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Left Atrial Appendage Closure

FAQ: I am considering closure of the LAA. What do I need to know?”

FAQ: Closure of the LAA

“I don’t want to be on a blood thinner for years and years. My doctor is talking about closure of the Left Atrial Appendage. What is an occlusion device?”

An occlusion device, like the FDA approved Watchman., is used to close off the Left Atrial Appendage (LAA), the source of most clots (90%-95%) and A-Fib-related strokes.

The Watchman is inserted in a very low risk procedure that takes as little as 20 minutes. Afterward, you would usually not need to be on a blood thinner (anticoagulant).

Closure of the LAA is often included in a Maze/Mini-Maze surgery and sometimes as part of a catheter ablation.

Side Effects: Closure of the LAA may compromise the ability of the Left Atrium to function fully. Serious athletes would probably miss the reduced blood flow from the left atrium. But most A-Fib patients would hardly notice.

Catheter positioning the Watchman occlusion device at the mouth of the Left Atrial Appendage

Catheter placing Watchman in LAA

Long-Term Effects: What are the long-term effects of leaving a mechanical device like the Watchman inside the heart? We know that, after a few months, heart tissue grows over the Watchman device so that the LAA is permanently closed off from the rest of the heart.

It seems unlikely that complications would develop after a long period of time (compared to long-term use of the blood thinner, warfarin). But we can’t say that for sure until enough time has passed. The first clinical trials installation of the Watchman device in the US was in 2009 and in Europe in 2004. So far, no long-term complications have developed.

Other Occlusion Devices: Besides the Watchman from Boston Scientific, other occlusion devices include the Amplatz Amulet from St. Jude Medical and the LAmbre from LifeTech Scientific.

EPs Installing the Watchman Device: To find EPs installing the Watchman or other occlusion devices, I highly recommend selecting an electrophysiologist (EP) who is certified in “Clinical Cardiac Electrophysiology”. For a list of EPs meeting this criteria, see Steve’s Lists of A-Fib Doctors by Specialty: Doctors Installing the Watchman.

Reference Articles: To learn more about the removal of the LAA, and the Watchman, see my articles, The Role of the Left Atrial Appendage (LAA) & Removal Issues and The Watchman™ Device: The Alternative to Blood Thinners.

Resource for this article
Holmes, Jr. DR et al. Left Atrial Appendage Closure as an Alternative to Warfarin for Stroke Prevention in Atrial Fibrillation. J Am Coll Cardiol. 2015;65(24):2614-2623. http://content.onlinejacc.org/article.aspx?articleid=2323039 doi: 10.1016/j.jacc.2015.04.025

At 55, A-Fib After Underwater Hockey, Then 2 Failed Ablations & a 3rd Using the ECGI Vest

By Martin Johnson, Champaign, IL. March 2018
With a post-script by Dr. Phillip Cuculich, Barnes-Jewish/Washington Un.

Martin Johnson

“My first A-Fib attack that I noticed, occurred in 2003 when I was 55 years old during a game of underwater hockey, an extreme sport requiring swimming under water while pushing a lead puck from one end of the pool to the other.

At first, I thought “well I did just swim 25 yards under water as fast as I could, so maybe this is just normal”. It lasted about 20 seconds.

The attacks quickly increased their duration to a couple hours each over the next couple months. I was forced to give up the game I’d been playing since age 37. I switched sports to softball, but that soon became impossible too, as I got an A-Fib attack every single game (but oddly, never at a practice).

A-Fib Progresses―Attack Just Sitting at Desk

For the first couple of years I only got attacks after physical exertion. As time went on, less and less exertion was required to trigger one.

I had my first attack without any kind of physical exertion while sitting at my desk at work. It scared me enough to see the local EP who recommended that I get an ablation. I thought that was too aggressive and instead started to try various drugs.

“My EP’s prognosis was―’ever more often, ever longer attacks until I would be in permanent A-Fib’”.

After going through 6 different drugs, most of which had no effect, one of which almost killed me and another that modified my attacks, I had no net improvement. My EP’s prognosis was “ever more often, ever longer attacks until I would be in permanent A-Fib”.

By 2010, I was getting approximately 24-hour long attacks approximately every four days plus occasional attacks triggered by physical exertion.

My First Ablation

I had my first RF ablation in July of 2010. I asked the EP if I should be in my natural A-Fib before the ablation, so that he could locate the problem cells. He said ‘no’. Instead, he induced A-Fib chemically. His approach was to isolate the PVs and draw several other lines in the left atrium. He then ablated the cells that he could detect taking part in the A-Fib that he induced.

He successfully got my heart back into Sinus Rhythm (SR), and was unable to further induce A-Fib. His OR report says that he expected this to have been a cure. (An O.R. [Operating Room] report describes what the EP did during the ablation.)

Two hours after the ablation, I was in A-Fib again.

In A-Fib Again―Leads to a Second Ablation

My A-Fib attack timing continued without letup— 24-hour-long attacks every 4 days. I agreed to a second ablation 6 months later.

“Two hours after the ablation, I was in A-Fib again.”

The OR Report for the second ablation was essentially the same as the first, and so were the results. After both ablations, I acquired new arrhythmias that annoyed me even while not in A-Fib. After about 6 months, the new arrhythmias abated, and my A-Fib pattern changed to 24 hours every 7 days—a small but welcome improvement.

Over the next five years, the attacks became longer and more frequent— by Jan 2016, I had 45 hours of A-Fib every 7 days.

Third Ablation? I Needed an Edge

Still I was not optimistic about a third ablation considering my previous poor results.

Medtronic ECGI vest

I decided I needed an edge—something that might be able to find whatever oddball A-Fib cause made me difficult to cure. The one thing that stuck out in my reading was the Medtronic ECGI vest used in Bordeaux, France by Dr Haissaguerre and others. [See How ECGI (Non-Invasive Electrocardiographic Imaging) Works.]

The 256 electrode ECGI vest enabled the graphic display of the electrical activity of the heart passively and totally non-invasively. Unfortunately, Dr Haissaguerre’s office would not respond to any of my attempts to contact him. And I learned that the FDA would not permit the use of the vest in the US as part of an ablation procedure.

Travel to St. Louis Where the ECGI Vest Was Invented

It seemed that all doors to the vest were shut. After some investigation, I discovered that the vest had actually been invented in the US at Washington Un. in St. Louis, MO. In January 2016

“I volunteered for a study…that might help me get use of the vest in spite of the FDA.”

I called up the inventor’s lab to get as much information as I could. I volunteered for a study with the hope of making connections that might someday help me get use of the vest in spite of the FDA.

In January 2017, I went to St Louis and got a CT scan and a vest recording for the study I had volunteered for. While there, I noticed a Dr. Cuculich come into the lab to borrow a vest. I immediately thought, this is the guy I need to keep track of.

FDA Approves Medtronic ECGI Vest―My New Hope!

Then the next month, Feb 2017, the FDA approved a commercial version of the vest made by Medtronic for use with A-Fib ablation.

By this time, I was having 48 hour attacks every 4 days. I called Medtronic to get a list of who in the US had bought the vest and who had any experience using it. To my relief, Barnes-Jewish Hospital in St Louis was one of only four buyers, and Dr Cuculich already had experience using the vest on non-A-Fib applications.

Now that I had located a possible vest practitioner, I still had to resolve other concerns. In particular, even Dr Haissaguerre in France didn’t use the vest on paroxysmal A-Fibbers. He only used the vest on patients with permanent A-Fib. I don’t know why. I was convinced that being in my natural A-Fib and not in chemically induced A-Fib, was essential to find the real causes. I also knew that I could put myself into A-Fib by physical exertion.

BisenseWebster Smart Catheter illustrations

Example of Contact force catheter (Biosense Webster)

Another Technology Edge: The Contact Force Catheter

Another technology that seemed important was the technique of dragging the catheter in order to burn a continuous line, rather than trying to burn individual dots. To help with this, a contact force catheter also seemed necessary. I first became aware of this due to a paper written by Dr Natale of Austin, TX. (see Resources below for article.)

A Concern: I Don’t Want to Lose My LAA

Another concern of mine was the insistence by some EPs to electrically isolate the Left Atrial Appendage (LAA).

“…in my mind…if the ablation worked, there would be no advantage to having closed off the LAA.”

During A-Fib, the blood in the LAA becomes stagnant, permitting the formation of clots.

But cutting off incompletely understood parts of one’s heart seemed exceedingly rash. Also, if the ablation worked, there would be no advantage to having closed off the LAA. So, closing off the LAA was just preparing for a failed ablation, in my mind.

About the Left Atrial Appendage (LAA)

What little is known about the LAA includes the fact that it is the source of heart stem cells needed for repair of the heart.

It was once thought that the heart cells you died with were the same ones you were born with. The latest belief is that about 40% of your heart is replaced during a full life.

This is a function I did not want to lose.

The LAA is also the source of a hormone which helps control blood pressure. The LAA also has a pumping function in parallel with the Left Atrium. And electrically isolating the LAA can often significantly reduce the contractile function of the LAA, thus making it a source of clots even when the heart is not in A-Fib.

Consulting Dr. Phillip Cuculich at Barnes-Jewish/Washington Un.

I called up Barnes-Jewish to inquire about my above listed concerns. Dr Cuculich called back and assured me that he was able and willing to meet all these requests:

1) Use the ECGI vest during ablation even though I’m paroxysmal;
2) To expect me to be in my organic A-Fib;
3) After getting me into Normal Sinus Rhythm, chemical induction of A-Fib was OK to track down more problems;
4) Use a contact force catheter and draw continuous lines rather than dots;
5) Leave my LAA electrically and physically intact.

Third Ablation―Running Up Flights of Stairs

The night before the scheduled ablation, I ran up and down a flight of stairs ten times which put me in my organic A-Fib in preparation for the following morning’s ablation.

On Nov 2, 2017, two Medtronic technicians fitted the 3-piece vest onto my torso. The ablation procedure took 5 hours—a lot longer than Dr Cuculich was planning on.

I woke up in NSR! The doctor noted that an A-Fib source in a pulmonary vein was active, but was already successfully being blocked by the ablation.

In Normal Sinus, But Short Bursts of A-Fib

Since the ablation 3.5 months ago, I have had about 15 A-Fib attacks totaling about 7 hours of A-Fib. [It’s not uncommon for A-Fib to reoccur during the three month ‘blanking period’ following an ablation.]

I believe every attack was triggered by drinking cold water. It took me a while to figure that out. I have not had an attack for the last month, during which I was able to remember ‘no cold water’!

Lessons Learned

For future reference: I read that Dr Cuculich was the lead investigator in a study of a totally non-invasive ablation procedure that uses the Medtronic vest to find the problems and ‘multi-beam focused radiation’ to ablate the errant heart cells.

I’m hoping that if my A-Fib comes back, that the FDA won’t have been as slow permitting this new method, as they were with the vest (see Resources below for link).

In light of my experience, I would recommend that no one get an ablation without the advantage of the Medtronic ECGI vest. Without it, the EP is only guessing.

Using canonical ablation patterns that might have worked on some group of A-Fibbers, or using the old fashioned way of dragging a sensing catheter along the entire inner surface of a beating heart looking for electrical anomalies, is laughable to me.

It’s no wonder that my first EP couldn’t find the A-Fib sources inside my coronary sinus and right atrium. I welcome your emails.”

Marty Johnson
martyj1949(at)yahoo.com

Comments from Dr. Phillip Cuculic

Electrophysiologist Phillip Cuculich, MD

Phillip Cuculich, MD

“Thank you, Steve, for the chance to reply [to Martin’s A-Fib story]. And thank you, Martin, for sharing your story with the world. Brave patients and advocates like you are a powerful combination in today’s world of medicine.

Our understanding of any arrhythmia mechanism falls into two bins: the initiating event (triggers) and the sustaining circuit.

Over the past several decades, invasive procedures have identified common locations that harbor AF triggers, which is how pulmonary vein isolation has been an effective procedure to control AF for most patients. In general, we as a field have struggled in identifying reproducible non-PV triggers and the sustaining AF circuits.

One reason for our struggle is the tools with which we measure. A second reason is that each person’s AF is different, so the findings of one group of patients is not easily applicable to an individual patient that I meet for consultation.

Martin’s experience with noninvasive ECGI is a wonderful example of personalized medicine: treating an individual patient’s AF physiology. Credit for the development and clinical validation of this technology goes to the scientists, clinicians and industry development teams which include Dr. Yoram Rudy (Washington University), the amazing scientists who graduated from his lab, the intrepid clinical and investigational teams in Bordeaux, France, and the hard-working developers at CardioInsight and Medtronic.

Presently, thoughtful application of noninvasive ECGI is getting us closer to personalized AF treatment. Further development, testing, and refinement of the ECGI system is underway. While there is much more to accomplish in understanding the critical components of each individual patient’s AF, one cannot help but hear the hope dripping from the story that Martin shared.”

Editor’s Comments
I admire Martin’s tenacity in seeking his A-Fib cure after two failed catheter ablations. He educated himself about his disease and its treatments. Then he sought out an EP who would meet his needs, even drawing up a five-point check list to discuss before his third ablation. Well done, Martin!
Martin’s O.R. Report: Dr. Cuculich found all Martin’s PV’s were still not isolated or had re-connected. After his two previous ablations, all Martin’s PVs had connected/re-connected. Dr. Cuculich also found many gaps in Martin’s previous roof and mitral isthmus ablation lines.
ECGI Vest Found Hard-To-Map Drivers: The Medtronic ECGI Vest mapping system found Non-PV driver areas in Martin’s heart that easily could have escaped notice with routine mapping systems, areas such as the Coronary Sinus, Left Superior Pulmonary Vein and lateral Right Atrium.
During Dr. Cuculich’s ablation, Martin’s A-Fib/Flutter terminated when his Coronary Sinus was effectively ablated and isolated. This is considered the best outcome of an ablation. Most EPs would have stopped at this point. But because the Medtronic ECGI vest had indicated there were more A-Fib signal sources not yet ablated, Dr. Cuculich ablated those areas as well.
Medtronic ECGI Vest Very Effective! Martin’s A-Fib was a difficult case after two failed ablations. Instead of the usually 2-3-hour ablation, Martin’s took 5 hours, probably because the previous 2 ablation lesions made the third ablation more complicated.
The Medtronic ECGI Vest seems to be a major advance and improvement in the treatment of A-Fib. It certainly worked in Martin’s case. But at this time, few centers in the U.S. are using it and are only beginning to develop significant experience. This is because Medtronic wants the system to work as best as possible before making it more widely available.
What this means to patients: If you have persistent A-Fib or would be considered a potentially difficult case, try to find a center or EP with experience using the Medtronic ECGI Vest (even though you may have to travel.) It seems to be the next major advance and best mapping/ablation system on the market.

References for this Article

Kolata, G. A ‘Game Changer’ for Patients With Irregular Heart Rhythm. The NewYorkTimes.com, Dec. 13, 2017. https://www.nytimes.com/2017/12/13/health/heartbeat-tachycardia-radiation.html

Cuculich, P. S., et al. Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia. December 14, 2017. N Engl J Med 2017; 377:2325-2336. DOI: 10.1056/NEJMoa1613773. http://www.nejm.org/doi/full/10.1056/NEJMoa1613773

Ryan, S. The New Era of Catheter Ablation Technology: Force Sensing Catheters. A-Fib.com http://a-fib.com/moussa-mansour-md-force-sensing-catheters-2014-bafs/

Ryan, S. The Role of the Left Atrial Appendage (LAA) & Removal Issues. A-Fib.com http://a-fib.com/left-atrial-appendage-role-and-removal-issues/

Natale, A., et al. Paroxysmal AF Catheter Ablation With a Contact Force Sensing Catheter: Results of the Prospective, Multicenter SMART-AF Trial. Journal of the American College of Cardiology, 2014. ISSN: 1558-3597, Vol: 64, Issue: 7, Page: 647-56. https://doi.org/10.1016/j.jacc.2014.04.072

Learn about sharing your A-Fib story

Return to: Personal A-Fib Stories

If you find any errors on this page, email us. Y Last updated: Friday, June 22, 2018

2018 AF Symposium Live Case: CryoBalloon Catheter for Isolation of the LAA

by Steve S. Ryan, PhD.

B. Knight MD

During this live streaming video, Dr. Bradley Knight from Northwestern Un. in Chicago, IL demonstrated the use of a CryoBalloon Catheter to isolate the Left Atrial Appendage (an off-label use, i.e., a new use not described in the FDA approved device labeling.).

Patient background: His patient was a 72-year-old man with hypertension and persistent A-Fib. He had an ablation in 2013. His ejection fraction was low but improved after a cardioversion to 40%. July 15, 2017 he had a right atrium Flutter ablation. He was on amiodarone which had to be stopped because of thyroid problems.
He developed severe Left Atrium enlargement and his ejection fraction went down to 30%. His PVs was were very large and hard to isolate. It was recommended to do both a repeat PVI and to isolate the LAA.
Live Streaming Video from AF Symposium at A-Fib.com

Isolating the Left Atrial Appendage

To isolate the Non-PV triggers originating in the patient’s Left Atrial Appendage, Dr. Knight used a 28mm CryoBalloon catheter in order to penetrate deeper into the LAA.

A second freeze was performed and then a third freeze was necessary because the LAA was still generating A-Fib signals. Before we could see this third freeze, the allotted time slot ran out.

The use of the CryoBalloon catheter appeared to be an effective treatment (though an off-label use) to isolate the LAA.

Editor’s comments:
I was surprised that two CryoBalloon lesions didn’t effectively isolate the patient’s LAA and a third lesion was necessary.
On the other hand, the use of the CryoBalloon catheter to isolate the LAA is in the very preliminary stage of research.
From watching Dr.Knight’s live case, it doesn’t seem like the CryoBalloon catheter will emerge as a viable method of electrically isolating the LAA.

If you find any errors on this page, email us. Y Last updated: Thursday, March 1, 2018

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2018 AF Symposium Live Case: Installing a Coherex WaveCrest LAA Occlusion Device

by Steve S. Ryan, PhD.
Background: The Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device is not yet approved by the FDA for use in the U.S. The WaveCrest is similar in purpose to the Boston Scientific Watchman™ LAA Closure Device (which is FDA approved).

Tom De Potter MD

Dr. Tom De Potter of Aalst, Belgium, presented a live case in which he installed a Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device in an 84-year-old female with longstanding A-Fib and a bleeding problem.

The WaveCrest has roll-out anchors which are then fixed into the sides of the LAA. It comes in three sizes to fit different LAA openings.Live Streaming Video from AF Symposium at A-Fib.com

He spent a good deal of time and attention washing and immersing the WaveCrest in water to make sure there were no bubbles.

When the device is expanded inside the LAA, it can be repositioned and recaptured. Dr. Potter seemed to tug and firmly push and pull the device to anchor it.  After insertion, it requires 2 months of dual antiplatelet therapy.

WaveCrest is from Coherex Medical, Inc., a subsidiary of Biosense Webster/Johnson & Johnson.

Coherex WaveCrest Video

Video still frames of Coherex WaveCrest occlusion device positioned in LAA.

Video animation is available: The Coherex Medical website has a short (35-second) showing the installation of the Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device. Go to video on the Coherex website->

Editor’s Comments:
To me the WaveCrest seemed similar to Boston Scientific Watchman LAA Closure Device which did all the heavy lifting to be the first LAA occlusion device to get U.S. FDA approval.
I didn’t see major significant advantages of the WaveCrest. Though it’s always good for EPs to have a choice of devices when closing off the LAA.
For more on the Watchman, see  my article, The Watchman™ Device: An Alternative to Blood Thinners. 

If you find any errors on this page, email us. Y Last updated: Wednesday, February 28, 2018

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2018 AF Symposium Live Case: Installing an Amplatzer™ Amulet™ LAA Occluder

by Steve S. Ryan, PhD.

Illustration: Amplatzer Amulet in LAA

On the Thursday session on Left Atrial Appendage Closure, two live cases were presented via streaming video from around the world.

Here, I cover the first live case featuring the Amplatzer™ Amulet™ Left Atrial Appendage (LAA) occlusion device. (For my report on the other occluder, see: Installing a Coherex WaveCrest LAA Occlusion Device.)

Note: The Amplatzer™ Amulet™ Left Atrial Appendage (LAA) Occluder, is not yet approved by the FDA for use in the U.S. It is similar in purpose to the Boston Scientific Watchman™ LAA Closure Device (which is FDA approved). The Amplatzer™ Amulet™ is from Abbott (formerly St. Jude Medical).

Patient Background: An 81-year-old lady with acute hypertension was in permanent A-Fib since 2016. Her CHADS2VASc score was 5 (at the top of the risk range), her HAS-BLED score was 4 (high for one year risk of major bleeding). She had suffered syncope (fainting) episodes and had a history of major bleeding on anticoagulants (the reason for the LAA closure). On the positive side, her Ejection Fraction was a healthy 61%.

Live From Milan, Italy

Claudio Tondo, MD

Dr. Claudio Tondo from Milan, Italy, demonstrated an LAA Closure by inserting an Amplatzer LAA closure device.

In Europe, a LAA occluder can be inserted at the same time as a PVI (catheter ablation). But for the AF Symposium live session, only the Amplatzer Amulet™ was inserted.  (Because of her history of major bleeding, Dr. Tondo decided to close off her LAA first while postponing a PVI till later.)

Amplatzer Amulet Features

Amplatzer™ Amulet™ illustration at A-Fib.com

Amplatzer™ Amulet™

The Amplatzer has two lips which close over both the outside and the inside of the LAA―like a sandwich. It comes in different sizes to fit better into different sized LAAs.

One advantage of the Amplatzer is less risk of leaking because the inside and outside lips overlap the opening of the LAA. Over time, heart tissue grows over the implant, becoming part of the heart.

Inserting the Amplatzer LAA Occluder

Live Streaming Video from AF Symposium at A-Fib.com

The primary imaging technology used to insert the Amplatzer was Intracardiac Echo, though fluoroscopy was used as an adjunct to help the audience follow the procedure. In the Echo you could see the Amplatzer being positioned and inserted into the LAA. (I could follow the fluoroscopy but found it hard to follow the Echo.)

Dr. Tondo described her LAA shape as “chicken wing” which is usually an LAA shape easier to close off. It appeared relatively easy to insert the device into the patient’s LAA, then fit it snugly into the LAA opening.

Dr. Tondo and his team used a type of dye pumped in behind the Amplatzer to see if there was any blow back or leaking. Once that was done, they simply disconnected the catheter used to insert the Amplatzer.

Amplatzer™ Amulet™ Video

A short animation from Abbott (formerly St. Jude Medical) illustrates insertion of the Amplatzer™ Amulet™ LAA Occluder (1:14). To watch the video, go to Abbott webpage->

Editor’s Comments:
About this patient: This 81-year-old lady was in a very difficult, risky situation. Her stroke risk was very high, but she couldn’t take anticoagulants to prevent a stroke because they caused her bleeding. By inserting the Amplatzer Amulet device to close off her Left Atrial Appendage (LAA), Dr. Tondo would significantly lower her risk of an A-Fib stroke which mostly comes from the LAA.
Her persistent A-Fib was very symptomatic with dangerous fainting episodes. She needed a catheter ablation to get her back into normal sinus rhythm. Dr. Tondo planned to perform the PVI as soon as possible after her LAA closure.

Two LAA occluder devices

About the Amplatzer Amulet: Having previously watched the Watchman Device procedure, to me the Amplatzer Amulet seemed simpler to insert. Though both are realitivly easy to install.
One potential problem with an Amulet might occur if a subsequent catheter ablation requires the LAA to be mapped and isolated. It will be harder to do so because the lips of the Amulet cover the LAA opening.
In Europe, the Amplatzer Amulet is used to close holes in the septum (called ‘patent foramen ovale’, i.e., a hole in the heart that didn’t close the way it should after birth.).
Once approved in the U.S. by the FDA, it will probably become a competitor or an alternative to the Watchman Device.

If you find any errors on this page, email us. Y Last updated: Wednesday, March 7, 2018

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2018 AF Symposium Live Case: Isolating the Left Atrial Appendage using RF Energy

by Steve S. Ryan, PhD.

Rodney Horton MD

Dr. Rodney Horton from the Texas Cardiac Arrhythmia Institute in Austin, TX, demonstrated in a live case how to isolate the Left Atrial Appendage (LAA) using Radio Frequency (RF) energy.

Side note: If you been in the EP lab before, the first thing you notice when viewing Dr. Horton at work is no one is wearing the lead aprons and protectors required when using fluoroscopy (x-ray). That’s because he uses 3D non-fluoroscopy (no radiation) imaging techniques.

Patient background: An 82-year old male with persistent A-Fib had a previous PVI but still had Flutter. He was also hypertensive. He also had a dual chamber pacemaker. Previously Dr. Horton had isolated the patient’s Coronary Sinus but hadn’t worked on his LAA.

Before the live case, Dr. Horton found that the patient had re-connection in one vein which he isolated before the live case demonstration began.

The Live Case: Mapping and Isolating the LAA

Live Streaming Video from AF Symposium at A-Fib.com

Live Streaming Video at AF Symposium

Dr. Horton used a mapping catheter in the Left Atrial Appendage (LAA).

To isolate the LAA, he used 40 watts radio frequency (RF) energy and a contact force sensing catheter with pressure readings above 10 but not higher than 25. The pressure readings indicate how hard the EP is pressing on the RF catheter to make a particular burn.

He discussed that if the LAA wasn’t contracting properly after the ablation, the patient would have to be on anticoagulation for life. (He, of course, discussed this possibility with the patient before the ablation.)

Dr. Horton rarely isolates the LAA during a first ablation unless he is absolutely sure it needs to be done. He stressed that the phrenic nerve often drops over the top of the LAA. For that reason, he doesn’t ablate too deep into the LAA but ablates at the base of the LAA. 

…he isolated the LAA and the Flutter disappeared as we watched.

Applause, Applause

There was excitement and clapping when he isolated the LAA and the Flutter disappeared as we watched.

Dr. Horton demonstrated for all the attendees that the LAA should also be mapped and isolated. And that isolating the LAA can be very effective in returning a patient to normal sinus rhythm.

Editor’s Comments:
No, no to Fluoroscopy: It’s a type of X-ray and its effect is cumulative. Therefore it should be avoided if possible. (Hence, the need for the staff to wear the lead aprons.)
Instead of fluoroscopy, Dr. Horton uses a non-radiation 3D imaging technique called Intracardiac Echocardiography (ICE), a form of ultrasound.
On a personal note, Dr. Horton has said that not having to wear those heavy lead aprons would probably add 5-10 years to his ablation career.
Importance of the LAA in Isolating A-Fib: More and more EPs are realizing how important the LAA is in mapping and isolating non-PV triggers. Many Master EPs after isolating the PVs, now go right to the LAA as their second isolation target.
What this means for patients: When selecting an EP for your catheter ablation, discuss the Left Atrial Appendage (LAA) as a possible site of non-PV A-Fib triggers. Ask your EP:
 “During my ablation, when you’re looking for non-PV triggers, will you also map and isolated the LAA, if necessary?” (You want an affirmative answer to your question.)

If you find any errors on this page, email us. Y Last updated: Sunday, February 25, 2018

Back to 2018 AF Symposium Reports

VIDEO: The Lariat Procedure for Left Atrial Appendage Closure

Dr. Eric Pena, cardiac electrophysiologist at Rogue Regional Medical Center, discusses the risk of clots and stroke in A-Fib patients not on anti-coagulation drug therapy. The Left Atrial Appendage (LAA) of the heart is known to be a major source of these clots.

He describes the LARIAT procedure, a lasso-shaped suture used to tie off  the LAA and why at-risk A-Fib patients may consider the LARIAT. EP lab footage and animation. 2:41 min. Published by Asante on Apr 11, 2013.

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

If you find any errors on this page, email us. Y Last updated: Friday, September 1, 2017

Return to Instructional A-Fib Videos and Animations

VIDEO: Watchman Left Atrial Appendage Closure—How it Works and Who is a Prime Candidate

Electrophysiologist, Dr Drew Pickett of Saint Thomas Health, discusses closure of the Left Atrial Appendage using the Watchman device to reduce the risk of clots and stroke. He explains how it works and who is a prime candidate, the installation process and length of procedure, and why a patient may consider the Watchman.

Includes EP lab footage and animation. 3:28 min. Published by Saint Thomas Health; July 13, 2015.

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

If you find any errors on this page, email us. Y Last updated: Friday, September 1, 2017

Return to Instructional A-Fib Videos and Animations

VIDEO: The Lariot Procedure: Closure of the Left Atrial Appendage Technique 2

How and why the LARIAT is inserted. For some high-risk patients, the LARIAT procedure is used to tie off the left atrial appendage thereby eliminating this source of clots. The heart’s left atrial appendage, is known to be a major source of blood clots that can lead to strokes. Features Dr. Eric Pena of the Asante Rogue Regional Medical Center. (1:24 min. excerpt.) Published by Asante on Apr 11, 2013.

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 30, 2017

Return to Instructional A-Fib Videos and Animations

VIDEO: The Watchman Device: Closure of the Left Atrial Appendage Technique 1

Animation of how the Watchman is inserted. For some high-risk A-Fib patients, the WATCHMAN Left Atrial Appendage Closure device is implanted at the opening of the left atrial appendage (LAA) to trap blood clots before they exit the LAA. (The heart’s left atrial appendage is known to be a major source of blood clots that can lead to strokes.) (1:04 min.) Published by jonathan penn on Feb 22, 2014.

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 30, 2017

Return to Instructional A-Fib Videos and Animations

My Top 5 Articles: Surgical Treatment Options for Atrial Fibrillation

When drug therapies fail or if not a candidate for catheter ablation, patients look to surgical treatments to reduce the risk of stroke, to ease symptoms or to cure their Atrial Fibrillation.

Here are my top 5 articles about the Maze & Mini-maze surgeries and role of the left atrial appendage:

  1. The Cox-Maze & Mini-Maze Surgeries and the Hybrid Surgery/Ablation
  2. Advantages of the Convergent (Hybrid) Procedure
  3. Considering a Mini-Maze? Don’t Destroy the Ganglionic Plexus
  4. The Role of the Left Atrial Appendage (LAA) & Removal Issues
  5. The Watchman™ Device: The Alternative to Blood Thinners

BONUS VIDEO
Mini-Maze Surgery with Cardiac Surgeon Dr. Dipin Gupta

See our library of videos about Atrial Fibrillation

Cardiothoracic surgeon Dipin Gupta, MD, discusses this surgical treatment for persistent atrial fibrillation. The Mini-Maze is done without open-heart surgery and using a small incision on the side of the chest. Published by MedStar and Cleveland Clinic. March, 2015 (4:35) Go to video->

A-Fib-Related Stroke Risk: Watchman Better Than a Lifetime on Warfarin

Background: The most prescribed anticoagulant, warfarin, reduces the A-Fib-related risk of stroke by 60% to 70%. Most A-Fib clots (90%-95%) come from the Left Atrial Appendage (LAA).

An alternative to anticoagulants, the Watchman occlusion device closes off the LAA. FDA approved, it’s a very low risk procedure that takes as little as 20 minutes to install. Afterward, you would usually not need to be on blood thinners.

CT brain with Ischemic stroke at A-Fib.com

CT brain with Ischemic stroke

Effects of a Lifetime on Warfarin

Warfarin (brand name Coumadin) and other anticoagulants work by causing bleeding and are inherently dangerous.

Among other bad side effects, long-term use of anticoagulants such as warfarin have been known to not only cause hemorrhagic strokes, but also microbleeds in the brain leading to dementia. (For more, see Patient on Anticoagulation Therapy for 10 Years Develops Microbleeds and Dementia).

A 2015 study found evidence of microbleeds in 99% of subjects aged 65 or older. When imaging strength was magnified, even more microbleeds were detected. Microbleeds are thought to be predictive of hemorrhagic stroke.

Conclusion: according to current research, to reduce microbleeds, ditch the anticoagulants. You’d do better having a Watchman device installed than spending a lifetime on warfarin.

Note: there’s no guaranteed way to avoid a stroke altogether.

What About the New Anticoagulants (NOACs)?

Does this research apply to the new anticoagulants like Pradaxa, Xarelto, Eliquis and Savaysa/Lixiana? Technically no. This research only applies to warfarin.

But intuitively one would expect the same general principles to apply. All anticoagulants cause bleeding. That’s how they work.

Caveat—Long-Term Effects of Watchman?

Catheter positioning the Watchman occlusion device at the mouth of the Left Atrial Appendage

Catheter placing Watchman in LAA

What are the long-term effects of leaving a mechanical device like the Watchman inside the heart? We know that, after a few months, heart tissue grows over the Watchman device so that the LAA is permanently closed off from the rest of the heart.

It seems unlikely that complications would develop after a long period of time as has happened with warfarin. But we can’t say that for sure until enough time has passed. The first clinical trial installation of the Watchman device in the US was in 2009 and in Europe in 2004. So far, no long-term complications have developed.

EPs Installing the Watchman Device

Want to learn more about the Watchman? See my article, The Watchman™ Device: The Alternative to Blood Thinners.

To find EPs installing the Watchman, I highly recommend selecting an electrophysiologist (EP) who is certified in “Clinical Cardiac Electrophysiology”. For a list of EPs meeting this criteria, see Steve’s Lists of A-Fib Doctors by Specialty: Doctors Installing the Watchman.

References for this article
Holmes, Jr. DR et al. Left Atrial Appendage Closure as an Alternative to Warfarin for Stroke Prevention in Atrial Fibrillation. J Am Coll Cardiol. 2015;65(24):2614-2623. http://content.onlinejacc.org/article.aspx?articleid=2323039 doi: 10.1016/j.jacc.2015.04.025

Best, Ben. The 2015 International Stroke Conference, September 2015. Life Extension Magazine. http://www.lifeextension.com/magazine/2015/9/the-2015-international-stroke-conference/page-01

Janaway BM, Simpson JE, Hoggard N, et al. Brain haemosiderin in older people: pathological evidence for an ischaemic origin of magnetic resonance imaging (MRI) microbleeds. Neuropathol Appl Neurobiol.2014 Apr;40(3):258-69.

Updated Steve’s List: US Doctors Installing the Watchman Device

If you are at high risk for stroke but can’t or don’t want to take anticoagulants, your doctor may suggest closing off the Left Atrial Appendage using an occluder such as the FDA approved Boston Scientific WATCHMAN™.

Steve’s List of Specialists Installing the Watchman: My original list of doctors installing the Watchman was limited to those EPs participating in the clinical trials. In 2015 the FDA approved the Watchman for use in the U.S. Since then my list of doctors installing the Watchman has expanded. (Internationally, the Watchman has been available since 2009.)

Watchman device - A-Fib.com

Watchman occlusion device by Boston Scientific

How to Find a Specialist: Today, you can visit the Boston Scientific website to find medical centers installing the Watchman device; just enter a state or postal code.

Use Steve’s List instead: When looking to install a Watchman device, I recommend you seek an electrophysiologist (EP) who is certified in “Clinical Cardiac Electrocardiography”. Use my list which is organized by state and city. Go to, Steve’s List of Specialists Installing the Watchman Device.

To learn more about the Watchman, see: The Watchman Device: My Top 5 Articles.

2017 AF Symposium: LIVE VIDEO! Two Procedures—Different Left Atrial Appendage (LAA) Occlusion Devices

AF Symposium 2017

LIVE VIDEO! Two Procedures—Different Left Atrial Appendage (LAA) Occlusion Devices

This live streaming video session from Milan, Italy, featured two Left Atrial Appendage occlusion devices: the Amplatzee Amulet from St. Jude Medical and the LAmbre from LifeTech Scientific.

LAA Closure Using the Amplatz Amulet (St. Jude Medical)

Amplatz Amulet occlusion device by St. Jude Medical - A-Fib.com

Amplatzer Amulet occlusion device by St. Jude Medical

Live from Milan, Drs. Claudio Tondo, Antonio Dello Russo, Gaetano Fassini, and Massimo Moltrasio inserted an Amplatzer Amulet (St. Jude Medical) into the Left Atrial Appendage of a 78-year-old women who had a high risk of bleeding. (The LAA is the origin of 90%-95% of Atrial Fibrillation-related clots).

Model of Patient’s LAA: These doctors did something I had never seen before. They made a physical model of the woman’s LAA, then showed how the Amplatzer Amulet fit into the model. This isn’t done in all cases of LAA occlusion, but was very helpful for the AF Symposium attendees to see how the Amplatz Amulet actually worked.

Illustration of placing the Amplatzer Amulet (St. Jude Medical) in the left atrial appendage

Illustration of placing the Amplatzer Amulet (St. Jude Medical) in the left atrial appendage

The doctors also demonstrated how they could easily retract and recapture the device (which isn’t easy to do with the Watchman occlusion device [Boston Scientific]).

Like the Watchman device, the Amulet also has hooks to hold the device in place.

VIDEO ANIMATION: showing how the Amplatzer Amulet device is installed (1:14 min.) from St. Jude Medical.
Watchman device - A-Fib.com

Watchman occlusion device by Boston Scientific

It seemed very easy to insert the Amplatzer device. It closed off the LAA opening with the bottom part completely covering the LAA opening into the left atrium.

For most patients, this might be an advantage of the Amplatzer device over the Watchman occlusion device which doesn’t have this overlap and can sometimes leak around the edges.

But, on the other hand, once the Amplatzer device is in place, the overlap of the LAA would prevent ablation and electrical isolation of the LAA should that be necessary. But in most cases, this isn’t often required.

Second LAA Closure Using the LAmbre (LifeTech Scientific)

LAmbre (LifeTech Scientific) occlusion device at A-Fib.com

LAmbre (LifeTech Scientific) occlusion device

Later in the session when the moderators cut back to the live video stream from Milan, the EPs inserted a LAmbre (LifeTech Scientific) device in the LAA of a second patient. She was a 50-year-old woman who had a very small LAA. She had suffered two ischemic strokes within a month of each other, but she had bleeding problems when she took warfarin and dabigatran (Pradaxa).

[She was definitely between a rock and a hard place. Ischemia refers to a restriction or blocking of blood supply as by A-Fib clots. She needed to be on blood thinners to prevent A-Fib clots from forming particularly in her LAA, but couldn’t tolerate blood thinners which caused her bleeding problems. An LAA occlusion device was pretty much her only option.]

The LAmbre LAA occlusion device (LifeTech Scientific) seems similar to the Amplatz (St. Jude Medical) as both are fully recapturable and repositionable within the LAA. But each has its own anchor design to hold the device in place. But the LAmbre can fit into smaller size Left Atrial Appendages.

Both the Amplatzer Amulet and the LAmbre occlusion devices are approved for use in Europe, but neither is approved yet in the U.S. (Not surprising since the U.S. approval  of the Watchman device also lagged the European approval.)

I predict the Amplatzer Amulet from St. Jude Medical will soon be approved by the FDA for use in the U.S.

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Wednesday, February 28, 2018

The Watchman Device: My Top 5 Articles

You’re on a blood thinner for your increased stroke risk from A-Fib. But you hate it.

Is the monthly testing or diet restrictions a hassle? Is the increased risk of bleeding stressful?  Have you developed side effects, i.e., gastrointestinal problems or poor kidney function? Maybe you just don’t want a lifetime on meds.

Or, perhaps you’re unable to take a blood thinner for other medical reasons. What do you do?

WATCHMAN™ Occlusion Device: The Alternative to Blood Thinners

There is an alternative to taking blood thinners―closing off your Left Atrial Appendage (LAA) with the Watchman™, an occlusion device. The LAA, a small sack located at the top of your left atrium, is where 90-95% of A-Fib strokes originate.

Inserting the Watchman is a very low risk procedure that takes as little as 20 minutes to install. Afterward, you usually don’t need to be on a blood thinner.

Review these articles to learn more about the Watchman:

1. The Watchman™ Device: The Alternative to Blood Thinners

2. Clinical Trials Results: Watchman Better Than a Lifetime on Warfarin

3. A Watchman and Ablation Combo? Everything You Never Thought to Ask

4. Technology & Innovations: The Watchman Device 

5. Steve’s List of EPs Installing the Watchman Device

Bonus: Video about the Watchman

Video - Closure of the Left Atrial Appendage Technique

Click image for video.

Closure of the Left Atrial Appendage: The Watchman Device

Animation shows how the Watchman is inserted and positioned in the left atrial appendage (LAA) using a catheter; then how heart tissue grows over the Watchman, closing off the opening of the LAA trapping any blood clots. (1:04)

He’s Got A-Fib but Can’t Take Blood Thinners: What to Do?

We’ve posted a new personal A-Fib story. William F Covert tells about how in 2014 his A-Fib returned when he developed a serious lung problem. The new problem meant he could no longer take anticoagulants. So how was he going to deal with the increased risk of stroke due to having A-Fib?

William writes:

Personal A-Fib story of William Covert at A-Fib.com

William F Covert

“My A-Fib symptoms started in 2012 with dizziness and constant fatigue. Several trips to my family physician proved to be futile.

“Let Me Take a Quick Pulse Reading by Hand”

On my last exam, the doctor stopped me as we were walking out of the exam room and said, “Let me take a quick pulse reading by hand.” She did so, then performed an EKG and announced: “You have A-Fib. Can you go to a cardiologist right now?”

This was my introduction to the world of A-Fib!

The cardiologist put me on Xarelto and after an electrocardioversion, I was A-Fib free…for 15 months.

I Began to Cough up Drops of Blood

At first it was occasional. Then as time passed, it became more frequent and larger amounts. Doctors thought that the use of Xarelto was the probable cause of the bleeding and advised me to stop the anticoagulant for 6 weeks, and hopefully the bleeding would stop.

Unfortunately, it got worse. And I went back into A-Fib.” continue reading William’s story…

 

GPA Disease Means No Blood Thinners: How to Deal with A-Fib Stroke Risk?

A-Fib Patient Story #85

GPA Disease Means No Blood Thinners: How to Deal with A-Fib Stroke Risk?

By William F. Covert, May 2016

My symptoms started with dizziness and constant fatigue. Several trips to my family physician proved to be futile.

2012: “Let Me Take a Quick Pulse Reading by Hand”

Personal A-Fib story of William Covert at A-Fib.com

William F Covert

On my last exam, the doctor stopped me as we were walking out of the exam room and said, “Let me take a quick pulse reading by hand.” (Blood pressure machines normally do not detect irregular heartbeat.) She did so, then performed an EKG. “You have A-Fib. Can you go to a cardiologist right now?”

This was my introduction to the world of A-Fib!

I saw a cardiologist the same day (November 2012) who put me on Xarelto (a blood thinner) and scheduled me for an Electrocardioversion a month later.

It was successful and kept me A-Fib free…for 15 months.

After my cardioversion, I was prescribed Sotalol (an antiarrhythmic medicine) for 15 months. But when I went back into A-Fib, they discontinued the Sotalol. They felt that, since the Sotalol didn’t prevent me from relapsing into A-Fib, there was no use in taking it.

2014: Coughing Up Blood

I began to cough up drops of blood. At first it was occasional. Then as time passed, it became more frequent and larger amounts. Doctors thought that the use of Xarelto was the probable cause of the bleeding and advised me to stop the anticoagulant for 6 weeks, and hopefully the bleeding would stop.

Unfortunately, it got worse. A second CAT scan 4 weeks later revealed my lungs were full of blood.

A second CAT scan revealed my lungs were full of blood. I was diagnosed with a disease called Wegener’s (GPA) 

I was diagnosed with a disease called Wegener’s (GPA-Granulomatosis with Polyangiitis), an uncommon disorder that causes inflammation of certain blood vessels. I was never told that Xarelto triggered the Wegener’s, but it certainly could make the bleeding worse.

Back in A-Fib, but Can’t Take Blood Thinners

The Wegener’s (GPA) caused damage and bleeding to my lungs, and I went back into A-Fib on March 31, 2014.

I was subsequently taken off of blood thinners and put on a low dose aspirin regimen to provide some element of safety from an A-Fib-related stroke.

Because of the Wegener’s, I would not be able to take blood thinners like warfarin (Coumadin) or Xarelto on a long-term basis.

Stroke Risk: Alternatives to Blood Thinners

I was acutely aware of the potential stroke possibility, because of being in A-Fib and not being able to take blood thinners. With A-Fib you need blood thinners to prevent a stroke. But Wegener’s (GPA) is a disease that causes bleeding. Blood thinners would only exacerbate the problem.

I was acutely aware of the potential stroke possibility, because of being in A-Fib and not being able to take blood thinners.

My cardiologist discussed the various alternatives to blood thinners. Some were invasive and not recommended because of my age (79).

After a few visits, my cardiologist told me about a new procedure using the Watchman device which would both help protect me from an A-Fib stroke and afterwards not require me to take anticoagulants.

[The Watchman Device closes off the Left Atrial Appendage (LAA) where 90%-95% of A-Fib clots and strokes come from.]

The Watchman Device: Weighing the Odds

If I decided to have the Watchman device installed, I would be required to be on the anticoagulant warfarin for 45 days afterwards. Then I’d need to take Plavix (similar to aspirin) for 6 months after that.

Why Coumadin and Plavix After Installing the Watchman? 

In the U.S., the Food & Drug Administration (FDA) requires the use of warfarin after installing the Watchman because it takes about 45 days for the thin layer of heart tissue to grow over the device. This is to insure you won’t have any blood clots that could pass around it and cause a stroke.

You will have a Transesophageal Echocardiogram (TEE) to determine the progress at the 45-day period and again at 6 months until Plavix can be stopped. Plavix is another requirement of the FDA. Doctors have to follow the FDA guidelines. (Boston Scientific is the manufacturer of the Watchman.)

For someone like me with Wegener’s, even this short a time on warfarin and Plavix was risky. But the effects of a stroke would be for life or might kill me.

For someone like me with Wegener’s, even this short a time on warfarin and Plavix was risky. But the effects of a stroke would be for life or might kill me.

My doctors would not offer their okay for me to be on warfarin and Plavix, even for that short a time.

Getting a Second Opinion: I also visited the Mayo Clinic in Rochester, MN for a second opinion. The pulmonologist (specialist in lungs and respiratory system) said that, because my Wegener’s was then in remission, a short course of blood thinners would be OK. However, the cardiologist told me he did not recommend doing this.

Bottom line: It had to be my decision.

2016: Chooses the Watchman (at Age 79)

After researching and reading the reports about all the clinical trials in the U.S. and the Watchman success stories in Europe, I decided, “This is for me!” I would go for the Watchman. This was better odds for me.

Catheter positioning the Watchman occlusion device at the mouth of the Left Atrial Appendage

Catheter placing Watchman in LAA

The procedure to insert the Watchman device took less than 2 hours at Ochsner Hospital, New Orleans, LA, January 20, 2016 by Dr. Stephen Ramee, Interventional Cardiologist.

I was on warfarin for a total of 45 days, and now I’m on Plavix for 6 months―till the middle of September 2016.

So far everything is going fine with me―but I’ll be glad when I’m finished with the Plavix.

I Still Have A-Fib, But It doesn’t Keep Me Down

I have A-Fib symptoms all the time. I feel the fibrillation, and it causes dizziness and fatigue. But I am better in the AM and get more fatigued around 2:00 PM. This doesn’t keep me down. I take care of our yard, play golf and travel, etc. My blood pressure medicine has been adjusted to assist in decreasing the light-headedness and fatigue. However, the GPA (Wegener’s) medication that I have to take can also cause these types of reactions.

I am now taking 100 mg of metoprolol daily which seems to be controlling my heart rate, although erratically. My heart rate is usually between 65-75 beats per minute.

Lessons Learned graphic with hands 400 pix sq at 300 resLessons Learned

If you have A-Fib and have other heart issues that will not allow blood thinners, consider the Watchman device implant.

I have never looked back and believe it was a great decision for me.

[William invites you to email him with your questions about Wegener’s disease and the Watchman device.]

William F. Covert, New Orleans, LA
covach(at)cox.net

Editor’s comments
Kudos to William for being proactive, educating himself, getting a second opinion and dealing with a very difficult situation.
William’s dilemma is not unique. Many people with A-Fib can’t tolerate or react badly to anticoagulants. Without anticoagulants, they are 4-5 times more likely to suffer an A-Fib stroke. With 90%-95% of A-Fib clots coming from the Left Atrial Appendage (LAA), the Watchman device (and other occlusion devices) are a welcome alternative to anticoagulants.
Guarantee Against Stroke? Does the Watchman Device guarantee William will never have an A-Fib or other kind of stroke? No. Like anticoagulants, the Watchman device basically reduces William’s stroke risk to that of a normal heart-healthy person (but they can have a stroke, too). There is nothing on the market that will absolutely guarantee you will never have a stroke. However, the Watchman Device comes close and it’s better than a lifetime on warfarin. (Be advised that clots and stroke can develop in other areas than just the LAA.)
William Can Still Have a Catheter Ablation: While William is protected from A-Fib stroke, he still has A-Fib. If he so chooses, he can have a catheter ablation to fix his A-Fib. Many EPs routinely perform a catheter ablation on people who have had a Watchman device installed, especially in Europe where they have been using the Watchman device since 2004. See: A Watchman and Ablation Combo? Everything You Never Thought to Ask.
Be proactive! Learn from William’s story. If he hadn’t done his own research and got second opinions, he might already have suffered an A-Fib stroke.
For more about the Watchman, see my two articles: Watchman Device Option to Blood Thinners and Watchman Better Than a Life on Warfarin.

Back to the Top

Return to Patient A-Fib Stories

If you find any errors on this page, email us. Y Last updated: Thursday, November 17, 2016

Become your own best patient advocate - horizontal Blue 400 x 328 pix at 300 res

Read other stories of A-Fib patients dealing with Atrial Fibrillation: see Personal A-Fib Stories.

65 and Older: 99% Have Microbleeds—So Are Anticoagulants Risky?

In a  recent study, 99% of subjects aged 65 or older had evidence of microbleeds; and closer examination of the cranial MRI images revealed an increased number of detectable microbleeds (i.e., the closer they looked, the more microbleeds they found).

Microbleeds in the brain are thought to be a precursor of hemorrhagic stroke.

Cerebral microbleeds (CMBs) are small chronic brain hemorrhages of the small vessels of the brain.

If Microbleeds Cause Hemorrhagic Stroke, Should I be on a Blood Thinner?

The fact that almost everyone 65 or older has microbleeds is astonishing and worrisome, particularly if you have A-Fib and have to take anticoagulants. Anticoagulants cause or increase bleeding. That’s how they work.

In plain language, this study indicates that cerebral microbleeds lead to or cause hemorrhagic stroke. It’s not surprising then that some doctors are reluctant to prescribe heavy-duty anticoagulants to older A-Fib patients.

Being older and already having microbleeds only makes taking anticoagulants all the more worrisome.

Risks of Taking Anticoagulants (Blood Thinners)

Taking almost any prescription medication has trade-offs. Older A-Fib patients find themselves between a rock and a hard place.

In the case of anticoagulants, on one hand you get protection from having an A-Fib stroke (which often leads to death or severe disability), but on the other hand you have an increased risk of bleeding.

For those over 65 who already have microbleeds, … Continue reading this report…->

Curing Long-standing Persistent A-Fib: Ablating the Left Atrial Appendage is Key

Patients with long-standing Atrial Fibrillation are often the hardest to make A-Fib free. Because of having been in A-Fib for so long, they may have developed many A-Fib producing spots in their heart besides in the Pulmonary Veins (PVs).

Patients with long-standing Atrial Fibrillation are often the hardest to make A-Fib free

To make them A-Fib free, the electrophysiologist (EP) must ablate (isolate) not only the Pulmonary Veins, but also many non-PV triggers. Isolating the Left Atrial Appendage (LAA) significantly increased the success of catheter ablation in long-standing persistent A-Fib patients.

BELIEF Trial—LAA Isolation 76% Success Rate

In a randomized study (BELIEF trial), 173 patients with persistent A-Fib either received standard ablation plus LAA isolation or standard ablation alone. (If patients continued to have A-Fib, they could have a repeat ablation which included LAA isolation.)

At 2 years, 76% of patients who had received standard ablation plus LAA isolation were free of arrhythmia vs 56% of patients who had received only a standard ablation.

Dr. Luigi Di Biase, who presented the findings at the European Society of Cardiology 2015 Congress, stated “We do believe (LAA isolation) should be the standard of care in patients with longstanding AF.

Isolating the LAA improved long-term freedom from persistent A-Fib.

But 52% Had Impaired LAA Function

Isolating the LAA can cause problems. If many burns have to be made at the LAA to achieve isolation, they may reduce the ability of the LAA to contract properly. … Continue reading this report…->

A Watchman and Ablation Combo? Everything You Never Thought to Ask

by Steve S. Ryan, PhD

The Watchman device closes off the Left Atrial Appendage (LAA), the source of most clots and A-Fib strokes.

The Watchman has been available in other countries since 2009, but only since 2015 in the US.

Research tells us that the Watchman device is not only as good as but is actually better for A-Fib patients than being on the blood thinner warfarin.  (See my post: Clinical Trials Results: Watchman Better Than a Lifetime on Warfarin)

Answers From Australia

A five-year study in Australia by Dr. Karen Phillips and her colleague, Dr. TW Walker, gives us ‘real world’ data and insights. Specifically, she studied combining the Watchman device with a catheter ablation for treating Atrial Fibrillation patients.

I’ve corresponded with Dr. Karen Phillips to help me answer your questions about the Watchman device.

“Can the Watchman be installed at the same time as my ablation?“

Yes.  Dr. Karen Phillips and several Electrophysiologists (EPs) in Europe have been doing this for over five years with no complications. She hasn’t seen any downside to doing the two procedures together. There’s very little, if any, experience in the US of combining a PVI with a Watchman device (US approved in 2015).

Should the Watchman be installed at the same time as my ablation?“

First answer: should the LAA be closed off? (Surgeons, unlike EPs, routinely remove the LAA in A-Fib surgery.) But the LAA isn’t a useless appendage and it has several functions. Younger people, especially the athletic, might be compromised by having their LAA closed off. (See LAA Important for Heart health.) There are many arguments for not routinely closing off the LAA in everyone. … Continue reading this report…->

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