Can One Have a Stroke If A-Fib Free? Years After Successful Ablation, He has TIAs

Steve from Minnesota had a successful catheter ablation in 2016 at the Mayo Clinic. He remained in normal sinus rhythm (NSR), off all medications and felt very good. He walked every day and felt well.

Recently he wrote to me that in the fall of 2018, he had a TIA (Transient Ischemic Attack, a temporary stroke) where his left arm went limp for about 30-60 seconds. Then in March 2019, another TIA caused him to lose complete vision in his left eye for 2-3 minutes.

In response, his electrophysiologist (EP) put him on the anticoagulant Eliquis. He wore a loop monitor which showed he was in normal sinus rhythm with only a single “5-beat atrial tachycardia” (only one irregular beat). All the usual tests came back showing no heart problems.

How can Steve have TIAs if he doesn’t have any A-Fib?

Unfortunately for A-Fib patients, clots and stroke can also be non-A-Fib related, such as vascular strokes or hypertensive lacunar stroke. (Vascular and cerebrovascular disease can produce a heart attack or coronary event as well as a clot or stroke.)

With A-Fib patients, clots more often come the Left Atrium and Left Atrial Appendage (LAA). But stroke can originate from other areas. For example, plaque deposits in the arteries can break loose and form clots.

Also, if Minnesota Steve developed some fibrosis while he was in A-Fib, his left atrium may not be contracting properly making clot formation more possible. And sometimes if the LAA is electrically isolated during the ablation, it may not be contracting properly and can develop clots.

(Doctors may want to check Minnesota Steve for Patent Foramen Ovale and Atrial Septal Defect where a hole in the septum can permit clots to pass to the brain. Though, normally, this problem would have been found when performing Steve’s original ablation.

Would a Watchman device to close off the LAA prevent these TIAs?

Not necessarily. For patients with A-Fib, clots tend to form in the Left Atrial Appendage (LAA) because blood tends to stagnate there. But if blood is being pumped properly in the left atrium, it’s harder for clots to form in the LAA. (And other areas of clot formation can occur in the left atrium besides the LAA.)

What should Steve do now? What can he do to guarantee that he will never have a stroke?

Having TIAs is a warning sign. Often, but not always, TIAs precede a major stroke. To help guard against clots and stroke, Minnesota Steve will likely have to be on an anticoagulant, such as Eliquis, for life.

What’s Next for Steve?

Minnesota Steve and his doctor should concentrate on treating vascular risk factors such as blood pressure, diabetes, cholesterol control, (CHADs2-VASc) and if needed, stop smoking. And, of course, continue monitoring for A-Fib.

Fibrosis makes the heart stiff, less flexible and weak, overworks the heart and reduces pumping efficiency.

Minnesota Steve probably should have an MRI done to measure for fibrosis in his heart. In addition, his Left Atrial Appendage (LAA) should be checked with a echocardiograph (TEE) to see if it is emptying properly.

His doctor may also want to determine how much plaque Minnesota Steve has in his arteries. How likely is it to break off and form clots? (Some doctors may suggest antiplatelet therapy in addition to the anticoagulant Eliquis, but usually the two are not combined effectively.)

I’ll continue to track Minnesota Steve’s progress and write an update if I get more information on his health status.

No Absolute Guarantee Against Stroke

While anticoagulants significantly lower the risk of an A-Fib stroke, they but do not totally eliminate it.

A close friend of ours with A-Fib was on Coumadin at the ideal INR range (2.5) and still had a major stroke.

After a successful catheter ablation such as Minnesota Steve had, one’s stroke risk generally drops down to that of a normal person. But normal people have strokes and TIAs, too.

There is no therapy that will absolutely guarantee one will never have a stroke.

Minnesota Steve is blessed to have no permanent damage from those TIAs. But they are warning signs which must be heeded, probably by life-long anticoagulation. No one wants to be on anticoagulants for life. But he may not have any other choice.

Share your insights: Without a lot of current definitive research, this is a difficult subject to discuss. If anyone has any suggestions, criticisms, or comments to share on this most important topic, please email me.

A special thanks to Steve from Minnesota for asking this question and sharing his TIA experiences.

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