Left Atrial Appendage Closure, why not do it as a matter of routine during ablation?

[destiny234]

From what I have discovered online, closing the left Atrial Appendage will help to stop clots pooling as this is where they mostly do it.

If this is correct then why don`t surgeons close this as a matter of routine whilst doing an abalation?

[Mrsvemb]

Probably because a catheter ablation is performed by an EP who is not a surgeon. I would think only a cardiothoracic surgeon can do this.

It is a very specialised procedure working on the beating heart. I have just had my LAA clipped as part of a mini maze procedure.

[mjames1]

Because catheter ablation is done from the inside of the heart and LAA closure is done from the outside of the heart. That's why it's often done with the mini maze, which is from the outside of the heart.

Jim

[bean_counter27 in reply to mjames1]

Watchman procedure done from inside heart and it appears to be via same route as catheter ablation but I'm not a medical professional. However different equipment used so presumably, would have to complete one procedure before commencing next i.e. totally withdraw and then insert next device and feed through to heart again unless someone invented multi-functional device to undertake both while catheter is still in heart.

[mjames1 in reply to bean_counter27]

Yes, you are correct. I was referring to the AtriClip, or similar which are done from the outside by a cardic surgeon , not an electrophysiologist.

Jim

[CDreamer in reply to bean_counter27]

Watchman is not suitable for everyone and has had some problems with clots forming on the device meaning that some need to continue aspirin and anticoagulants. In UK it’s not a procedure freely available or advised without good reason.

[bean_counter27 in reply to CDreamer]

Not advocating it. Just highlighting to mjames1 it is a procedure for closing (off) the LAA that's done from inside the heart. I'm not even on AC, let alone contemplating any LAA procedure.

[BobD Volunteer]

You have been given reasons by two others but there is also the point that the LAA is there for a reason. We may not fully understand this but removing it willy nilly may not be the best idea ever.

[Abbyroza]

Because it often leaks, according to this article.

“Watch out: the Watchman ‘solution’ should be considered inferior to anti-coagulation meds. “

drjohnm.org/2016/11/say-no-...

[destiny234]

Thank you for all your replies although I am still rather confused as they conflict somewhat. Having read a similar post from 8 years ago, it seems like the opinions as to the actual need for the LAA have not changed , ie nobody knows it`s usefulness, is this correct?

[CDreamer in reply to destiny234]

Pretty much.

[Cookie24 in reply to destiny234]

I am in the USA. My LAA was isolated during my afib ablation. EP said this is higher stroke risk so he recommended Watchman. It is my understanding Watchman is placed using catheter and it takes an hour. I haven't decided on Watchman and still taking Eliquis. I read a couple articles about problems with Watchman leaking.

[Sweetmelody in reply to Cookie24]

You’re right. DRT (Device Related Thrombosis) can result from a Watchman implant. I believe statistically the chances are less than 5%. I’d have to look that up; I think it’s even lower than that. DRT occurs prior to complete embolization of the device, which means before one’s body miraculously grows tissue over the device and creates an impenetrable wall to the left atrial appendage. Embolization is checked 45 days post-implantation by a TEE (transesphogesal echocardiogram), when any clot formation around the device in crevices not yet sealed off (i.e., there is a “leak” resulting in DRT) is also checked for. If DRT occurs, it can be fixed. Like any invasive medical procedure, there are risks. DRT is a risk, but if you’re in good hands, it’s not one to worry about to the extent that you feel it outweighs the benefit of LAAC, at least in my estimation.

I don’t understand your sentence about your LAA being isolated during an ablation, but without a Watchman?

If your EP recommends a Watchman, that means you’re a good candidate. I’d listen and learn. Check out this article:

The WATCHMAN Device Review: A New Era for Stroke Prophylaxis - PMC 2023

ncbi.nlm.nih.gov/pmc/articl...

[Cookie24 in reply to Sweetmelody]

Thanks for your responeand to others who have responded. I may be using the wrong terminology with closure, isolation, occlusion of L AA. Hope someone can explain these terms to me.

[Sweetmelody in reply to Cookie24]

”Closure” and “occlusion” are used interchangeably in regard to closing off the left atrial appendage so that blood cannot pool there and form clots there.

”Isolation” seems to be the term used to mean that areas of your pulmonary veins where electrical impulses are misfiring are shut down, cells killed to create scar tissue, thus “isolated” from the way the heart beats. That’s just my layperson’s understanding

Here are some quotes from in internet that might help in understanding what “isolation” involves.

“Pulmonary vein isolation treats Afib by targeting your pulmonary veins. These are the veins that bring oxygen-rich blood back to your heart’s left atrium. Your pulmonary veins are where the abnormal electrical signals that cause Afib usually begin.

The treatment is a type of heart ablation. That means it uses very hot or cold temperatures to create small scars. Scar tissue inside your pulmonary veins disrupts the electrical signals that cause Afib, preventing them from reaching your atria.”

————————————

I found the following explanation easy to understand. I included the link. It’s from the Southampton Hospital site.

“Pulmonary vein isolation is a procedure used to stop abnormal electrical signals in your heart that cause heart rhythm problems. It is a form of cardiac ablation….. The aim is to regulate your heart rate. …Atrial fibrillation happens when abnormal electrical impulses suddenly start firing in the atria.These impulses override the heart’s natural pacemaker, which can no longer control the rhythm of the heart. This causes you to have a highly irregular heartbeat.

When the heart beats normally, its muscular walls tighten and squeeze (contract) to force blood out and around the body. They then relax so the heart can fill with blood again. This process is repeated every time the heart beats. In atrial fibrillation, the heart’s upper chambers (atria) contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions. This reduces the heart’s efficiency and performance. In many patients with atrial fibrillation it has been found that the extra electrical signals responsible start in the area around the pulmonary veins on the left side of the heart.

There are four pulmonary veins that carry blood from the lungs back to the left atrium. Where the two types of tissue from the atrium and veins meet is where the extra electrical signals that cause AF originate.

Pulmonary vein isolation is a catheter ablation technique where the doctor uses an energy source, either radiofrequency energy (heat) or cryo (cold) energy to destroy this small area of tissue and form scar tissue. The resulting scar tissue blocks the extra electrical signals from the pulmonary veins reaching the left atrium, so the area can no longer generate or conduct the fast, irregular heart beats.”

uhs.nhs.uk/Media/UHS-websit...

[Sweetmelody]

Wow. The replies you’re getting certainly show a lack of quality information. I suggest you look here for starters.

The WATCHMAN Device Review: A New Era for Stroke Prophylaxis - PMC 2023

ncbi.nlm.nih.gov/pmc/articl...

Following is a reply I wrote to another member querying about a Watchman. I hope you find it helpful. I see LAAC in conjunction with an ablation as being on the forefront of treating afib and improving quality of life for those with afib. I should note that my quality of life was seriously compromised by drugs I took for afib. That is certainly not true for everyone, but it was true for me. My goal of being drug-free and afib-episode-free means to me a vast improvement in my quality of life.

Here’s what I wrote to a fellow member:

“I had a Watchman implant in conjunction with an ablation on 2/6/24.

I chose a Watchman because LAAC ( left atrial appendage closure) closes off the area in my heart where somewhere around 95% of blood clots form. A Watchman reduces my risk of stroke to less than 2% according to recent studies. More studies are needed, of course. Always.

I chose to go to the physical source of my afib/flutter and try to correct it (ablation) and go to the physical source of blood clot formation (LAA) and fix it with a Watchman implant.

To me, drugs treat the symptoms and attempt to manage the problem, but they do not fix or change it at its source. And importantly, drugs have side effects that have to me at times been intolerable and badly compromised my quality of life.

I am anticipating being essentially drug free by August. No more metoprolol, amiodarone, ugh, etc. Blood thinners are still needed during the initial 6-month healing stage after the implant. Thereafter it’s nothing but baby aspirin. That’s a drug I can deal with. Compared to amiodarone?? There’s no comparison!

Even if my afib-flutter returns and I need another ablation, the Watchman remains as is, protecting me from blood clot formation that could result in a stroke.

Clots form in the LAA due to an irregular flow of blood (afib), allowing blood a place to pool. When the LAA is closed off, the clotting agents in our blood no longer have that particular place in our hearts to hang out and start sticking together, forming a clot. Again, the LAA is where give-or-take 95% of blood clots form. That’s what a Watchman prevents—or other LAAC procedures.

Those with afib have a 1 in 5 (20%) risk of a stroke. (I’m assuming that means untreated afib). With the Watchman, my risk is reduced to less than 2%, or even less in combination with a successful ablation. That is why I’ve chosen the path I’ve chosen in dealing with my afib.

I look forward to being drug-free after the six-month post-Watchman healing period. I am at present, post-ablation, afib free with an 80-90% chance of staying that way (given this last one was #2 and was aimed atypical aflutter arising in the left atrium; #1 was a pulmonary vein isolation aimed at afib). The statistics are on my side. I have a healthy, active lifestyle and no cormorbidities, even at 82. My CHAD score is 3 only because I’m old and a woman.”

[destiny234 in reply to Sweetmelody]

Thank you that extensive information. I see the Watchman is available in the UK. I shall definitely be asking cardiology about this option. I`m glad to hear you are doing well with yours, take care xx

[Cookie24 in reply to Sweetmelody]

Thanks for your info. I also have atypical aflutter.

[Sweetmelody in reply to Cookie24]

My EP and my research tell me that the ablation success rate for atypical aflutter is around 90%, a bit higher for typical aflutter because that’s in the right atrium and easier to access (something like that). Let’s wish ourselves the good fortune to be in that 90+%!

My EP told me after the ablation that it was easy for him to see the aberrant aflutter cells in my left atrium and he felt the procedure had been successful — though only time will tell. He also checked out the pulmonary vein isolation done in the first ablation and said the scars were holding; he found no leaks and no reconnecting (which I guess is something veins sometimes try to do, and if they do, can bring with them a return to afib This ablation stuff is tricky business—but the rewards can be great.)

I’m close to 3 months out without a flutter in sight. 🤞 SR as steady as can be. Only drug is Eliquis for another 3 months, then FINI!

Wishing you the best.

[Letofeyd]

Just to add something to what others have said.The full function of the LAA is unknown, but the problems it causes *are* known, ay least to some extent.

It is the opinion of some cardiothoracic surgeons who do AFib procedures like mini maze that the LAA is actually a *generator* of aberrant electrical impulses that can cause AFib.

Because of this suspected potential to generate rogue impulses, sine surgeons feel that either removing it or clamping so it cannot function at all is preferable to just blocking it up (as the Watchman does).

I had mine removed as part of my WOP in Tokyo under Dr Ohtsuka 11 weeks ago.

[Sweetmelody in reply to Letofeyd]

There’s always more to learn. I’ll look into what you say. Thank you. The cardiac intervention field is moving ahead so fast that it’s hard to keep up. And of course, practically every research study, after presenting their conclusions, say more studies are needed. Nobody has all the answers. We do the best we can with the information available to us — and by finding doctors we trust with our lives.

[Cookie24 in reply to Letofeyd]

Do you have links to info about removing or clamping LAA? I am confused about terms isolate, closure occlusion and you have used terms remove or clamp.

[ochinee in reply to Cookie24]

The LAA "occlusion or isolation or closure or exclusion" can be defined several different ways depending on who is using those terms. A search using "left atrial appendage occlusion isolation" will give you a lot of information on them.

The Watchman is used to block the pathway (on the inside) from the LAA to the heart

One well known thoracic surgeon uses a clamp (on the outside) to permanently occlude the LAA while doing pulmonary vein isolation for AFib.

Another well known thoracic surgeon clamps/staples (on the outside) the LAA shut at the heart opening and then removes it completely while performing pulmonary vein isolation for AFib.