My cardiologist doesn't seem to fully understand LAA isolation

As I posted recently, I have been experiencing cold feet in relation to getting a Watchman...especially during a surge in Omicron in NY, which is where I'm having it done. I am only doing it now because Dr. Natale is in town next week, and it seems necessary for better protection after my LAA isolation ablation. Being someone who goes back and forth on big decisions, I have been tormenting myself with Google searches on the Watchman, and then...calling my Cardiologist for her blessing to get it done.

Of course, I found things like "Say NO to Watchman" and also see just what they do in the procedure, and think.....geezz...do I really NEED to get this? When I asked my Cardiologist that question, and for confirmation that it keeps me safer from strokes, she said "No. It doesn't keep you safer from strokes. It's the option if Dr. Natale thinks you could come off anticoagulation. If he thinks you still need a blood thinner despite the Watchman, then there's no point in doing it. She added "the Watchman is not necessarily safer than being on anticoagulation.

What? If she thinks getting off of a blood thinner and getting the Watchman is a good idea, (which she first stated), why would she later say that the Watchman isn't necessarily safer than a blood thinner? I called Shannon, who listened to my angst and cleared up the confusion. As my LAA was ablated, this apparently puts me at a great risk of having a stroke - especially if I forget a dose of Eliquis, have a major fall, have to get off of it for a surgery, etc. I thought I was well protected by just taking Eliquis.

Still, I keep feeling hesitant, as I'm doing fine on Eliquis. But I have forgotten doses sometimes (and yes, I set my alarm to take it, but I'm not always in a position to do that when it goes off...and then...forget).

By the way, no one has called to tell me if I should be going off Eliquis before the procedure (this Tuesday)....shouldn't they have told me that?

Sorry if this dragged on too long....just needed to get this out. If you've read this far, thank you. And a big thanks, to Shannon! ~ Barb

Do not stop the Eliquis unless they tell you to, and I'm not surprised they haven't. It's standard procedure to continue Eliquis through the procedure.

I think you're overanalyzing your cardiologist's answers. She's simply trying to give you accurate answers and you're interpreting it as negative advice when that's not what it is.

Sounds like Shannon told you the same things I tried to earlier. Please believe us.



Edited 2 time(s). Last edit at 01/08/2022 12:17AM by Carey.

Wasn't that incorrect advice to tell me that anticoagulation is safer than the Watchman, and that it doesn't keep me safer from having a stroke, Carey?

Thanks for letting me know about staying on Eliquis...I was assuming it's like other procedures, when they want you to temporarily stop it.

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tobherd
Wasn't that incorrect advice to tell me that anticoagulation is safer than the Watchman, and that it doesn't keep me safer from having a stroke, Carey?

Well, yes it is. Anticoagulation and the Watchman are roughly comparable in stroke protection, and the Watchman doesn't carry a bleed risk like anticoagulants do, so it is in fact safer. But she's right that it won't make you safer from a stroke. It will make you equally safe. The overall safety is better since there is no bleed risk. (Also no side effects, no ongoing cost, and no worries about needing to stop for medical procedures.)

The Watchman provides a 90% stroke risk reduction, but not 100% because clots can form elsewhere, and ruptured arterial plaques can also cause strokes. So she's right that nothing provides 100% protection, and I think that's what she's saying. But I believe (without proof) that a Watchman plus 1/2 dose of Eliquis comes about as close to 100% as you can get.

But I doubt she's really all that ignorant about the Watchman. Like most doctors, she's probably just slow to accept new treatments, so she's taking the pessimistic view.

Just to clarify, she is supportive of the Watchman, but seems to be saying it's only worth getting it if i can get off of Eliquis. I would think once you get a Watchman (because you had a LAA isolation), you have just as much risk of a stroke as any other person in your age group who has no Afib history. Maybe that's what she meant...?

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tobherd
Just to clarify, she is supportive of the Watchman, but seems to be saying it's only worth getting it if i can get off of Eliquis. I would think once you get a Watchman (because you had a LAA isolation), you have just as much risk of a stroke as any other person in your age group who has no Afib history. Maybe that's what she meant...?

Your thinking is correct: once you get a Watchman your stroke risk will be the same as anyone else your age with the same general health status. You will no longer be the high risk patient you are now.

If you get a Watchman you will be able to stop the Eliquis. The FDA and your EP might think you should take aspirin, but there's little evidence to support that thinking, so that will be your choice. Your options will be 1) take nothing (common in Europe), 2) take aspirin only, or 3) take 1/2 dose Eliquis (or Xarelto or whatever).

I went with option 3, but that's a very personal decision based on personal circumstances. Choosing 1 or 2 could be perfectly valid choices for you. .

Not quite sure how to ask this but…..Is the stroke prevention benefits of being prescribed Eliquis etc designed to protect during AFib or also during periods when you are not in AFib? If I am not in AFib and off Eliquis am I still at a greater risk than average for a stroke?

Just a FYI- if you get a watchman and not taking full strength Eliquis or equivalent afterwards, and then get an afib that requires an ECV, you may find some resistance in the ER.

I am getting a watchman soon and Saturday I asked the ER doctor if currently there is no resistance in them ecv me since I am on Eliquis, will I get any problems asking for an ecv with a TEE proven watchman either fully off Eliquis and on an aspirin or half a dose of Eliquis? Sadly he replied he agrees both NOAC and watchman provides the same stroke protection, but there will be be many conservative ER doctors who will not ECV when off Eliquis and with a successful watchman implant.

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walt
Not quite sure how to ask this but…..Is the stroke prevention benefits of being prescribed Eliquis etc designed to protect during AFib or also during periods when you are not in AFib? If I am not in AFib and off Eliquis am I still at a greater risk than average for a stroke?

The answer in general is it's designed to protect you whether you're in afib or not. Studies have shown that having afib presents a stroke risk even when you're not actively in afib. It's not hard to find examples of people having strokes despite not having had an afib episode for months.

The best tool we have for deciding whether you need to be on anticoagulant is the CHADS-Vasc-2 score. You can calculate yours here and it will explain what the results mean for you.

Susan D...why would you need to be on full strength Eliquis after getting a Watchman? Everything I'm reading indicates this is not the normal situation. My understanding is that when someone has been successfully ablated and Afib is no longer rearing it's head, you should have no reason for needing to be cardioverted. In my 10 years of having active and regular Afib, I only needed to be cardioverted once..and that was when i went into flutter. I have been Afib-free for over 7 years, so am getting the Watchman strictly to ensure better protection from an Afib related stroke (due to my LAA isolation), and to avoid needing blood thinners for the rest of my life.

Carey - if I'm a woman over 65, and had high blood pressure (well controlled now on a low dose of Atenolol), that would give me a Chad score of 3. That sounds like they would make me stay on a blood thinner.....is that right??

Barb

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tobherd
Susan D...why would you need to be on full strength Eliquis after getting a Watchman? Everything I'm reading indicates this is not the normal situation. My understanding is that when someone has been successfully ablated and Afib is no longer rearing it's head, you should have no reason for needing to be cardioverted. In my 10 years of having active and regular Afib, I only needed to be cardioverted once..and that was when i went into flutter.
Barb

I had three ablations: 1st lasted 6 months, 2nd three months, 3rd two months. I agreed to another and my EP said I may need additional more to be maintained for life on arrhythmia drugs.

That’s why I want the watchman. I want my gallbladder out (main reason for the watchman) and instead of bridging, I can stop pre major surgery and then afterwards resume Eliquis to appease a future ER. I had bleeding problems during my pacemaker surgery while on bridging and later back on Eliquis post surgery.

Regarding your solo ecv- you are quite blessed. I had 51 —36 @ER plus additional 3 because of human error the pads were not placed right so I got double zapped, plus 4 during my first ablation and 8 during my 3rd. Currently I’m only getting ecv if my tachycardia doesn’t stop after 2-3 days and if the heart rate is super high >200 and when a chemical conversion or pacemaker boost therapy doesn’t work after days in high tachycardia flutter.

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tobherd
Carey - if I'm a woman over 65, and had high blood pressure (well controlled now on a low dose of Atenolol), that would give me a Chad score of 3. That sounds like they would make me stay on a blood thinner.....is that right??

They probably won't count the point for being female. Beginning in 2019 the ACC modified their guidelines and that point is no longer considered in most cases, so you could probably come off anticoagulants. But my guess is the advice from Natale will be to continue a half dose.

So is my Cardiologist comment, "if you have to stay on blood thinners, there's no point in getting a Watchman" right then?

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tobherd
So is my Cardiologist comment, "if you have to stay on blood thinners, there's no point in getting a Watchman" right then?

Risk from missing a dose after LAA work is very different than the general risk after getting a Watchman. IMO

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tobherd
So is my Cardiologist comment, "if you have to stay on blood thinners, there's no point in getting a Watchman" right then?

No. Your cardiologist is ignoring the risks and cost of anticoagulants, and in particular the risks of having to stop your anticoagulant for medical/dental procedures or unexpected problems like losing it in a foreign country, forgetting to bring it on a trip, etc. With a Watchman none of those things will be a big deal, but without it they are all big deals. I'm still taking half-dose Eliquis by choice, but when I needed hernia repair surgery and was told I needed to stop the Eliquis for 5 days, I asked Natale what to do. His answer: "Just stop. It's no big deal."

Is your cardiologist a general cardiologist or an EP? Honestly, if they're a general cardiologist then they probably don't fully understand LAA isolation, just like the title of your thread says. (Even some EPs don't.)

And, most importantly, following a successful Watchman implantation and follow-up period, you will have the option of stopping anticoagulants. As I said before, my prediction is Natale will recommend continuing half-dose Eliquis in lieu of the low-dose aspirin the FDA recommends, and I guarantee he won't recommend a full dose. There will be no need for that. But the decision will be yours and stopping both is not an unreasonable choice for someone like you.

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Carey

Not quite sure how to ask this but…..Is the stroke prevention benefits of being prescribed Eliquis etc designed to protect during AFib or also during periods when you are not in AFib? If I am not in AFib and off Eliquis am I still at a greater risk than average for a stroke?

The answer in general is it's designed to protect you whether you're in afib or not. Studies have shown that having afib presents a stroke risk even when you're not actively in afib. It's not hard to find examples of people having strokes despite not having had an afib episode for months.

The best tool we have for deciding whether you need to be on anticoagulant is the CHADS-Vasc-2 score. You can calculate yours here and it will explain what the results mean for you.

Thanks Carey

My age gives me a +2 right off the bat. Still have some Q’s but feel it would be going too far awry of the thread. Will continue to read though.

A couple of questions about LAA isolation and Watchman:

1. Is a LAA isolation the same as a LAA ablation?
2. Do you need to, or should you, have a Watchman implanted if your LAA has been isolated?
3. I read that you need a successful TEE before a Watchman is implanted. Is this correct?
4. So if you fail the TEE after the LAA is isolated, you cannot have a Watchman implanted. Is this correct?
5. If you have had your LAA isolated and you cannot have a a Watchman implanted, is your risk of a stroke higher than if you did not have your LAA isolated in the first place? (most important question).
6. If you want to do the most to reduce the risk of a stroke you should isolate the LAA, implant a Watchman, and take 1/2 a dose of Eliquis for your lifetime. Is that correct?
7. Does Medicare pay for a Watchman if you are on Eliquis and do not have a high risk of bleeding?

Thanks,

1. I believe yes.
3. Good question! I would like to know the answer. My LAA was isolated/ablated during #2 ablation. #3 ablation I was told it was silent. I never read anywhere on my hospital or ablation reports that any TEE was performed. How will Medicare pay then for a watchman if no tee was taken? I will get a TEE during my next ablation, not prior like Tom, because of schedule limits. I’m guessing that’s when they measure my LAA for either of the watchman’s five sizes.



Edited 1 time(s). Last edit at 01/12/2022 06:31PM by susan.d.

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JakeL
A couple of questions about LAA isolation and Watchman:

1. Is a LAA isolation the same as a LAA ablation?
2. Do you need to, or should you, have a Watchman implanted if your LAA has been isolated?
3. I read that you need a successful TEE before a Watchman is implanted. Is this correct?
4. So if you fail the TEE after the LAA is isolated, you cannot have a Watchman implanted. Is this correct?
5. If you have had your LAA isolated and you cannot have a a Watchman implanted, is your risk of a stroke higher than if you did not have your LAA isolated in the first place? (most important question).
6. If you want to do the most to reduce the risk of a stroke you should isolate the LAA, implant a Watchman, and take 1/2 a dose of Eliquis for your lifetime. Is that correct?
7. Does Medicare pay for a Watchman if you are on Eliquis and do not have a high risk of bleeding?

Thanks,

1. Yes.
2. It depends. About 40% of the people with an isolated LAA have sufficient blood flow in the LAA that they can come off anticoagulants entirely if their CHADS score justifies it. The other 60% will have to be on anticoagulants or a Watchman for life regardless of CHADS score.
3. Yes, but that can be done in the same procedure as the Watchman. It's only necessary to size the device. However, assessing LAA function is a separate TEE and that's usually done 6 months after your ablation.
4. No. There's no way to fail a TEE. All the TEE 6 months after the ablation tells you is whether you need a Watchman or anticoagulation at all. So if you've got great blood flow in the LAA and a low CHADS score, there would be no reason to do a Watchman and I doubt any insurance carrier would cover it. There would also be no reason to continue anticoagulants.
5. Yes. If your LAA has been isolated and you weren't one of the lucky 40% whose LAA still functions just fine then you're at no more risk than anyone else. Otherwise, you are at high risk of stroke if you discontinue your anticoagulant or miss doses. However, if you never miss doses then you're not at higher risk.
6. If you want to do the most to reduce the risk of stroke you wouldn't isolate the LAA in the first place, but that would mean living with afib. So assuming you isolated the LAA out of necessity, then I believe a Watchman plus 1/2 dose Eliquis probably provides the best stroke protection you can achieve. It should, at least theoretically, provide a lower stroke risk than the average person without afib who's the same age and health status. Two EPs and my PCP all agreed on that, but I don't have hard data to prove it.
7. What Medicare will pay for with regard to the Watchman has been evolving quickly over the last couple of years, but as it stands now I do believe they will if your LAA has been isolated and you have a CHADS score over 2 for men or 3 for women (because women get a point for being female, which doesn't count).

Carey, thanks for the detailed answers to my 7 questions. I will use this information when I discuss options with my doctor next month.

I gather from your answers that it is most important to get a TEE after an ablation so that you can decide what to do next.

If your TEE blood flow is high in the LAA then you to come off anticoagulants entirely if your CHADS score is less than or equal to 2.

If you cannot stop the anticoagulations based on a low TEE blood flow, then you determine if you should continue with the anticoagulations or implant a Watchman if your CHADS score is less than or equal to 2.

What is the LAA cutoff flow number from the TEE used to make this decision?
.

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JakeL
What is the LAA cutoff flow number from the TEE used to make this decision?

See Shannon's post here, there is a three step testing process.

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JakeL
What is the LAA cutoff flow number from the TEE used to make this decision?
.

It used to be 40 cm/s but Natale raised the bar to 45 cm/s. There are also other criteria. See Shannon's post that George linked to.