Is It Possible to Remove the Left Appendage of The Heart Without Other Surgery like an ablation or Mini Maze? That appendage is often clipped so that no circulation is possible there anymore, and no leaking.
I don't have much wrong with my heart other than an occasional bout of SVT if I get my food intake wrong, which happens very rarely now. I wonder if it could be an alternative to Apixaban or other anti coagulant?
All the best.
Roy
Roy there is a procedure known as Lariate which is done laproscopically via a small puncture between your ribs. Not common and only one surgeon I know of who does it here in UK .
The big question is why would you want to?
The function of the left atrial appendage is largely not understood though many people suspect it has importnat duties in regulating blood pressure. Cutting it off just because a person doesn't want to take tablets is ill advised at best IMHO.
Yes for a very few people for whom tablets are not the answer (those with bleeding problems for example) it is a possibility to reduce stroke risk but of course not all clots are formed there anyway.
Thanks Bob.
I've been scouring the internet and it seems non of the studies showed any difference in the function of the heart with the appendage removed in conjunction with an ablation. There was a lot of discussion on what the appendage actually did, but only conclusion seemed to be that no one really knew.
The advantage would be that it would cut down on the small risk of a bleed with an anti coagulant. Of course there is a risk to every operation though.
All the best.
Roy
Interesting question Roy. Yes, it's possible but the question is should it be done and will someone do it.
I imagine the reason you are asking is that you don't need or want a catheter PVI or Mini Maze but want to come off thinners? Then it becomes the risk versus reward of the procedure versus coming off thinners which you and your doctor will base a decision on.
There are also arguably less invasive procedures to get off thinners such as the Watchman Device which is catheter introduced, but I assume you prefer the true surgical route?
You should also know there is no guarantee that either a surgical or catheter solution will be 100% successful in the sense that you can safely get off thinners, however I would assume the stats are pretty good and they should be out there to review.
Jim
Thanks Jim.
Surprisingly there are no stats for just removal of the appendage on it's own. Only stats for with other procedures. There was a lot of discussion on what the appendage actually did, but only conclusion seemed to be that no one really knew. The hormone that is produced to lower blood pressure produced by the atrial wall stretching. Not the appendage.
All the best.
Roy
That's a very good point because stroke risk might decrease from the PVI itself, unless there was a relevant study control.
Also I haven't had my morning cup of coffee yet (other side of pond) which I stopped drinking anyway, so missed that you only have occasional SVT episodes and not afib.
So that begs the question if you need thinners at all which is above my pay grade as I read in your bio that you also had a stroke. There are also some papers out there on the efficacy/wisdom of thinners in an older age where more cormobitities are present. And then there is your family history of bleeds and the fact you still race competitively. So it's really a matter of risk stratification which sometimes leads to no correct choice.
Jim
I'm not really competitive nowadays Jim as I'm never on the Podium any more. I just like racing on tracks as they are always less punishing than my training route being relatively flat. My power output has increased a lot since I've been drinking the green tea. It's almost back to my pre stroke output. (when I was 75) Have seen a max of 900 watts and an average of 160 watts for 2 hours.
"So that begs the question if you need thinners at all which is above my pay grade as I read in your bio that you also had a stroke. There are also some papers out there on the efficacy/wisdom of thinners in an older age where more comorbidities are present. And then there is your family history of bleeds and the fact you still race competitively. So it's really a matter of risk stratification which sometimes leads to no correct choice." That's basically what they said on the stroke unit.
All the best.
Roy
Roy: 'm not really competitive nowadays.. My power output has increased a lot since I've been drinking the green tea. It's almost back to my pre stroke output. (when I was 75) Have seen a max of 900 watts and an average of 160 watts for 2 hours.
---------
That's competitive enough for me! Just started daily treadmill training and introducing coffee again, but based on what you just said, got to look into that green tea! But of course I was talking about the risk of falls which I assume is less on the tracks but still there.
Curious, what is your workout heart rate range? Because intense exercise has triggered my afib, I'm trying to keep my HR at 70% of age predicted maximum so try and workout between 95-105bmp with short intervals in the 110-115 range, which is a far cry from my younger days but enough to keep me somewhat fit and so far out of afib.
In any event, sounds like your in good hands with the stroke unit and would be interested in what they have to say about the hypothetical surgery should you get to the point to ask them.
Jim
I've seen max 154 bpm on the hills. In SVT that can become 204. I never take any notice though and try to put out the same power. My first SVT event went to 254 bpm. So I regard 204 as being not too bad. The hospital and GP were never able to reproduce any arrhythmia though. Even though I was having check-ups for 2 years before I had a stroke. I always know if I'm having an SVT day as my heart starts at around 150 straight away. On a normal day it starts at 83 bpm. rising to 123 bpm as I get going.
In the stroke unit they put me on a bike that measured power output for each leg and on my side that was paralyzed at first had dropped from 168 watts average to 60 watts average. So enough to walk, climb stairs, and ride a bike after 2 weeks out of hospital.
All the best.
Roy
For comparison, when I was 50 I made the switch from mountain to road bikes and I used to race with a heart beat of 178 bpm average for an hour. I used to be able to do 40 mph for short periods on the Herne Hill Velodrome. I used to average 25 mph everywhere I went on the roads even when I wasn't training. I just did not know how to ride slowly in those days. Came close to being British number one in my class of cycle racing. My endurance and recovery was legendary in those days. Fortunately the bikes have gotten faster while I've been getting slower, so I'm still quite fast even if the young guys are faster.
All the best.
Roy
Wow, Roy. You sound world class. My best, ten years ago (age 65) on the rowing machine, was 188W for 30 minutes - not racing just steady state.
I followed you on Strava and saw that you did a 10.5km ride for 45mins, which is similar to my 8.5km 45 min row.
Perhaps your stroke did not originate with a clot in the heart but excessive pressure on blood vessels, which caused a rupture?
nicswell.co.uk/health-news/...
I read that the Watchman device, which is a plug inserted via a groin catheter into the LAA (Left Atrial Appendage) is statistically more prone to stroke because it is inside the heart with the blood supply.
The other options are keyhole (side of chest between ribs) stapling or clipping the LAA, and can be done stand-alone.
No. That would have resulted in a bleed, not a clot. No sign of a bleed. I was taking a post lunch dump when it happened. Folded up on my right side and ended up with my bum on the john and my head on the floor. Not a move I am usually capable of due to my bad back. No pain while it happened though. (Or afterwards) Just a weird feeling of lack of control and wondering what was going on. When the stroke unit put me on a heart monitor my heart rate was all over the place during the night, but stabilized the next day. Lost my voice as well as being paralyzed. On the good side my hay fever allergies went away and so did my IBS. Didn't come back until a long time later. It was nice being able to smell flowers in the summer, and taste food that I wasn't able to eat normally.
What was the date of the Strava ride you looked at? I have thousands recorded. Non from the old days of course, they are all in notebooks as computers like we have now weren't for sale to the public and no internet of course.
All the best.
Roy
Hi Roy. Looks like you rode today: 10.5k 40mins. I could swear the one I saw earlier (same course) was 45 mins.
Really sad to hear about your mini stroke. It's great that you recovered so well.
Perhaps time to tone it down a bit?
Lots of benefits in long, steady state exercising at a lower effort?
Regarding the stand-alone LAA clipping, why not contact Dr Steven Hunter, Alison's (MummyLuv1) surgeon (see her comments below). She had the keyhole maze procedure just four days ago.
Wishing you all the best with great health. Saul
Hi Saul. I was only doing a recovery ride today. I'm a fully paid up member of Strava. Not sure what you see if you're not. You can follow me if you want a regular update on my cycling progress. I should have raced on Sunday, but my wife had a TIA recently so I've not been racing so that I can be on hand if she needs me. I still went training on Sunday though. Had a bit more speed (For the Sprint 26) even though it was a longer hillier ride. strava.com/activities/71084...
My hand made German Velomobile is a lot, lot faster, as it's about half the weight and 10 times more aerodynamic.
Nothing mini about my stroke.
All the best.
Roy
Hi Roy. Shows you how little we get in Greece. Never heard of a Velomobile. Is this what you ride?
Also never heard of Northiam, but it looks very nice.
Take care to avoid another stroke.
All the best from hilly Athens. Saul
Yes Saul. Very big on the continent. Here is a BHPC race I participated in last year. recumbent.news/2021/10/31/s...
And here is a photo of the last World Championships held in the UK. I came 80th out of 160 in the 3 hour race. I could have finished higher but I chose to do it on my 30 year old bike as I wanted to see how it related to my previous World Championship performance on the same bike. I knew I had no hope of beating the current world champion anyway, My heart started of in SVT at 204 for about 40 mins but then it went to a normal rhythm of 123 bpm for the rest of the race. I did 86 km if I remember correctly.
Here is me in practice for the 3 hour.
Here is my first race after I bought the After 7 back from Germany (586 miles) I came 4th in my class.
Very nice, Roy. Your bike version, which is "Monty Python"- like, compared to the Velomobile, would not have a chance against the sleeker contraptions. I read that the recumbent position and the effort required is much less than a bike, hence the 35km/hr for even normal bikers.Wishing you luck for the season and to not forget the heart...
Saul
The classic Kingcycle used to dominate the tracks back in the day and I was lapping other bikes in the time trial on the Velodrome. I broke the course record with it in the World Championships road race. It is still a very competitive machine in the hands of a strong rider. The Kingcycle factory gave me one of their special race machines after that (Kingcycle Wasp) and I came within seconds of beating the world champion with it. He also rode for Kingcycle in a Wasp, and still does ride for the factory but in a Kingcycle Beano.
All the best.
Roy
Roy, I had no idea, but knew you were world-class from your power output.Well done to you. I was misled by Alan's Kingcycle with the yellow raincoat...
youtube.com/watch?v=TkorPHB...
On a serious note, I hope that your EP approves of the strain that you are placing on your heart.
Maybe time to dial down a little?
Sincere wishes to you. Saul
That is my Kingcycle Alan is riding with the front fairing on. He bought it after my stroke as I kept falling off my bikes so had to sell them all. As he said it was one the first practical recumbents that could do everything. He loves them and they are so old now they qualify for vintage races. I ordered the Velomobile at the World Championships in 2018 and had to wait in a queue for 2 and a half years due to Daniel Fenn's order book. (He has a factory in Romania that produces his designs as well. But not the After 7) I collected it as soon as there was a break in the Covid travel restrictions in 2020. As for taking it easy. I still enjoy it and your a long time dead Saul and I'd rather die on a bike than in bed.
An American magazine came over with a camera crew to film the 2018 World Championship and here is the video they made. The German guy Daniel Fenn who designed my After 7 (and all the DF's) won the multi track class so you can see him on the podium. Also Steve Slade my nemesis, whom I was never able to beat on the hills. He did not take the win this year as he was unlucky and beaten because he was held up by a slower group of riders just before the finish line despite having averaged 40 mph for three hours. He does not have AF and is 18 years younger than me as well.
All the best. Roy
I just came in and I'll have a look at both videos.I saw that you are 78, so there's still hope for me to train up- 76 this year...
You are right that we're long time dead and also long time alive, so I am not rushing...
I knew that you're world class and I can se how much you enjoy the racing fraternity and the challenges.
Was the stroke because you were in AFib (or SVT) for too many hours?
I am not on an AC because I tend to fall about a bit, and read that it takes quite a few hours of churning for the blood to form a clot, which may not be true ?
How is your AFib (SVT) now and how do you control it ?
Stay well, Roy.
Not that I know of, just bad luck according to the stroke unit. Wasn't aware of being in SVT at the time the stroke happened I don't think the Apixaban delays clotting for very long, (20 mins?) only enough time for the blood not to be able to form a clot in that appendage So I'd have thought a faster heart rate was an advantage as blood would clear the appendage quicker.
"I am not on an AC because I tend to fall about a bit, and read that it takes quite a few hours of churning for the blood to form a clot, which may not be true ?" I think that's a myth.
I rarely get any SVT at all as long as I am strict about my diet, no milk products, no fat, or empty calorie food, high fibre bread lots of vegetables and fruit, avoid stress, avoid alcohol, have a regular bed time, get a good nights sleep. Allow time for recovery when I race or train. I do weights once a week, stretching exercises once a week, and go for a 30 min. walk twice a week.
One thing I'm convinced of is that recovery from any injury is faster if you are fit. I saw some truly sad things on the stroke unit. They really cannot do much for a bleed and I saw a 40 year old man who had been to the pub for a night out and suffered a massive bleed who was totally screwed and his partner and Mother were absolutely devastated when they were told that was as good as it was going to get. I felt like a fraud as I was recovering so quickly the stroke unit were having trouble keeping up. Every time they interviewed me to write a report things that had been on the previous report from the day before were no longer a problem for me. In the end they discharged me early because I think they were fed up with me getting up every day at 6 am and going for long walks around the hospital and grounds.
All the best.
Roy
This is the Kingcycle Wasp that I had a lot of success with. Hit 70 mph in the Darlington Time Trail. Held off Steve Slade for most of the 30 mile race but he took me on the last hill climb.
Roy, from what I understand, as Bob says the appendage does have something to do with blood pressure because some people with high blood pressure who have had the mini maze and the appendage clamped have been able to get off blood pressure meds. That tells me that it has an effect on bp. Good or bad I don’t know but apparently good for people with high bp.
I have very low blood pressure. I'm not on any blood pressure meds. Not sure if that makes it any help with removal or not.
All the best.
Roy
Yeah I wondered what happens with low blood pressure. I don’t know how removal would affect low blood pressure. Best of luck to you!
When I am a bit more recovered I’ll dig you out the research papers but from memory a left appendage closure reduces stroke risk by 97%, blood thinners by 60%. Nothing is 100%.
The left appendage is known to help you flush out fluids from the body. In time the smaller right appendage takes over this function but in the meantime you may need meds for a few weeks to ensure you have no fluid build up.
I’m not sure if anyone in the U.K. will do a stand alone appendage clip unless you have a reason for not wanting to take blood thinners or can’t (in my case I had a brain bleed years ago and I want off blood thinners as soon as possible). You would be going through surgery to have it done.
Personally I am not a fan of the watchman device as a route to closing the appendage. From what I have read vs surgical closure there is a higher risk of clots as it’s like putting a plug in the appendage and the appendage is all different shapes and sizes in us all so how can a standard plug be a snug fit?
The stuff I've read says it's the stretching of the atrial wall that produces the fluid flushing hormone that is sent to the kidneys. The articles I've read come to no conclusion what the appendage does though.
Agree about the watchman device, any object inserted into the body causes clots to stick to it. Eventually they get big enough for a bit to break off. That's the problem with metal pins and joints.
All the best.
Roy
The comment on fluid was from my surgeon yesterday. His experience rather than the stats from research papers 
I've just had a thought that maybe it's a function that's needed in childbirth to lower blood pressure while the baby is being born.
It must serve some purpose at some point?
All the best.
Roy
Roy previously: "'I've just had a thought that maybe it's a function that's needed in childbirth to lower blood pressure while the baby is being born."
Roy, if that's the case, after the procedure, maybe you should consider taking birth control pills.
Jim
🤣
I’ve had two strokes and one TIA. The new Watchman Flex, which came out in July of 2020 is far superior to the older Watchman. My EP highly recommended it to me because of my history of strokes. It is a very simple procedure with 95% of patients getting off of blood thinners within the first 45 days. You do remain on a daily baby aspirin indefinitely if you are at higher risk of forming clots outside of the LAA. There is a Watchman FB group you may want to check out. Read about other people’s experiences. As with any surgery you want someone very experienced with what they are implanting. My EP has done more Watchman placements than any other in the US. Someone mentioned the Lariat. My EP has done about 45 Lariats. He does not recommend them due to 16% leakage and can be a dangerous fix. The new Watchman Flex, if leakage (an area where the Watchman does not seal over) occurs can be easily fixed with a device called an Amulet to go over the hole. Also checkout Watchman.com. My EP is very straightforward. Told me the old Watchman had problems with about 31% leakage. You will run across studies on the older Watchman that are not very favorable.
Thanks for the info. Not sure what to make of the stats. EP does not approve of a 84% success rate! Presumably because it's difficult to fix if your one of the 16% with leakage. However I don't like the idea of aspirin as I have a dodgy stomach even when it's behaving it's self.
All the best.
Roy
Yes, that is a dilemma alright. I would never do the Lariat after speaking with my EP. Way to risky. Also, not everyone has to stay on baby aspirin after Watchman. It is up to the discretion of your EP and how prone you are to blood clots.
Left Atrial Appendage Closure, why not do it as a matter of routine during ablation?
Left atrial appendage occlusion
Article on left atrial appendage.
Does anyone have experience of Left Atrial Appendage occlusion.
Arrhythmia after open heart surgery - any others with similiar experiences?
