Removal of left atrial appendage

[Aqua_1]

Hi, has anyone here had just their LAA removed without having the entire mini maze procedure? I understand that by removing the LAA stroke is reduced by 97% and is a minimally invasive procedure. If that's the case, why isn't it this being offered as a first line of defence against stroke?

[CDreamer]

Because it’s an invasive procedure accompanied by it’s own risks, for most people in UK not available on NHS unless they have blood disorder which means they cannot take oral anticoagulants and studies I have read is that removal of the Atrial Appendage may have consequences as it’s purpose is not yet fully understood but there could be advantage to holding on to it. Wouldn’t be my choice.

[BobD Volunteer]

I agree with CDreamer but will go further.

Many doctors believe that the LAA has an important job in regulating blood pressure. The LARIATE trans thorasic laproscopic procedure has been done from memory by Dr Jonathan Hyde in Southampton. I met him at conference some years ago soon after he returned from USA where he had studied it.

In the meantime for those people for whom anticoagulation is contra indicated there is still Watchman. (Tea strainer over the LAA entrance.)

The longer you are in this business the more you realise that nothing is a simple as you might wish.

[Aqua_1 in reply to BobD]

It's interesting though Bob that there are surgeons that are removing the LAA? Dr Wolf comes to mind?

[Poochmom in reply to Aqua_1]

Dr Wolf doesn’t remove the LAAHe clips it with an atriclip, a device he pioneered to completely isolate it. It is similar to the watchman except the atriclip is complete isolation, tested by a TEE where the watchman can leak as it plugs an opening that isn’t always completely round.

Some patients with high blood pressure can come off blood pressure meds after clipping as their blood pressure reduces. So I would surmise that the LAA sometimes raises blood pressure and according to Dr Wolf sometimes AFib can originate in the LAA. Dr Ohtsuka in Japan does remove the LAA.

[Aqua_1 in reply to Poochmom]

Thank you Poochman. What happens in cases where patients already have low blood pressure prior to removal of the LAA? Would you or anyone in this group know?

[Poochmom in reply to Aqua_1]

My blood pressure wasn’t high. It’s always been normal and has not changed since mine was clipped. I don’t recall hearing anyone talk about having it go too low after surgery even if they had lower blood pressure so I don’t know what it is about the high blood pressure that lowers.

[Goosebumps]

it’s a good question to put to a thoracic surgeon, I suspect that the medical profession avoid surgical intervention ( non Catheter) if a relatively cheap drug can do the job. Now generic Apixaban is available apparently in the UK so it will be even cheaper to take that route. Plus I wouldn’t let anyone try this operation on me unless they had a lot of experience, and that’s a catch 22 because there aren’t enough surgeons around with the skills to make it an everyday operation.

Dr Ohtsuka who does the Mini maze in Japan has a flow chart where he shows his decision path to only doing an LAA. Don’t quote me, and you may already know this, but I think he states an incision to closure time of 25 mins to staple the LAA. But then he is an expert.

[Aqua_1 in reply to Goosebumps]

Thank you I an seeing my EP in a few weeks and will ask.

[MummyLuv in reply to Aqua_1]

an EP will offer you the watchman device rather the left appendage clipping.

[MummyLuv]

you would need to have a very good reason for not taking anticoagulant before a left appendage closure will be considered. It’s an invasive procedure with risk and so your reason would need to be strong. I have a history of internal bleeding which is why I didn’t want to be on anticoagulant for too long and had my left appendage clipped.

[Cat04 in reply to MummyLuv]

I recently had my LAA clipped too.

[MummyLuv in reply to Cat04]

hope is going well for you Cat. Did you have it done as part of other surgery?

[Cat04 in reply to MummyLuv]

Yes I had OHS for AVR, LAAe clip,ligament of Marshall divided and pvi ablation.

[MummyLuv in reply to Cat04]

hope you are all recovered now 💕. I’ve personally never heard of left appendage clip on it’s own in the UK but that doesn’t mean it doesn’t happen

[Cat04 in reply to MummyLuv]

My understanding is that it is only performed at the same time as other procedures but I may be wrong. It's a fast moving area of medicine and its difficult to keep up with all the new techniques.

[Aqua_1 in reply to Cat04]

Thank you. We're you on anticoagulants prior to getting your LAA clamped?

[Cat04 in reply to Aqua_1]

Yes I was on warfarin initially but found keeping my INR stable was very difficult & was changed to apixaban in 2018

[Aqua_1 in reply to Cat04]

Thank you Cat04. I hope you have had a complete recovery.

[Aqua_1 in reply to MummyLuv]

I would need to discuss with my EP as I'm not sure if I can even take anticoagulants as my blood thins out easily with aspirin and fish oil.

[Auriculaire in reply to Aqua_1]

Aspirin and fish oil are anti aggregants not anti coagulants. They stop platelet clumping which is not the same as slowing the rate of coagulation . The two processes should not be confused. This is why neither aspirin nor fish oils should be relied upon for preventing clot formation in the heart as can happen with afib.

[MummyLuv in reply to Aqua_1]

definitely discuss but unless they work closely with a cardio thoracic surgeon they are unlikely to know much about left appendage closure,

[Goosebumps in reply to MummyLuv]

Hello Alison. Through your extensive research on the Mini maze, do you know if all of the practitioners routinely close off the LAA as well?( US, Uk, Swiss, Japan and Netherlands being the areas you have said are most forward in the MM).

I can’t believe that these experts would risk creating issues in patients( blood pressure that Bob D refers to) simply because they happened to be on the operating table. They must see the clipping of the LAA as a real benefit, even in patients who have no issues taking anticoagulants.

I’ve seen a few open heart surgery patients on here mention having their LAA closed as well, (like Cat04 has done), but I’ve no idea if they do this routinely for bypass ops where the patient isn’t on anticoagulants.

It’s just all so damned confusing and contradictory.

[MummyLuv in reply to Goosebumps]

yes, it’s standard for the left appendage to be clipped or stapled in any mini maze or open heart maze where surgery is being undertaken anyway. Bob is right that the purpose of the left (and right) appendages are not fully understood but you still have your right appendage after surgery. It has a more open link to the heart so clots are less likely to gather there.

[Poochmom in reply to MummyLuv]

I wondered about the RAA. Thanks for that explanation.

[mjames1]

I was wondering the same myself and did a little research. Dr. Wolff of WMM fame will do a LAA without the mini maze. Not sure what his criteria is, but I'm guessing he will do it if you have a legitimate reason and so many legitimate reasons not to take thinners and I'm sure you have one. Not sure on your side of the pond.

The comparison would be against the Watchman device which is often done outside an ablation, however the Watchman is a less invasive procedure although the LAA is much less invasive than a Mini Maze. That said, the Watchman requires daily Aspirin and that could be an issue for some. It is for me.

If you research this further, please report back on what you find.

Jim

[Aqua_1 in reply to mjames1]

Thanks Jim. I'm actually not on anticoagulants at the moment however I'm sure as I age I will be required to take them. I have a real fear of taking them as when I was first diagnosed with AF the cardiologist told me of the risks and benefits of taking them at the risks scared me. I have seen another 3 EPs and all are comfortable with me not taking them at the moment. There has to be another option other than taking anticoagulants for life?

[mjames1 in reply to Aqua_1]

That's great you don't need them yet. As to "another option" -- and I assume you mean non-surgically like Watchman -- there is a study now starting by Dr. Rod Passman on PIP anti-coagulation.

You should be able to 'google' the trial and some of his videos. In short, you only take the anti-coagulant (AC) at the onset of an afib episode lasting more than an hour and for I think 30 days after. So, if you only had two episodes a year, you would be on AC's for only 60 days and not 365. And while this concept has been around for awhile, most ep's are against it, but maybe the trial will change some

Personally, I am CHADS 3 (one point for hypertension history and 2 points age related) and have been on PIP anti-coagulation until recently, when the frequency of my episodes increased to the point where it wouldn't make sense. After my ablation, depending on how successful it is, I may go back to PIP AC, but frankly I will be a bit uneasy until the trial data comes in. That said, I'm uneasy taking them now! Rock and a hard place.

Jim

[ozziebob in reply to Aqua_1]

Further to mjames1's reference to the trial of a PIP use of anticoagulants, here's a short article about that trial ...

news.northwestern.edu/stori...

[Aqua_1 in reply to ozziebob]

Thank you!

[JefferyW]

There is an alternative procedure. I had a Watchman device fitted which is like mesh type expanding doughnut washer that internally seals off the LAA. It’s part of a trial and I no longer take Apixaban. Wathchman devices have been used for sometime and this trial of several thousand patients in USA, UK mainly is seeking to establish whether it is more effective at reducing stroke risk with afib patients than those on anticoagulants. The advantage would be the elimination of internal bleeding risk associated with anticoagulants. I had my procedure at Oxford University John Radcliffe Hospital back in November and feel great. Just take daily low dose aspirin for next 6 months and will be monitored for next 5 years.

The procedure is minimally invasive - it’s inserted into the LAA via the groin and takes about 20mins. It is a cost effective alternative to long term drug use and has a high success rate.

The long term objective is to offer this more widely to Afib patients to avoid long term use of anticoagulants.

[Aqua_1 in reply to JefferyW]

Thanks JeffreyW, the Watchman sounds like a good option however I am not sure if it would be a good candidate as my blood easily thins out with aspirin. I was taking aspirin daily when I was in Europe a few years ago and I was bruising very easily. My GP ordered a few blood tests and when he saw how much my blood had thinned out the asked me to stop taking them. Even fish oil does the same to me.

[Cat04]

I didn't have my LAA removed but had it clamped off with a spring clip.

[Aqua_1 in reply to Cat04]

I think that's what Dr Wolf does. He clamps the LAA with the Atriclip.

[Poochmom in reply to Aqua_1]

yes that is what Dr Wolf does and he tests it to make sure it’s completely isolated.

[2018NSR]

I rarely comment here but do have some information about the LAA. You are correct in saying the LAA has hormonal factors that causes water Retention thus increasing blood pressure. After the mini maze either done by Dr Wolf or Dr Ohtsuka blood pressure meds are taken in half and many times after the healing period people are able to get off blood pressure meds altogether. What many don’t know is that you also have a right atrial appendages as well but it does not pose the stroke risk that the left atrial appendage does. Dr Ohtsuka own words are “ the gift of removing the left atrial appendage is the prevention of stroke, decreased blood pressure and improved homeostasis”. Also 20% of afib can come from the LAA and clamping or excising the LAA electronically isolates the appendage eliminating afib from coming from the LAA. Dr Wolf has clamped the LAA without doing the mini maze on those who are unable to take blood thinners or just wanted to reduce stroke risk but were unable to have the mini maze for various reasons. It is about a 20 minute procedure. Dr Wolf uses the atriclip and Dr Ohtsuka removes and staples the appendage. I know of a 78 yo who had his LAA clamped about two months ago. He was unable to have the mini maze due to scarring from a previous heart surgery but was having significant bleeding issues and could not take Eliquis. This was an excellent choice for him. I’m hoping with surgical ablation now being offered more for my UK friends this may be a future option as well.