Ablation plus Watchman to be successful???

@m245837 The ablation may not be necessary if he is so seldom in AF. Yes, it's a progressive disorder, but in your hubby's case it seems to be very slow. But more, if his heart echos don't show any enlargement of the left atrium, and if we know he has no ischemia due to blockages, then he could afford to wait for an ablation. That is my inexpert opinion (no medical training whatsoever, although I have done a ton of reading as an AF sufferer (yes, I did suffer, as many patients do). The idea is to nip AF early, but it's best if it's a bit more active than just two isolated bouts of it. In most cases, the person is in and out of AF once or twice a week, or a month, and it is at this point that the electrophysiologist stands a better chance of finding AF and where to ablate. There's more to this, but this will suffice for the moment.

The Watchman only reduces the risk of a clot emerging from the left atrial appendage (LAA). When in fibrillation, that small grotto doesn't get good blood flow and clots can form. If the heart resumes normal sinus rhythm, it can dislodge the clot(s) which can then travel up the aorta and out the the heart, itself, to the brain, or to the lungs....all very bad. The Watchman seals off the appendage so that no clots can emerge. From there, with a very seldom fibrillating heart, and almost no risk due to LAA leakage, your husband might be able to forego anti-coagulation drugs like Eliquis or Xarelto. If he has other comorbidities, his risk still might be too high for your doctor's liking, at which he may be encouraged to take a DOAC like Eliquis or Xarelto (DOAC is 'direct-acting oral anti-coagulant;).

Thank you for the reply. He has been on Eliquis for a year and getting more concerned for bleeding and the recent second recent recurrence of AFib leading to the EP referral from his Mayo CVD for possible intervention. What I found to be concerning is that the Flex pro version is only 2 years old while the Watchman version (all) started in 2009. I don't like to refer to stats on a public forum, but the device seems so new, but it was still apparently indicated in my husbands' case according to the Mayo EP.

@m245837 I can understand your husband's reluctance to stay on a somewhat risky anti-coagulant, no matter how hifalutin it might be. 😀

I don't think the risk is so onerous that the manufacturer either can't underwrite the risk itself, or that its insurers won't. It's not like Vioxx where a few people developed heart conditions, so the drug was withdrawn...while people I knew well said it was a miracle drug that helped with their arthritic hands and gave them mobility back. The DOACs seem to be worth the risk of a major bleed, which fortunately happens to a very few people. I have fallen off my speed bike, struck myself or bumped things, cut myself, and bled. None of it was so bad that I had to be taken to a hospital. A compress left in place for 36 hours has always been enough to stem any further bleeding. Sub-cutaneous bleeds have been few. I get eye floaters (darn, because I use telescopes and cameras), and if they are the result of bleeds or cataract surgery, to name two common cause. Seven years into taking Eliquis now, and with both an adhered vitreous sac requiring a vitrectomy and a cataract, I don't have more than the normal age-related number of floaters in either eye.

The other thing is that new devices must be approved for public use after trials, and surely those same insurers would balk at underwriting a device with a spotty history. If the Watchman has a new model, and it is being offered, then it has passed the reviews for safety.

@gloaming You mentioned that AF is progressive. Does that mean that everyone having an initial first bout of AF will go on to develop into a case of constant AF given enough years in some cases?

@sandw40 Perhaps not everyone, but the majority will. The rate varies, and it slows with management (drugs or a successful ablation, but sometimes a substantial improvement in lifestyle will work very well), but once the heart enters any kind of arrhythmia it's a sign that the heart is commencing to remodel itself. It's a sign that the heart is already electrically disordered, but just now the symptoms show up with enough of the rogue firing cells wanting to act to send a signal to the left atrium so that they take over the beating signalling....working against the SA and AV nodes which are supposed to do all that.

Once you understand that there are formally adopted stages to atrial fibrillation, they being paroxysmal, persistent, long-standing persistent, and permanent, you can see that it MUST be progressive in nature.
https://pmc.ncbi.nlm.nih.gov/articles/PMC5153232/

@gloaming I know and understand the different phases but doubt that everyone affected by AF necessarily goes through them in their order. Unfortunately the cause of AF remains a mystery so most treatments still remain a short or longer term solution. But some develope an episode of AF for various reasons as in a surgical procedure or for some even a highly stressful event. They then go onto remain event free or at the least free of any detectable events 👍🏼

@m245837 he has Afib episode only twice? Hard to believe. Afib comes and go. I strongly doubt any doctor would recommend ablation for only 2 episodes of Afib

@sandw40 The various causes of AF are not mysterious. The various triggers that people swear set them off are somewhat of a mystery because we're all so different, but the causes of AF are well-established: cardiomyopathy, mitral valve prolapse, pathogen, systemic inflammation, and several other comorbidities. The real cause of atrial fibrillation is the establishment of routes for the spurious signals to enter the atrial endothelium which causes extra beats above those enabled by the SA and AV nodes. https://www.nhlbi.nih.gov/health/atrial-fibrillation/causes The risk factors are also numerous, some of which I have already mentioned.

It is precisely because the disorder is progressive that drugs lose their efficacy over time, again with the majority of patients. It's progressive nature is also why, as you say, that most treatments are temporary. As the disorder takes over more and more walls of the atrium, it begins to overcome the intended effects of medications of all kinds. It becomes more resistant to any treatment, including ablations. But there is one important saying in the field, 'AF begets AF.' The longer you're in AF, the more likely you'll stay in AF or at least continue to build the amount of time you're in AF. So, ablations, for the most part, stall that progression for many/most patients, maybe only for three years, while some get relief for a decade or more.

And yes, you're right, some patients have a cardioversion at the local ER and never have another blip as long as they live. I know one person who drinks a liter of magnesium water every/most days, avoids overconsumption of calcium by mouth, and is AF free for many months at a time. He uses a 250 mg flecainide tablet as a PIP (pill in pocket) if he's out and about and his heart begins to fibrillate, which he says happens about once or twice a year. He takes no medications, nada, except for the flecainide when needed, and has never submitted to an ablation.

@m245837 I’m on this site because I had an ablation 1-1/2 years ago at Mayo. I read your question to a heart rhythm expert and this was their response:
A key foundational principle in preventing the progression of atrial fibrillation episodes—beyond procedural treatments—is the modification of risk factors. If you are overweight, weight loss may be helpful. Exercise has also been shown to reduce recurrences, based on a landmark series of studies conducted in Australia. In addition, blood pressure should be well controlled. If your heart’s pumping function is even slightly reduced, medications that help the heart recover strength are critical, because overall heart health is a major determinant of outcomes.

If you proceed with a Watchman device to minimize the risk of stroke—which is determined in part by the CHA₂DS₂-VASc score, a system that considers factors such as congestive heart failure, hypertension, advanced age, diabetes, prior stroke, and vascular disease—then many clinicians will also consider treating the arrhythmia with an ablation, since the catheters are already in the left atrium during the procedure. These are complex decisions that are best made in close consultation with an expert who knows your specific situation. It sounds like you’re on the right path.

@gloaming Staying alive and healthy is complicated 👍🏼