Mayo Clinic cardiology experts
Abhishek J. Deshmukh, M.B.B.S., Christopher V. DeSimone, M.D., Ph.D., and Siva K. Mulpuru, M.D., M.P.H., provide insight into troubleshooting common and complex premature ventricular contraction (PVC) ablations. This case-based presentation illustrates the approach and shows how to tackle challenging situations.
Drs. Deshmukh, DeSimone and Mulpuru discuss how best to approach common complex PVCs including those in the left ventricular (LV) summit, LV papillary muscle and peripulmonic regions. They also provide insight into troubleshooting complex case scenarios and alternative approaches.
The discussion includes important anatomical considerations regarding critical sites for PVC ablation and how to best optimize efficacy and safety during procedures.
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Mayo Clinic Medical Professionals — Cardiovascular Diseases. Good evening, ladies and gentlemen, and thank you very much for joining us for our complex PVC ablation, tips and tricks for success. Webinar. We're joined by two very special guests that we have the privilege of joining us tonight. Dr. Siva Mall, Peru Newly minted professor of medicine here at the Male Clinic, College of Medicine and Sciences and Dr Abhishek Deshmukh, Assistant professor and newly minted Rick Nishamura, Teacher of the Year Award E We hope to bring great evening of joy, innovation, interesting cases and have this very interactive so something different. So work with us and we hope you have a lot of fun tonight I will have the distinct pleasure of interesting Dr Chris DeSimone of phenomenal electro physiologist and even a better and the most positive person you can ever meet. And I'm sure the whole vibe of this evening is to see how we can have a lot of fun and how we can done from each other. The theme is really hot. If three friends are sitting together and discussing a complex PVC insulation, what we're going to chat about That's exactly what we're going to discuss today. Among all of us who are here. Thank you, Chris. Again. Excellent. We have no disclosures in our learning objectives. We've already showed you in the previous slide, but we want to encourage everybody to submit your questions live. This is going to be taped so everybody just relax. It's 110° outside. Feel free to have any cool beverage you wish. Very relaxed atmosphere. Anything that's unanswered live. We're going to either do through the webinar or through the taping, which will be up shortly. And we'll let all of our attendees know this via email. You can always at any time, email the three of us and all of our emails are up there. If you have any questions after the talk, if you have any questions at any time in the future about electrophysiology, any cases you want to run by us, we're more than happy to discuss with you. So I really hope you have a lot of fun and we'll get started Briefly, go over the learning objectives one and again. We want this to be something different, something that you haven't heard from before. And like Dr. Deshmukh said it's exactly how if you were to come into the office with Siva Abhishek myself and we had one of these conversations either before and after. And we learn from ourselves and really pick these cases apart and really milk them for all they're worth and give you really the tricks and practical approaches of how we look at these. We get a lot of referrals from outside. So sometimes second time, third time, fourth time redo PVCs. We're trying to give you our insights to maybe have you be successful right off the bat or when you're faced with those PVC reduced. So we'll go over these cases again. We want aiming for quality, not just quantity. So if we don't get to all these, that's completely fine. But our aims to go over a pair of harmonic region PVCs, LV, Summit Region PVCs as well as troubleshooting LV, papillary muscle region PVCs. We're going to provide our insight, and we want to get your input and buybacks on this as well. And then we'll also discuss certain points where you have to be critically safe and critically focused in at certain things that we're looking at. When we're doing these life cases, this will allow you to best optimize the efficacy and the safety of the procedural approach. And with that, well, start with civil in the first case of the evening. Thank you, Chris, for the introduction. And welcome everybody to this webinar. Um, this is a patient that I saw in the clinic. Patient is a 50 year old male basically coming to the clinic for new onset fatigue and tiredness. Um, as you can see in the on this particular E c g. This patient is in a by germinal rhythm and you can see the PVCs don't have a preceding P wave. Every after the T wave, you don't see a deflection of a P wave. So you have a PVC white Q R s and then followed by a little notch in the TV. That's most likely a retrograde P wave resetting the Sinus node. So you have a little bit of a pause there, and this pattern repeats many of us. When we think of PVCs, we are thinking about tachycardia, but I think it's important to understand why the patients have symptoms. It's not just palpitations or heart failure mediated symptoms. It's good to look at your arterial line tracings, especially when you're doing these cases. So you understand why these patients actually have symptoms. Okay, so in this case, you could see the PVC morphology is we want to be six. It's almost prick ordeal, concordance, something coming from somewhere near the base of the left ventricle. It's a right bundle, so coming from the left ventricle and it's from the inferior wall, so it's negative in the inferior lead. So somewhere basil, inferior left ventricle, is what we're thinking when we look at this particular SCG. Any thoughts? Chris the Abhishek When you look at this particular SCG normal healthy heart, a young patient with new onset symptoms I think this comes up very often, and as you pointed out, the symptoms can be quite multifactorial. I also tell people sometimes is that you know, it's like having a bad back or a bad me. You just get used to your these symptoms and really don't know what it is to have abnormal heartbeat. But based on the morphology, I agree that right bundle, you know, kind of positive concordance from V one to V six lead to three a VF being negative so kind of inferior one Aviall Positive septal so kind of LV in Farah septal type location. And, uh, other things I'm looking at is the coupling interval of the PVC That looks pretty fixed here, at least to my eye. Maybe slight variation, but reasonably fixed. And a good retrograde conduction from the BBC No observer in your experience. Why do you think these people get really symptomatic? Is it the palpitations or fatigue? As you pointed out, what? How would you sort out in a clinic visit that the patient is fatigued from this BBC? Any tricks you can tell us? Yeah. One thing you know the patient is having by Germany on an S e g in the in the in the clinic. A quick way to understand what the symptoms are from by is by checking the pulse at the time of the big. And if you're heart rate when you palpate, the pulse is half of what you're seeing on the BCG. Those patients are less likely to complain of palpitations but rather fatigue, tiredness and shortness of breath. And I think the next two slides actually show you a correlate of what we see when we measure him a dynamic tracings. Great. I also sometimes look at the karate when I'm like talking to them. And then exactly when I see a more curated fullness, I asked them, Did you feel that PVC? And sometimes they feel it. Sometimes they don't feel it. But at least that also gives us a clue like how really symptomatic they are from these PVCs. Yeah, I agree with Abhishek. So when you're listening to the patient, I sit there and I don't let them know I'm listening to the PVC or listening for an exorcist, Li. But my eyes are also fixed on their corroded and see that And then I don't say anything for a few seconds. And I say, Did you feel that a couple seconds ago? And then I really tease out what they're feeling. And then you kind of put that together. Sometimes even taking them for a walk can help and then feel their pulse intermittently. If the PVC gets suppresses with walking, Then again, I try to ask them, Are you feeling better? Are you feeling worse just to be 100% sure that we are managing the symptoms of the patient because a lot of times these PVCs are quite benign. If the ejection fraction is normal, those are all great points. So, um, let's move on to the This is the same PVC. This particular patient ended up coming to the lab, um, due to symptoms and similar superior Lee directed positive concordance in the lab. And here is a coupling in trouble that we show and when we actually have an arterial line tracing you really don't have away form that corresponds to this PVC. And that explains why this patient has fatigue and tiredness rather than shortness of breath. Right, Great point. Really fantastic, really fantastic side. Sometimes, especially when getting access the patients in frequent PVCs. You'll see Jets little jets coming out when you're getting access and you'll know they're in PVC is just by looking. It's been apparent in some of these patients, and I found it quite fascinating. And then I would tell them afterwards. I really see why you were feeling the way you did, because basically every other beat or whenever these PVCs come, you're not perf using the rest of your body, including your brain. Yeah, one other trick I do in clinics. Sometimes I just put the pulse oximeter on it because that also shows you the oximetry tracing. And that also gives you a kind of a head start. The same principle, what we use when we are listening Hearing PVC in the e p. Lab, that tick, tick, tick tick is going. And once you lose a couple of you know that sound, then you know that there is an extra bit or there is no extra bit and all those things. So just some simple clues what you can use clinically to see whether these PVCs are perf using or not perf using so lack of this arterial way from can explain fatigue or tiredness. But, you know, this patient also continues to have shortness of breath. So in order to understand why these patients have shortness of breath Sometimes during mapping, you perform a trans septal puncture, and it's good to look at their lava forms. So here, at the bottom of the tracing, we have an elevator, a form here, um, you know, A and A V wave, and similarly, for the last beat, you have A and V wave. But when you have a PVC and that a way Because of the retrograde conduction happens, You can see there's a marked increase in the pressure that increases. Um, you know, pulmonary venous pressure, probably causing that subjective sensation of shortness of breath. So in this patient, that lack of way form on the arterial trade in a tracing corresponds to the symptoms of fatigue and shortness of breath can be explained by what we're seeing on the lava form. Nice. Okay. And, you know, some people call this, uh, mechanical bradycardia, so basically, electrically, your rate is fine, but just the mechanical, you don't have a mechanical perfusion. So something to keep in mind You're not. Everybody has palpitations are, uh, you know, sensation of tachycardia with PVCs. And it's good to troubleshoot this in the clinic. Exactly. And that's the same reason why the blood pressure machine at home gives an error because all of them work on this optical sensor. And if the PVC is not perf used, a sensor is not picking up the signal, and the machine gives an error or a false bradycardia the same concept again. It airs because it's just trying to average so many and things are falling out, so then it just quits out, right? So what did you survive in this case? And this This patient, you know, we were able to map the PVC to the basil left ventricle. And once we a bladed, uh, you know, these profusion became normal. His off medications clinically, he did well, but I thought it was interesting to show the arterial tracings and the pressure tracings for everybody to understand, to have a symptom and the rhythm correlate here nice in your experience, because you have been doing this for so many years. I didn't mean to call you old, but just you have been doing it for so many years. That's the location of this PVC kind of LV in Faroe Septal in a normal heart. Does that make you think anything more or it's not your garden variety. You'll say outflow track or pap muscle or one of these PVCs, right? Yeah. So you know, this patient did not have any Q r s abnormalities during Sinus rhythm on an echocardiography. There's no suggestion of any myocardial abnormality. Um, if he had multifocal PVCs, I would be looking for inflammatory heart disease or prior scar. But if it is just one morphology monem or Fick A fixed coupling interval. Um, you know, it's most likely idiopathic VT. You can have these PVCs. You know, sociopathic doesn't mean just out for track. You can have other areas of the heart. Um, so if I didn't really have a big suspicion for inflammatory or scar based disease in this patient and with the ablation, the patient did well and we did not do further work up in this particular patient. So the point being that if it's a single morphology fixed coupling in trouble than even doing like more advanced imaging, cardiac, m r A and all of the pre clinical suspicion is low, you probably won't be pursuing it, right? That is right. Yeah, I would do probably the same thing unless I find, like, a lot of abnormal signals when I'm mapping in that area. If I don't find that, then even post population, I probably wouldn't, you know, explore more for any other inflammatory cardiomyopathy type situation. And let's stretch that back. That's great. So let's say you saw and this is not uncommon, right? We get in there, we have just the echo, and then we get in. We do our mapping. You see lots more fractious nation than you expected. What's your goal to imaging? So I think the best imaging when you are already in the lab would be. You can look at ice and make sure whether you are having any kind of bright shadows, a little bit of calcification or something, which is not more academic than usual, what you're used to but in those patients. Also, after the PVC is done, I would do like a good wisdom to make sure we're not seeing any other re entrant, VT type situation, especially if we believe that there is some scar located, but certainly after the operation is done. You know, if again, my prickly if my clinical suspicion is high, then I would consider getting a cardiac MRI or a cardiac pet scan if I'm concerned about sarcoidosis. But I think any good imaging, whatever is available in our institution, and we trust that imager is going to give us good result, I think I would get that sort of imaging done. I agree. I like the cardiac MRI and then if I really, really need to go further. I do one of two things. One will move to the pet scan or if we're really there and we really have high suspicion, get a biopsy at the same time. I think if we do the ablation, sometimes we could let be led astray. So we have to just be cautious with that. And if the patient's stable and doing reasonably well, what I'll do is when they come back in three months for re visitation. I'll do the imaging at that time so that I don't falsely bias myself, right? Well, there is a question for you. It says that the PVC is looking quite narrow. Can this be more parking J P, V C or of a secular PVC than muscular or semi McArdle PVC, Um, and can it be a re entrant beat with a short coupling interval? So, just like narrowness and whiteness of curious, how do you account for that? Those are both their separate questions there. one is narrowness. Does it mean it's particular? So you can only answer whether it is particular or mild cardio By doing high density mapping or doing really good mapping, you can have myocardial PVC with early engagement of the historic in the resulting in a narrow PVC. Or you can have a physical er origin with with an exit causing a narrow PVC. So in this patient, after doing the mapping, it turned out to be myocardial T v c. There were no physical er signals. The second question that, um, Dr Sue asked is can this be a re entrant? PVC. So, in re entrant PVC, you tend to find, like, very late signals, which we're going to show or discuss in our next case. Whereas if it is just a focal, you will find a very small area that is earlier than the PVC. So this turned out to be just a focal PVC and not not a parking G based PVC. Nice. Thank you, Sylvia. So, Chris, there is one more question. Um, what do you see? If we have interpolated PVCs, what would you expect the hemo dynamics to be like? I haven't done human annex during the time of PVC. But I think with interpretative PVCs, you're going to have more dissing pretty, because that's coming in during normal contraction. So it's not what we're seeing on the screen. right now with the PVCs where you have delay. It's kind of coming in between the both because some of those are where patients could get even more systematic. Or we think those are, in theory, more likely to lead to PVC cardiomyopathy. What I've seen is right after the PVC, your cardiac output is going to be lower, so may not have a, um, higher systolic pressure. But after the normal beat, because of a relatively longer filling interval, your pulse pressure may be higher. Overall, interpolated ones, depending on the coupling in trouble, can be perf using or non perf using, um, you know, and it's dependent on on the patient's e f coupling interval and the autonomic state mhm Great. One other trick. I thought that was nice just going along. This if we're really looking at human dynamics, sometimes when I've had these b b. C. S. I looked down short axis on ice, and I just put color Doppler along the aortic valve and you can see the pulsations will change. Nice. All right, So shall we go to that? Yeah. There we go. Okay. So this is another case, and, uh, you know, it points out to This is a Elderly Gentleman, a 70 year old gentleman who comes with frequent palpitations. And in fact, this patient feels palpitations is predominant symptoms as palpitations, not fatigue. Er, shortness of breath. Maybe I'll ask, um, Chris or object to look at this tracing and see. Tell us describe as what they see and how they would approach this particular patient. This patient failed, um, in a V normal blocking agent, and he came to the lab for an ablation procedure. And just to show, there is on the on the left hand side of the tracing, we have an arterial line waveform lead the leaves. One we won before, um, the the right ventricular Electra Graham is on the top, followed by high right atrial Electra. Graham, We have a his bundle. Electra Graham. We also have a multipolar catheter in the coronary Sinus. And we also have an ablation catheter, um, in, in, in, in a region of interest. Um, in this at this point, when the patient is having these PVCs. Nice. So I think this is an amazing, uh, tracing, so just you know, I'll tell you what How I would interpret this. But I wanted to say, Is this your typical workflow to put all these catheters, you know, atrium, his R V C s and all that, But we'll come to that, but at least the way I could, you know? Look at this. I know I can see lead to is positive. Vivant has a small R wave and left bundle morphology and lead. One is quite flat. I can't clearly see it, but being lead to positive left bundle maybe somewhere in the outflow tract based on the way you're catheters are positioned you have RV catheter or his bundle catheter that his bundle catheter we signal is clearly late compared to the onset of the surface Q R s. So that tells me it's not on the R V septum. Your distal CS CS 12 would give you some information of the anterior intra ventricular way in great cardiac way Injunction. Cardiac summit, LV summit left Sinus of El Salva basically that ballpark area and that also seems to be late compared to the surface QRS So it's not LV summit. It is not on the septum. And maybe it might be in there. I mean, the only place remaining would be in the right ventricle. Outflow tract. Your signal is just incredible there. I mean, the longer I look at it, the more I feel that we should just come on ablation here. Your ablation distal is quite early. Uh, and it is a complex signal. The signal below your ablation distal, exactly ablation proximal that also has that you type signal, followed by a ventricular bipolar signal. So I see there is some local scar or delay or some complex signal there which is causing that PVC and the onset of the bipolar signal to the PVC. The timing appears to be quite nice and long. And when you compare it to the Sinus rhythm QRS on the right of the screen, you can see there's a little bit of this chatter towards the end of the bipolar signal, and I wonder whether that is all coming in earlier kind of a reversal of that sequence. But, uh, this looks really good. Another thing I kind of look at this is I don't want to make sure I don't see any far field atrial signal because if you see that is artery and you don't want to. A blade, the artery next to it. So, you know, here I feel pretty okay if you come on ablation. But signals certainly look very, very interesting and very, very enticing. I agree. I think signals are really early and you bracketed it well and again. I think we'll have more to say about how much and where to go and how he had planned for some of these procedures. But clearly you're way early, and I still see some chatter. I like to call it that comes in late, So there's something else going on after your initial signals. But you're really, really far ahead. But there's got to be some reason you're showing us this. Yes. So, you know, in a young patient, whenever we think of outflow track, we're trying to just look for earlier than the Q. R s. So that's been our go to strategy for outflow tract idiopathic young patients. But in older patients, you know, with the outflow tract morphology fixed coupling interval, it's not always triggered. Activity is the mechanism. As Dr Cold is pointing out, we have this signal, you know, way out in Diastolic. But when this signal doesn't cause the second component of the Electra. Graham, you don't have a PVC, so this could be a very late delayed diastolic signal. Somehow, in the outflow track, it is able to re excite the heart. You have a PVC. So this is an example of, you know, thinking about re entrant mechanism of a PVC very long delay if it's able to re excite. Here you have a PVC. You have to still have to do mapping to define the circuit. But whenever you see these long delayed signals, think about re entry as the mechanism and not triggered activity. Great. There was just one point question I had you pointed out that this could be if you can see what I've drawn. Could be like a block octopi. But how can you be sure that it is not like a valve artifact from the palm onek value? If you're in that particular location and it tricks you have, you can share with us. So usually the valve artifact will be on top of the TV. But many of these cases we have an intra cardiac ultrasound catheter, and you can see whether that artifact on the valve closure is happening on time with the signal or not or whether the valve is actually making the catheter move. Usually the valve artifact signals are right at the peak of the TV around. They're not so late, okay? And it looks quite far filled This signal, you know, like a valve artifact because it is hitting the catheter might just look more sharper and more near field. But this just looks a little bit more blunted and far field. Yeah, and the definite of them. Uh, you know, the proof is if you if you make, if you diagnose reentry and if you a blade a very late area, usually the signal goes away. Whereas a mechanical artifact by ablation, it typically doesn't go away. A late activation beat. If it is a cause of the PVCs with ablation, the beats go away and the signal also goes away. Nice. Okay. And another example is in this This this is this is an example from a different patient again. Re entrant outflow tract, morphology beat. You can see very similar examples. Late diastolic signals. If it is able to re excite the heart, you have outflow tract morphology here. You have that late diastolic with block to the mile cardi. Um, and then you don't have the PVCs. So this is proof that this late delayed activation is indeed participating in the cause of those PVCs in, in in Abhishek. The one thing you mentioned, I think it's worth worth reiterating. You said if you're in the outflow tracts and you see atrial signal or you're not expecting it what? What does that make you really nervous? About what? That what should that make everyone really nervous about? So, first of all, you know, two places As you're going into the R bot, you may see the, uh, a signal one would be As you're just crossing the his area, you will see A S and D. Obviously, you know, you can't really justify a plating that area. But when you climb up into the outflow tract beyond the palm onek valve and you're looking more separately, that's where your left main is going to be. And the structure to another structure close to it is a left little appendage. You're going to get that far, Phil. Atrial signal from the left atrial appendage. And if you see that, then that's just your market, that you're very close to the left main. And let's not a blade that, in your case in point, whenever we are doing so retrograde approach for PVC mapping or waiting mapping, you know I don't want any of us to try it, but sometimes a catheter by accident move goes into the left. Men, just pay attention to the signal. There, you'll see a big A and of the signal both. And that is, or the near field a signal. What you see in the left lane again is from the left atrial appendage. So whenever I see any A, I just think if is artery and a saucer bottom and he'll look at us and say, What the hell are we doing here? You know, So I would just not look up a plate, Anything which looks like an A signal in the outflow tract. Exactly. And for the A, I'll make it would be angiogram. Exactly. Have to explain that A If you see that a sometimes you'll also see this. If you're kind of at that left, uh, left cusp right junction or below, and you're kind of slipping a little bit too close to the left. A tramp that's a little bit more safer because you're going to be below the cost. But anytime you see an A on your signal anywhere, the other thing is, can you be creeping towards the non cost? And then if you're near the right non customer, the penetrating bundle of hiss is you want to stay away from that. So any a signal up there, you've got to explain it. You've got to convince yourself why you're seeing it. If that's an angiogram, do not just rely on ice. That's an angiogram. Or you have to maneuver. Maneuver the catheters you need to do that. Great. Very nice. And you know, this is the schema how this can happen. So sometimes when you have a slowly conducting zone that's able to somehow come back and re excite the myocardial, um, you know, in the outflow tract sometimes very hard to delineate the complete circuit, and sometimes you may find just the area of delayed activation, so finding that very late delayed activation would be a target rather than early systolic activation. So sometimes if you try to target here, if you don't get out of the delayed zone. You may have a different morphology. PVC. The clues here are usually this is an older patients and fixed coupling. Interval, Um, is what we see fixed coupling interval. You have think about re entering these patients. All right, So when you're mapping in this area above the palm onek valve, at least sometimes I get a tendency that the Catholic just keeps slipping out above the valley below the valve. And then you lose your position and it tricks. You have to make sure that you have, like, a really good contact in that above the in the Super Bowl memory space. Yeah. So, first, whenever we're doing this outflow tract T V. C s, it's it's having an intra cardiac ultrasound is key to understand where your catheter is. Do you have adequate contact or not? Um, sometimes on Flora Skopje, you think that you may be somewhere, but when you actually look an ultrasound, you are somewhere else either about the valve below the valve. So I think having an intra cardiac ultrasound for all these difficult cases is key for success now, specifically having a contact in these costs or about the costs. If you want to map inside the cusp, if you're coming from below and going straight at it, you have to heat up the cast and the tissue behind it. Some of the other colleagues have described using taking up a Catherine to the pulmonary artery, making a U shape and trying to map it in a different in a reverse reverse circle direction. That's something you could do. You have to use a tighter curve like a B or D curve, so it actually curves and you are mapping with this end of the catheter. So I think one if I can make a few points. So there's nothing in EP that's a straightforward procedure. Slam dunk procedure, Garden variety, our bot. To me. I think you should remain terrified of anything on the anti r B o. T. I think that's a spot. You've got to be really focused. You've got to be hyper focused in the P Lab at all time, but you've got to be Michael Jordan's Game six Utah jazz focused when you're in the anti r B l t. Because the perforation risk is very high and that area right there is just you're looking for trouble. It's just really, really careful movements. So Abhishek, can you walk us through? Maybe. How you get up to the anti R bot? What tips? What tricks Should anybody be pushing anything? Should anybody have their ice catheter a certain way? Walk us through this because I think this would be tremendous benefit to all the listeners or viewers. Sure. So what I use is I use an irrigated catheter, always for mapping and a bleeding any of the outflow tract PVCs and BTS because it's also important when we go to the LBO, decide that we have an irrigation going on to prevent stroke and everything else. Then I generally use an S R O sheet while going into the outflow tract. I get the catheter, I get the sheet up. Then I get the catheter up. I marked my his bundle location. You know, I'm not. I generally don't put all the catheters. What Savard is, because I just want to prevent any chance of perforation with extra catheters, especially Sometimes you have to give isopropyl and everything else, and then I advance the catheter in. And then I tried to clock the catheter and the sheet making the tip Look up When it goes up, I don't just advance the catheter. Indirectly. I make sure on ice that the catheter is not touching any surface. And then I gently advance the catheter up, and I tried to advance the catheter up under ice to a place which is going above the palm Onek valve. So then I know where the palm Onek valve is, you know, in in our bot and in life, and it's easy to go from top to bottom than to go from bottom to top. So once you're above the valve, then it's easier to come down. And then I just make like a quadrant type of a move. I go left, I go right. I go back, I go front. So I just make like a circle around it. And then, as you are going at different levels, once we start to see any good signals, then I kind of zone on into that area. If I'm in that location, what you're showing on the R. V. O T. And then the 23 challenges there. One of them, which several alluded, is that if the categories above the palm, Onek, Val. And then it comes down, You know, you lose that you if you're above, you're here and then you lose that position, then you're going to slip down here again. So at least what I do, I try my best to remain above the leaflets map and then gently just un deflect. So that automatically falls below the cusp below the leaflet and then try to map here. What power would you lose here? Use here, Chris? Yeah, I'll tell you about that. I just want to just hit on one thing. I think this is a multi person job. You need someone to work the ice while you're making these fine movements. And when I try to do is as I'm going through the rvn flow all the way up to the outflow tracts. Just as you mentioned, I try to watch my catheter, so I'm hugging the septum almost like I'm hugging and wrapping right around that infant double. Um, so I'm hugging where the area is. I'm not pressing too hard, because remember, once you get higher up, there's nothing covering you like a quote set them posterior but exactly like you mentioned. I don't want any resistance at any time. I go as high as I can, and then I come down so that I think is really key. And I'm watching this on ice all the time. And as you just the question Now get to your next question about the powers I stay No more than 25-30 watts at this region. Very, very good. I've never gone above 35 watts here. I'm more than happy to stay with ablation. 30 seconds. Come off. Wait till I've got all this region nice and a bladed. I don't want any steam pop zero to be catastrophic, so I don't want anything like that. Then I have three eyes going on. one eyeball is looking at the ice. Another eyeballs looking at the impedance, another eyeballs. Looking at the Electra Graham, it's critical you need to do that fellow. Whoever is with you, everybody that's in the room has to be very, very locked in here because it's a very dangerous place. I have seen personally a few cases who have gone to the O. R. After a successful operation just because there was a pop or something like a big perforation in this location. It's very hard to, you know, just keep on draining it and that particular location. So today is the time of taking pictures and selfies and everything else. When do you actually floor? Oh, this And when you see this, So when I'm in there, I'm in a whole nother zone. I'm not interested in images for Webinars or case reports or Twitter. None of that stuff. What I do when the job's done. When the ablation is finished, PVCs are gone. Leave the catheter right where it last was. Then someone could take the city so I don't have to move at all or whoever else is in the room. I'll have them take the city as well. Never Am I taking my eyes off of those three things I told you to do? A scene that's not not good for the patient. That's not good for safety. Same. Yeah, Same thing I do. I don't even do a lot of flora for avian charity. I'm just looking for the signal. You know, if you see a fire filled his you see the air getting bigger than you know. You have to stop so key thing that we have to focus really well on the signal and the impedance, One other from civil service. Beautiful ice image is beautiful. And I learned this from from civil because he's EP 601, right? He's at another level. But that ice image that he's showing you right there, that muscle tissue when we get these referrals are reduced. And all of these things when we get that area, it's usually never one spot. And I learned this from civil. On many occasions, you usually have to create an archetypal lesion. So what do you want to tell us? Your approach in this area, like muscle sleeves, signals, timings, pace mapping on that collegial straight. Give us give us some knowledge here. Yeah, so, you know, I think if it's a difficult case, you know, you have to Ice actually provides you good clues. Are there these bundles that are going about leaflets? So, for example, if I If I If I look at this ice view here, the aortic valve is here, and this is the harmonic valve. And pay attention to this. There is a little muscle bundle that kind of goes about the cast. So here the ice catheter or the ablation catheter is kind of straddling the cast and trying to touch that muscle bundle. And you know you may or may not get good Catherine contact this way, because the leaf that is trying to push away the catheter and you can come proximately. And you can also have success by a blading that muscle bundle below the valve. But this may require three or 4 lesions rather than just one or two lesions about the well, so ice. You know, it gives you an understanding of this continuity of these muscle sleeves. That's amazing. Sometimes, too, I think you need to go a little bit left and right, or or septal and lateral, depending on how you look because the muscle arc Uh huh 11 question is, when should a patient who is getting an RV or T P V C get an angiogram? One is one situation where he would always do an angiogram, so that's where it is. I would not do an angiogram, but if the catheter was more kind of in this particular location 100 person, I'm going to do an angiogram, if you could see that. So I would definitely do an angiogram there and whenever. And that's the place where you're going to see that far field a signal. So definitely in that location below the palm onyx valve. Generally, I would not do an angiogram. Yeah, so for me, right Where? Silva showing the ice image. If I'm on that anterior wall and I could see where I am there, I don't do a coronary angiogram. If I'm posterior, I'm born of Sam Ash of athm. I am doing a corny angiogram or I'm not burning. That's just clear and simple. Even if I could see on ice and trace the entire coronary anatomy, I do not care. Poster Orville T angiograms happening or I do not a blade. Yeah, that's the closest closest side to the left main area posterior our bot. And that's the key point to remember, right? So with this, I think Well, this is Dr Dismukes case. He's got a very interesting case here. I would let him present the details of this case. Um and he will He will take us through this particular tracing. All right, so this was the teaser what we had sent out. But basically, can you advance the slide, Chris, But basically a young man was having frequent symptomatic PVCs during exertion. And I did all the tricks. What I learned from Silva, I, you know, except of doing a transept er in the clinic to measure the A wave and the wave. I did everything else. And we were convinced that this patient was symptomatic and also had PVC mediated cardiomyopathy. So in this setting, we brought him to the E P lab. So based on this morphology, Chris, where do you think you are? What? You have the right ventricle left ventricle. What's your initial strategy? So, to me, looking at this V one, I have maybe a tiny are but more of a tiny cube, but more of a broad are So we got right bundle, clear, superior axis. I think I can't tell if two or three have any discordance. I think there are almost equally, um, superior. Lee directed one gives me a nice little clue. There's an R s. So I'm thinking something might not just be septal, but or at least start something and then exits more laterally and then I definitely see it on V four v five v six. So to me, I'm thinking Pat muscle. I don't know how close the poster media or the anterior lateral, but I'm going exactly right to the L V. I'm not wasting time in the RV. Same with me. Whenever I see, it's like, you know, if you know where it is coming from. I also try my best to go straight to that location with that without mapping at a lot of other places. Just because the key thing is really going to be a good activation map. And then once you know, sedation starts and patient starts to move and you'll give more propofol and all these things, I'm very, very concerned that the PVC would go away and that would be a shame. So I also go straight to where I think this PVC is coming from. And then, you know, you can spend their time for more detailed mapping silver in your own approach. You know, if we if we think this is coming from the l V Pap muscle, what's your access preference? Do you go normally trans septal or retrograde? I know you have had some cases of France. A pickle puncture also. But just generally you would you go transept a lord retrograde as a start. So in general, we are more used to transept punctures and we try to avoid arterial access. Complications? Um, you know, young patient, you could go either way. In some patients, you may need mapping from both routes to have a complete map. But, you know, young guy, maybe try a trans septal route first. And if you're not getting good contact based on ice, are not getting good numbers, you try the other way. They're both complementary, and one is not better than the other. Just complementary, depending on your ease in the lab and what you want to do in the lab. I agree. I think this has also been an evolution. You know, back in the day, you know, when people are applauding left lateral pathways by reprogramming approach and now you know, because we are so far side with the left little mapping with all the air populations, what we do and the trans septal punctures what we perform. Certainly my also in access of choice to get into the L B. Is a trans septal puncture. And certainly I'll use this terrible sheets so that can help us move around the left ventricle. Little bit better now. What I notice here is, uh, What I notice here is the coupling interval is quite long. So this is less likely to be like a triggered automaticity. More like an abnormal abnormal automatically rather than triggered activity here, consistent with the papillary muscle arrhythmias. Great, I think. One point to make you know, even if they're young or old, you still run the issues with retrograde. So I try again. I always want to have both options available, retrograde and transept. Oh, but I try as much as I can to use transept. Oh, reason being if they're younger, usually they'll have smaller aorta, and it's really hard to make that curve and prolapse safely. So I'm just worried, going up to the order with them if they're older. I'm worried about knocking off calcium or or any type of of plaque, so I really might go to first stage. I got a really, really have a that option there, but I really want to go transept if I could. If I'm going not in the outflow tracts. If I'm need to map above the Arctic Cups and I don't have a mechanical valve or something else blocking me, then I'll try to do transept. So, Chris, one question we have is how did you How did you narrow on the papillary muscle? Can you reason us? What made you think it is a papillary muscle based on the C g? Sure. And again, all of these are exits of the of where our PVCs are coming from. This is where I'm thinking or where I'm thinking of going to still got to do the fine mapping. But the clues are This is If we're saying this is right bundle and again, I don't want to do any pattern memorization looking at broader wave and V1 or all these memorization things. I don't do that. So I look at V one right bundle. I start thinking, Okay, I'm looking to the left ventricle. I see two and three there really strongly superior axis. So I'm thinking somewhere low in the left ventricle, opposite of what you would see in the Outflow tracts. I always try to gauge between two and three to see if there's a discordance, sometimes if you're closer to the septum and you're closer to lead three, then you'll be more negative in lead. Three. If you're more on the free wall or lateral wall and away from the septum, you'll be more negative in two because you're coming away from that lead here. I don't really get that information. Then I look at lead one initially, it's positive. But then there's an S wave, so it's going away from it. So there it kind of doesn't help me exactly where we're at, but it gives me a clue that maybe I'm exiting somewhere, at least going away from the lateral wall towards the end. But really, what started me tipping off more is when I see that RS, especially in V four, V five and V six. I guess if I had to do any type of pattern recognition, it's sort of that, you know, if they're flatter, uh, subject mentioned earlier, I think of primordial concordance being at the base. But when you see that R S v four v 5 to 6, you got to think some things around the mid to lower part of the LV cavity as you're going towards the apex, and then you have to kind of go towards the V four V 56 lead and then go away from it. So that's really what tipped me off that this is probably anterior lateral pat muscle. I'm at least gonna be interested in mapping. That was very closely. So if you're a lateral postal, postal, middle back muscles are in for a data terminal because of Yeah. Sorry, poster amino. Because that initial lead one is positive. Great. Perfect. You know, I think it is to hone in the point if we want to be six. All positive. It's basil. We want to be six. All negative. Ethical. And if you have a transition, we want to be four are positive, and we 5 V6 are becoming more negative. Think about mid LV. One structure that's there in the mid LV is the papillary muscle. Great. Perfect. All right, we will keep going. Chris, can you move the next slide? Absolutely. I can. So then then we see this signal. And this looks like a great juicy signal. Would you come on ablation here or No? And I can tell you I once I saw a signal which was kind of minus 48 milliseconds either. Either I'm dreaming about either I'm dreaming about this signal or this is like, I'm really lucky that I ended up on a great spot here. So I came on abolition. And, uh, you know, nothing really happened. Keep going. You have the control of the staff I would come onto because it just keeps going, and then we map more and we start to get even better signals like 52 milliseconds ahead. And even if you see the local signal, it is quite fractionated. So we know that this is kind of a diseased area, maybe even a little bit of a signal here. So when I put the ice scattered her in, the first thing I do when I look at the popularly muscles is that in my own mind, I think that it is really not a poster, a middle and an trilateral popularly muscle. It is kind of a network. It's a mess out there, and all of them have different heads and trilateral popularly muscle for that patient may have three heads. Poster Middle may have five years. Who knows so First I do is try to see if I see any funny calcium on these popular muscle. Is some part of that popularly muscle more bright than usual? And then in my mind, if I think that the SEC is kind of suggestive that the PVC can come from that particular location once I know that, then I put the ablation catheter there as we are mapping these PVCs and then try to see if we can find that perfect spot where we could oblate this particular PVC. But, as Sarah pointed out initially, as against EP. that this was not like an automatic PVC in a normal heart because he pointed out that the coupling interval for so long. So I had that in my mind, and I was looking for any abnormal signals what I could see on the pap muscle. Sometimes you also look at the mitral valve itself to see if there's any contact areas. I think that's what gives rise to the echo Genesis, itty or maybe those calcification. But are you honed into that? Yeah, I do. And especially when people are mitral valve prolapse it even like tries to hit the leaflet kind kind of hits the path muscle even more. And then they can have a local reentry and Cosby TV from that particular location. So again, when I'm preparing to make sure there is no metal well, prolapse, there is no mitral, annular disjunction and all those things so that you know that's not creating that mechanical irritation in that particular location. Amazing. Can you go to the next thing? Yeah, absolutely. Go next again. Maybe she was the ice image. Yes, the next one. Good. Can you play this good? So this was the area where we felt that that the the best signals were seeing there. And if you just keep playing the ice again, you would see that we are a bleeding pretty well. There were almost creating a legion next but next. But the catheter keeps on slipping on the head of the popularly muscle so that whenever that seems to happen, and if I know that I'm in a good spot but the catheter keeps on flipping. Then I just changed the I just go to cry because only the cryo can oblate is that if it is stuck to that issue. If the cryo catheter, if I can get it at the same spot, get it stuck on that same head of the popularly muscle. And if you give energy there, I think we are going to take care of this PVC. So, um, let me let me ask you about that. How do you know you're not making good contact? And how do you know you're slipping? You're packing If you're going, if you are. If you think you're at the right spot with the signal, which is 50 millisecond ahead. And if you're not able to oblate that, you know, you have to make sure that you know whether you're really giving good energy. So an intra cardiac echo. I saw that the catheter was kept on flipping and was not really making good contact, you know, that is a clue. The second clue is that you know, if you're not making a good lesion, you know, no matter how good the mapping is, we are here to oblate. And if you can't oblate, then the previous is never going to go away. You can't go and show the patient that I was 50 milliseconds ahead and then I couldn't oblate, and then that becomes a problem. So that's why I try my best to once I have the mapping and try my best to see how I can deliver good energy, I start 30 35 watts in that particular location, and then I think that sometimes is enough. If I believe based on mapping, that they'll focus might be more deeper. Intramural then can certainly go 40 45 watts, but generally don't want to go much higher than that. So we and what about going higher than that? So you know there's a problem because you could have a steam pop and you know you could, in fact, the papillary muscle. And then you know the two things that can happen. You can create a wide open M R Michael regurgitation, or even that denuded tissue can go into the brain and give us stroke. So you don't want any of those two things to happen. So again, looking at the ingredients like a hawk to make sure that if we don't have any changes in the impedance for cryo, it is more forgiving. You are never going to have a steam pop with cryo because you're really not hitting anything. So you know, cry. Oh, you know, I give like 44 minute lesion. Make sure that the temperature is nicely dropping, and then you can actually see good lesions on the PAP muscle with cryo. So obviously, this is one more reason to go transept. Well, it's very hard to take a cryo catheter retro greatly. It's a much different catheter, and I think having a deflect herbal sheet helps you get that cryo catheter to the area of interest. We have a hand rice from Faisal motto. Maybe if you wanted to ask a question, I'm not sure we're able to do that. But But, Faisal, if you put it through the Q and A, we could read your question out loud. There's one more question. Do you use to access into the L V one for multi leopard mapping and one for ablation catheter? I don't if I have one trans septal. I just you know, if I'm using multi electrode mapping, I just map with that catheter and then I put the English. I take that catheter out and put the ablation through the same sheet. I don't do multiple access. Same thing. I'll take just one access. I'll do my mapping. And remember, you're not gonna see the same signals that you did on the multipolar. So I make my annotations on that map, I go to it. But just like Abhishek was showing you really, really critical thing is on ice now, um, did we get all the questions? Is there any other questions, then? Nope. We got all the questions. Okay. The other thing is, how do you know when not to use crile? So just to tell you what I've been doing, especially the last 4-6 months, is I've been doing the radio frequency. Even if I see the PVCs go away, I'm still not sure. Or if I see I've modified the exit, I'm still not sure that it's completely gone. So I've had a low threshold to take out the cryo again, just like Siva mentioned. I've never put a cryo catheter across the article. I've never done it retrograde, always transept. Um, but I've been starting to put the cryo so I could get the tip. I don't know if it's you're getting the base. And that's where the initial PVC exit is. And then once you have a bladed that, then your exits at the tip. But I've noticed in some cases that I've done really good ablation around the base. And then I'll see a variant or that same PVC sort of comes back later on during wash out and it will be at the tip. And then I pull my cryo out. You guys have seen that, or I can explain that. Yeah. Sorry. Go ahead, Tahir. You know, with the RFE, as Abhishek mentioned is contact some tissue oedema. You know, you can change your exit site. So cryo gives you that fine finer contact for creating the lesion formation. Especially much more stable at the tip of the papillary muscle compared to the R F catheter I've been using cryo for practically all my cases. After the r f is done, I still go there. I just have this oak D that the previously shouldn't come back as possible. So I do my best and then put cry out there again because it's hard to get like, even if you believe the contact force technology, it's hard to get amazing contact on the tip of the pap muscle. You can certainly wedge the catheter at the base of the Pap muscle, but, you know, on the tip of the pap muscle is very hard to get a good contact. So I I'd like to use cryo after that. Very careful wedging either. This is one key. I'm always careful wedging either. It's between two of the tips of the papillary muscle heads. As you mentioned, they could come try fit by fit or at the base, wedging that I'm really nervous about steam pop. That's where you got to be again. You should always be honed in on the signal impedance, but you've got to be really, really careful. Whenever that catheter gets trapped and there's low flow, that's when there's issues. But I agree. Cryo. I've basically done almost every. I'll start with our F, probably because I want to see if I can get a good enough lesion, and I think I have on some, but also because that's what I'm using my mapping for at that area anyways. Another thing is, whenever we're plating with our F in this location, I have one of our nurses or text and by the soul or a defibrillator to, you know, to give a shock, because it's not uncommon that you could have VF when you're plating there. And Guru are of, uh, you know, future colleague is going to say he just said that if you use cryo than less chance of VF, which I also agree that it's less chance of VF if you're using cryo. But you know you're going to map with the ablation catheter. You're just going to get better mapping with, you know, ablation catheter, R F catheter So and let me answer that point objects say you came on in the R f and you started to see, you know, polymorphic or V F. What do you do? It all depends. I sometimes try to oblate through it. But once I see that it's, you know, from the polymorphic stuff it becomes VF. Then I just come off, have them defibrillate. Wait, make sure everything is okay and then, you know, start again. Good. Same thing I try to a blade through it. So So because sometimes you can get into a really bad storm. When we are in this parking g my cardio area. You could have bad things. So I try to a blade through it, you know, and try to keep it safe. But that's what I try to do as well. And then I'll come off cardioverter if I can't get to it. But maybe sometimes your best weapon in that issue is not just defib. It's burning. Yeah, great. All right, well, It's 115° outside. It's June. We've all been locked up for a year and a half. We don't want to overextend and keep anybody longer than we need to. We really appreciate your attention. And I'd really love to think. Abhishek, Deshmukh and Sivam all Peru who are just expert ablation ist further insight in journey with us tonight and in the seminar and for everyone out there. Thank you so much for joining us. This will be taped. This will be put on YouTube as well as our CBC, any website and we will get to all the questions you have as well as all the questions you've asked us. VR VR cv webinar, email inbox. You have our emails. You contact us at any time you have any questions or want to run by any cases by bias at all. And I think I speak to the three of us to say this is a lot of fun. Thank you so much. And we look forward to maybe doing this again on a different time. Great. Thanks a lot, everybody. Thank you, Kristin. Thank you, everyone for attending.