@tommy901
Hi Tommy, I have registered on the Hypertropic Cardiomyopathy and Heart Rhythms groups.
I have an enlarged LA as a result (in all probability) of a lifetime of endurance activities: NovaScotia/Maine/rough water sea kayaking, marathons, etc).

Probable MI 9/22. 10/23 StressTest: cannot exclude mild ischemia of small extent involving the apical anterior wall Recent 3/26 CAC 217, but most all in LAD 187. 10/23. I am fairly sure that's when this began. It is a typical Athletes Heart pattern. LA already stretched. Vulnerable to a strenuous effort at 74 yrs.
That schooch too much.

Afib rxed 10/23 LA 51ml afib 24% NO SYMPTOMS until 2/26. I asked my cardiologist about possible cardioversion. I did not realize her response was fueled by conservative (perhaps old school thinking). She slide sideways and said, 'Not now.....rate control is perfect. mostly 120s/70s, HR always 58 - 68..'
I was in need of "Oh, you are doing fine"

I began to wake up and ACTIVELY seek other input in 9/25. NOW, I was in 100% afib.
First, there was a cardiologist who IMMEDIATELY wanted to do a cardioversion (which was a procedure he was licensed to do). I had begun to research. I knew the reported success of that with a NOW 60ml LA was 0.

I sought an EP's eval in Charlotte 1/26 (a more urban center). He was clear, reasonable. He did NOT advise ablation. In his notes, he emphasized continued perfect control/no symptoms.

On THIS 2/26, I first experienced symptoms. To ME, it was a doozy. 3 days of
left sided moderate 'jabs', total medialstinal fullness, palpitations, random/changing every 20 mins. nasal congestion (venous backup? nasal membranes) which forced me to spend much of day doing deep breathing to feel adequately aerated.

Back in Weaverville, 3/26, I had gotten a 'new' cardiologist who SAID he respected CClinic in our initial visit.
I had decided to seek 'expert' advise 1) now that symptoms had begun and 2) now that I understood the major difference a 60ml LA makes in afib treatment. Of course Cleveland added its testing to existing data. The Wville MD wanted a 14 day Holter to consider med management. I can give that data if you like.

I am focused on CC's 4/26 ECHO which shows:
CURRENT ef=60% (from 72% 12/25 ECHO for EP)
RA = 8
E/e = 8
E/a =3.07
TR peak Vel = 2.7
TR Peak Grad = 30
I have researched to find logical explanation why these numbers reflect a structural sound 'athlete's' heart, not a restrictive failure.

But the squeeze can't keep it up forever. That's why I am fairly sure a Cox 4 at maybe 80% chance of success is the only reasonable chance. Otherwise, its CHF, major thromboembolism or procedures which NO MATTER WHAT THEY CLAIM can not truly get good visualization for a biatrial lesion set and LAA clamping with a LA that big. A robotic approach has limitations. "Trying to flip or maneuver a robotic camera and instruments to meticulously burn the necessary lines on the right atrium and vena cavae through the same tiny ports is a logistical nightmare. Also a robot relies on a single-point pen or wand, which struggles to replicate that firm clamping force across thick, athletic atrial tissue." Mini thoracotomy "Uses direct vision and specialized hand-held bipolar radiofrequency clamps allows the surgeon to physically clamp the atrial tissue, ensuring a "transmural" (full-thickness) scar line. BUT
"When working through a tight space between the ribs (a right mini-thoracotomy), the surgeon's angle of approach to the left side of the heart is physically constrained. It is much harder to maneuver the rigid clamping tool all the way around the left pulmonary veins and back toward the left atrial appendage." There is also difficulty freezing a perfect mitral isthmus line.
In conclusion, it seems an important factor that, "a surgeon may decide that for a 77-year-old patient, a faster, highly efficient 45-minute open-chest procedure is safer for the brain, kidneys, and body than a highly tedious, 90-minute restricted-view thoracotomy."

That is a lot of my story. Oh BTW, the most recent cardiologist who said he respected CC?...he said HE " disagreed with their advise, b/c HE BELIEVED IN DOING NO HARM???!!! " He could not tell me what he DID advise as a treatment plan which ALSO showed an awareness of how the enlarged LA changes the "living a long, happy life with afib" statement he made. I MUST find a local cardiologist who is open to various options and is able to give neutral pro/con evaluation.

You are the only commenter I see who may have some suggestions of where/how to find my cohort. The ELA makes treating the afib difficult. Getting supportive/helpful advise is difficult. Even finding a supportive informed local cardiologist is hard. Ideas? Thank you for your time. Susan