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HCM, afib, atach, RFA, a/v node
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HCM, afib, atach, RFA, a/v node

Dr,

I have HCM, and have had worsening afib since about 3 years ago. My LA is 54mm. I have had 4 ablations now. The first 2 did little. The last 2 by Andrea Natale have made progress. Since the last ablation in Sep, I have not had afib. I do have an atach, that Andrea warned me about post-op. He said he could get at it next time. I believe it was from the non-corinary cusp. My plan was to have that 3rd Natale ablation to eradicate the atach. I was scheduled for mid-Feb. However, a couple weeks ago, I got sick (DHF) from the atach (120bmp), and wound up in the hospital. In the echo, they found clots on the LA wall/lining, and on the pulmonary veins (because of some stenosis). My INR was therapeutic at 2.5. I had to cancel my next ablation until they cleared. I was on heparin, and am now on Lovanox.

Now, I have to wonder if all the ablations are causing structural weaknesses in my LA that make me more vulnerable to clots. Were these clots an anomaly or result of the process of healing from the Sep ablation, or are they a risk forever? I presume if they are a constant risk now, then my move is to start the process for transplant. If they are not, then I am left with options of another ablation, a/v node ablation, or maze/LA reduction surgery.
I wonder if I can ablate the remaining atach without causing a greater risk for clot formation. I wonder if the a/v node ablation might be better since my LA is so big and I do not get much atrial kick as it is. This would allow me to get off a lot of these meds too. And I know nothing of the surgical maze and left atrium reduction surgery other than it is an option.

So what are you thoughts on the short term? Are any of them a long term answers (with respect to my risk for clots)? Is it worth it to go to somewhere like Mayo that has HCM expertise, or will they say what everyone says which is, "we don't know." Please give me a different point of view.
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If the atach is truly coming from the non-coronary cusp then he would not have to go into the left atrium at all.  These atachs are ablated from the aortic root approach.  There wouldn't be a higher risk of clot formation or dislodgement with this approach.  Of course, for the purpose of the ablation, because of a small risk of needing a cardioversion, I would want to make sure that the clots have resolved.  I probably would not recommend going back into the left atrium at this time to chase this atach because of what's happened already with the clot formation.  The stenoses don't play much of a role as far as reablation goes because the veins are probably isolated at this point, so any additional ablation wouldn't be performed to isolate the veins, instead it would probably on the posterior wall of the atrium, the septum or around the mitral valve.  So if going back to the left atrium were necessary, I would wait, until the clots have resolved and the atrium had some time to heal.  AVN ablation would be my last option as would surgical approach to treat this problem.      
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