Ablation: Just Got Back to Room

Just talked to Dr Natale and he said it was about normal amount of time (1 1/2 hours) Said they can only do so much on 1st ablation. Although I may have additional spots to ablate, they only do what they can see or they would be guessing. Guy who did echo yesterday said my heart looked pretty good for someone who has supposedly had Persistent Afib for 3+/- years.

Empirical knowledge says there could be more but it would be being too aggressive to assume it is there. He said they would see how it goes and it is not unusual to do touch if they didn’t get it all.

Going to keep me on Flec 100mdx2 and Met 50. Heck, less than that kept me in NSR for 3 weeks.

I guess iI didn’t get the new pulse technology as they just gave me Carafat for my throat for ulcers? I guess they wouldn’t need Carafat if they didn’t burn tissue using new Pulse technology.

Congratulations, you had your ablation! Thanks for checking in. How are you feeling? Did they say that the ulcers are from the ablation or could it be irritation from being intubated? I don’t think they are using the pulsed field technology yet except in the ongoing clinical trials.

I don't believe he has any ulcers. He's saying they're giving it to prevent them. And he's in a clinical trial, but he's blinded from knowing which tech they used so it's 50/50.

Carey is correct Daisy. So if they are trying to blind me they could be giving me medicine to cover up which group I was in. I am sure they are allowed to do it based on all the papers I had to sign

Quote
Geocappy
Carey is correct Daisy. So if they are trying to blind me they could be giving me medicine to cover up which group I was in. I am sure they are allowed to do it based on all the papers I had to sign

Ah, I didn’t realize that you were in the trial.

Hi Geocappy,
I also had an ablation (touch up) with Natale today. I must be down the hall from you.
My first ablation was March of 2021…..and per Natale today, no touch up was needed in those areas. I was having enough flutter post ablation that a ‘touch up’ was scheduled but ended up having my LAA ablated today. A watchman is in my future. But’s it’s all good. Very happy with my touch up today….smooth as silk so far. As usual, staff and facility are top notch. Natale told me he just returned from Italy where the Italian medical systems just got approval for some new procedures that he does here, so he was teaching them while relaxing on the Amalfi coast. Good for him! What a legacy. I am more impressed with him every time I am privileged to talk with him.
Good luck Geocappy with your recovery!
Carey…..I have been reading your posts for years.You led me to Natale. Any advice on the Watchman, please let me know. Again…..wha a legacy helping so many others!
Cindy

Quote
Cindy L
Carey…..I have been reading your posts for years.You led me to Natale. Any advice on the Watchman, please let me know.

Reading for years but you just posted for the first time today. It's surprising how many people do that (I did it myself). When I see the web site stats on how many daily visitors we have, the numbers are in the thousands, but there are only a few dozen people who post regularly. I'm glad the site has been helpful for you. Thanks for saying so.

The only advice I can offer on the Watchman is if you need it and your insurance will cover it, don't hesitate. It's a trivially easy procedure that only takes about 20 minutes (but of course they'll make it 2 hours total with you spending almost all of that time waiting). The only "recovery" involved is staying one night in the hospital feeling perfectly fine and then not lifting anything heavier than 10 pounds for a week. You'll feel almost as if nothing happened. Then 6 weeks later you'll have to undergo a TEE, but that's an even easier procedure. Maybe a couple of hours out of your day with no hospital stay required. After that, you're protected for life and you'll have the same stroke risk as someone who's never had afib. Whether you should continue taking aspirin or half-dose Eliquis/Xarelto is another more complicated debate that depends mostly on your personal particulars. When you get to that point, talk to the EP doing the Watchman about it.

Is the watchman something you recommend getting done by Natale? It does seem very important

I would recommend any EP who has done at least a few hundred of them. It's not the exquisitely difficult art that ablations are.

Carey, I’ve never seen a study saying that a watchman reduces to chance of a stroke to the same as the non-AFIB population, but rather that it’s non-inferior to oral anti coagulation. Is there a study supporting what you wrote. I’m currently scheduled for a watchman in 2 weeks but sort of on the fence about it. Thanks.

Quote
jasams
Carey, I’ve never seen a study saying that a watchman reduces to chance of a stroke to the same as the non-AFIB population, but rather that it’s non-inferior to oral anti coagulation. Is there a study supporting what you wrote. I’m currently scheduled for a watchman in 2 weeks but sort of on the fence about it. Thanks.

I've never seen a study that makes that direct comparison but the numbers are about the same. For example, this article reports a 1.53% stroke risk among Watchman recipients and that's comparable to the stroke risk in the general population among those in their 60s. To be exact about it you'd have to break it down by all the factors like age, cardiovascular health, weight, diabetes, etc, but in general it's not incorrect to say that a Watchman eliminates the increased risk that an afib diagnosis gives you.

What is it you're on the fence about? In the hands of an experienced operator there are almost no negatives to a Watchman.

Carey,

I’m on the fence because a watchman is permanent. Whose to say that in a few years there won’t be a better device; just like the watchman flx is better than the original 2.5?

Plus, since the watchman requires a lifetime of aspirin, that’s a bleeding risk that the general population doesn’t have. I should add that I had a fall which resulted in some minor brain bleeding while on eliquis; so I’m anxious to get off a DOAC, but antiplatelets aren’t safe either. In fact, aspirin is no longer recommended to prevent a first heart attack. The risk of bleeding outweighs the benefit. Of course, this contradicts what was the conventional medical wisdom up until a couple of years ago.

Reminds me of the movie Sleeper, when they say at one time people thought milkshakes and cigars were bad for you.

I have a Watchman FLX, which is the newest model. Will there be a FLX 2 someday? Oh, probably, but that's irrelevant to me because once it's fully endothelialized, which happens within the first few weeks, one model is the same as another. There is no better or worse after that. And I wouldn't expect to see a newer model for years. It took several years just to complete the clinical trials for the FLX even though it was only some minor adjustments to the original Watchman design. Besides, there really isn't a whole lot about it that can be improved. It's nothing but a plug, after all.

A lifetime of aspirin... I haven't had an aspirin since 2018 when I took them for 6 weeks after implantation. After that I was switched to 1/2 dose Eliquis only, which I continue to take today by choice. The recommendation for lifetime aspirin is only that -- a recommendation by the FDA -- and there are many EPs who question that recommendation, including Natale. If I wanted to stop the Eliquis, I can at any time and Natale wouldn't object. So don't think of it as a requirement because it's not. It's long been the practice in Europe to discontinue aspirin and anticoagulants after six weeks. In fact, the Watchman was originally designed for people who can't take either one, so for the FDA to recommend it is actually rather odd.

If one could take no anticoagulant or anti platelet at all, I don’t know why one would chose to take eliquis. It certainly has a non-zero chance of causing a major bleed, including intracranial bleeding. I did read the article you linked. The problem with all of these articles is that they raise as many questions as they answer. Not sure I agree that one device is as good as another after endothelialization. In the USA, a leak less than 5mm is considered fully sealed. In Europe, the limit is 3mm and it’s unclear whether any size leak is acceptable. The watchman FLX reduced the number of devices with leaks over 5mm and the next iteration might reduce it even further, or even eliminate any leaks.

I appreciate your replies. Educated patients are the best way to ensure that the best treatments become available. Had I known this when I was in school I would have taken more science classes!

I choose to take Eliquis because I'm 66 years old, I have hypertension, and like virtually every westerner over the age of 60, I have mild aortic plaque. (I only know that because the TEE after my Watchman spotted it.) Half dose Eliquis is extremely safe, much safer than low dose aspirin, and the LAA isn't the only source of blood clots in the body. The risk/benefit ratio is very positive.

I don't think that 5 mm number is accepted by all EPs. But whatever criteria is used, after endothelialization a leak doesn't matter because it will be sealed for life, so with most leaks we're only talking a matter of weeks of concern. And remember: leaks can be plugged. With an experienced operator, a leak of any size is extremely unlikely. I personally know about a dozen people who've received a Watchman and none have had a leak. I don't think leaks should be a major concern for you. The major concern should be operator experience because the vast majority of Watchman complications come from inexperienced operators. That's something you won't find in the literature directly measured, but it becomes apparent when you compare early studies of the Watchman when it was a new device with more recent studies now that there is a lot of experience out there.

Why is one of the 1st questions someone ask me is “Did they ablate the LAA?” I did ask and Natale said no because it would be too aggressive and they had nothing except empirical knowledge which would have them do so on 1st ablation. He said we would wait to see if it is needed later. What does all this mean?

I could not have ablation report since I am part of blinded clinical study.

I haven’t found anything saying that half dose eliquis is safer than low dose aspirin for intracranial bleeding. Certainly eliquis has a better risk-benefit profile than aspirin for afib, since aspirin has very little effect in reducing afib related stroke. The watchman duplicates or betters the ischemic stroke prevention of eliquis, so it’s only the risk of bleeding between eliquis and low dose aspirin that’s relevant. And, if as you say, you can stop aspirin once endothelialization is complete, then the bleeding risk would truly be reduced to that of a non- AF individual. As for half dose eliquis reducing the chance of a stroke emanating from somewhere besides the LAA, that seems unlikely to me. Full dose eliquis without LAA occlusion does not eliminate stroke risk, but reduces it. Also, aspirin has fewer drug interactions than eliquis.

Thanks for this exchange of ideas. I’m now leaning towards going ahead with the watchman. Best of health!

Carey,

Why is aspirin necessary after th Watchman?

Aspirin is supposed to help avoid device related thrombi.

Quote
Cookie24
Carey,

Why is aspirin necessary after th Watchman?

I also had to take it after getting a MitraClip—protection until devices endothelialize.

Quote
jasams
I haven’t found anything saying that half dose eliquis is safer than low dose aspirin for intracranial bleeding. Certainly eliquis has a better risk-benefit profile than aspirin for afib, since aspirin has very little effect in reducing afib related stroke. The watchman duplicates or betters the ischemic stroke prevention of eliquis, so it’s only the risk of bleeding between eliquis and low dose aspirin that’s relevant. And, if as you say, you can stop aspirin once endothelialization is complete, then the bleeding risk would truly be reduced to that of a non- AF individual.

I get the impression you didn't read my answer as to why I remained on 1/2 dose Eliquis. It has absolutely nothing to do with my Watchman. I don't think I need anything for that. Eliquis has a lower bleed risk than aspirin in all categories, so not sure why you're looking for specific intracranial bleeding comparisons. I've seen both compared in several studies and Eliquis comes in safer every time.

Quote

As for half dose eliquis reducing the chance of a stroke emanating from somewhere besides the LAA, that seems unlikely to me. Full dose eliquis without LAA occlusion does not eliminate stroke risk, but reduces it. Also, aspirin has fewer drug interactions than eliquis.

Of course it does. Like almost all drugs, there's a dose-response curve, not some on/off point at which the drug works or doesn't. If you really doubt that, you're disputing the opinion of a whole lot of EPs and researchers who keep abreast of the literature far more closely than you and I. As for drug interactions, I'm not so sure about that. What do you base that on?

There is a NIH study underway that will determine if the Watchman is a reasonable alternative to NOACs. It is scheduled to be completed in December 2027.

CHAMPION-AF Clinical Trial - NIH US National Library of Medicine

Study Description, Brief Summary:

The primary objective of this study is to determine if left atrial appendage closure (LAAC) with the WATCHMAN FLX device is a reasonable alternative to non-vitamin K oral anticoagulants (NOACs - Xarelto, Pradaxa, Eliquis, Lixiana) in patients with non-valvular atrial fibrillation.

Actual Study Start Date : October 15, 2020
Estimated Primary Completion Date : December 2025
Estimated Study Completion Date : December 2027

Carey,

I did read your posts, but perhaps I misunderstand.

You’ve said:

1. A watchman reduces an afib patient’s chance of stroke to that of someone who never had Afib.
2. After endothelialization, no anticoagulant or anti platelet is needed.
3. You have a fully endothelialized watchman, but still take Eliquis because you’re 66 years old, have hypertension and like all westerners your age have mild aortic plaque. I am 65, have hypertension that is controlled with medication and have non obstructing CAD, so very similar to you.

Should low dose anticoagulation be given to people without AFib based upon their Chads-Vasc score?

I said that aspirin has fewer drug interactions simply because I’ve never been told I couldn’t take any drug (other than a DOAC) if I took an aspirin. I have been told not to take.a number of drugs if I was on a DOAC, including Paxlovid and some antifungals.

Also, perhaps you can point me to a study showing that eliquis has a safer bleeding risk than low dose aspirin. If that’s so I would likely forego the watchman and stay on Eliquis.
That would be very helpful to me in my decision making. Thanks!



Edited 1 time(s). Last edit at 08/14/2022 02:53AM by jasams.

Quote
jasams
2. After endothelialization, no anticoagulant or anti platelet is needed.

Allow me to clarify that that's my opinion, and although I think it's based on sound reasoning and medical facts, there is no authoritative source I can provide to support it. So if you go and repeat that to an EP, they may or may not agree since the official FDA position is aspirin for life. But I would love to hear the FDA explain what they base their recommendation on because I know of no data that supports it.

Whether or not people should take a low-dose anticoagulant based solely on their CHADS-Vasc score is an interesting question and I believe the answer may someday be yes, but right now there are no studies supporting the idea that I'm aware of, so most doctors would say no.

I don't have them at hand, but I'll find some studies comparing bleed risks between aspirin and DOACs. The real problem is when we get into our 80s and beyond. Bleed risk goes up significantly with advancing age. I'm a little surprised you would choose Eliquis for life over a Watchman without aspirin or a DOAC. That would be your minimal bleed risk.

Carey,

First, thanks again for your replies. As you can see, I’m struggling with this decision. Unfortunately, it’s my nature. I know that all the choices we’re considering are based upon statistics and statistics are meaningless in a population of one.

Of course you’re right when you say a watchman with no anticoagulant or anti platelet would be my favored route, but I’ve found nothing saying that is a choice. I suppose the chance of a device related thrombosis is too high to warrant a study or maybe the market hasn’t forced such a study. I do know that watchman has asked the FDA to approve dual anti platelet therapy instead of 45 days of anti coagulation to match the protocol for the amulet occlusion device. And I agree with you that once the watchman has been endothelialized, it seems logical that no anticoagulant or antiplatelet should be needed, but I’m not a doctor. Biology doesn’t always follow logic. People without Afib, and no foreign objects in their bodies still form clots. Intellectually I know I’m going to be rolling the dice no matter the choice I make.

Thanks again and I wish you continued good health.

Quote
Geocappy
Why is one of the 1st questions someone ask me is “Did they ablate the LAA?” I did ask and Natale said no because it would be too aggressive and they had nothing except empirical knowledge which would have them do so on 1st ablation. He said we would wait to see if it is needed later. What does all this mean?

Basically he did what he thought was necessary. They will see how you do and if afib occurs again, then they might have to work on the LAA to solve it. Because ablating the LAA carries a 60% risk of needing either lifetime anticoagulation or the implantation of a Watchman device, they don't do it on a first ablation. Many do not need work on the LAA and are "one and done." Especially people with longstanding persistent afib (not you, from what you've reported) tend to need this work.

Being an afibber with diabetes and sleep apnea I doubt I will get away wuth no anticoagulants or watchman. My chart says I have hypertension but I never was diagnosed with it. 4 PCP ago I was told I was being prescribed BP med to protect my kidneys as we brought my new found diabetes A1c down to 5.8 from 12.1.

Anyway, no real symptoms except high BP this morning at 5:30am waking up from very strange dream. Seems like my body gets surge of something at around this time everyday. BP was 152/89 and HR was ok at 83. I noticed a waysback I also wake with significantly higher blood sugar then I went to sleep with.( 150 vs 120) Endocrinologist says not that crazy as body may give shot of hormones to get body started. Who knows?

Do have huge bruise on right groin. Almost foot long. Nothing on left groun



Edited 1 time(s). Last edit at 08/15/2022 12:31PM by Geocappy.

Quote
Geocappy
Do have huge bruise on right groin. Almost foot long. Nothing on left groun

You have a hematoma on that side. That means you bled from the insertion site, which is what made that big bruise. Did you break the lifting rule at any point?

Gravity will take over and that bruise will keep dropping lower. I had one following my first ablation and at one point it stretched from my groin to my knee. You'll probably find that after the bruise clears up there will be a hard ball you can feel under the skin at the site and that could take months to go away.

Quote
Carey
I would recommend any EP who has done at least a few hundred of them. It's not the exquisitely difficult art that ablations are.

I was seen by an EP on call in November @Robles and I asked him if he does watchman implants because I was curious about his skill set as an EP. He was assigned to me. He replied he stopped after tearing up hearts (plural he told me) during insertion that required open heart surgery afterwards. I had dr Natale insert my implant. Even so imho one needs a skilled EP. I had twisty veins/artery? and the watchman kept getting stuck. Dr Natale was trying numerous times very gently to get pass the curve…and he did it. Unless you had unknown anatomy issues plus a long LAA shoulder which made it tricky to get a perfect seal, you may needed the best EP. I know of a few EPs who won’t insert a watchman because they had difficulty. Obviously I never asked if they had at least a few hundred under their belt but I like to get the best in case of unknown difficulties. But that’s me.

That's a very rare complication, so I'm glad to hear that EP no longer attempts them because they're clearly not in his skill set.

Nope. Didn’t break the 10lb rule. SW nurse today and she said no big deal. Don’t have hard lump. Do have a small bullet size hard spot more like a bead in the shape of a bullet.

Quote
Geocappy
Do have a small bullet size hard spot more like a bead in the shape of a bullet.

Yeah, that's what I was talking about. It will probably be there a good long while.

I only get the bullet hematoma on the right side each of my 3 ablations. They lasted 6-8 weeks. My watchman lasted longer because it was a twisted tight fit.

A person cant just take Eliquis after Watchman procedure instead of aspirin? My question is aspirin required to be taken for a period of time after Watchman procedure?

Quote
Cookie24
A person cant just take Eliquis after Watchman procedure instead of aspirin? My question is aspirin required to be taken for a period of time after Watchman procedure?

The FDA recommendation is either aspirin or Plavix for 6 weeks following implantation, and then aspirin for life after that.

However, some EPs will modify that to use half-dose Eliquis instead of aspirin after the first 6 weeks, or just stop everything. It depends on the EP and your particulars. Not everyone gets the same advice from the same EP. In Europe they generally don't give anything after the first six weeks.

Geocappy,

I had my first ablation the day after yours - one week ago per Dr. Natale. I appreciate reading about all the experiences and advice everyone added to your commentary.
Although my surgery went very well, I had a little glitch in my blood pressure later in the evening, which landed me in ICU for the night. The next morning, Dr. Natale came in to visit me and reassured me that the surgery went as planned, and that I would be able to go home that day, which I did.

Outside of a little pressure in my chest for several days following, that was the only side affect I had. After reading the above comments tho, it occurred to me to check for groin bruising, which I noted on my right side. Thank you. And yes, I believe I did not behave well and inadvertently bent over to retrieve something off the floor, maybe more than once until I remembered NOT to do this. It is a challenge for me to rest and to not be compelled to pick up items that require me to bend.

My meds remain at Eliquis 5mg twice a day, and a decrease in Metoprolol from 25mg twice a day to 12.5 mg twice a day due to fluctuating blood pressure.

I feel good and I am grateful.

I developed a very large haematoma after my first ablation, and like Carey a large bruise, however, mine stretched from my groin to my calf. I did do some long walks around a few days after ablation and also rode my bike. EP was most unhappy with me.

The second ablation, again a haematoma and bruise altho not quite as large as the first one. This time I did everything right( but don't think my EP believed me )

I wonder if some of us are predisposed to getting haematomas etc. I have always been a very free bleeder and taking Eliquis probably adds to the potential to develop bleeds after procedures.

I have been very dizzy since the second ablation, altho my heart seems ok, nice and quiet most of the time. Maybe unrelated but it worries me.