Okay, everyone, I think we're going to go ahead and get started. I'm very happy to be here this morning. Last year, I was here, not here, but in this session last year, and was lucky to receive the Eric Pszczalski Lectureship Award. And I think it's a little bit, I think, ironic for me that Dr. Curtis is receiving it this year, because she clearly should have received it before me. I think that it's, you know, like Eric said last year, I think the award is enhanced by the people that actually receive it, and I think that there's no doubt that Dr. Curtis has been a trailblazer. I'm really excited to hear about her work, but I'm actually really excited to hear about her journey, and her observations along the way. So, I don't want to take up any time. I actually feel it's unfortunate for the rest of the EP community that they don't know that this is going on, because this is going to be a fantastic session. And I don't want to take up any more time with Dr. Curtis and ask Anne to come up and to please receive this award. It is a privilege to be here, I really am excited to have been given this award. I wish Eric were here, but he had to go back. This is a unique opportunity to give a lecture like this, and so I decided to have some fun with it and do something a little different from sort of the garden variety talks that are very cutting edge, but that go on here that are purely about the science, and I did want to actually sort of give a range of my journey through the beginnings, through what I do with patient care now, and so I titled it Intersections, Career Colleagues and Advances in Patient Management. So I hope you'll all enjoy it. So first of all, starting from the very beginning, I had to pull out some old photos, that's me when I was two years old, on a tricycle, and I was a go-getter from back then, and then this is my family, including my dad. Dad was always the one taking the photos, so he never wound up in any of them. It's a funky picture because this actually was a cutout that one of my brothers put together, and my mother isn't quite that short, but that's me with the pigtails there, and I was the oldest of five, and we grew up in the New York, New Jersey area, so all children were born in Brooklyn and then raised in that area, so that's from the very beginning. And then from there, we went, as I said, ultimately to New Jersey. The top picture on the right is eighth grade graduation, and then the bottom is medical school at Columbia, and so I did my undergraduate at Rutgers, graduated from the Columbia University College of Physicians and Surgeons, which is now the Vigelos PNS, and did my internal medicine at Columbia, and then went to Duke for cardiology and cardiac electrophysiology, and that was probably the first most unique part, was getting involved in cardiac EP a long time ago, and so if anybody knows the Triangle area, the Duke electrophysiology fellows went by the name the Wolfpack, and the reason why that name came up was partly because we were doing a lot of patients with Wolf-Parkinson-White syndrome at the time, this is before the pediatricians took care of them all and we don't get to see them anymore, but the NC State team is called the Wolfpack, and so it sort of got this name of guys going around the Duke hospital at midnight looking at tracings and just getting ready for the OR the next day, so I took off the NC State there and put WPW in there because that's why we were doing it. Now, the Wolfpack was all men at the time, but I knew I loved electrophysiology, and I said, I can put up with anything for a year, and I think most of us would feel the same way, but I wanted to give that feel for the way it was, a pretty male-dominated field. I went to CHAT-GPT, the AI, and I said, give me a picture of wolves that I want to put on here, and the first one that came up was these very gentle white wolves in the snow, and I said, this just looks too nice, I said, give me something meaner looking, and so they came up with this, and so, yeah, the guys weren't quite that scary, but I just got a kick out of what you can get out of AI if you go with it. From there, I went to the University of Florida, and this was back in the 1980s, where most of us finishing EP training were starting programs wherever we went, because they didn't exist in most places, so I started the program at the University of Florida, and Go Gators won the national championship this year in basketball, so that was fun to watch. After being there for almost 20 years, I moved on to the University of South Florida, it was actually a department chair at the time, chair of cardiovascular disease, and then finally went to the University of Buffalo, where I am now, as chair, I was chair of medicine for 12 years, and then stepped down a little over two years ago, so that's the career I've had in terms of locations. These are my children, the three on the left, and then the bearded guy is my son-in-law, with my daughter, so raised three children along the way, and they've all done very well for themselves. But then looking at career beyond just the locations I was at, this is a picture of HRS presidents you can see from 2008, and you'll see a common theme here, which is a bunch of men and me, and so obviously in recent years, we now have Mina Chung as president, Jody's a past president here, and there's been a lot more of that, but it wasn't that common at the time, Nora Goldschlager had been a previous president, it was about 20 years up until I got to do it again, and Doris Escher was also one. So that was what the presidents looked like at that time, and then when I became chair of medicine at UB, they actually threw a party for me the first summer, just before I was about to start, and guess again, I was actually the first woman to be chair of the Department of Medicine at the University of Buffalo, and if you look on the far opposite side of me on that, that is Evan Calkins, who happens to be Hugh Calkins' father, and he died a few years ago, he was 99 years old, I got to know, but he was chair of medicine at UB, and so he was thrilled when I came up there, and I got to know him and his wife Virginia very well, so they were all very welcoming, but that was sort of the group I got into. Now, looking at women in medicine in general, we know that more than half of women, half of medical students now are women, but yet if you look at cardiologists in practice, it's about 15%, I've got some statistics there, and in practice, a little over 10% of electrophysiologists are women, and then there's this term that I found on one of the references there, active female EPs represent about 6% of the total, with no recent change, and so it's really still stayed very low, and if you look at the Medicare provider utilization and payment database from 2013 to 19, 5% of what they called EP operators were women, so it's still a very small group, which really was a surprise to me, having gotten into this in the 1980s, I would have thought things had changed a lot more by now. Now, sort of what fits with that, I'm going to tell you, these are, I tried to anonymize this as much as I could, but we have seen over the years with some of my colleagues that if you look at certain major EP symposia, here's one that was U.S. based, this goes back about 15 years or so, 50 faculty members, and there wasn't a single U.S. woman EP invited to be on the faculty, and we found that after the faculty list was published. There was one PhD from the U.S. and one European woman EP. Industry sponsored symposia, there's another one that we know of that had 54 men and one woman, so the representation in these kinds of symposia, which if you're in academics is important for promotion, networking, and getting other opportunities, has been pretty limited. We had another one, this is a very busy slide, but it's making a point. We had another one where it was a very, very, to our dismay, found out that there was a symposium, and here's the key part, the faculty roster for the symposium includes 48 men and zero women, and this is another major symposium. So we all got together, wrote a letter, I was asked to be the primary signer on it, which I was happy to do, but what I included here was some of the co-signers, but it was four pages of women signed on to it, and said, basically, this isn't right. And so we've had to advocate for ourselves in terms of showing this, and we keep doing it. There actually has, and the problem hasn't gone yet. Within the past 12 months, there was another symposium where the same thing happened. So we have to be very active at this because of the fact that if you don't shine a light on it, things don't change. So what have we done to try to change things? Well, Jody Hurwitz and I have been the co-directors of the Women in EP program that Medtronic has been kind enough to sponsor, and we just celebrated 25 years of doing that program late in 2024. And so it has been an opportunity to get women together in one venue over a weekend, speakers, networking, all of that. And for women who are in residency or fellowship or early career, to see that there are many women who are successful and have that support has been very powerful for them. So we've been very pleased to be able to run that program. This is just a photo of one of that program, showing everybody together and enjoying. I think we're holding this champagne there. We did have champagne to celebrate the quarter century. There's another program that I've been fortunate enough to be involved in as part of the steering committee, and it's the American College of Cardiology has a clinical trials research upping your game program. Now this is a photo from the most recent cohort. It's held at the ACC Hart House in Washington. We've done four cohorts all together. The first one was all women. Subsequently it's been women and minorities. And it's a year-long program that allows people to get skills in clinical research and also networking. So that's another program that helps, I think, improve people, opportunities. Just on Thursday, a few days ago, at the beginning of this program, I had approached the Heart Rhythm Society with the idea of holding a clinical research summit for looking at the whole issue of getting women into leadership positions in clinical trials, because that is still, unfortunately, pretty unusual. And so we did hold a program. We had a session on the current state and a second one on working towards solutions. We had a nice turnout. And the whole point is to look at the current state of participation in clinical trials leadership, discuss the barriers, and develop solutions. And the notes from that, we're going to be taking that forward to see what we can do to try to improve that situation. Now, all of that is my career, my colleagues. Now, how does that inform taking care of patients? Well, one of the things I have been interested is sex differences and disparities in cardiac arrhythmias. And that is something that, again, you don't understand unless you study it. And so one of the things we do know, and we have colleagues in basic science who have studied this, is that if you look at ion channels and the action potential, there are differences between men and women. And one of the important ones is that women tend to have a longer action potential duration, which is one of the things that directly impacts their susceptibility to QT prolongation from things like antiarrhythmic drugs and torsade de plant, just as one point. You can see there's a difference in QRS duration in men and women, too, which I'll highlight here. So if you look at basic EP parameters, I want to highlight two out of this list. One is QRS duration. The mean QRS duration in men and women is different. And nobody ever thought about that when we started looking at cardiac resynchronization therapy and said, what QRS duration are we going to use as the cutoff that would get somebody eligible for that? So we just picked one, saying, you know, one size fits all, not realizing that if you pick a particular cutoff, say 130 milliseconds, it's a bigger difference from the average in women than it is in men. The second part is that if you look at the average QTC, it is longer in women than in men. And again, that is going to inform their susceptibility to prolongation of the QRS, QT interval in arrhythmias. So from that, this is a paper I did with one of my fellows way back when, just looking, I said, how much have we looked at gender differences in just the ICD trials? And if you look, these are some of the pivotal trials from early on. And you can see most of them, for example, AVID, the number of women in it was, you know, you could see the death in there, but the percent female was 21%, SCUD have 23%, definite 29%. They're all very, very small. And when you have such a small number of women in the studies, sometimes the hazard ratios don't be, wind up being significant. And we don't really know if it's because of small numbers or because of a difference in effect between men and women. And so that leaves it as sort of an unknown question. Again, this is something else that I looked at with my colleagues. Miracle, one of the pivotal CRT trials, and we looked at whether there was a difference between men and women in outcomes. And you can see right here, very interestingly, that women had a lower risk of heart failure, hospitalization, or death. And in men, it didn't matter whether they got CRT or not. In women, it made a big difference. And so this is one of the early indications that CRT actually appears to be more effective in women. And we did control for the type of heart failure. So then, knowing some of these differences that we've observed, I was also interested in looking at disparities in the use of guideline-directed defibrillator therapy. And so this is one study that we did looking at over 1.5 million patients with a diagnosis of heart failure. This is from the Optum database. And 47 healthcare networks across the United States. What it does is it gives you such a large group of patients to look at that you can get very good data. And we looked at the output of natural language processing from provider notes. And what we were looking at specifically is patients who met guideline indications for device therapy. And what we found, first of all, you know, unfortunately, these are patients who had class 1 or 2A indications for ICDs or CRT. And, you know, nowhere is this close to 100%, which it really ought to be much higher. But if you look at men versus women, you can see that there was a disparity in the number of women getting implantable devices. I showed these data recently at a Grand Rounds talk. And one of our EP colleagues was adamant that that could not possibly be true. So the data don't lie. This is what the facts are right now. And there are disparities with respect to race as well. And then, as I'm getting close to the end, we are looking now at a contemporary ICD benefit. And this is going to be a paper coming out in Jackie P. sometime this year. We looked at real-world contemporary ICD patients and a query of the CareLink database from 2013 to the present. And we looked at first-time ICD recipients to see their time to first therapy, shock, or ATP, or both. The composite data are shown here. And I showed this at HRS two years ago. And what you can see is that, you know, I think to some people's surprise, if you look out to 10 years, 48% of the total population eventually got an appropriate shock or ATP therapy. So when you only look at the first year after implant on the left-hand side there, you say, well, not that many people use an ICD. Well, you just got to wait long enough to get there. And I personally adjudicated 500 of these to be sure that we were looking at these correctly. And it is what it is. I said analysis by sex is in progress because the data are showing that women are a little bit less than men, but not as much of a difference as you might think. And so women do use these devices as well. And I think it's going to be important data for us to share. So knowing that, are there things we can do in terms of quality improvement? And this is from the improve HF registry that I was on the executive committee for. And we looked at the use of CRT and ICDs in outpatients. And this was a quality improvement registry we did some years ago. You can see if you look at CRT alone that there wasn't really a difference between men and women. But there was with respect to ICDs. Now, this was a quality improvement program. So from this baseline data, we then looked at a quality improvement program and said, can we improve this over time? And I have an arrow there highlighting the two relevant rows. And what they show is that both for men and women, and particularly for women, that with a quality improvement program, we did get the numbers up closer to where they ought to be based on the indications. And so seeing what we've learned about sex and clinical research, we know now that we need to account for this. So what are the challenges in doing that? Well, sometimes you don't even see a stratified analysis when people publish things between men and women to know if there's any difference there. Secondly, as I mentioned, under-representation of women in clinical research is a problem because then you don't always really know what the answer is. But it is an opportunity to improve the accuracy of data interpretation and combat stereotypes and get better and more targeted therapeutics. And finally, government policies can help. And we know that the NIH, things have changed this year, we know, but we hope that they won't stay forever. But the idea that one has to account for these things and have a broad representation in clinical research is important in order to get the correct, the right answers. And so my food for thought as we end, what if 80% of patients in ICD and CRT trials were women? What if it was like that, if it was flipped from what we've actually seen? I think the survival benefit with ICDs might have been more difficult to prove. I don't know what we would have found, but we'll never know that. It also means that you can't really do those studies now. But I also think that the indications for CRT might be more liberal. It could be at a shorter QRS duration than we see now. And some of the international guidelines have started to say that if you are looking at women eligible for CRT, that the QRS cutoff can be lower than you would for men. And that, to me, is a strong argument for inclusiveness in clinical trials across sex. Thank you for your attention. Thank you very much. And we have five minutes for questions, if anyone has any questions. And I have a couple of quick ones. So as the father of two daughters, your points about representation of women in clinical practice matter a lot to me. A question for you. You point out about, whatever, between 5% to 10% of practicing EPs are women. What's happening in terms of new EPs? So if you look at the graduating class, Yeah, it's higher than that. In terms, probably in the 10% to 12% range, it's still not that high. Yeah, not 50%, though. No, yeah, no. The pipeline goes down, right? So you start from medical school to internal medicine residence is about 45% women. Then if you get to cardiology, you're looking at the 20% to 22% women. And then you get to the clinical trials, then if you get to cardiology, you're looking at the 20% to 25% range in there. And more women go into non-invasive cardiology. And so then when you look at interventional and EP, that's where it gets really small. And interventional EP fellows, it's about 15%, 16% now. And do you think that's related, to the extent that you can guess, how much of that do you think is related to, let's say, lifestyle factors, women not wanting to go into this because of their lifestyle, and how much of it is related to, let's say, perceived barriers, or actual barriers, I suppose, because of lack of role models? It's both. And so Pam Douglas, actually, and a group of people did a study a few years ago looking at exactly why do people choose or not choose cardiology. And lifestyle is a factor. But I think, even at this meeting, I've had a couple of women come to me and say that they went into EP because, like I said, I raised three children. I manage it. And they go, well, if she could do it, I could do it. It's that sort of thing. So I think those are two key factors that you just mentioned. Are you talking about me personally or what? Well, you know, I think EP is becoming so, the pressures today, it's just not electrophysiology, it's across the practice of medicine. The drive towards RVU productivity and pushing people to that, it just means it's got to be so much more procedurally based, less time to actually talk to patients. So much of that is actually being turned over to nurse practitioners. I think that makes it more difficult. Still it's a great field, really enjoy it, and so, you know, but how that's going to play out over time, you know, it's, I guess we'll learn. Yeah. Thank you so much for this wonderful talk. It's really great for all of us to hear your experience. And I guess I have a couple comments and a question for you. You know, that study by Pam Douglas, one of the things I thought was really interesting about it, they surveyed both men and women trainees, and the men and women had a lot of the same lifestyle considerations when they asked those questions, but the women, the main difference among the women was a perception of a female-friendly specialty. And defining what that means, so that was leading folks to not select cardiology. I think she was looking only at cardiology, not at electrophysiology specifically. How can we overcome that perception, because that's almost a PR problem more than it's an actual problem, and we may need our male colleagues to help with that to overcome those kinds of barriers. No, I think you're exactly right, and I think, you know, if there are women faculty members, you know, in EP, then it becomes easier for women to see themselves in that, right? So anytime you've got, you know, eight male EPs, I bet you the number of women who go into it at that institution, wherever it is, is going to be lower, because that's perceived that way. And, you know, and yeah, it's still a problem, and, you know, it's interesting, because if, you know, women run into things like, at some point, you want to have children, right? So you take some time off for that, and then often, you know, the punishment is you get twice as much call when you come back, and you've got a three-month-old, you know? So it's understanding that, first of all, you know, at that part of your life, it's not a vacation, taking care of newborns, right? And so how do we provide that support a little bit more? But, you know, I think the female-friendly part of that, it has to be, it's something that we need to talk about, and really sort of think about policies that work better for that, yeah. And the other question I had was just related to the pipeline, or more of a comment, that because we lose so many women already at the cardiology level, do we need to go earlier in training? Do we need to approach people in medical school? Do we need to approach people in residency to try to get folks to be interested in our specialty? And why not? Yeah. No, I think you're absolutely right. Yeah. Sorry. And one last quick question. Based on the data that you've shown, and maybe I should know this, but have people looked to see, if you account for, let's say, a delta of normal QRS to this, does that account for the differences in results between men and women for CRT, or are there other biological factors? I don't, I'm not aware of other biological factors people have looked at. I think it's really, it's just, you know, I guess technically it would really be more of a hypothesis, the fact that you're starting off with a shorter one. So a formal analysis of that, not aware of it, but it would be worth looking at. Thank you again, and congratulations. So I'd like to introduce our next award recipient, the recipient of the Wilton Wells Webster Award. And for those of you who don't know who Wilton Wells Webster was, he was a mechanical engineer originally from Caltech. He founded Webster Laboratories, which was the genesis of Biosense Webster that we're so familiar with. And he was sort of in collaboration with Sonny Jackman and others, the inventor of the first radiofrequency ablation catheter. And I have sort of the same feeling that Vivek was mentioning about Dr. Curtis, is that Dr. Natale is a giant in our field, and for him to receive the award that I received last year seems a strange circumstance, but Dr. Natale needs no introduction. He's been a giant in electrophysiology for a number of decades and has been involved in the early work in pulmonary vein isolation to treat atrial fibrillation among many, many other accomplishments. And I think today he's going to talk to us about his experience and journey with atrial fibrillation, and I'd like to say congratulations to be the recipient of the Wilton Wells Webster Lectureship. Thank you. Check. Okay, great. Wilton Webster, Jr., known as Will Webster, was a pioneering inventor of cardiac catheters and one of the founding fathers of Biosense Webster. His love of science and technology started at an early age and continued through his career. But perhaps most important was his commitment to listening to customers and wanting to solve their problems. In fact, that's what led him to start his own company, Wilton Webster Labs, to develop customized catheters to meet customers' specific needs. Eventually Webster Labs became part of Johnson & Johnson, ultimately merging with Biosense Inc. to become part of the company we all know today. While the company evolved and its name changed through the mergers, its core philosophy never did. It remained centered on listening to and fulfilling the needs of physicians in order to drive better outcomes for patients. I can attest to this fact that his philosophy endures today in everything Johnson & Johnson MedTech does through its Biosense Webster portfolio. We continue to be focused on harnessing the latest insights, science, and technology to deliver solutions that meet physician needs and help those with AFib live better lives. Will Webster passed away in 2018 at the age of 90, and he's remembered for his partnerships with physicians that resulted in innovative technologies that help patients around the world. He felt a great responsibility to mentor the next generation of scientists and engineers, and in his name, Johnson & Johnson and HRS joined to develop the Will Webster Fellowship and Lectureship Awards. It is my great honor to be here today to present the Lectureship Awards and experience firsthand how Will Webster's legacy continues to live on in EP research. With that, I'm pleased to announce this year's winner, Dr. Natale. Born and raised in Italy, Dr. Andrea Natale earned his medical degree from the School of Medicine and Surgery at Universite degli Studi di Firenze in Florence before attending Rome's Catholic University School of Cardiology. He is now board certified in cardiovascular disease and clinical cardiac electrophysiology and a true pioneer within our field. Dr. Natale's impactful career first began as a member of Duke University's faculty and has since progressed into a multitude of roles across the US, including being named to the task force for atrial fibrillation at the FDA. A true leader within the treatment of atrial fibrillation, Dr. Natale has proudly developed innovative techniques, such as a circumferential ultrasound vein ablation system and percutaneous epicardial radiofrequency ablation. He has been and continues to be involved in many first in human trials to test investigational devices, such as ablation catheters with contact force sensing technology, three-dimensional intercardiac echocardiography probes, and the novel left atrial appendage closure devices. He performed the first preclinical and clinical studies to develop and perfect ablation catheters, utilizing pulse field technology, and also performed the first cases here in the US. Dr. Natale has authored thousands of publications and holds several patents for life-saving medical devices, while also receiving numerous accolades, including the Cleveland Clinic Innovator of the Year. Passionate about education, he created EPLive, an international meeting for electrophysiologists that focuses on advancements in the field. He is best known for combining innovative technologies with a strong patient-centered approach, consistently achieving exceptional outcomes. His forward-thinking methods and dedication to excellence have earned him widespread respect and recognition within our field. We cannot think of someone more deserving of this award. Please join me in congratulating this year's winner, Dr. Andrea Natale. Thank you. After Anne's presentation, I was wondering if I'm here because my name is Andrea, joke aside. Joke aside, I have to say that I enjoy all my career, my relationship with my fellow women. I train many women, I have the pleasure of working with many women, even now in Austin, my closest collaborator is Mitra, that's here in the room, is a woman. I have many friend, cardiology, electrophysiology that I work with, I enjoy working with the women and many women supported me, I have two daughters, so I care a lot about women. So, said that, let's go on with my journey, as I make my disclosure. There you go. So obviously, one area that I care a lot is atrial fibrillation. And over the last 30 plus year of my life, I sort of focus on how to treat the best I can this patient. And obviously, trying to be involved in new tools and technology that help all of us to perform a procedure to treat this patient as much as best as we can. Pulmonary reservation is now the sort of premier target in patients undergoing fibrillation. But this journey started in a different way. We started with the right agent. This is an old paper in early 2000. There was sort of the first one, the first attempt in trying to treat this patient. And then obviously, once the Bordeaux group reported, then the field really exploded. This is a paper that, to the credit of Bill Wespser, this is a paper that we were involved in describing pulmonary vein trigger in 1998 with the first generation of CARTO, which is now sort of the background of most of the work we do. And this is actually sort of the evolution to that, where we describe in patient with persistent cardioversion identification of this sort of non-PV trigger. And this was a really early work in the late 90s that eventually published in 2000. This is actually, I'm kind of proud of this, is the first paper where the word pulmonary vein isolation was used. It was with the ultrasound balloon that never made it to the market, but there's the first time in a paper where we use the word pulmonary vein isolation. And we actually tried to do that. So that was certainly very exciting. Also, circular mapping is something that we are involved early on with actually a device that was a prototype built by an engineer in Cleveland that I think eventually was bought for very little money by St. Jude, now Abbott, at the same time that Carto was developing the LASO catheter. And this is an example of, again, paper where we try to look at those sites. We very early on, we evolved to a strategy that still remains our strategy, which is PV isolation plus. And one of the plus that we sort of made part of the menu very early, this is a paper in 2002, so in the early 2000s, is the posterior wall. Based on this paper, we show that after you isolate the osseum of the vein and challenge patient with a high dose of isoproteinol, you have a lot more proximal trigger. That sort of clinical observation was supported by the embryology of that area. That is really common to the primordial pulmonary vein that expanded to incorporate the posterior wall. And also, we were very early user of eyes. By looking at eyes, we saw that actually there is a posterior extension that we see on eyes that we don't see with angiography, that we start calling antrum. And people for a long time didn't kind of understand what that meant. Also, and this is kind of the first description of what the antrum isolation meant for us and that incorporated the posterior wall. And kind of this is the difference at that time of how we did it versus the other sort of leader in the field that kind of focus more on the pulmonary vein. We sort of show that empirical isolation without circular mapping can be potentially dangerous. This is a study where we used the technique at that time was pushed by Dr. Papone showing that actually with that approach, it was very difficult to isolate. And also, there was a higher risk of pulmonary vein stenosis, which we learned to be really a problem. And actually, we have a paper very early on in Annan, so it's basically describing this new syndrome, which is PV stenosis that many times was misinterpreted as cancer because of a lung consolidation of other things, pulmonary hypertension, there are a lot of different, I mean, we saw all these patients that went through incredible workup before the diagnosis was made. And this is, you know, the evolution of that, and when, you know, this is actually the Annals of Internal Medicine, 2003, where we described pulmonary venous stenosis, the emergence of a new clinical syndrome. Obviously, I put a lot of effort over my year of experience in trying to really talk about problem and how to avoid them. So this is something that I feel strongly about, I think we have to own it, and we have to really be willing to talk about it. This is actually the first study where we showed that by using intracardiac echo, we were able to eliminate severe pulmonary venous stenosis. This is something that has become standard in US, not yet in Europe, because of cost issue, but that's sort of the first evidence of how important is imaging in what we do, and in trying to make this procedure safer with intracardiac echo. We also reported, more recently, the left atrial sleeve syndrome as a potential congenital. So, you know, I think this is something that we all have to be willing to talk about. You know, we want to push the field forward, but we need to own the problem that sometimes we create and find solution to that. Our group was the first to introduce uninterrupted anticoagulation that now is mentioned in the guidelines, and this was one of the first paper where we described at that time with Coumadin, and then, obviously, that more recently translated in the use of NOACs, Eliquis, and the other one. So, what beyond the PVI? Our group has been vocal since early 2000 about non-PV trigger. I think I found this a physiologic approach, although people talk about other physiologic approach that consists in mapping in a fee, but I think this is a physiologic approach, certainly not easy to do, but with high-dose of isopropanol, if you have a good setup, the minimized mechanical PAC, I think, can be done effectively in many patient, and this approach over the year made us aware of other potential target beyond the pulmonary vein. One is the posterior wall, but a few others that I'll mention, obviously, the posterior wall that I mentioned already. Let me go through quickly this. That was also validated with cryo. This is a paper with Dara Sharyana that showed the benefit of doing that with the cryo balloon. And also, how, with high-power short duration, which our group sort of introduced in early 2000, at that time, by using microbubbles, monitoring with intracranial kegel, then has evolved with open irrigation to current day, and we sort of eventually come up with a menu that allow us to be more effective, but still, the posterior wall is a challenge because the esophagus is right there, and that's probably the only area that still remain a challenge until recent day with the PFA, and once we became aware of that, then we start implementing strategy to either cool or deviate the esophagus to really solve that issue in that particular region. This is something that showed the benefit of some of the new technology. One of the issue of the posterior wall is achieving permanent isolation, which I think has been one of the big issue in proving that ablating that area is important in improving the outcome, and this is a paper in few patient with the endo-epicardial mapping after PFA, showing that with PFA, we might have a better chance to achieve that, and this is some of those patient. Something very difficult to do. So one of the non-PV triggers is superior vena cava, and this is one of the early paper that we publish, and actually, this is a randomized study showing the benefit in paroxysmal that we did with a group in Italy. We also report about the left atrial appendage, and this is working with people with multiple redo, so we try to look by using the non-PV trigger approach what other side could be responsible, and we find out that the left atrial appendage can be important. Also, and this is something that I strongly advocated for many years, we need to follow our patient. If we don't follow our patient, we never know if we're doing something wrong or not, so this is a recent paper where we have now a 20-year follow-up showing that if you take a patient with paroxysmal AF that has been updated successfully, if you follow them long enough, eventually, they're gonna come back with new PV trigger, so this means that IFIB is a progressive disease that evolve over time. In this series, we describe obviously non-PV trigger as the reason for recurrence that obviously were not there 10, 15 years before when they were successfully treated by just the pulmonary vein isolation, so this is something I think we need to become more aware and think about. As I mentioned, the appendage that we reported in patient with multiple redo or clearly the pulmonary vein were not important anymore, and this is kind of a controversial target still, but I think we see daily the benefit that when many patient come to us after four, five, six procedure, it really that's the only area that is left to take care of. We prove the benefit of that structure in long-standing persistent AFIB that there's still a group that somewhat neglected in many part of the world and are not considered for ablation. In that group, clearly, the appendage is an important target and this is a paper that multi-center study that show that. Also, the coronary sinus, that actually is probably even more common than the appendage and certainly is one of our early target in the persistent to be before we do the appendage, which is the last sort of things we leave, and this is an example of a few cases that we publish already. So, overall, this is the way I see atrial fibrillation. I think substrate in my mind is a marker that you have to look for non-PV trigger. It doesn't necessarily mean that has to be the target, but it's clearly a marker that you have to look for a pulmonary vein trigger and sort of a driven and our approach, certainly in that group, we really spend more time at the time of the first procedure to achieve better ablation of those extra pulmonary vein site. New technology also is something that I care always to be involved, but always with the spirit of finding problem if they exist. So, with the remote binding medication, we reported many year how difficult is to, again, to isolate by just making circle around the vein. It is actually show the recording before and after this is what was made, and one issue at that point was also that without irrigation, that was one of the problem we had, which we had to sort of recognize. Obviously, with irrigation, all of that disappear. Then, involving contact force, actually was the PI of the study with the biosensor, the smart touch catheter, that was approved. This is the data from the study that has become sort of the standard or RF care therapy until recently with the event of pulse-feed ablation. And even, obviously, in the era of this new technology, which is very exciting, Vivek did on Thursday the PFA Summit that was very popular. I think this is the buzz of the day. We are all very excited about this technology and how quickly it's evolving. So, this is one of those catheter and that even if you show similar result to the thermal energy, actually when, in a recent paper Vivek analyzed, that if you burden instead of recurrence based on the 30-second traditional endpoint, actually show some benefit. But consider this is a technology that we use for one or two rollover and then start enrolling patient versus what we use for the last 20 years. So, the fact that we have good results with something so new in comparison to what we use for the last 20 years is actually a good outcome. And this is another of those technology. Also, this one is the Affera catheter that I think is probably among the exciting tool that we have right now at our disposal. And this is the body pulse. So, we've been involved with all this technology and some of the one that are coming up that you see here that I think will bring certainly positive things to our field. Although, as I said before, we need to own the issue that we are learning about this and there certainly has been a focus of many of us involving the field. A few things that we are learning with the pulse field, the blanking period probably has to be redefined. This is a paper we published with our data showing that beyond a month, it really there is no point to wait for redo. And this was also confirmed by an Amir sub-analysis that show the same result. Also, the benefit of this technology, we all know that so far, despite 200,000 cases done with the far away, cases of esophageal fistula, but this is an absent present here at HRS where we look at gastric dysmotility, which is also one of the problem with RF. And we found that really a pulse field ablation also impact on this potential issue. So really, there are obviously problem that we need to deal with that are new, but some of the older problem we dealt for the last year, they're really gone away. So, this is something exciting. And also, anticoagulation. This is a technology that cause less disruption to the endothelium. And so, this is a paper also that is coming up in our rhythm showing that maybe discontinuation of anticoagulation is not two or three months as it's been with RF, but can be even one month, and it's safe to do that. And again, the benefit of ice. Obviously, this is something that I think most of the U.S. operator use. This is a serious, well-described position in the ice catheter in the superior vena cava by using the mark that you used before with RF, which is the lower border of pulmonary artery. And by doing that, we saw that there was no impact, negative impact on the sinus node. So, proper position is important. That's where ice can help. But ice can also help with outcome, because if you use ice to assess contact, which right now is not available in our, in the current first generation of pulse-field ablation device, that can impact on the rate or reconnection, and also on success rate, as you see here, with some benefit as compared to fluoroscopy-guided procedure. So, lifestyle modification has also become an integral, an important part of what we do. And we have also a few papers showing how that impact in a negative way in our outcome, and how important it is to do that in our patient. Obviously, in long-standing persistent, although there is an impact in quality of life, there's an impact on success of the procedure, but it's still important. One thing that we certainly need to work on, and this is something that we saw in our attempt to implement consistently lifestyle changes is education, especially in the U.S. population where most patient refuse, even if we provide nutritionist and trainer for free, refuse to do that. And on the 50% that embark into this journey, after one year, only 30% is still compliant. So, clearly, this is an area where there is a need for a lot of education and improvement. So, also, I wanna, before I finish, mention quickly about the contribution of my group in this area. This is actually the first description of coronary casp PVC that we published in 2001. At that time, everybody thought we were crazy, but now everybody does it. So, and also, we were very early, together with the Bordeaux group, involved in ablating non-PV trigger. This is a report in 2002 of a patient that come with the VF storm, where we found Purkinje-related trigger in the moderator band, actually, in the right ventricle. And then, this sort of translated into VF storm in patient with ischemic cardiomyopathy, where we also recognized that, in most of them, everything starts with a monomorphic PVC that, if ablated, eliminate this. And those PVC usually are on the scar border, so that can become an empiric target if PVC are not present at time of ablation. We are also very early, what is the amylodosis case with the VF storm, where clearly, instead, mapping become important. We're also involved very early in pushing substrate as the preferred strategy. This is in patient with diabetes dysplasia, where we reported early the importance of the endo-AP approach as a first line. And also, the same is true for the substrate homogenization with the endo-AP approach in patient with ischemic cardiomyopathy. I don't know how many of you know, but my group was the first to import the epicardial axis in US. The first case that we did was in 1995, I think. And that became, very quickly, sort of a backup strategy for difficult cases. But then we realized that maybe that should be considered more frequently, even in patient with ischemic cardiomyopathy, where we always thought that maybe only 10% need that. So the substrate homogenization has been sort of something that our group has been very vocal very early on. And certainly benefit this patient, not only by preventing recurrence of OVT, but also allowing them to come off antiarrhythmic drugs, which is not trivial, because the antiarrhythmic drug of choice for this patient is amiodarone, which we know is an independent predictor of mortality in patient with heart failure. So it's important. And same is true for, when we look at this in randomized study, this is the VISTA study. And also, when we look at the long-term follow-up, I'll show you that more recently. So one of the issue with VF ablation is the tuning the PVC. As I said, in ischemic cardiomyopathy, that can be overcome, because most of the site are on the SCAR border. But in non-ischemic cardiomyopathy, you really need the PVC. So recently, we reported this paper where we look at VF substrate ablation in non-ischemic cardiomyopathy that present with VF storm, and then no PVC at the time of the procedure. This is a recent paper that we describe, that our group reported. And this is some picture from that. And obviously, again, new technology. This is something that Vivek has done more case than I have. We've done a few cases, but they were very excited as the next sort of upgrade in pushing outcome in ventricular tachycardia ablation, again, with pulsed field ablation. And this is actually a case Vivek did where with endocardial ablation, it was able to affect the epicardial substrate. I'll stop here, saying that I've been around for a long time but I feel that the journey is still continue, and I thank you very much for this honor. Andrea, there are a few electrophysiologists who've done as much for as long as you have. So congratulations and thank you. Thanks. Just no questions, just a comment. Thanks. Thank you. Okay, I think we're gonna go ahead and close in the interest of time. Thank you, everyone.

cardiac electrophysiology

gender disparities

Dr. Curtis

Women in EP program

clinical trials

Dr. Andrea Natale

pulsed-field ablation

atrial fibrillation

cardiac care