Second ablation - LAA isolation

Assuming Natale,

Can someone give me the statistical odds of him isolating the LAA during the second procedure?

It seems that it’s almost 100% to have the isolation done, if Natale is the EP.

Anyone have a second procedure with him that it wasn’t isolated?

How do they determine if isolation is truly required, or is that the standard for #2 Ablation?

Concerned, Thanks.

Nobody has that number unless they have access to his entire patient files, and I'm entirely sure it's nowhere near 100%. Not sure where you got that idea.

He determines that LAA isolation is necessary by finding that afib signals are originating from the LAA. It's an entirely objective decision based on what he observes with a mapping catheter inside your heart. No afib coming from the LAA? Then no LAA isolation is needed. Afib is coming from the LAA? Then LAA isolation is needed. He doesn't ablate anything because "it will probably work," which is what many EPs do with simple PVIs and cryo ablations. He ablates the sources he actually finds and nothing more, and he knows how to find sources that average EPs don't. That skill set is what sets top EPs apart from average EPs. Natale's not the only one, but he is one of the pioneers.

Okay, thanks.

I wasn’t sure because I heard they ablate first, then do the isoproteronol challenge.
But that is probably for the first procedure.

So I was thinking, isolate LAA first too?
Or the LAA is activated by isoproteronol attempt later??

You're mixing some things up that don't go together.

An isoproterenol challenge is done at the end of every ablation by well trained EPs. The purpose is to provoke afib if it's lurking somewhere and didn't reveal itself during the procedure. It has nothing to do with the LAA.

As I said before, the LAA is isolated only if it shows itself to be a source of afib. It's not part of a standard ablation and the average EP doesn't know how to detect afib in the LAA, much less how to isolate it. Isolating the LAA is a procedure reserved to top tier EPs, and it's never done as a matter of course. If the LAA is isolated during the procedure, the isoproterenol would be given after that. It's the last thing done in an ablation because it's like testing for leaks after you patch a tire or a leaky pipe. The whole point is to simply confirm that you patched the leak and didn't miss any other leaks.

Where are you getting your information? Are you just putting stuff together that you've read on the forum?

The isoproteronol and adenosine are used to challenge the heart's tissue whenever the EP wants to be sure he can extract the catheter and call you done. It isn't always a sure thing, as I can attest. My EP said he tested me and that I should be good. Trouble is, within 6 days I was in the ER and placed on Amiodarone.

The EP won't do more than is necessary; no shot gunning. The whole point of mapping and challenging is to make the best determination possible that you are adequately isolated and can be removed from the surgery. If he/she is mistaken, and the rate across the profession is near 25% for a first ablation, then he/she will take more pains the next time to identify and to isolate newly discovered extra signals.

For what it’s worth: i too developed left flutter 9 yrs after my pvi in 2012. My ep here in Charlotte ablated me march 2021. Didn’t touch LAA. My flutter returned in 6 weeks. I sought out Dr Natale thru Shannon and Carey. I was in Austin aug 6 2021. Dr Natale ablated me which included the LAA CS and PW. Im 14 perfect months now. I did return to Austin Feb 2022 when Dr Natale placed the Watchman. TEE 3/31 here in Charlotte. Perfect. In my report it says : disassociated firing seen at LAA. I saw an interview with Luigi Diabase. He called the LAA the fifth PV. I have 5 so for me it was the 6 th PV lol

Recently had third ablation and I went to elite, top notch EP Pasquale Santangeli, M.D. who was trained by Dr. Natale. This ablation was facilitated by Shannon Dickson. Many thanks and gratitude to Shannon. Dr. Santangeli was promoted to Cleveland Clinic but he graciously agreed to perform my ablation before leaving Hospital of the University of Pennsylvania in Philadelphia.

He found reconnections and gaps from prior ablation and areas that had not been ablated as was necessary. Atypical flutter caused by gaps at the anterior MI line were ablated and terminated and converted to a focal AT from the LAA which was targeted and isolated along with CS isolation. Isoproterenol administered with no initiation of non PV triggers. During isoproterenol washout RA AT was induced, mapped, and terminated. CTI was found reconnected anteriorly and ablated. Ablation resulted durable block. Dr. Santangeli told me he is confident of the outcome, so of course, so am I. Jill

Thanks everyone!

I appreciate all of the feedback!