Alternative to Anticoagulation?

[mjames1]

This is very new and exciting. Just a case history for now, but apparently they have done a Left Atrial Appendage (LAA)Closure during an RF catheter ablation procedure, guided by 3D printing technology!

As many of you know, there now exist several devices like Watchman and Amulet that are inserted into the left atrial appendage via catheter, sometimes as a standalone procedure, but usually as part of an afib catheter ablation. Studies show that patients with these types of devices are at the same reduced stroke risk as those on daily anti-coagulants (AC's). However, the issue with these devices, even though you can stop AC's, are that you still have to remain on low dose daily aspirin for life, which some may not want for various reasons.

The alternative has been a true LAA closure procedure like AtriClip. Like it's name suggests, there the LAA is simply clipped off. The results are as good, if not better than Watchman, but daily aspirin is not required for life. The downside, however, is that unless you are combining this with a mini maze procedure where AtriClip or similar are routinely used, AtriClip is much more invasive than Watchman/Amulet.

So, it sounds like if this case study ever comes to fruition, we may have the best of both worlds. A relatively non invasive procedure to clip off the LAA, giving us the same stroke prevention as AC's without their risks and without the risks of daily aspirin.* A procedure that could be done at the same time as catheter ablation, but I also see it as a standalone for those who have already been ablated, or do not require ablation.

There is the issue that strokes can originate from other than the LAA, but again, there is strong study data to show that an LAA closure device in the real world prevents strokes just as well as daily AC's, with less bleed risk.

Anyway, I'm excited and am going now going to right now check out 3D printer prices on Amazon

Link to article below.

Jim

* I'm assuming daily aspirin is not required, however do not have access to the full-text version, nor is this procedure at the trial stage yet.

onlinelibrary.wiley.com/doi...

[KiwiBlake]

Very interesting Jim. My hope is that in my lifetime medical research and advances will continue, to the point that we will be free of this burden. Thanks for posting. Blake

[BobD Volunteer]

I fear that my life span may not allow it but wouldn't it actually be a lot better if they found the reason for AF and treated that rather than the symptoms? (Getting cynical in my old age!)

[mjames1 in reply to BobD]

I think it's unfortunate that this particular concept has taken so long to come around. 3D printing technology has been around for many years.

Hopefully this, or something similar, will be available within 5-10 years for both you and I to have the option. As to finding the reason for Afib, that may take longer.

However, the next big leap appears to be treating afib from the outside, not the inside, using targeted radiation. No catheters, no surgery. Promising results already in animal models and a few human experimental cases. Progess with afib is slow, but at least a few ep's are working on it, as opposed to must churning out one ablation after another!

Planning on watching Canadian Grande Prixe, or not your kind of Motosport?

Jim

[BobD Volunteer in reply to mjames1]

Best way for me to get a nap Jim. Still start watching it though. Never been any different. I remember in the eighties when we were always support race at British GP parking our van on the infield at Stowe Corner, climbing on the roof and falling asleep. It was only when John Watson took the lead that the roar from the crowd woke me up!

[mjames1 in reply to BobD]

In high school in the 60's, told parents I was staying at a friend's overnight. He told his parents the same. We both ended up driving 800 miles, 11 hours to Indy for the 500. Got an infield ticket and promptly fell asleep in car for most of race. But in all fairness, quite tired from the drive. He had a 50's (maybe 40's?) MG convertible and loved cars, so was easy to convince.

Something about F1 though. A unique combination of soap opera and motorsports It's gotten quite popular here now with the NetFlix series, which I haven't watched except for one episode. Been following F1 for many years, but have to admit I frequently record and fast forward when someone eventually/hopefully makes a pass. But today will be watching live since it's in Canada.

EDIT: Now that I think of it, I think my friend had a 40's something Alpha convertible. It was some time ago.

Jim

[Espeegee in reply to BobD]

I think that's how medicine operates in general, treat the symptoms not the cause. Keeps the drug companies in profit.

[Mumursa in reply to BobD]

I agree with you. Clipping the LAA doesn’t necessarily mean no DOACs

I have had my LAA clipped with an atriclip but I still have to take Edoxaban because I still have AF.

[Goosebumps in reply to Mumursa]

please tell us more about your situation if you don’t mind. During what operation was the atriclip implanted? If you were hoping to be out of Afib I do sympathise most wholeheartedly that you are now suffering again. Hopefully it is only temporary.

I am quite bewildered by the apparent inconsistency of logic and information on the LAA and it’s part in creating strokes. Anyone can have a stroke, but if one has AF it is apparently 5 times more likely than the general population. We are told this is because clots form in the LAA. So if the LAA is occluded, the risk of a stroke should be no greater than the risk in the general population unless there is a subset of information regarding strokes and AF that I’m not aware of. And stopping an anti coagulant also reduces the bleed risk, it must be a delicate balancing act.

I am sure that your cardiologist is completely correct in asking you to stay on an anticoagulant for reasons that suit your case, I would just like to understand more so that I can update my thinking.

[Mumursa in reply to Goosebumps]

Both my EP and GP have been firmly of the opinion that I should stay on an anticoagulant, and I choose to accept their advice even though I have read information which would appear to contradict this. I have a degree of heart failure, an enlarged atrium and two leaking valves, and in my case, I believe, clots can form elsewhere.

My LAA was occluded during a simultaneous hybrid ablation in 2021. I agreed to it on the basis that the LAA is said to be a possible source of Afib, more than for the prospect of discontinuing the anticoagulant.

The aim of the procedure was to get rid of the Afib. For approx. 9 months my Afib was at 2%. Even at this level the EP and GP advised continuing anticoagulant. It's now over 40% and gradually getting worse. It's measured by my pacemaker. It doesn't stop me doing very much though, it's mostly that I get out of breath and my heart feels tired after a few days of it. My valve condition deteriorates with more Afib.

I appreciate your expression of sympathy, but I'm not too disappointed with the results of the medical interventions I've had, I've been able to get on with a slightly restricted but still pretty good quality of life. 🙂

[Goosebumps in reply to Mumursa]

thank you so much for the informative reply. The enlarged atria comment strikes a bell with me as I have that condition which has stopped the EP doing anything at all to tackle my symptomatic AF.

[Mumursa in reply to Goosebumps]

I’m afraid I don’t know anything about atrium size, but I was originally referred to my EP by the heart failure team so that he could carry out an ablation. That’s what he does.

I’ve been quite firm about wanting treatment and I acknowledge that I have had quite a lot and still have AF, but between the HF team, EP and the surgeon, my AF burden feels a lot less, and it’s been worth it.

It sounds like you may have to make a case for what you want. I’m sure you can - good luck!!!

[sunlovah in reply to Mumursa]

Which begs the question.......then why was it done ?

[Mumursa in reply to sunlovah]

Goosebumps commented that his EP wouldn’t carry out an ablation because of his enlarged atrium. Mine did. Presumably there may be different opinions on this, or a difference in the extent of atrial enlargement in our individual cases.

[BobD Volunteer]

After over sixty something years in motorsport starting as a marshal and ending up as a team manager/race engineer it is hard to walk away. I was offered the chance in around 1970 to work in USA but foolishly chose my marriage, which of course failed anyway. These days I act as consultant to my boys who run Bob D Motorsport and build a few historic race engines to stop me being too bored. Next month we will be doing a two day event at Shelsley Walsh Hillclimb with a very dear (and old) friend. The boys will do all the prep work and he and I will sit and yarn. That's the plan anyway. lol 😁

[Poochmom]

You mentioned that the atriclip gives the same protection against stroke as an anticoagulant or a watchman. That is not true. The atriclip reduces stroke risk by 97%. And no aspirin. The watchman and anti coagulants reduce stroke risk by 60%. Much better results with atriclip however you are correct it is more invasive a procedure. However it has been done as a stand-alone procedure on those that aren’t suited for MiniMaze.

[mjames1 in reply to Poochmom]

I believe I said, "same or better" regarding AtriClip. I don't have stats, but your figures don't look correct. I believe AC's reduce stroke risk more than 60% as well as Watchman. I am aware it can be done as standalone and have thought about it for myself.

Jim

[mjames1 in reply to Poochmom]

To amend my previous reply, this article suggests both Watchman and AtriClip are equally effective in preventing stroke and my guess so are AC's. Each has its advantages and disadvantages.

froedtert.com/stories/atric...

Jim

[Goosebumps]

I’ll repeat what I have mentioned on a few previous posts, that Dr Ohtsuka in Japan quotes a first cut to stitch time of only 20 minutes to staple off the LAA using minimally invasive surgery. (He doesn’t use an atricilp).

Now he is a recognised expert with thousands of these types of operations behind him but if you gave me the choice between a watchman type device or stapling/atriclip I would go for the latter every time.

Downside is that the operation requires a GA I believe and I’m no surgeon so I don’t know of the relative risks difference between a minimally invasive operation and a catheter one. Upside, no more anticoagulant/aspirin, supposedly better protection against strokes and also reduced bleed risks.

Also quoted by Dr Ohtsuka ( I believe) in another post was that 20 % of AF originates in the LAA. I wonder if it’s occlusion eliminates or reduces that risk?

It all seems blindingly obvious to me which way the profession should be going and some of us don’t have the time to hang about waiting. So I will be investigating going privately in the not to distant future.

[Pigleywigley in reply to Goosebumps]

I’m with you I would consider a trip to the right person! At 49 I am looking for a long term solution that doesn’t include meds!

[mjames1 in reply to Goosebumps]

Dr. Wolf, Ohtsakaka's mentor, uses AtriClip. So that's only 20 minutes under general anesthesia (GA) to clip off the LAA? I believe that's shorter than with Wolf. I am not a big fan of GA, but with only 20 minutes, I might consider it. Did you see my thread about clipping off the LAA using a catheter based system with 3D printing? Posted earlier today. That might be the best of both worlds-- minimally invasive but no aspirin for life like Watchman. Unfortunately, probably won't be available, if at all, for some time. Just a case study so far.

Jim

[Pigleywigley in reply to mjames1]

thanks Jim so interesting and flipping amazing! I can’t have any catheter procedure because I have an occluder fitted in the atrium wall for previous closure of atrial septal defect. Any procedure now for me has to surgical so any next steps have to be clearly thought through. Hoping the external stuff picks up some pace!

[Goosebumps]

Here is the link to Dr Ohtsuka’s page

newheart.jp/pdf/WOP.pdf

I think every cardioversion, and there must have been millions worldwide, has been done under a short GA or heavy sedation. Dr Ohtsuka’s quoted 20 minutes is only the time from cut to stitch so not the actual time that you are under but he says it includes a cardioversion as well . The Champion study posted here by Mummyluv (which I think you may be referring to) isn’t due to report until December 2027.

Personally I’m sure that the Apixaban I take has far more side effects than I realise, but of course I dare not test it for any prolonged period. My luck would run out, what little I have left.

If my cardiologist had a better view of my LAA, it’s size, shape, attitude, I think more informed decisions could be made about a stand alone LAA occlusion.

It would seem that the surgical skills required for a minimally invasive LAA occlusion are in short supply compared to those required for a Watchman implant which I think is a prime reason for the study looking at the Watchman. From what I read, the placement of the Watchmen and it’s shape are critical to it it’s success and that relies on imaging and echocardiography which is still catching up in my view.

If a surgeon can actually see the LAA via a camera and occlude it there and then (as in the minimally invasive procedure), it’s gets my vote.

[mjames1]

They do use a "camera" to confirm Atriclip or Dr Ohtsuka’s staple technique. Called a TOE/TEE. None of his patients here (or Wolf's) are supposed to remain on AC's after LAA is occluded. .

Jim

[Down10FTN]

One to watch for sure

[sunlovah]

What happens to the clip when the LAA shrivels and dies?