Dr. Mario I. Pascual , Medical Director of Electrophysiology at Baptist Health’s Miami Cardiac & Vascular Institute presents on The Rapidly Evolving Field of Electrophysiology. View his pre-recorded lecture to learn more.
Good afternoon and welcome to our cardiac and vascular lecturer, Syrians. I am dr Gallin Hakim. Assistant Vice president of international health care partnerships and insurance development at baptist health. It is my pleasure to welcome all of you to this informative presentation. I would like to extend more ingredients to our friends across latin America, the caribbean and everyone joining us today during this interactive presentation you will have the ability to ask questions via the Q. And a feature located in the bottom of your screen. I will be your moderator for today's lecture this afternoon. I have the distinct pleasure of introducing dr Mario Pascual who will be presenting a lecture titled the rapidly evolving field of electrophysiology. DR Pascoe is the medical director of the electrophysiology, electrophysiology service line at Miami cardiac and vascular institute at baptist health South florida. He is a board certified in internal medicine cardiovascular medicine. In clinical uh cardiac electrophysiology. DR Pascual received his medical degree from the University of Miami Miller School of Medicine. He completed his residency in internal medicine at the University of Miami Jackson Memorial Hospital, followed by a fellowship in cardiovascular diseases at the National Clinical Foundation Heart and vascular Institute in New Orleans Louisiana, where he was named Chief cardiology fellow. Additionally dr Pascual completed a fellowship in clinical cardiac electrophysiology at the University of florida in Gainesville. Dr pasquale honors include the Herman L. Price and the Clinical Excellence and Heart failure Award and the Edward Grant um and the Clinical Excellence and cardiology Award from the Ocean or Clinical Foundation. He was also named the Chief cardiology fellow by the Austrian Political Foundation. Dr Pascual has published in medical journals and lectured at national and international conferences and issues related to his field of specialization. In addition, he has conducted several clinical research studies to improve the efficiency of treatments such as cardiac dressing, crown ization therapies. Please let's give a warm welcome to dr Mario Pascual. DR Pascoe. Thank you so much for accepting our invitation. Welcome. DR King. Thank you very much. Thank you for giving me some time to talk about my field, something that uh that really passionate about. So I appreciate that at the time of course, go ahead and share your presentation if you can talk. Okay, Okay, able to see the screen. Well thank you. Thank you for taking some time to spend with me today. Um We're going to talk about the rapidly evolving field electrophysiology and I thought specifically we would discuss VT abrasions as we've had some pretty exciting opportunities. Um So you know, I think in electrophysiology of the last five years there have been significant technological and intellectual advancements in the field of VP. And really the success rates for ablation procedures have never been higher. They've never been safer. We've never been more efficient in the lab and cut down procedure time. And our device based therapy for heart failure continues to reduce mortality and decreasing rheumatology and I may be biased here. But in my opinion this is one of the reasons that E. P. Is the most exciting field of medicine just how rapid things are advent are advancing. But despite these advances we continue to have limited access to E. P. Procedures. If you see the number of patients in the United States and across the world that are diagnosed with arrhythmias and then treated with certain procedures that can be curative or at least really decrease the burden of arrhythmias. You can see that there's a big discrepancy. So a large lag between our procedural success rates and our ability to educate our referring physicians or patients and really anybody in the field who could really benefit from our procedural successes. So education I think is a personal endeavor of mine, certainly a personal endeavor endeavor of our service line and it's something that we're passionate about. So we really thank you for giving us and spending some time with us. You know I think when Miami cardiac and vascular institute was started many years ago now the philosophy was always to use a team, team based approach to patient care. And I think now more than ever we have realized that you know back 20 years ago, 25 years ago M. C. V. I was really thinking way ahead of the curve because now in 2021 it is clear that you can no longer practice in silos and medicine and especially in the cardiac and vascular space. We use a multidisciplinary approach which has been proven to improve patient outcomes, improve patient access and truly fosters innovative approaches to the treatment of medical issues. And so the mammy cardiac and vascular institute, something that we'll talk about and we'll go over a case presentation very soon is we performed our first radio ablation for incessant ventricular tachycardia, Miami and cardiac and vascular institute and we're really one of the only centers in the country and truly in the world and certainly the first in florida to have done this using radiation therapy to treat the cause of ventricular tachycardia in a patient and will review the case in detail in just a bit, but highlighting the multidisciplinary approach to treatment of arrhythmias. So let's talk a little bit about ventricular tachycardia. Um this is a ventricular arrhythmia. That's the major cause of sudden cardiac death, causes about 4.2 million deaths per year. We certainly have multiple therapies that exist for patients with arrhythmias, including anti arrhythmic drugs, implantation of defibrillators. Not so much to prevent arrhythmias, but more so to treat them as well as abrasions. Um in order to get rid of the arrhythmic substrate and one of the ablation is called radio frequency ablation when we talk ventricular arrhythmia ablation. There's truly a wide range of ventricular arrhythmias. And the treatment is really going to depend on the prognosis. The prognosis of ventricular arrhythmias can be quite benign. Um something such as outflow tract pvcs where they can really be life threatening and one of the main kind of differentiators of if ventricular attack of card is going to be life threatening or benign is going to be the absence or presence of structural heart disease. So the first thing we look at when we talk of ventricular arrhythmias is this is patient have structural heart disease. That meaning underlying coronary artery disease or a heart attack in the past? Or does he have some type of cardiomyopathy or weakening of the heart muscle that can contribute to that ventricular arrhythmia? Or is their absence of of structural heart disease? Does he have no heart disease whatsoever? And that usually can separate those arrhythmias from life threatening in the line. Just like everything in medicine. It's certainly not absolute but it's a good guidance as to where we're coming from. When we talk to ventricular tachycardia in the presence of some type of structural heart disease. So again history of heart attacks, weakening heart muscles are dilated cardiomyopathy. These are usually the patients that we worry about because these arrhythmias are usually life threatening. These patients are usually very symptomatic with recurrent I. C. D. Shocks if they have an I. C. D. In place which if you talk to any patient that has had an I. C. D. Shock. They will all tell you the same thing. It is extremely unpleasant and painful. So something we don't want our patients to receive our I. C. D. Shocks. They're unpleasant. Their painful and they really interfere with quality of life. They're doing a very important purpose there resuscitating the patient and assuring that there is no death. But we don't want our patients to get shocked because it's very uncomfortable. So if we have a patient with I. C. D. Shocks this is where VT ablation will come into effect. And VT ablation is a class one indication for symptomatic drug refractory, ventricular tech accordion. So the question question often comes up if you have a patient on medical therapy with a different relate er and they are getting I. C. D. Shocks. Should we just add some medications and watch those patients what we call escalate therapy or should we do what's called an ablation procedure to talk about in a second. And before we talk specifics this was a trial that came out of the new England Journal of Medicine in 2000 and 16. That showed in those patients that have an I. C. D. And our own therapy as opposed to escalating therapy. If we proceed for ablation or some type of procedure intervention. The incidence of the primary outcome which was death ventricular tachycardia storm or I. C. D. Shocks was significantly decreased in those patients who underwent an ablation procedure as opposed to those patients that had an escalation just of medical therapy and that was predominantly driven by decreased incidence of recurrence of ventricular tachycardia here after the ablation as well as reduced incidence of appropriate. I see the shocks. So when we talk VT or traditional VT abrasions, what we first do, I'll show you them in a second is create a map a map of the left ventricle. So we're actually putting catheters within the left ventricle of the heart in order to understand how healthy or unhealthy is the left ventricle or the right ventricle of the patient. To understand where this arrhythmias propagating or coming from, we use a separate catheter that has a small tip, usually three millimeters and that catheter delivers tissue or heat energy into the ventricle in order to get rid of the area where this abnormal tissue and this abnormal rhythms are coming from. But of course the heart is not a very smooth structure and we have to maneuver around obstacles And the heart continues to move. We don't arrest the heart while we're bleeding, the heart continues to beat anywhere from 60 or if they're in ventricular tachycardia, 1600 and 1780 beats per minute and catheters, stability is crucial to critical to success. So if we can't get that small tip catheter and put it exactly where we want it to be and can't have it be stable. There are successful R. VT ablation will not be successful and that's where the ep kind of field continues to progress and our technology understanding of arrhythmias continues to progress to have more stable catheters and technology to allow us to maneuver and assure we have good contact. And the first thing I'll show you is what we call ultrasound maps. So similar to an echocardiogram where we put an ultrasound in the patient's chest. What we do here is we do what's called intra cardiac ultrasound. So we're actually getting an ultrasound catheter that's quite small. It's a nine french sheets, so about, you know, eight centimeters. We're putting that catheter within the heart and that catheter then gets images of the heart. And I want you to look here inside the heart. The heart has an inside or what we call the endo cardi. Um it has a middle or muscle and has an outside what we call the epic cardio. And these ventricular tachycardia can come from anywhere within these areas. It could have come from the indo cardi, um the mid myocardial or the epic kardian. This here is what we call the popular Mosul. So you can see here the popular Mosul attaching to the Court eight of the Mitral Valve, another obstacle to maneuver your catheter around. And so we use this ultrasound to get a picture of the heart slice by slice. So we can understand not only where the inside of the heart is, we can look at where the popularity muscles are and we can look at where the outside of the heart, understanding how thick or thin the tissue is there. And if we continue to get different slices of the heart, we can eventually create a three dimensional structure of the heart. And this whole process takes probably about you know, seven minutes to do So we can have a very good understanding of what this patient's left ventricle looks like. And we haven't even yet put a catheter within the left ventricle. Okay. Not only understanding what the left ventricle looks like, but also understanding the obstacles we're going to have to go around. The next part of that procedure will be putting that catheter within the heart and creating these very beautiful, abstract pictures. This abstract art. Okay. And this catheter. We've put it into the heart and what these colors are showing us our how healthy or unhealthy the heart is. And we've created this picture of the heart. And I want you to think about a football. This would be the top part of the football. So the top part of the heart. This would be the lateral aspect of the heart or the lateral wall. This would be the septal wall and this would be the apex here. Purple on this map means nice, normal healthy tissue. Red means dead. That meaning scar tissue. So you can see the amount of scar tissue this patient has developed within the heart at the apex of the heart. And if I go to the next slide here, this is kind of the septal so the septum aspect of the heart as well as the inferior wall of the heart. So the bottom all of the heart, the apex and the septum have all suffered significant damage. So significant um heart attack that has affected that area of the heart. And so you can imagine this large area of scar. We have a three millimeter catheter and we're just going around the heart of blading. That's what these red dots are with a small catheter going in and burning all the areas of abnormal tissue conduction. And in this video I'll show you exactly what we're, what we do. This is the aorta. The catheter is going around the aorta. You can see the catheter is going through the aorta now pointing directly down towards the bottom part of that football or that inferior wall. This blue thing here is what I showed you earlier, the papillary muscle. Okay, so we're using our ultrasound catheter here and I can show you that again to show you exactly. You can see here with a little green where that catheter is within the heart, how the heart is bouncing up and down up and down. You can see that movement within the catheters. So our mapping system and there's a tip again, mapping system allowing us to show exactly where the catheter is. If we're catheter is stable or not and where our force is pointing. So we're pointing directly down directly where we want our catheter to be and catheter stability is great. We're delivering a very good lesion But towards the end of it you can see the catheter kind of just slips out of the heart. So not good catheter stability. Giving us an understanding of how well or how poorly the area of ablation was at that spot. And so at the conclusion of the case this was our map. All the abnormal areas of conduction were a bladed or gotten rid of. But you can see that there's a lot more red tissue, a lot more dead tissue. And luckily there was no further arrhythmias from anywhere with anywhere else within the heart. But that's certainly a possibility in the future and that's why when we talk VT ablation we can decrease the incidence of recurrent I Cd shocks By about 70%. But about 20% of patients will need a second ablation at some point but we can significantly reduce the incidence of recurrent VT. We can significantly reduce the incidence of recurrent I. c. d. shocks and that's always our number one goal. These VT ablation is generally in our institution are done with general anesthesia. Sometimes done with moderate sedation. These are usually patients again with structural heart disease. So they tend to have poor heart function and we tend to sometimes have to use mechanical heart support because their blood pressures can drop so can be complex abrasions and can sometimes lead to some consequences such as Icu stays. So on V when we were presented with this patient and we'll go step by step into exactly what I thought process was. This is where that multidisciplinary approach became very handy for us. Okay so this was a 77 year old gentleman and ischemic cardiomyopathy. His ejection fraction was 10%. He had had a cabbage and mitral valve repair in 2004 with a redo cabbage in 2020 mitral valve replacement. Try customer drive repair a traditional kind of ablation or VT ablation in the past with a cryo ablation which will talk specifics in a second with a bi ventricular IcD. And despite all to medical therapy use of three medicines and Miramax, Latina Oprah pendulum. He continued to show up to the emergency room with what we call V. T. Storm meaning kind of incessant ventricular tachycardia for over 24 hours. So in april 2020 he presented to our institution with palpitations and lightheadedness. I'll show you the E. K. G. In a second but it was consistent with ventricular tachycardia. The ventricular tachycardia was paced terminated which means we use his own defibrillator to just paste them out. Instead of having a shocking he started an immune or um the echo at that time didn't look too bad. Normal ejection fraction of 65%. He was found to have a large aneurysm which I'll show you a nice picture of a little bit later. But unfortunately from that mitral valve repair in 2004 was now found to have once again severe mitral regurgitation. This was the E. K. G. And presentation. So when I look at this E. K. G. I see a very wide complex tachycardia that doesn't look like a typical right bender left bundle. And I can tell you that there is some V. A. Dissociation on this E. K. G. Consistent with ventricular tachycardia. So certainly a dangerous rhythm. We know there's a patient that has coronary disease status post cabbage. So he has structural heart disease. So this is a ventricular tachycardia that can be and it was life threatening. We worry about this patient and he's found to have severe mitral regurgitation. So in May of 2020 he underwent Redo Cabbage. He underwent now a mitral valve replacement. He had a trick a speech about repair. And because of that history of ventricular tachycardia during the operation we did a VT ablation and instead of getting that small catheter and delivering he energy to the areas we got a big clamp and kind of clamped that aneurysm and just kind of burned around the aneurysm from the outside. So remember the heart has an inside the window cardi um has the middle the mid myocardial and has an outside the epic cardio. So we clamp from the outside and burned all around the aneurysm hoping that we're able to oblate across the entire thickness of the heart tissue. He had a prolonged hospital stay. The recovery from that surgery is a pretty extensive surgery um was about three weeks. So hospitalized for about three weeks post but kind of recovered pretty well. But unfortunately in September presented with a two week history of increasing increasing discipline exertion, significant weight gain and now we noted a significant changes. Echocardiogram instead of a normal ejection fraction, his rejection fraction has now dropped to 25%. His heart had severely dilated and he was again found to have that aneurysm which was a bladed but not could offer anything. So it's still there. But at this time he also had severely dilated right ventricle. So instead of a normal heart now he has a failing left ventricle as he has a statement of failing right ventricle. His tacky cardia. He had recurrent ventricular tachycardia which required an I. C. D. Shock And at this point he only had a single chamber I. C. D. And so at that time we optimized his medicines. So he was started on beta blockers. He was started on um entrust. Oh an emery the Jackson and S. G. L. T. T. Two inhibitor which is now approved for heart failure and was placed and loaded on immune or um because he only had one lead and was pacing from the right ventricular lead. These patients can develop what we call the synchrony. So if you're only pacing on the right side of the heart and not the left side of the heart. So if you only have one lead and not to your activation and you're pacing comes from the right ventricle to the left. So if you're only pacing from the right ventricle to the left, you develop what's called the synchrony. Your ventricle is not squeezing or activating at the same time. So what we did is we add an additional left ventricular lead. So now we can have synchronous activation of the right ventricle and the left ventricle. So you have a failing LV of failing RV. We were hopeful that by upgrading them to abide ventricular I. C. D. We can improve his ejection fraction and by proving the ejection fraction his ventricular tachycardia would only improve. But unfortunately in december he presented with recurrent palpitations and lightheadedness. He was found once again to be in this E K. G. Once again, what we call a very wide, complex tachycardia which has a right bundle morphology suspicious for coming from the left side and based on our E. P evaluation of this E. K. G. This is once again coming from that aneurysm that we have already tried to a blade a couple of times twice VT was a bladed and now his eF is once again 10 to 15%. So very sick patient. So now he comes with recurrent VT storm, he was already on them, you know, running for panel law, we added max guillotine again because of the severity of his sickness and his low ejection fraction And we kind of had a discussion with the family. He had just had a large surgery, had a tough recovery. His heart function was only getting worse at this time and we thought he was a very high risk for a traditional VT ablation which already had been offered twice to him. And so we knew that this was somebody that we had to offer an alternative solution. Okay so we offered him cardiac radiosurgery. But once we offer cardiac radiosurgery it's not just offer cardiac radiosurgery and go straight to surgery. This requires a very comprehensive or multidisciplinary approach. So he is evaluated by general cardiologist R. E. P. Cardiologists are heart failure specialists and we have cardiac imaging specialists. Our pre treatment assessment was done by a radiologist. Radiation oncologist Who have been extremely helpful in the treatment of these patients are medical physicists are dosimeter wrists and then we establish multiple imaging to establish our kind of target for treatment. And so if you look at their treatment plan, we create these 3D maps which we have shown you earlier. We obtain a cT imaging and we integrate the CT image with our electronic tapping on an atomic imaging to really define what we call our target. We delineate our target with the C. T. Scans done at the Miami cardiac and vascular institute and then the radiation oncologist kind of decide how much energy can be developed or deliver. Excuse me or radiation can be delivered to that area of the heart to get rid of that abnormal conduction tissue. That abnormal radiation and the patient then goes under undergoes radiation. And we talked about our traditional VT ablation which requires general anesthesia. It's usually a 345. Our case sometimes requiring mechanical support like a balloon pumper in Pella a lot of times requires an ICU stay. And we're delivering energy little by little within the heart just one dot by one dot radio ablation instead. When this patient came in and I told you already how sick he was. We established a peripheral I. V. Access. He required no sedation and we're with him the whole time procedural time was about 30 minutes Monitor for additional 20 minutes after the procedure. And he was home for dinner. He did extremely well with no prolong this day. And so this is what we targeted. We talked about that large kind of bezel inferior wall aneurysm in this cT scan. This is the left ventricle here and you can see he has this little out Pao ching what we call that aneurysm. And so the radiation oncologists you can see they highlighted this area. They delivered radiation to that area in order to get rid of its ability to conduct electricity and produce that arrhythmia. And we couldn't be more excited to say that we're now six months out he is off of amiodarone. He remains on low dose, makes a Latina and beta blockers. But he's had no recurrent ventricular tachycardia. He's had no recurrent hospitalizations and you can see that his ejection fraction although it had dropped all the way down to 10% Is now back up to about 45%. So again kind of single patient experience but certainly in the excellent outcome. And so we believe that cardio cardiac steri attacked IQ radio surgeries and promising innovative treatment alternatives or select patients with symptomatic VT especially those that are not candidates for traditional VT ablation because of the overall severity of their illness. Right now we know that the the toxicity profile is extremely uh favorable out to one year but we are currently doing studies looking at the long term benefit and long term toxicities out to five years and so we certainly await results of ongoing clinical trials and continue to treat select patients on a case by case basis. But we have had excellent outcomes. Just highlighting the multidisciplinary approach. If you want to shift focus a little bit too. Now, ventricular ablation in the absence of structural heart disease. So we talked about doing the T ablation in the presence of structural heart disease. Now we'll kind of switch a little bit more to be more benign but still highly symptomatic arrhythmias which can affect our patients. And in the absence of structural heart disease the most common PVC or VT will be what we call outflow tract PVcs. These are idiopathic PVCS or premature ventricular complexes that arise from specific areas in the heart. As we know, we have a right side of the right ventricle and we have a left side or left ventricle and the right side will have an outflow track or a tube like structure that evacuates your, sends blood out to the lungs through the coronary artery. The left side of the heart will have an outflow track that sends blood from the left ventricle outflow track to the brain and kidneys. This area here is what we call the left, the outflow track of the heart because it is exiting to the lungs or exiting to the systemic circulation. And based on certain E. K. G criteria, we can identify where these patients have outflow tract PVCS. These are usually seen in younger patient population in the 3rd and 4th decorative life. And they can be highly symptomatic causing palpitations seem to be loss of consciousness near sympathy and importantly they can lead to attacking mediated cardiomyopathy or heart failure. So if you have a high burden of PVCS which we define anything above 10%. These patients are at risk to develop a cardiomyopathy from their PVcs and it's completely reversible and that's why we like to really educate patients physicians, referring physicians about the importance of monitoring and diagnosing outflow tract PVCS because they can certainly have consequences, especially in the young patient population. And so recent advancements to help us oblate PVcs and reverse that cardiomyopathy or help those symptoms that can really be bothersome our integration of cardiac imaging and the addition of their ultrasound maps which we saw earlier today. So again, really defining cardiac structures and catholic patients have never been better in electrophysiology and we'll show a couple of examples now. So this is a CT image or CT integration that we obtain prior to our ablation. To really show us the aorta. We can then define our right coronary cusp. RCC are left coronary cusp in our non coronary cusp. And in this cat patient we've put in that ice catheter or ultrasound Catherine within the heart. We're looking towards the coronary costs and we have the CT image that we we can integrate and then get the live image in the lab of the left corner cost, right corner customer, non coronary costs. And now we can have an excellent correlation between our left corner costs and our left main coronary artery, r right coronary artery. Because when we a blade in this area, we want to be able to eliminate the PVC but we want to avoid very important structures such as the left main coronary artery and assure that we're at a safe, safe enough distance from it. So at this point, what we've done is again, integrator ct image. We've brought our ablation catheter around the order, which we'll see in a couple of slides. And we put our catheter within the heart. And as the patient is having Pvcs we want to assure that we are within the area of the heart where these PVcs are coming from. And once again we start to make these abstract colors. And when we do what we call our activation, that means that we're putting our catheter in the heart and once the PVC is activated we're trying to see how close or how far we are from the earliest source of that activity. So we want to find the cell or cluster of cells that are triggering or causing that PVC. And if we can get to that location in a safe manner with goods catheter stability, we can burn that area and eliminate that PVC. In this case we can see on this right side here, red is early and yellow is a little bit later. Green is later, blue is later and purple is very late. So in this area here we have found our earliest spot. So this is where the PBC is coming from. It is coming from what we call the left coronary cusp. So he's had abnormal conduction of electricity abnormal. We call automaticity arising from the left coronary cust integrating R. C. T. Scan our activation map and our ultrasound map. It doesn't display very well but ever so slightly you can see a little red structure right here. So I can tell you that's where our catheter is and that's where exactly where we burned. We can be 100% sure that our catheter is stable on this spot that it is sitting within the left coronary cusp. And that it is a very safe distance away from the left main coronary artery, assuring that we're gonna blade in a safe location with signet with very good stability and not anywhere near the left main coronary artery which can cause significant damage, such as an acute myocardial infarction with occlusion of that main. And we don't just met the left left ventricle outflow track. This is a map of the right ventricular outflow tract. So this is the pneumonic artery sitting up top. This is the outflow track. And you can see everywhere within the right side, purple means late. So we're very late in reference to the PVC. And then we're getting earlier as we map closer to the coronary costs. I like this slide also because it shows you the proximity of the left ventricle outflow track and the right ventricle outflow track. So as electro physiologists were very interested in the anatomy of the heart. We consider ourselves cardiac anonymous because we really have to understand relationships. And if we map in the right ventricle and we think how early, you know we think we're early. Well now we map the left ventricle and you can see how close the left coronary cost and right coronary costs are to what we call the septal aspect of the right ventricle outflow track. So you can see it's proximity and understanding and using the C. T. The ultrasound and what we call the activation map, we know exactly where that PVC is from. We a bladed within the asteroid. Now again it's not just a blading. We have to sure that we deliver a good lesion or an effective lesion. We have to make sure our catheter is stable. So there's a lot going on on this slide and we're going to kind of go step by step into how as electro physiologist we can assure that we're delivering an effective lesion. So I've shown you all the maps before showing that we're very early there. We've mapped it. This is our target. We've used the ultrasound to assure the catheter stable there. We've used the ultrasound in the C. T. To assure that we're a safe distance from the left main coronary artery which you can see here and now all we gotta do is burn there and burn effectively. But remember the heart is moving At 60 70 80 beats per minute. We've taken our cather the catheter is sitting within the left quarter cost and now I have this what we call our directional vector. So I know our catheter is pointing in this direction. Now it's not enough to just point in some direction. We have to make sure that we're pointing with a certain amount of force to make good contact. So our catheters have a little spring at the end. It's a tiny little minuscule spring. And that spring can detect differences in grams of force. So that spring is detecting that the force is going in this direction and it is going in that direction with a force of 23 g. And based on studies, we know that any force between five and 20 g can give you an effective lesion. So I have 23 g, I'm pointing directly at the cusp. If the direction was pointing this way, not where I want to be burning, I don't want to be burning up. I want to be burning directly towards the cusp. If it's burning this way. So kind of leftward and upward. Were burning towards the left main coronary artery, definitely don't want to burn in that direction. We want our directional force to be exactly towards the left corner, cussed here, where that abnormal tissue is conducting. If you see these little bars here, that tells us how stable or a catheter is. So if our contact is intermittent, so as the heart contracts and then let go, let's go. Our catheter is kind of falling off. Only one kind of square bar would be blew. The rest would be black. Here, we have three out of three blue bars with 23 g of force pointed in the right direction. We know. Using ultrasound ct integration as well as what we call our contact force catheters. Or that little spring telling us the direction of our of our force with how many grams that this is going to be a very effective lesion. We delivered one lesion in this area and the PVC terminated with very successful results. This is about one year out. No recurrence of the PVcs and this patient had complete resolution of their cardiomyopathy in a very young patients who is very symptomatic for their PVcs. So as opposed to medical therapy for suppression and young people, we can offer them a procedure to eliminate the need for any further work up and that can with a very high successories eliminate the diagnosis of a cardiomyopathy for these patients. In discussing a cardiomyopathy. I wanted to highlight a little bit the cardiac re synchronization therapy just because we presented a case of a patient that had the bi ventricular I. C. D. Which we we I showed you a chest x ray of earlier and um kind of highlighting its effect and its success rate in in heart failure patients. So you know this is one of the most successful heart failure therapies over the last 15 years and it's indication is anybody with a dilated cardiomyopathy With an underlying left on the ranch box. So the ejection fraction less than 35 with an underlying left on the branch block. This is the addition of a lead in the lateral vein that we put within the coronary sinus. So the heart's kind of the heart you know the the arterial side of the heart or the coronary arteries and just like the rest of our body. It has to have a venus blood flow return to the heart. And that venus blood flow is through these lateral veins back into the coronary sinus, which then drains into the right atrium. And so with cardiac re synchronization therapy, we can have a significant improvement in symptoms. We can have decrease in mitral regurgitation and we can have an improvement in the ejection fraction of the heart. And this is a cardiac re synchronization device. This is an old picture because this was an older older lead but this lead is sitting in the right atrium. This this lead is sitting in the right ventricle and just like I talked about that the venus return to the heart is through a vein called the coronary sinus. So the coronary sinus is here and it dumps back into the right atrium to then go into the right ventricle and through the right ventricle outflow track. So what we do is we put catheters and we engage the coronary sinus and then advanced this lead into the lateral portion of left ventricle because when you have a left bundle branch block, your activation is coming from the right ventricle and then kind of deep polarizing or activating towards the lateral portion of the left ventricle. So your activation is going in this direction from your septum to your lateral. So your latest point of activation is going to be your lateral and the heart doesn't like that, the heart likes to beat synchronously right and left side at the same time if you're right side is beating and then your left side beats, that can cause a cardiomyopathy. So by putting a cardiac resentment. Re synchronization therapy are responder rate, meaning improvement in New York Art Association class, decrease in micro regurgitation and significant improvement in ejection fraction is out to about 50-60%. But we were limited by technology because we find a very nice lateral branch. We put that lead within the lateral branch, but then we only have a responder rate of about 50-60%. We have to do better. And so that's where the newest technology which is called multi point pacing. So pacing for multiple locations within the same lead has now resulted in improvement in that responder rate. So if you go back to that lead here, you can see it only has one electrode. So our options to paste this lead is only one electrode in these leads. Now we have four electrodes, one electrode here, one electrode here, a 3rd and 4th electrode here and only. Not only is it different for electrodes, but they're differently shaped. So you can see the distance between each electrode is different given us better options to pace from. So if this electrode doesn't work. Well, we got three more electrodes that we can see if they work. And instead of simply pacing from one single electrode, we can now pace from this electrode as well as this electrode. By pacing from more electrodes, we activate a larger proportion of the heart. We allow more re synchronization therapy and now our responder rate, instead of being stuck at 50-60%, are responder rate now has improved 76% with a more significant rise in the ejection fraction compared to our patients with traditional or conventional cardiac or synchronization therapy. So once again, a procedural intervention not only decreases mortality, but makes patients feel better, improves their ejection fraction and offering improvement in technology to improve our success rates, improve our responder rates. So in summary, I think we can see that electrophysiology is a rapidly advancing field as an electrophysiology. I'll tell you, it's one of the most challenging parts of our fields. There is so much research and so much technology and really new intellectual intellectual advancement within electrophysiology that it's tough to keep up. We really have to dedicate ourselves to go to conferences and, you know, keep up with our journals In order to understand this new technology and more and more. We learned that we can operate in silos. Electro physiologists no longer operate in silos. We have the support of our advanced heart failure specialists. We have our support now of our radiation oncologists to offer innovative solutions to patient cares at the Miami cardiac and vascular institute. I think we've taken up our time there once again. Thank you very much. And I'll open it to questions at this time. Thank you so much. Doctor pasquale were an incredibly insightful presentation. I know that as you stated at the beginning these past years have been just revolutionary uh for electrophysiology and special especially for your area of expertise. Um I know that some of you have questions directly to dr Pascoe. I want to remind the rest of the audience to please post your questions directly to the Q. And a session section in the bottom of your screen. And uh we will try to address those as we go. So dr pasquale, you you mentioned a few important things that I wanted to recapitulate define A. And one of which is the new approach of actually managing heart failure and obviously managing arrhythmias and all the different components of the conditions that leads to heart failure. Now you did mention uh an interaction with the interdisciplinary team. So you submit these cases to an interdisciplinary team type conference in which the modality is perhaps uh suggested the question that I always get to think about is with the electro physiologists already predetermined the type of modality that uh you're going to be using a specific patient, be it chemical, like we used to do it before or the appellation, beit cry, or thermal or or radio. How do you determine exactly the type of modality that you're going to be using for a specific condition. Sure. Yeah. So every arrhythmia is going to kind of take a different approach and there are certain patient characteristics and indications that will lead us to determine which approach to use. So our traditional um kind of ablation technique has used heat energy and in patients with certain indications we know that heat energy will be the most effective and best strategy for those patients. But there are other options such as cryo ablation or cold energy which will kind of be more favorable in certain patient populations. So looking at the overall patient population, understanding the mechanism of this arrhythmia then leads us to determine which is the best treatment modality and which is the best ablation strategy to decrease their burden of the arrhythmia and hopefully offer them a good cure. And using that multidisciplinary approach for example, using a heart failure specialists is not so much to determine which is the best ablation strategy but is to assure that that patient is optimized as best as possible prior to undergo any type of procedural intervention. And if we need some type of mechanical support we have our heart failure specialists which will help us manage these patients in the post op setting mm. The you did mention the cardio stereotype Actiq radiosurgery that is perhaps one of the uh newest things that uh we tend to hear you talk about and you also talk about the prevention component for BBC. S for instance, um uh Oftentimes, you know, we find these patients that perhaps it's a little bit too late in the process and in their disease process rather. Uh and I'm wondering if we're doing enough in educating our physicians, our primary care specialists in identifying the source of arrhythmias or an arrhythmia. Uh and uh what do you think we should actually do? Your message was very to the point we need to be educated in order to prevent, but what do you think that we should really do in order for us to identify earlier these conditions? Yeah, yeah. I think, you know, education, education will be the key and um, you know, early referral as well if, you know, as a as a primary care position as a cardiologist. When I speak to them about when to send that patient to see an electro physiologist. My message is, is pretty consistent and almost always earlier is better. And the reason for that is not necessarily that I think every patient needs an ablation as soon as you're diagnosed with an arrhythmia. But I can speak to that patient about when is the right time to have an ablation if I see in a patient and maybe he's had one or two episodes there are short lived and he's not very symptomatic or he hasn't tried some medications that may be helpful. I can say, you know, you know, great, um great opportunity to discuss when is the right time to have an ablation so that you know, when he goes, he has a better understanding of the disease process. And if he sees those indicators such as an increased burden or highly symptoms that are breaking through the medication, he can remember, hey, when I spoke to the electro physiologist, he told me this is the time to do the ablation because their success rates would never be better than now. As opposed to if we have a patient that hasn't been seen, hasn't been educated as to when is the best time to proceed with the ablation and we catch them 345 years later and our success rates, let's say, instead of being 90% are down to about 40% because of the extent of disease progression that we find the day of the ablation. So there's very there's different types of arrhythmias, there's different types of procedures and medications, but the message is usually the same in terms of when to refer those patients and earlier is usually better. Again, not because we think patients should rush into procedure interventions, but just to educate the patient and hopefully the referring physicians as to when is the right time to oblate these patients and not let that disease progress enough, we will have limited options in the future. And dr Rivas joined the conference a little while ago and he is greeting you and thank you for the phenomenal presentation. And as a matter of fact his question was do we wait too long to refer or under refer these types of patients? So there's Dr Rivas Hello doctor Rivas. Hello doctor amazing amazing presentation for all of you to know that he is my doctor off. So um but yeah I I thank you doctor again I wanted to I had to join in late but I was joined in as an attendee but I find that sometimes the referral, like you said, sometimes the referral comes in too late or we wait too long many of times an insurance company might come back to Dr Hakeem and I said you know why is this costing so much but by the time that we get the patient the situation and then again, you know when when is the best time to refer? I mean as a general practitioner I'm seeing a patient I detect an arrhythmia. Is that the best time right away or what was your recommendation on that dock? Yeah, again I would I would and again, not necessarily because I think as soon as you're diagnosed with arrhythmia need an ablation. But again we can talk about you know what are those symptoms, what is the right time to a plane, what are the warning signs saying? Okay this is a rapid progression of your underlying disease process. This is when we need to jump on it or they're certainly arrhythmia is that, you know, first time events are enough. A lot of times patients with super ventricular tachycardia as We can cure those arrhythmias, 99% of the time with a complication rate less than 1%. So young patients with super ventricular tachycardia, as I usually tell them, you know, I think population is our first line therapy. We can have a very high cure rate with a very low complication rate. So, depending on the, you know, on the underlying disease process, on the Arrhythmia, but, you know, we can always meet with the patient and not always jump to an ablation. I would say, you know, the if I say 20 patients in a day, probably only four of them, we'll need an ablation that day. But 16 of them, I can really sit down educate them and we can discuss, you know, what medications to take to prevent progression or one would be the right time to jump into a blinding revelation. We have a question from the audience and it says, is there a threshold threshold or limit? Who can benefit for electrophysiology at the earliest or latest time? Example if they are in early chf or there already in severe chf. Yeah. So, you know, I think um we as procedure lists and and and as any type of physician you want to be, you want to do procedures on uh as healthy patient as you possibly can because we know the healthier the patient is, the better the outcomes will be. So the earlier that the patient is referred to us and the less severe their heart failure is usually the better the outcomes are. That doesn't mean that we don't want to tackle complex interventions and patients with advanced heart failure. But of course our procedural risks and our outcomes usually suffer the more advanced that patient's heart failure is. And like anything in medicine, there are certainly patients that are not candidates for any type of procedural intervention. So the earlier in the disease process we can do a procedure and the healthier we can get that patient prior to the ablation. Always ideal. But we're certainly willing to treat patients with even severe heart failure if that's the right choice for them. Certain patients of course we won't will turn down for surgery because of the risk of the procedure, but not very common. Okay. Um There's a patient in the audience and it says I did an E. K. G. In the past, the g was normal, but said that I had tachycardia. Uh would this be the same as ventricular arrhythmias? Not not the same. So tacky cardia. So it's important to address this because there's different definitions. So tacky cardia just means, you know, the when they studied it as a long time ago and there's a little debate over this, they found that your average heart rate will be somewhere Between 60 and 110 beats per minute. As electro physiologist. We go everywhere anywhere from 50 to 110 beats per minute. So by the E. K. G. standards if your heart rate is above 100 beats per minute that is the definition of tachycardia. That does not mean that that's an arrhythmia. All that means is that your heart rate is above 100 beats per minute. And there's many different types of tachycardia. There's sinus tachycardia which is just your native sinus node. That what kind of drives your heart rate. And as a normal process beating above 100 beats per minute which can be perfectly normal. Or there's arrhythmias that can be tachycardic such as atrial fibrillation with tachycardia. So atrial fibrillation with a heart rate above 101 100 beats per minute. So tacky cardia does not mean ventricular tachycardia. Tachycardia simply means heart rate above 100 beats per minute and defining what type of tachycardia would be the important part of that. E. K. G. No our parents. Yeah thank you. And uh as a follow up to that and the question of dr hakim a you know you talk about you know tumor boards and all this for for cancer. And when it comes to car I would like to call it like cardiac boards. But the importance of M. C. G. I. Of is underestimated of having everybody that sees one different part of the situation and everybody has a vote right I apologize I've construction going on. But uh you know how can you talk a little bit about that about the importance of having everybody available and how working as a team has improved all of this. Number one and then number two, what's the next frontier? What is what is the new star trek? You know or there's there's amazing there's amazing technology coming up and I think it's gonna be probably we're probably 23 years away from it but the multidisciplinary approach um you know improving patient outcomes, it's clear improving patient access. So as you know before if you practice in silos it would be okay. See the interventional cardiologist one day in two weeks, see the electro physiologist in another two weeks see the heart failure specialist. And so now you have a six week process before you're actually seeing a multidisciplinary approach to your care. Now using a multidisciplinary approach we can have a team meeting what we call a heart team meeting where we get together and in one morning we have all discussed the patient's case and have all decided what is the best treatment plan for that patient. So as opposed to waiting six in an average of six weeks to have a decision on what's the best way to go. In one morning we sit down review the case and we have a plan for that patient. And not only do we have improved patient access and improve efficiency but we've shown that we can improve patient outcomes because every specialty is gonna look at the case with a different set of eyes and a different level of understanding. And so something that I see as an electro physiologist, our heart failure specialists will see differently as a heart failure doctor. And our cardiothoracic surgeons will see different as differently as surgeons. And so everybody can give their input and a lot of times my eyes are opened as an electro physiologist by what insurgencies or what electra heart failure specialists these and and I can tell you these meetings are very educational I think for all we have one more questions and question and it says in a traditional ablation how long does the patient needs to stay in the hospital after the procedure? Sure. Um This is something that that we're very proud of for the majority of our cases the patients are discharged on the same day. So if we look at any type of S. V. T. Atrial fibrillation, atrial flutter. Even our PVC ablation is the vast majority will be discharged same day for a more complex ablation such as our ventricular tachycardia abrasions or patients with a fib and underlying cardiomyopathy or heart failure. We usually watch them one day but the vast majority of our patients are either discharged the same day or require 11 day hospital stay for kind of tuning up prior to discharge you know what dr price? Well we can wait for the future, we can wait to hear more of uh the new accomplishments and electrophysiology and I know that the sky is the limit when it comes to technology. So it's going to be very exciting for all of you guys. We can keep you here for hours on end because it's very exciting topic doctor reveals, I think that it is time to close unless you have any comments or any other questions for Dr Pascual. Amazing thank you Dr Pascoe and thank you to all the guests and uh Dr King take us home of course and uh dr Rivas and on behalf of yourself and the entire team at baptist Health International would like to thank you again Dr Pascoe for your presentation to all of you. If you have additional questions about today's presentation or any questions in regards to a particular condition or procedure that you'd like to explore, please feel free to send it to be a chai webinars about this health net. We'll make sure to forward those questions dr Pascual and get back to you soon. Thank you once again. Hope to see you soon and please stay. Say thank you dr pascal Doctor Rivas have a great evening very much. Thank you doctor
