PFA procedure with stroke risks

Thank you for explaining so well. I checked my CHA2DS2-VASc score as you advised. My score is 3. I have been on Eliquis for 5 years and I have a pacer. Cardiologist presented 3 options: 1) Do nothing and live with AF using Eliquis and Sotalol, 2) change medication from Sotalol to Tikosyn as Sotalol is not working , 3) do PFA (which I am afraid of due to stroke risk even though you explained it so well). I am the only care giver for an 80 yr old). Am seeing cardiologist again next week re PFA as he himself says that 50% of his patients need a second PFA.

If you don't mind, please advise he name of the drug he received for Eliquis reversal. Thank you. Regards

There is a lot of good data now that PFA is better than being in afib. For both stroke and heart failure risk. I’m disappointed that there isn’t good data collection for post PFA complications, we really should have robust systems to quantify complications. I had an ocular migraine on day 2 and day 3 after my ablation. I’ve had 2 previous ocular migraines in my life over the course of 4 years. I think the hemolysis from the PFA could have caused it, but who knows. My experience isn’t going in any registry. . My brain is better now than pre PFA. AFIB was caused me a lot of symptoms. It’s been 39 days since my last afib, I feel so much better. My groin hurt for the first week and the anesthesia recovery was miserable. Don’t push it that first week. I was a fool.

I can see your concern for others dependent on you is stronger than your concern for yourself. It happens that you needn't fear an ablation. The surgical team and the nurses who prep you will follow protocols to ensure you do not have a stroke related to the operation, and your risk of a catastrophic bleed due to Eliquis is very small in the rest of your life outside of the cath lab. Eliquis would be bad to have in a very bad bleed, but you'd be in danger of such a bleed even without having apixaban in your system. Apixaban is not a clot preventative; it is a clotting retardant. Big difference. So, for your average kitchen knife cut, you compress it, bandage it, and leave the are undisturbed for a day or more. It should clot normally, just not quickly. Happened to me dozens of times, and I have been on apixaban for 7.5 years by now.
Once again, to put your mind at ease, you get cerebral strokes and lung embolisms from clots. If you are pumped full of aspirin, heparin, and Plavix, which is what was swilling around in my blood for my angiogram during workups for my ablation, you simply have all the clotting bases covered. The idea with the ablation is to dam the area where the extra electrical signal is entering your left atrium, usually at the mouths of the pulmonary veins. Those extra signals emanate from the ostia of the PV, and they spread in a wave along the endothelial lining of the atrium, which causes a rhythmic contraction that is also really a wave if you follow how the muscle tissue under the electrical impulse moves. So, all an ablation does is to put a 'hot' needle tip against tissue surrounding the pulmonary vein ostia, each one, and repeat until he/she has literally created a stockade, or a circle, of scarring where each dotted scar touches the next one on either side. The impulses cannot cross the scar tissue like it can the healthy endothelial tissue around it. If it's blocked.........................it stops! If it stops, it can't make the atrial muscle contract. All your atrial muscle has to do now is to respond to the normal signal coming from the SA node (sino-atrial) in the right atrium, next door. And that's what you want. None of this causes strokes. The stroke risk lies in the left extreme of the left atrium, where that weird 'grotto' called the left atrial appendage is.
By the way, next time you chat with your cardiologist/EP, ask about the Watchman device. It may be appropriate for you, it may not be. If it is, read up on it, and if it can seal off your LAA, you would not have to take apixaban for that purpose. You still might have to take it for other matters about your health, but again, it's worth the ask.

Thank you also for your Watchman device comment. At my EP appointment yesterday ( which only lasts 15 minutes as expected), the EP said at the end of the appointment, OK, I will add the Watchman Device a the same time as the PFA procedure. I did not have any time to consider or research this device in any way. I do not know if it would be suitable for me or not. Some doctors do not advise it due to various risks (I have researched now). However, if the PFA controls the AFIB and puts my heart back in sinus rhythm, then maybe I don't need the Watchman? I am 76 and I read about the risks (appendage size, device related thrombosis, allergy to nickel/titanium or other device materials, cardiac tamponade, device dislodges etc). Unfortunately, it is difficult to talk to my EP, so I am trying to meet with his NP and another cardiologist, but I am afraid they will say it is my decision at the end. This is not calming or reassuring. Thank you so much.

It's always your decision since it's your body and future at stake. The EP is just offering his/her studied advice based on their experience and learning.
The best EPs that I know of suggest a Watchman anyway, despite the success of previous or future ablations, because the disordered heart is permanently disordered. Just because the EP blocks the extra signals from causing your atrium to beat chaotically doesn't mean you don't still have that disordered state! And further, the disorder tends to progress for all but a very few people. This means that many of us, if not most of us, can expect to experience ectopy again in the future. For some, it happens inside of a year, for others it might be as long as ten years. But it happens so often that it's almost a given for the majority of AF sufferers: once you have it, you have it. And wouldn't it be better to have that Watchman insurance already in place? And save all the DOAC costs during the interim? If the Watchman shows no leakage at the 6 month point (done with a TEE) after a successful ablation, then you can opt to forego any further DOAC. At least, many EPs will agree to that.

Thank you again for your message. Appointments here in Denver with an EP specialist are 15 minutes. I agreed to do the PFA, but at the last minute, EP added that he will also implant a Watchman device. I did not have any time then to discuss this with the EP or research it which makes me very uneasy, nervous and perplexed. Anyway, this would involve a multi device procedure. The Watchman's list of cons include Pericardial Effusion and Tamponade, device Embolization, Device Related Thrombosis, Stroke (even though Watchman is for avoiding stroke), but this can be due to formation of clots on new device mainly occurring days after device implantation! Since I cannot get another appointment with EP soon, I will talk to his NP. Hopefully she can detail how my body is suitable or not, as no analysis was done by EP regarding Watchmen. Anyway, I have tolerated Eliquis for 8 years now and can continue on it with doing just the PFA procedure (which 50% of patients say they had to do twice). As of now, I am leaning towards NO Watchman! I am surprised at myself for making this decision so difficult and causing so much stress! Thanks again for helping. Regards

I'm not in agreement that approximately 50% of PFA patients need a touchup or a redo sometime soon after their first (known in the medical community as and 'index...') ablation. The PFA is safer, all things considered, with fewer potential complications, but it isn't more effective for either index or for subsequent ablations. RF and cryo have about the same success rate, and most of us who learn all we can about arrhythmia and ablations soon realize that the across-the-field success rate for any method relies more on the skill and experience of the EP than almost anything else!
So, across the field, the success rate for index ablations is about 75%, with subsequent attempts running near 85%. But there is a lot of variance, and that variance is not due to the method of delivery; it's due almost exclusively to the duo of patient's heart's state and the EP's skills. As an example of an index ablation failure, I can tell you that you'll be taken care of...both times, and that you should be optimistic in either case; the index or the possible redo...whatever happens. They are day surgery. You'll be home in your own bed that night, unless you've had to travel and must return home the next or following day.
The watchman, likewise, can only be successful with the right match of patient and practitioner implanting it. I do know that some of them leak, in which case it's a loss and you just have to take a DOAC for life if other comorbidities or continued arrhythmia warrant it.
BTW, we haven't talked about your CHA2DS2-VASc score. The medical establishment uses that derived score to assign a risk of thrombo-embolism. A score higher than 1.5 is cause for concern, but certainly a score of 2.0 and higher warrants a DOAC prescription. You can google that score, as I spelled it above, and find an online calculator. Be scrupulously honest with your answers and you'll see what your apparent (not expertly assigned since neither of us is an expert) score is. Again, 1.5 and above often warrants a DOAC or some other prophylaxis to minimize stroke risk.