Saturday, July 21, 2018

My Catheter Ablation With Dr. Natale At St. Davids

Was released from St. David’s today following my procedure yesterday.  Everything went really well and my future prognosis is good.

I will be updating this blog over the next week to try to capture everything. Also, there are some links within the blog as usual for more in depth descriptions.

Thursday CTA and Consult with Dr. Natale

My CTA was scheduled for early morning so we caught a LYFT to the hospital and was early. I was impressed with St. Davids right out of the shoot. The reception area personnel were very friendly and accomodating. This would become a trend throughout my entire experience there. Once i was all checked in a I was escorted to the nuclear lab for the CTA.

Now St. Davids is a very large hospital and we were in for an unexpected long walk which was fine, The young man that was taking us was fairly new and as we approached hsi normal route we ran into a construction blockade. Long story short we finally arrived at the nuclear medicine lab with several laughs along the way.

Ater some blood testing they came and took me to the lab. There were 6 or 7 lab personnel there and all of a sudden it appeared I had assumed rock star status (this would not be the first time). The energy in the room was super positive and energetic.lots of good conversation and continual information about what they were doing along each step of the way.

I never have had a CTA scan before and I must say it was quite interesting. It did not take very long and was not stressful at all. Though some may find the warm dyes pulsing throughout your system unnerving, it felt quite pleasant to me.  Once I was done they unhooked me with the same enthusiasm as before and I returned to the waiting area to await someone to take me to see Dr. Natale.

Dr. Natale

Once I reached Dr. Natales office I checked in right away. I was no sooner checked in when a nurse came to take me back to get vitals and such. She covered all the normal pre-op stuff along with some history of my afib. Once she was done my nurse educator Jacquie, who I have been talking to via email and phone since my procedure was scheduled, came in and we went over allot of stuff. She was very knowledgeable and was able to answer many of my questions. It was a very productive visit as well. Dr. Natale was tied up in the hospital so it was a while before he came into the room

The visit with Dr. Natale wasn’t very long but informative. As I stated before my case nurse Jacquie had discussed allot of things and answered questions for me before he arrived. She also remained in the room when he was there to help with any questions that she was unable to address.So he was able to go pretty much to the nuts and bolts of  Fridays activities. I had asked if there was anything he had seen from my previous ablation notes that gave him any insight or made him suspect of any particular part of the heart that might be suspect. I will also add here that Dr. Natale has a very warm personality. He comes across as someone who has your best interest in mind and will do anything he can to help you.

He said that it probably is no longer PV (Pulmonary Vein) related as I have already had 2 ablations to address that possibility, but he wasn’t ruling that out either. He did talk some about the possibility that it could be related to the left atrial appendage.  If this is the case it may require for me to come back for a second procedure. The reason for this is two fold. One being it’s location and second being structural. I’ll explain as best I can.

The left atrial appendage lies closely to the corroded artery. So when they ablate that area they can only allow the catheter to remain in any one area for a shorter period of time. The reason fo this is to eliminate the risk of doing any damage to it. The structural issue here is that the walls of the opening to the appendage are thick and thin depending upon the area. Also the structure of the consistency of the appendage is different as well.

The other caveat with the left atrial appendage is that if they do ablate it I will have to remain on anticoagulants for life. This is due to the fact that the LAA is a major cause for stroke by itself. Ablation only increases this risk. The other option to anticoagulants would be the Watchman Device. The Watchman is block that they would implant that would isolate the LAA preventing any clots from forming within it thus eliminating the need for anticoagulants.

So far as the beneficial activity of the LAA other parts of the heart will pick up in that function. The drawback is that the LAA sort of acts as a pressure relief valve of sorts. Which being an active person I may notice.

Friday - Ablation Day

I arrived at St. Davids early again Friday morning. I checked in and was quickly taken to the cardiac unit where I met Michelle who would be the nurse to get me ready for my procedure. Her job was to get all my vitals and draw blood. She was just as upbeat and pleasant as everyone else I had met to this point. We had some great conversation and laughs during our time together. I also met Ryan at this time. He is part of their research staff and asked if I would like to participate in one of their programs which I readily agreed too. I have participated in several afib studies over the years and am always happy to help in any way that I can.

The research Ryan is having me participate in is cognitive. (face,dance,church,velvet,red). And that there folks are five words I can't get out of my head since meeting Ryan. OF course those five were part of the testing he gave me that morning. He gave me those five to remember before the litany of other questions he had for me after that. Fully expecting me to remember them at the end. Well I remembered Tew at the time, face and dance. Remembered all five upon returning to the room following the procedure and now I cant get them out of my head.

Once Michelle had me ready, Carlos, the EP Lab Coordinator came to take me to the pre-op waiting area. Carlos was great as well and made sure that I was ready to go. He got me to the waiting area and checked on me numerous times until they were ready for me. Ryan was also with me at this point helping me fill out the rest of the study paperwork.

I waited about a half hour or so before they came to get me. Carlos started wheeling me towards the lab then Matt took over. Mat was the comedy relief in the EP lab. Matt was, I'm guessing six foot with the build of a linebacker and a even bigger smile. I can't remember everyone else's name but there were six others in the room at this time to my recollection.  And again, I seemed to achieve rock star status. the energy in the room was phenomenal. Everyone was addressing me and striking up conversation and making me feel super comfortable. Of  course just when I was starting to have fun I was out.

The procedure was a 65 minute burn time. Dr Natale addressed several issues. He did some touch up work on my previous PVI Work. There was no issues there but he decided to make a pass to increase the scar tissue.  Afib Rider fun fact. As a rule there are 4 Pulmonary Veins, I have 5. He then addressed the posterior wall, Left Atrial Appendage and the coronary sinus . He also did some ablating on the right atrium septum before proceeding through the wall into the left atrium.

A few explanations of what was done:

Posterior  Wall - Roof line and Posterior Line were created to isolate the left atrium. These lines both connect to scar tissues surrounding the Pulmonary veins both above and below. Then the catheter is moved side to side to create scarring in the areas between them.

LAA -  The LAA was ablated but due to the location and construction of the LAA the ablating cannot be as aggressive. First due to the construction, thin walls in areas, of the LAA. And second is it’s proximity to the pulmonary artery. So instead of spending 10 seconds at each burn they can only spend 5. Therefore the burns aren’t as substantial as they are in other parts the heart. That being said there is a possibility that he will have to revisit that area. He actually did ablate this area twice during the procedure which I will cover later.

Coronary Sinus - The coronary sinus was ablated both posterior and inferior. The coronary sinus delivers blood to the right atrium from the lower extremities of the body. There is a flap at the end where the blood returns from these areas. The catheter is inserted through this flap and into the Coronary SInus to allow for ablating the beginning  end of the vein as it terminates at its beginning. The sinus is also ablated around the area of the flap.

Right Atrial Septum - This is the wall that separates the left and right atrium. This is also the wall that is punctured by both catheters to access the left atrium. There were some electrograms that were ablated on the wall before proceeding into the left atrium.

Right atrial Septum Puncture - As  I stated the septum is punctured by both catheters. The puncture is created by the ablating catheter. This is done as it requires very little pressure which reduces the risk of a left atrium puncture. The second advantage is that as the catheters are removed the create a burn scar that seals off the holes.

More On The LAA - The Left Atrial Appendage (LAA) as I stated before is the most worrisome part of the procedure I had. However, it was causing issues and needed to be ablated. The downside is that I will have to have a Watchman Device implanted or be on blood thinners the rest of my life. The Watchman was not done at this time for several reasons. The main reason being that there is a possibility that I will need touch up work done in this area and if the watchman is implanted the work cannot be done.  If this is indeed the case, it is at this time a Watchman would be implanted. Second issue with the Watchman is that due to my ripe young age I am not a candidate for it according to insurance. Even though I am an avid road cyclist, sometimes off-road and ride dirt bikes from time to time so I am a somewhat high bleed risk. They are working towards a solution at this time as it is a big issue for younger victims of afib. Thirly there is a new improved version of the watchman device that is currently being evaluated in clinical trials.

The LAA in itself is problematic as it is one major cause of stroke as you get older than me. Ablation only increases this risk as it reduces the pumping action of the LAA. The LAA also produces hormones that another part of the heart will take over for over about a 6 month period once the LAA is isolated. The LAA really serves no functionality beyond that, however, in our earliest stages of development it is our heart. Here is a link to more info on LAA

During the procedure my heart went out of rhythm organically. This happened as he was starting to do work on the coronary sinus after he had completed his work on the LAA. The arrhythmia organized in the LAA then proceeded to the coronary sinus. I achieved a rate of 240 bpm. This is a rate I have seen before early in my afib journey. Dr. Natale believes that since I have experienced this before, that the area of the coronary sinus has been an underlying issue since the very beginning. Afib is not a static arrhythmia. If not addressed it could continue to progress to persistent afib. Once he was done with the coronary sinus he went back to eht LAA that he had already done some work on and touched up the spots were the organic afib originated.

240 bpm = Panic In the cardiac lab Sirca 1992

The Very first time I had a recordable rate of 240 was back when my Cardiologist sent me for a stress test in the very early days so I was still in my mid to late 20’s. They put me on a treadmill (I had requested a bike) and stared pacing me. They kept increasing the speed and asking me if I felt alright I said yes and started a conversation with the tech. He was having non of that so he kept bumping it up and I kept talking. At one point after he and another technician started to look at me as if I had spiders crawling out of my ears they concluded the test. Said that was the first time they ever ran that machine that fast. They then took me to a room, had me lay down and watch my rate drop.

A Dr came in and talked to me and looked at my strip. He looked st me again then turned to the nurse and said leave me hooked up for a while longer. This whole time I had been watching the screen as my heart rate was dropping. 140,130....... 100,90,80.......BOOM........ 240. Alarms and mayhem from my nurse ensued. She looked at the monitor then at me back at the monitor then she was off like a shot as I tried to say something to her. All I could hear was here yelling Dr. DR getting further and further away. I just laid there shaking my head smiling to myself as she had left me alone.

 Finally I saw her running back up the hall towards me with the Dr trailing way behind. When he finally arrived he looked at the monitor, at this point I was below 200, then he looked at the strip, then he looked at her for a moment. He then looked back at me and said “come see me, go ahead and unhook him”, then left. She then unhooked me as I was back in sinus rhythm and led me to the discharge area. I never did see that doctor again as I had already been through several cardiologists to this point and had one I liked. So I never did get to find out what he was thinking. He may have been an EP for all I know.

Follow Up 

My follow up appointment will be with Dr Natale in January. He will do a TEE at this time to check the function of the LAA. In between I will continue on anticoagulants,a lopressor and antiarrhythmic drugs. These will be elequis, metoprolol and either Ticosyn or flecanide. He had no real preference so I have a few days to decide. I stopped the Ticosyn on Monday(07/30) and Resumed the flecanide on Friday (08/01).

In the interim I will follow up with my other EP for an EKG, and blood work and anything else Dr Natale might need. Dr. Natale will now be my go to EP for ablation and or Watchman implantation.

Final note 

If you have afib and are considering ablation go to no other than Dr Natale @ St David’s in Austin. If you can’t find an EP that has alot of ablations under his belt. Also, if you want the best information on supplementation or just want to share your experience with others or have general questions or concerns this site is a wealth of information.

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