for AF -Blood thinners or surgery

Leaks after LAA closure: ignored or neglected?

by Gemita - 2022-03-12 17:47:23

https://www.karger.com/Article/Pdf/513901

New to Pace, I promised to have a quick search for you and I have found the above link which may be significant.  I think my main concern after reading this briefly is the fact that residual leaks may be a common finding in patients who undergo LAA closure for preventing thromboembolism and there would appear to be no evidence-based management strategy available for these leaks and longer term studies are still needed.  Have a read and see what you think.  I believe the link covers all the different closure devices you mention.  

The take home message from this report seems to suggest that "Residual leaks are frequently diagnosed after LAA closure procedures, regardless of closure methods, although there is controversy about the clinical significance of the leaks, particularly about its association with thromboembolic events".  But I think it is important to be aware of this possibility as you consider all your options to try to prevent an AF related stroke.

I am glad you have received so much feedback about your transmissions.  At least you know what is going on and you can take action.  240 bpm ventricular rate from SVT/AF without a rate control medication could lead to worsening symptoms very quickly during arrhythmia episodes, so a beta blocker or calcium channel blocker is I feel necessary.  

Thank you for sharing so much information new to pace.  It tells me that your arrhythmias are increasing but if you take action hopefully you will be able to control this.  I think you have done well with natural products for many years and hopefully with the right choice of meds now, you can continue to stay safe while treating your arrhythmias more effectively.  

i to have been reading more on this subject

by new to pace.... - 2022-03-12 17:57:49

Thanks Gemita.  In  other articles  that i have been reading, they do speak about leaks.  Am also concerned about how these reach the heart.  Not sure if willing to have them not go smoothly toward the heart.  

The watchman device also is of concern with possible leaks.

I have not made a decison  yet.  If the doctor was really concerned about these new espisodes.  Am sure would have referred me to another Dr. in her office this week, while she was out of the office. 

new to pace

Decisions

by Gemita - 2022-03-13 08:37:05

new to pace,

To have successfully reached our age, we must have made the right decisions along the way, so I would be confident that whatever decision you come to now, will be the right decision for you.  Sometimes quality of life has to come before longevity. 

It took a long time for me to decide whether I wanted to take life long anticoagulation or risk getting a stroke. Neither option appealed. I was getting such high heart rates from AF and surges of blood to my head at the time and felt it would explode.  I also witnessed what several largely silent strokes did to my husband.

I was relieved to be able to take low dose Edoxaban without experiencing any side effects and still be fully protected.  It is all about finding the right med/treatment for you.  There will be a medication out there that will suit you but you will have to work with your care providers to find something suitable.  I nearly gave up when my first cardiologist told me unkindly he wouldn't treat me "off" anticoagulation but my anticoagulation clinic worked hard to find a solution:  switching me from Apixaban to Edoxaban low dose and I haven't looked back.  In the meantime, I firmly believe your supplements and lifestyle will be helping you to remain safe

Atrial fibrillation and stroke

by Selwyn - 2022-03-13 09:53:32

Dear New to Pace,

You cannot under estimate the risk of stroke with atrial fibrillation.

( see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6515763/).

My Mother (with a pacemaker and paroxysmal atrial fibrillation) died from this in spite of warfarin anticoagulation.  Warfarin is said to reduce the risk of blood clot stroke by 68% per year (compared to aspirin at 21%). God knows what the risk reduction is for turmeric, perhaps you are best qualified to clarify this?

I take clopidogrel 75mg daily and apixabam 5mg twice daily. Apixabam has been shown to be a safer and more effective intervention than warfarin.

With regard to Watchman: the safety endpoints of life-threatening bleeding and significant bleeding as well as procedure-related complications presented a significantly higher risk (7.7%) compared to warfarin.

The situation with regard to estimation of risk has changed since 2019. There is a lot of work being done to try to clarify what is best for people with AF.

Thanks for your review article on left atrial appendage surgery. There is nothing in life without risk, even bed rest! At present, it seems that there is less risk with oral medication compared with surgery, though individual risk must be properly quantified. 

afib and stroke

by new to pace.... - 2022-03-13 10:22:13

Thank you Selwyn for your thoughful comments.

new to pace

LAA closure

by AgentX86 - 2022-03-14 01:14:39

Most ablatoinists are very concerned about LAA leaks. Clots are caused by AF/AFL creating a turbulant flow in the heart resulting in pooling of the blood. the low-velocity blood allows clots to form.  Since the LAA is a pocket outside the normal flow of blood, it is a prime location for this pooling/clot formation.  Something like 90% of the clots are formed in the LAA. If the LAA is completely closed off, the increased chance of stroke (from AF) goes down to close that of the general population.  However, if there are leaks in the LAA closure device, the pooling in the LAA can be even worse.

I don't have a Watchman, rather an Atriclip.  One of my ablations was called off because a possible leak was seen by the TEE before the ablation (TEEs with only a local aren't all that much fun). I went back a month later and it was the same so my EP figured it was just some scar tissue on the closure.  I asked about the need for anticoagulation. My EP laughed at me.  I'm in permanent flutter so, even thought my LAA is completely closed off, there was no way he was going to drop the anticoagulant. It's not automatic.

Regarding anticoagulation after LAA implant, many are put on half-dose DOACs  as a belt and suspenders sort of thing.  The half-dose reduces clotting some with an associated reduced chance of bleeds.

Aspirin and turmeric are poor choices (to put it gently) as anticoagulants. Turmeric has it's uses but anticoagulation isn't one of them. My cardiologist prescribed turmeric for me because of its anti-inflamation properties.

LAA closure

by new to pace.... - 2022-03-14 06:54:56

Thank you AgentX86 for your thoughtful comments.  

 Which anticoagulat are you taking.?  

I cannot take aspirin.

new to pace

Anticoagulant

by AgentX86 - 2022-03-14 17:50:59

I'm taking Eliquis. It's considered the safest of the bunch and is *highly* recommended for those over 75 (I'm 69) because the lower probability of brain bleeds. It can be rough on the stomach so some can't take it.  However, at least one cardiologist's has said "It's a lot easier to treat a bleeding stomach than a bleeding brain.".

Watchman's leaks

by TAC - 2022-03-14 22:19:46

If you definitly don't want to be on anticoagulants, the best option is surgery to amputate the LAA. There are some minimally invasive surgical techniques to the effect. Other more conservative methods, have a high incidence of leaks or failure. 

"amputate the LAA"

by AgentX86 - 2022-03-14 23:37:32

Is that done?  I had mine '"clipped" during a CABG, which would have been a perfect time to "amputate" it but that wasn't an option.

amputate the LAA

by new to pace.... - 2022-03-15 04:14:54

Thanks TAC i had thought i might go that way besides the possiblity of a leak, would be free of anticogulants.  Which is one of my objectives.  Do you know of anyone who went this way.  Do not know if my age might be a factor am 81.  Am sure my heart could stand this type of surgery.

Thanks AgentX86 fpr ;letting us know your medication,  It is not on my lactose free medication.  Most of the drugs that are mentioned have not seen mentioned on this forum.

new to pace

A very difficult decision

by Gemita - 2022-03-15 09:14:11

New to pace, 

I do not believe there is a way of completely avoiding taking anticoagulants at some stage leading up to, during or after any LAA procedure, whichever LAA procedure you decide to consider?  

Also I am not sure that they would offer this procedure at your age as a stand alone procedure unless they were having to do another procedure like a replacement valve, an AF ablation, bypass surgery at the same time because of the potential risks?  

I will be interested to learn what your doctors have to say about the benefits versus the risks of having your LAA amputated compared to the benefits/risks of taking lifelong anticoagulants?  Results of trials following amputation of LAA are still in their infancy so this will be another consideration. Moreover, emboli in AF do not exclusively originate from the LAA. There are multiple additional sources, so I would argue why go through a procedure which may carry a risk, if protection is expected to be less than that that can be expected from an anticoagulant?  It seems to me from reading the research that both an LAA procedure combined with anticoagulation may give a better success rate to prevent an AF related stroke, than one treatment alone but that further research is still needed to confirm this.

LAA amputation

by TAC - 2022-03-15 12:36:47

I didn't know you were 81 years of age. If I were you, I would avoid any type of surgery and would go the way of Eliquis (Apixaban). I underwent the Cox Maze procedure for AF in 2009. It worked well for a few years but the AF came back in 2017. My cardiologist put me on Eliquis despite the fact that my LAA had been amputated during te Cox Maze procedure. Now, after being placed on the anti-arrhythmia medication Tikosyn and having a PM implanted in 2018, the AF is been controlled by 99%. In a month, I will be seeing my heart doctor for a routine check up. I will ask him if I could stop the Eliquis. I don't know what his response will be. But I will share it in this forum by the middle of April. A renown surgeon has told me that after 80, all types of surgeries carrie the same risk, whether it's a minor or a major procedure. As a matter of fact, for that reason I'm skipping an eyelid "minor" surgery procedure because I'm 89. The reaction of the body to a surgical and anesthesia stress is unpredictable after reaching an old age. A friend of mine my age, died while having surgery on his hand. It's better to play safe, go for the anticoagulants. I have never had problems with "Eliquis".

surgery risk

by new to pace.... - 2022-03-15 13:04:39

Thanks, TAC.  i was 80 when i had my right shoulder replaced.  Had to have a stress test before and passed.  Which was sent me down the road to pacemaker.

After i see the caridologist on Monday will post a new answer.  Now am going to see(what a pun) the eye doctor to find out why sometimes am unable to read the street signs as i pass them by. Then have to made a u-turn.  Was wondering if related to the heart beating.

new to pace 

LAA "Amputation", Anticoagulants

by Marybird - 2022-03-15 13:23:57

I very much appreciate the discussions and information in this thread. Made me do some reading on the various options for LAA closure, and anticoagulant options before/after in people with A-fib.

I couldn't find anything on outright surgical amputation of the LAA,except for a single mention of doing it during open heart surgery. I think what the "amputation" mentioned in the literature, information from providers that do these procedures most likely refers to is the shriveling of the LAA following the ligature/clamping off processes involved in the Lariat Loop and AtriClip procedures, when the blood supply to the LAA is cut off. Sounds as though they figure after either of these procedures over time the LAA will shrivel, break down and eventually be sloughed off, or reabsorbed into the tissues. I guess what actually happens depends on the individual, and there are any numberof reports of leaking from the Lariat loop during the healing process ( perhaps not always enough to cause clotting associated with strokes), enough to caution patients to ensure they have followup TEEs and/or CT scans every 3 months in the first year, followed by annually thereafter. I'd imagine the same issues might occur with the AtriClip since it's a clamping off method too, but the warnings seemed to be mostly for the Lariat. 

They tout the AtriClip and Lariat as devices attached outside the heart, with no direct contact with the circulation ( as opposed to the Watchman) between that and the walling off of the LAA, this would eliminate the need for post-procedure anticoagulation. Yet I read a number of sources that recommended anticoagulant during the healing process for the Lariat, and Atri-Clip, to cover possible leaks, inflammation ( which can contribute to procoagulant activity), and considered on a case by basis depending on patient histories, preferences. But I'd also read about long term anticoagulant use with the Watchman, with aspirin use currently recommended indefinitely after the 45 day post-procedure anticoagulant use being up for discussion on a case by case basis too. Investigations are ongoing, and it makes me think anticoagulant/antiplatelet agent use in patients with all these devices is up for debate and it's hard to tell what the future will hold in that regard.

And the anticoagulants. New to Pace, I can't recall if you've had a history of A-Fib before the recent events reported by your remote pademaker monitor, or this is new for you. If it's new, frankly I'm surprised that your cardiologist's office has not contacted you to discuss your starting an anticoagulant. That's exactly what my cardiologist did ( I had to go into the office to see him) when they received an alert of several hours long afib incidents from my pacemaker monitor. 

Or, if the A-Fib isn't new to you, and you have already discussed your concerns and choices about taking anticoagulants (or not) with your doctors, they may have decided to wait till your upcoming visit to discuss the matter again. There are a number of concerns, and it wouldn't surprise me if your doctor pushed on the idea of either taking an anticoagulant ( either one of the NOACs, or warfarin if you can't take an NOAC) until you can get your LAA closure device, whichever one you can get. You probably know of the CHADS2 score for stroke risk, its this score they use in determining a person's stroke risk and need for anticoagulation or alternative LAA closure methods. Age plays a big part, with being over 75 ( adds 2 points to the score) almost seeming (from what I read to my chagrin, I'm almost 75) to be a reason in itself for pushing anticoagulation. Though if you're over 80, the doses of some of those newer anticoagulants can be cut in half, so there is that.

I'm there myself, currently taking Eliquis even though I don't have frequent episodes of A-Fib. I toy around with the idea of getting off the Eliquis if I go for a long time without A-Fib-( there has to be an upside of all these pacemaker monitor reports, they know when things happen) though I've been assured by the cardiologist and company that due to my other risk factors, I'll probably be a lifer on Eliquis. 

 I had never considered an LAA  closure device, I haven't had any issues I could see with the Eliquis, and didn't want another surgery/procedure or as I thought of it, any more hardware rattling around in the old chassis. But a routine checkup with my PCP showed I had a drop in my hemoglobin of 2 grams since my last visit 6 months ago- to 9.8 grams, and further testing showed a severe iron deficiency. I'm not aware of any overt bleeding going on, but it's very possible the Eliquis is at least contributing to whatever is causing the problem. I'm aware that the last thing they will do is let me cut out the Eliquis, and will address the possible source (occult GI bleed?) if it continues. I'm currently taking an iron supplement and proton inhibitor antacid (at widely separated times) and am following strict instructions to cut out even occasional NSAID use ( I had been taking Aleve occasionally for arthritis pain) and hope that will correct things. 

But in this process, a Watchman device was mentioned as a possible alternative for me in the event Eliquis-related bleeding/anemia becomes a serious problem. I really don't want to go this route, would rather continue on an anticoagulant if I need to. But handed this as a possible issue for me, I thought the information and discussion on the topics of LAA closure devices, as well as anticoagulants both interesting and pertinent to me. 

medication vs

by new to pace.... - 2022-03-15 16:31:27

Thanks Marybird for your thoughtful comments.  

I have had A-Fib since  at least  the pacemaker  implanted Aug 21.2019 at 6 weeks was at 8%,  which suppose is common as the heart was irritated. then it settled down  to 7%,    Then  in Jan 2021 started averaging around 4%.  Till these past 3 months the average was 8%.  Now thinking I will check out the new supplements i started taking for osteroporis. 

Otherwise am feeling really good and have more energy. Not having to worry if i cut something.

new to pace