so clear about flutter.

In case of a healthy patient, normal heart, having not yet been ablated, with no history of afib or flutter (myself)... How would you describe the phenomenon making both afib and flutter appear in the same time? (I mean typical afib generated in the LA and typical flutter circuit in the RA.)

Afib and flutter often appear together. Sometimes flutter will appear first, and when it does it's a pretty good bet that afib is in your future. They're both caused by caused by the same underlying process, which goes by the not-well-defined name atrial myopathy. Basically, fibrosis forms in the atria, which creates barriers the same way an ablation does. It's likely related to atrial stretch, which can be caused by hypertension, valve problems, and/or prolonged strenuous exercise (endurance athletes). Those barriers can have gaps, so there's the flutter. And by processes that aren't well understood, they can also cause the random firing of cells that make up afib.

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Carey
Afib and flutter often appear together. Sometimes flutter will appear first, and when it does it's a pretty good bet that afib is in your future. They're both caused by caused by the same underlying process, which goes by the not-well-defined name atrial myopathy. Basically, fibrosis forms in the atria, which creates barriers the same way an ablation does. It's likely related to atrial stretch, which can be caused by hypertension, valve problems, and/or prolonged strenuous exercise (endurance athletes). Those barriers can have gaps, so there's the flutter. And by processes that aren't well understood, they can also cause the random firing of cells that make up afib.

It's clear. At least in the description of the phenomenon.
But the reasons why there might have been fibrosis in my heart chambers (not sure) are obscure.



Edited 1 time(s). Last edit at 01/07/2022 02:55PM by Pompon.

I have never had flutter, I had paraoxymal for 20 years, no flutter, afib and always converted on my own. I am in permanent AF now but no flutter. I have read that after an ablation flutter rears its head, i have never had an ablation so is that why i never had flutter?

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Elizabeth
i have never had an ablation so is that why i never had flutter?

My speculation is yes.

Flutter after an ablation is by no means to be expected. It doesn't happen in the vast majority of ablations.

Naturally occurring flutter can happen to anyone, ablation or not. Some people start with flutter and eventually develop afib, and some people start with afib and eventually develop flutter (without an ablation). And some people develop one of the two but never develop the other.

It's largely a roll of the dice.

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Pompon
But the reasons why there might have been fibrosis in my heart chambers (not sure) are obscure.

Here is a review article on atrial myopathy. [www.ncbi.nlm.nih.gov]

"Recently, several clinical studies in which patients’ atrial rhythms were continuously monitored showed a temporal dissociation of the episodes of device-recorded subclinical AF and stroke 5, 6, 7, 8. For instance, in the ASSERT (Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing) trial that enrolled 2,580 patients with cardiac implantable electronic devices, only 8% of patients with stroke had AF events detected within 30 days before stroke, and 16% of patients with stroke had their first AF event after their strokes (5). The lack of a temporal relationship between the onset of AF and stroke suggests that additional factors may be important contributors to the occurrence of stroke and that the presence of AF is not necessary. The current paradigm of selecting individuals at elevated risk of stroke and who therefore warrant oral anticoagulation (OAC) therapy, as endorsed by major international societies 9, 10, is by the CHA2DS2-VASc score (congestive heart failure, hypertension, age older than 75 years, diabetes mellitus, previous stroke, or transient ischemic attack or thromboembolism, vascular disease, age 65 to 74 years, sex category), but not the properties of AF per se (frequency, duration, ventricular rates, and so on). All these risk factors are known to cause atrial myopathy. There is mounting evidence that supports that atrial myopathy not only leads to stasis, but also to endothelial and/or endocardial dysfunction and the hypercoagulable state, which are 3 key factors in thrombogenesis described by Virchow (11). AF may not be the root cause of stroke, but rather, a marker that the atria are diseased."

When I first dived into the afib literature, I did not know about this last statement, "AF may not be the root cause of stroke, but rather, a marker that the atria are diseased." I had a sense that, in my case, chronic fitness was a likely cause of fibrosis for me. In these last 17+ years, I've tried to minimize my time out of rhythm as well as avoiding high intensity long duration endurance, as I figured these could encourage my fibrosis to progress. I also have tried to keep the two factors in the CHA2DS2-VASc score that I have some control over optimal, i.e. hypertension and diabetes mellitus. Meaning my unmedicated blood pressure target is <110/66 and my HbA1c target is <=5.0%. I refine the latter even more, not wanting a post meal blood glucose elevation > 110 mg/dL (6.1 mmol/L) and I want a fasting glucose <85 mg/dL (4.7 mmol/L).

Later in the paper, "The genesis of chronic inflammation with aging is unclear, but inflammation could be an underlying mechanism that connects aging to atrial myopathy and AF (43). Clinical studies have connected various circulating inflammatory mediators, including C-reactive protein (CRP), interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, and immune complement activation, with persistent AF (44). Epicardial fat is a major source of adipokines, inflammatory cytokines, and free fatty acids, which contributes to fibrotic remodeling within the atrial myocardium (45). " My doc tests for HS CRP, IL-6, TNF-α and we endeavor to keep these optimal with diet and lifestyle. I also keep organ fat low. In my last DEXA scan, in 2017 (age 62), my trunk fat was in the 9 %ile for a young normal male and 1% ile for someone my age. I weigh what I did in Grade 10 and am leaner now than I was then.

When a high school friend recently was diagnosed with afib, I offered to coach him to see if he could keep it in remission. He declined as he said my lifestyle was 6 standard deviations from normal and he'd rather live a shorter life than do what I do. Everyone has their priorities. Not saying that what I do will help anyone else, but I have tried to address as many of the factors that I can that will lead to fibrosis progression.

Flutter does happen quite often after an ablation for AF.

[pubmed.ncbi.nlm.nih.gov]

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Elizabeth
Flutter does happen quite often after an ablation for AF.

[pubmed.ncbi.nlm.nih.gov]

I don't dispute that, but it doesn't occur in most ablations. I was responding to your post that seemed to imply that you don't have flutter because you've never had an ablation. No, you're just lucky. Most people who've had ablations also don't have flutter. We can only wish afib and its cousins were so simple.

Hi George,

I am trying to keep all my blood test scores within a certain level in preparation for coming off Bisoprolol. My C reactive protein level was 2 in October but 1 in August. I have been severely anxious about my paroxysmal Afib, currently controlled with Bisoprolol.Do you think stress and anxiety could be causing this as I’m aware I need to get it back to 1 as quickly as possible? My CHADS score is 0. I don’t smoke, drink or have diabetes or hypertension, or any thyroid problems. I’m 56 with a BMI of 23.9 ( within healthy range for my height, age) you have been very helpful to me in the past and you may remember I’m the one with severe anxiety

How would I be best reducing my C reactive protein level to 1?

I am not getting on with my beta blocker bisop and have tried coming off ( only been in on it since Sept) but went straight into Afib. This time, I’m trying to get more control with all my blood results before coming off.

Thankyou,
Tweez



Edited 1 time(s). Last edit at 01/08/2022 03:47AM by Tweez.

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susan.d

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i have never had an ablation so is that why i never had flutter?

My speculation is yes.

I disagree. I've had afib AND flutter in my second ever afib episode. Likely so in my first episode a tenth days before, but not diagnosed. So, no need to be ablated to have flutter.
I then have been ablated. 4 times. No flutter since (just one occurrence, three years ago, likely caused by flecainide). I've still afib from time to time. No flutter at all.

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Tweez
How would I be best reducing my C reactive protein level to 1?

Hi Tweez, the issue with CRP (I assume it is high sensitivity CRP?), is that it is a non-specific marker of inflammation. It can be lots of things, dental health, a dental procedure before the test, an illness before the test, autoimmune issues, and yes has been associated with anxiety. My wife has had 3 foot operations that have never really worked, as a consequence, she has orthopedic issues that can flare before a blood draw and increase her hsCRP, one time up to 5.2 mg/dL. Hence it can be a bit of work to figure out what is causing an elevation. That being said, a level of 2 mg/dL (these are the units your test is reported in, yes?) is only mildly elevated. To answer your question on how to lower, you'd need to figure out what is causing the elevation and address that. This can be a trial and error process.

On anxiety, this article popped up in my feed yesterday. I've played with Wim Hof's method for some time. I've had rhinitis since birth, as well as other autoimmune issues. I've continued to work on this for many years. In 2014, I connected with my current doc and aligned my eating with his suggestions. This reduced the rhinitis by about 80%. I then did some more refinement to my eating, improving the rhinitis another 10%. I found that daily Wim Hof breathing would get me close to 100%. I think the exercise creates an an acute stress, which seems to reset the autoimmunity for a time. Besides the linked article, I've seen many other anecdotes of people saying that cold immersion has helped their anxiety. I'm in a group where folks convert chest freezers to cold tubs, trying to hold the water temps at 2 C (36 F) so they can do brief (2-5 min) soaks in the water. If you decide to pursue this, I suggest doing it under supervision with training, initially as cold can be dangerous, if not done correctly. I've also played with cold. I don't have a chest freezer, but do take cold showers and soaks (my winter tap water is about 7.8 C, 46 F), do morning walks and shoveling snow in sub freezing temperatures (as low as -12 C, 10 F wearing shorts, t-shirt and sandals. I've not had the breathing or cold initiate afib, though it could be a risk.

{edit} A guy in one of my groups just published this book on cold, "The Cold Therapy Code." [www.amazon.co.uk] In the UK, it appears to be free on Kindle, at the moment. I've not read it yet.



Edited 1 time(s). Last edit at 01/08/2022 09:33AM by GeorgeN.

Thanks, George. From what I can understand, it's interesting, but it's not easy for me to read that, since I'm French talking and no scientist.
From what I've learnt, mainly from you in this case, the root cause of my afib may be over exercising. But it's hard to be sure of that for two main reasons. The first one being I've never exercised a lot, nor too strongly. I've never been an avid athlete. Far from that. Just the amount of exercise one would read as recommended. That's why my heart is normal.
The second reason is I've detrained to a point where I've been nearly sedentary, and it did not change anything. Now, I've re-trained a bit, and it's still the same.
To date, nothing I've changed in my habits, food, drinks, supplements, drugs... has showed a result. And all exams I've had (and I've had some) have returned fine results.
The only thing I've yet never been able to change consistently is my stress level. It does not seem high, but I'm far from being quiet all day long. Next year I'm retired, so let's hope it'll bring some good changes...

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Pompon
Thanks, George. From what I can understand, it's interesting, but it's not easy for me to read that, since I'm French talking and no scientist.
From what I've learnt, mainly from you in this case, the root cause of my afib may be over exercising. But it's hard to be sure of that for two main reasons. The first one being I've never exercised a lot, nor too strongly. I've never been an avid athlete. Far from that. Just the amount of exercise one would read as recommended. That's why my heart is normal.
The second reason is I've detrained to a point where I've been nearly sedentary, and it did not change anything. Now, I've re-trained a bit, and it's still the same.
To date, nothing I've changed in my habits, food, drinks, supplements, drugs... has showed a result. And all exams I've had (and I've had some) have returned fine results.
The only thing I've yet never been able to change consistently is my stress level. It does not seem high, but I'm far from being quiet all day long. Next year I'm retired, so let's hope it'll bring some good changes...

I think what will trigger afib is very individual. In my case, I know exercise (with some genetic predisposition) was a very likely cause. I did participate in some high exertion events, but my training overall was fairly mild. It was enough, in my case. Also, hard to know how much fibrosis has occurred, so could be hard to reverse - again an individual isse.

I had a Natale LAA ablation in September 2013. Lots of work to get me in NSR. All was well until May 2014, when I went into Flutter as my Acupuncturist inserted a needle into my left shoulder area - and pow - flutter immediately. After dealing with afib for 10 years, then my 2013 ablation, Dr. Natale instructed me to get a cardioversion - my first and last. Flutter went away for about two weeks, and then came back. I went back for a "touch up' in June 2014 with Dr. Natale and have been in NSR ever since. Been taking Eliquis 5mg. twice/day since then.

On Tuesday, I'm going for a Watchman, as Dr. Natale will be up in NY (my area), and it seems like the wise thing to do as I am getting older (I'll be 69 on Tuesday - yikes - how did that happen?)

Interesting that acupuncture triggered Flutter, right?

Hoping this Watchman is the last thing I'll need to do that is Afib related.

BArb

It does not surprise me. Acupuncture is an "electrical" thing. Our nervous system relies on electricity to communicate.
In my case, the ANS is disturbed. I went see a Chinese Dr who tried to cure my problem with acupuncture. It did not work. Some people report it did for them.
I know about people having "cure" their afib after having had some work done on their neck. Isn't it the place where the vagus nerve takes its source ?
I may have a nervous issue somewhere. Pinching or things like this... Who knows? I have not yet tried everything.

Hi George,

Apologies for coming back to you so late. I do appreciate your responses and again, you’ve been so helpful to me. My Last CRP level was done in October and I was VERY anxious, probably more than I am now even and it had gone to 2 from being 1 in Late July. It is interesting to read about your wife’s reading and the process of elimination. Funnily enough too, around that time I was having issues with some dental work, which has calmed down slightly ( I hope) so that may also have contributed, I’ve asked my GP Doctor if I can have another blood test to determine my levels, but unfortunately I haven’t had a reply as yet. I’m not sure if it is a high sensitivity test….it doesn’t say unfortunately.

You are certainly very brave to be shovelling snow in your shorts and I applaud you on the cold therapy that you have been doing. We haven’t got a chest freezer either, but I can see how they would be useful for this. I have just looked at your link regarding Win Hof. It is certainly food for thought…..I live near the seaside in the UK and there are groups of ladies, my age, who regularly go into the sea, weekly in their costumes all year round. They come out the sea very pink, but happy. I’m not sure if I am brave enough.

I will certainly look at the kindle book link. Thankyou again for all your help,

Tweez

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Tweez
I live near the seaside in the UK and there are groups of ladies, my age, who regularly go into the sea, weekly in their costumes all year round. They come out the sea very pink, but happy. I’m not sure if I am brave enough.
s

I looked up the hsCRP & CRP tests, the CRP starts at 10 and goes up. hsCRP range is 0.5 to 10. So yours is hsCRP.

In the Chest Freezer FB group, There are a number of anecdotes on the cold (water near 0 C) helping anxiety. Here is a search on that group, you'd need to join it first. Here is the group: [www.facebook.com] and the search: [www.facebook.com]

An article on the mammalian dive reflex & anxiety [www.bustle.com]

For some, just Wim Hof breathing seems to be enough, maybe with cold showers. Others need the very cold plunge, but only for 2 or so minutes. Again, hypothermia is dangerous, so don't do this along. It could also cause afib, though it hasn't in me.

Maybe chat with the ladies who go in the water and find out their experiences and why they do it. Ask about anxiety.