All right, we'll go ahead and get started. Good morning, everyone. I am Sana Al-Khatib. I am an electrophysiologist at Duke University. I'm the program chair for HRS 2025. And I'm delighted to be joined by my colleague, Dr. Ed Cronin. We have a great session planned for you today. And this is basically going over recorded cases, difficult CID cases. So these should be really interesting. And it is my pleasure to introduce the first speaker, if I can actually invite you to come up to the podium, Dr. Ryan Kunin. And his presentation is titled, When You Cannot Get There From Here, Leadless Pacemaker Implant from the IJ. Just a quick reminder, guys, there's a QR code that was shown. You can also enter your questions through the app. I'm sure all of us have the apps if you have any questions. But we also don't have a lot of people in the audience. So you can walk up to the microphone and ask questions. And what we're going to do differently from what's shown here is we are going to allow time for questions after each presentation, rather than saving them till the end. And with this, I'll turn it over to Ryan. Go ahead. Great. Thank you very much. Thanks for having me. It's an honor to be here. I apologize. I started losing my voice yesterday. So bear with me a little bit. I brought some water up with me. So I was asked to talk about some of my experience with the IJ approach for leadless pacemaking. So go ahead and get started here. Skip over that since that was already playing. So why should we consider the IJ approach? Really probably the main indication for using the IJ with a leadless system is some sort of access issue. So if there are problems with tortuosity, occlusions, interrupted IBC, IBC filters, anything that's giving you a hard time to get up from the femoral access site, then you could consider an IJ approach as an alternative. Interestingly, you can also use it for just otherwise challenging anatomy, whether it be tricuspid valve issues, replacements, repairs, large right atria, which can essentially change the contact points in the atrium where you use to kind of cross the valve. Sometimes that, particularly a very large atrium, can make it challenging to get into the RV. And other things like Ebsen's anomaly and whatnot. Alternatively, patient convenience. There's no flat time with an IJ approach. Patients in some groups just get up and walk off the table out of the room because they don't need to lie flat at all. And I included this image here from a paper from last year from the groups in The Hague and Zurich. They do a lot, and I'll go over this paper a little bit in the next couple of slides, but I really like this image because it shows the general relationship from a kind of essentially a caudal perspective of the relationship between the superior vena cava and the inferior vena cava. You can see that kind of here. With the inferior vena cava generally being a little more posterior than the superior. And in doing so, can sometimes make access to the RV septum, which is our target for leadless pacing, a little more challenging, just given the angles that come into play by that approach. So talking about this paper, this is a nice kind of large experience from, again, the same group in Zurich and The Hague. They're doing the majority of their cases from IJ approach. So this is a report of 100 cases. They had two complications in the IJ group, 16 in the femoral group, mostly being major hematomas. Overall, the end results were pretty similar. It's unclear, but the jugular approach led to a little more dispersion in terms of the lead locations for where the devices were implanted, versus the femoral approach where they were kind of able to target the mid-septum pretty significantly. Otherwise, things were pretty similar, slightly lower fluoro time, but statistically significant. And then just long-term findings, the device basically showing that the devices were stable. Thresholds, impedance, sensing was all stable over time with both approaches. So it's possible to do. And as we continue to do more and more leadless devices in general, whether it be Micra or Avir, we're seeing that people are utilizing the IJ approach for alternative, instead of just implants, for also different ways to do things. One of the more interesting, these are two recent case studies from this year. This one shows a atrial Avir approach from the IJ, which I think would be challenging just given some of the limitations of the catheter and how aggressive the curve can be. But they were able to successfully implant it. I believe this is from the UC Davis group out of Sacramento. And then here, this is the, I believe the Rochester group, or the Mayo group, I'm sorry, the Cleveland Clinic group. But this is showing an extraction of a leadless device via the IJ approach using, this was a Micra device, but using the Avir retrieval catheter to remove the device. And this was done because of some, they already had IJ access for some other aspects, so they decided the device needed to come out, so they decided to give it a shot just from the access they already had and were able to successfully remove the device. So the IJ can be useful to help kind of get you to places that you otherwise weren't able to get to, either given limitations from below or just ease of use. So a brief review of the anatomy. We're targeting the internal jugular vein here, which runs next to the carotid. You can go either left or right. I think the other thing I forgot to mention is this actually was left-sided IJ access in this case, but left or right. And we're looking at the anatomy, this is probably familiar from back in residency or fellowship days, getting central access in the IJ, but we're targeting the triangle that's made up from the sternal and clavicular, sorry, over here, the sternal and clavicular heads of the sternocleidomastoid muscle as well as the clavicle. And in that triangle, you'll see, you'll find the internal jugular vein as well as the common carotid artery. This is kind of what things will look like under ultrasound. And the internal jugular being compressible with the common carotid, obviously not. If you're gonna target, if you're gonna take this approach, you probably want to try and find with ultrasound an orientation of the veins or the two blood vessels that looks more akin to the picture on the left than on the right. If you can find a place where they're separated next to each other as opposed to on top of each other, you may have a little less risk of inadvertently damaging the carotid artery. So one of the big things with IJ approach, and I think that will be a challenge for if you want to try and start doing this in your lab, is figuring out the ergonomics of this and how you're gonna set up the lab. In our system, this is kind of generally how we're set up initially. With the primary table, I mean, most labs are set up for femoral access or chest access for devices, but we have our primary table and then anesthesia at the head of the bed. The thing that I found can be helpful with IJ approach is to ask the anesthesia team to locate themselves on the opposite side of whatever side you're gonna go into. So if you're gonna do a right approach, then asking the anesthesia to set up their machine off to the patient's left could be helpful. And then you have your primary table that can be helpful for just kind of size, and particularly with a lot of the delivery catheters that we have for these devices, you need something larger. But a secondary working table can be very helpful to set up near the patient's head. And I think there's two kind of helpful approaches, and it kind of depends on what you find the most useful for yourself. But either with the table kind of coming off at a 90 degree angle and standing closer to the head, or you can alternately switch, have the table going off this way and standing kind of closer to the patient's side there. Both are reasonable. So I'll get to my case. This is a 28-year-old gentleman with a history of AV septal defect, status was repair, mechanical mitral valve repair, and a bioprosthetic tricuspid valve complicated by heart block. He needed a pacemaker. That was implanted in 2013. He's followed by our adult congenital team and had progressive symptomatic tricuspid valve stenosis. So he additionally has bilateral femoral venous occlusion as well as right IJ occlusion. So the plan from our adult congenital heart kind of multidisciplinary team was to do a dual chamber pacemaker extraction in order to facilitate percutaneous valve-in-valve tricuspid valve replacement via left IJ approach, and then micro-AV implant through the new valve. So here is kind of the initial setup. They've already put the valve-in-valve, percutaneous valve-in-valve in place, and were kind enough to leave wires across the valve for me. So I upsized the sheath to the micro-sheath. And interestingly, coming from the left approach was actually pretty convenient because the way I had the table set up 90 degrees off to the patient's left side, and in doing so, your hand positions are the same as they would be coming from the femoral side. So your right hand on the controls, left hand kind of controlling the catheter, which is one nice aspect of the left-sided approach. So my first thought here was to try and see, since it was a new valve, I wanted to see if I could potentially even just get the sheath across the valve and not have to worry about potentially disrupting or dislodging the valve. But as you can see here, that was a bit of a challenge. It was just too sharp, acute of an angle, and wasn't able to get the dilator across. So I'm going to pause there and then just kind of talk about how these devices are implanted from the IJ. So the best approach is really to advance the introducer into the right atrium. You want to target the radiopaque tip a little bit lower down at the, sorry, a little higher at the RA-SVC junction, and in between that and the clavicle. Oftentimes, because there's not as much tissue for the introducer sheath to go in, it can be challenging to keep it in place. So it's helpful to have an assistant make sure that you don't accidentally, inadvertently pull the introducer sheath out. You can instill with your delivery catheter in place. So it's helpful to have that there. And then essentially you want to unsheath the device, cross the valve in a right anterior oblique view, about 30 degrees. And then the initial position of the delivery catheter, at least for the microsystem, is going to be with the buttons facing down. So everything's going to be opposite as it is from the femoral approach, where you start with the buttons facing up and you clock to go to the septum. Starting from above, you're going to start with everything upside down, with the bias pointing leftward, cross the valve, and then counter-clock to come to the septum. So here is our same case. We've pulled the sheath back, and at this point I'm trying to cross the valve. And did this in REO, able to get across. And once you're across the valve, for the microsystem, for the veer, you don't have to apply as much forward pressure. But with the micro, a critical part of successful deployment is going to be that forward pressure, that contact with the septum. And while we talk about a gooseneck coming from below, the recommendation for coming from above is this so-called flamingo neck, which upside down flamingo, I don't know where this came from. You basically want to reverse J approach, and you can get some contact with the septum in that way. And you need enough in order to engage the tines. And so this was the different views of my case. We have REO, roughly REO 30 on the left, a kind of moderate LAO in the middle, and then a steep LAO on the right, which we check in all cases in order to ensure we're at access on the septum. And once we confirmed we were on the septum, we were able to deploy the device, and worked well. And interestingly, another kind of aside for this case, we weren't sure how the AV was going to work in somebody with bilateral valve replacements. One thing you can check is the E to A ratio in mitral valve filling to see, get a sense of what the atrial kick is. But it was unclear to us if having had bilateral valve replacements, he was going to be able to sense the atrium well. But once we got the device in and turned it on, he actually did excellent, had excellent AV sensing, and did very well with this device. So the last thing I wanted to discuss with these cases are one of the things that comes up frequently is closure. So how do we make sure that we can close these large bore IJ accesses? One option is manual pressure. The IJ is a remarkably low pressure system, and just holding pressure for a while, maybe putting the patient in reverse Trangelloberg for a bit, you can usually get hemostasis pretty quickly. But kind of short of that, I think that most commonly, we're doing some combination of either a double perclose, similar to what we use in the groin, or just a simple figure of eight stitch. So that is it. I have a nine-minute recorded case, if you guys want to do that. I'm just kidding. We've only got a minute left. So if there are any questions, please let me know. Thank you very much for sharing this great case with us. Just as a reminder, and especially for people who walked in a bit later, we are going to take questions after each presentation, and we're not going to save them till the end. So let me start with a couple of questions. The first question is an easy one. How long of a follow-up do you have on that patient? And how has he done during that follow-up? So this case was done, I think, either two or three years ago. So it's been quite a while, and he's been doing very well. Wonderful. Wonderful. My other question is a procedural question. You mentioned that you went on the left with this. How many of these have you done, by the way, going through the IJ? From an IJ approach, I've probably done around 10, maybe. Oh, wow. Not a ton, but some. Okay. And so what is the split of going from the left versus the right, and can you tell us a little bit about differences in difficulty, advancing the sheath, and all of that? Sure. Yeah. So the vast majority have been from the right. It's just kind of the sort of standard approach that we use for IJ access in general. And it's also a bit more of a straight shot, coming straight down into the heart. The interesting thing about coming from the left is, because the size of the introducer sheath is large enough and stiff enough, that it tends to straighten out some of that tortuosity or kind of the turds that you have to go through to get down there. And I haven't really seen much difficulty advancing the sheath or manipulating it from the left. One thing that, because also it's the straight shot from the right, I think that the introducer sheath stability is probably a little less on the right than it is from the left, because you have those turns to kind of hold it in place a little bit. Do you have any questions? I think we have one question. Go ahead, please. Yeah. So I guess I would ask you, why not do them all from the IJ? Why would you even do it from the femoral? I've done a bunch from both. I just find it quicker and easier. I'm just more used to doing it from the femoral. But I'm just wondering what keeps you from doing all of these from the IJ? That's a fantastic question. And the two groups from Zurich and The Hague do do that. The vast majority of their cases are from the IJ. And the main limitation in my practice has been just, like I said, logistics. And I'm not sure what the motivation is, but our anesthesia team is very reluctant to move anything around. So it can be a lot of discussion to try and ask to move that around. So sometimes it's just easier to just do it from the femoral. I always joke they can't charge their iPhones as well from the IJ. Have you had any complications with any of your 10 cases that you did? No. They've all gone smoothly. OK. Great. One of the issues is just having gas on both sides as well. If you have gas outlets or inlets, whatever you want to call them, typically only on the right side of a room. And some rooms have them on the left as well. So it's easier to switch. I think we have another question from the audience. Take your time. Take your time. Some of my steps got in. OK. So I just want to share with you that this is great. And I totally agree that just setting up and getting everybody on board, and this is how the room is going to be, is a heavy lift. But we had two cases, and I don't know why it happened. It was a rash. One was 550 pounds, and the other one was 600 pounds. And so the first one we reported in JCE. And we did it IJ, right IJ, no fluoro, all with TEE. And then two months later, and the other guy shows up, and we actually didn't even take him off his bed. We, you know, off the trolley. He just went down to the OR on the same thing. We didn't even bother trying to put him on a fluoro table. That's fantastic. So it worked with TEE guidance, and it's easier to take care of that. And I could envision where he'd do ice, and it would be even better. The second case I did with ice as well. Ice and TEE. I didn't report that. And then I didn't see these patients again, and I didn't ask for them either. That's wonderful. I haven't heard too many cases. The second patient did well. The first patient I reported did not do well for other reasons he was in the hospital for. But I mean, I didn't see these 500 and above. I haven't seen the needs to go to the IJ as well. Yeah, yeah. And I think that's a wonderful use of this approach. With BMIs of that category, femoral access is like a major issue. Yeah. So that's great. Okay. Just one question from the app. How many cases do you think is the learning curve for IJ, or are you still learning at the 10 case mark? I think it's pretty intuitive. I would say only a couple of cases is all you really need, because it's just thinking about the hand movement a little bit differently. And so the interesting thing, coming from above, even though the catheter was designed for a femoral approach and an apical placement, coming from above, the bias of the catheter almost draws you towards the septum. So it's, in some ways, potentially a little easier to get it on the septum. We'll take one last question. Go ahead. Yeah. Are all of your cases under anesthesia? Because, you know, that's a... It's not easy. Now we're on the West Coast to have anesthesia readily available. Do you do it with sedation at all, or without sedation? Yeah. All these were done with... Just at the University of Michigan, we have an agreement with our anesthesia group that they cover all of our cases. So they were done with moderate sedation, with propofol, not necessarily general anesthesia, but with an anesthesiologist or a CRNA in all the cases. Okay. Thank you very much. Thank you. Yeah. Okay. Next, it's my pleasure to introduce Dr. Daniel Friedman from Duke, who's going to talk to us about left bundle lead placement, when you just can't get what you want. Good morning, everyone. Thank you for joining, and thank you for the opportunity to present. So I'm just going to pull up my slides from a pretty difficult case. So, you know, we spend a lot of time looking at beautiful images of left on a branch capture in ideal hearts. And so, you know, I'm excited to actually have the opportunity and venue to discuss, you know, a challenging case and discuss some of what went really well and what went okay. Because I think it's something that, you know, we don't discuss enough in these conferences, you know, when the conventional criteria are maybe going to fail us a little bit. So thank you very much. So I'm going to spend most of my time on a case without much didactic. So this is an 81-year-old gentleman with a lot of the usual comorbidities that we see, including coronary disease, five-vessel CABG, and trifascicular block. He was initially referred to me actually for a PVC ablation because of an increasing PVC burden and a decreasing ejection fraction. And as part of that workup, he underwent a stress test, which showed infarct in the basal and receptal region and mild reversible ischemia in the mid-inferior wall with peri-infarct ischemia in that region. And again, he was referred for PVC ablation. So I brought him to the lab. Unfortunately, he didn't have any PVCs initially, infused isoproteinol, and instead of getting my PVCs, I got AV block before even putting in catheters. We did get PVCs, did put up catheters so he could map and ablate that, but also had the opportunity to look at the health of the conduction system. And as you can see here, we have an impressive HV interval of 106 milliseconds, so very long, indicative of very significant infrahisian disease. And during episodes of block, you can very clearly see that the level of the block is not surprisingly infrahisian. So before I go into the details of this case, I just want to review what a good appearance of a pericordial transition is during left bone branch area lead delivery. So over here on the left, you can see at the RV endocardial pacing site, you've got that nice W and V1, AVR, AVL discordance, a small R wave and a small S wave in two, and then a normal pericordial transition. A lot of folks like to map out the HISS or do RVN geography to understand the base to apex location. I like to use a pericordial transition since this is an electrical therapy. I like to use an electrical reference for a target, but there are other good options. And as you're deploying with continuous pacing, you can see you go from a W to more of a slur than more of a V. And then once you approximately cross the midline of the septum, you'll see an R prime and V1 becomes a little more pronounced. When you're capturing the left septum, you have an R wave peak time of 92 milliseconds. And as you get to the left bundle itself, your R wave peak time will pull in as you see here. Now, in contrast, I'll show you the initial pacing sites from my patient. So I pace mapped in several locations with the Ingevity Plus lead. And although I was able to find several instances of a W-like pattern in V1, there is significant notching indicative of the extent of septal scar. So I knew that I was in for a rough case. But ultimately, I picked what I thought was a reasonable site. I did select to say those a little bit higher in efforts to try and target the main trunk of the left bundle, because there's significant infrahisian disease. And my hope is that I'd be able to accrue maximal fibers by starting there. Fluoroscopically, you can see in REO and then LAO where I started. And I apologize, the video is actually not playing, although they did play in the speaker resource room. So I apologize for that. But what we're seeing here is in LAO, the lead is being burrowed across the septum or attempting to go across the septum. And what you can see here is the pericordial transition with pacing. So you see as we're going deeper, you end up losing that W in V1. But two concerning things happen. So one, we don't see the development of that R prime in V1 like we like to see. And the other thing is we actually lose the amplitude of the R wave in one and actually develop a small Q appearance in AVL. And these should all be warning signs that you're going in the wrong direction and you ought to stop. Fluoroscopically in the REO projection here, you can see that the lead was going more anterior and apical. This, of course, was recognized, and so there are no issues here. But this is something to keep an eye out for, particularly in the more difficult cases where it may be hard to find any way to penetrate the septum. And you start to be in a situation where you may consider a less than ideal RV endocardial pace morphology for your starting point. Here is a second deployment attempt at the main trunk. So here you see some snapshots from different points during the second deployment attempt targeting the main trunk of the left bundle. And you can see that although we're able to get a resolution of that W, I was unable to get to the left septal region and to get that R prime and certainly wasn't even close to the left bundle. Maybe I have to turn this. Okay. So the laser pointer prevents me from doing it. Okay. And so here you can see in LAO and REO how the lead is penetrated. And actually overall, the fluoroscopic view is certainly more favorable than the first attempt, but I was just unable to penetrate deeper. So what can be the cause of this? So there's a lot of different things that can cause a failure to progress. And there's a differential that I would encourage you all to think about as you find yourself in these situations. So sometimes it can just be simply malalignment of the lead relative to the septum. If you're using a stylet-driven lead, you need to think about helix retraction or incomplete stylet insertion. If the stylet is not fully inserted, then you're going to end up flexing between the tip and the ring electrodes with the Biotronic and the Boston leads. And that can impair your ability to transmit force and may also increase the risk of preconditioning for distal electrode fracture. It's also possible to have helix entrapment in the myocardium, whether it be healthy or fibrotic. I'll mention that a little bit more in the next slide. A helix deformation can occur. More common with stylet-driven leads and lumenless leads, but it can occur with both. Sometimes you're actually just too basal and you're trying to penetrate through the tricuspid. So if you're not penetrating, particularly at the RV endocardium, it's important to stop early. But then oftentimes, as I think is likely the case here, there's just a very fibrotic septum. So before I get back to the case, I want to talk a little bit about entanglement. So it can be caused if you've got a lead that's not progressing, but you continue to try and deliver clockwise lead body rotations. What can end up occurring is what you see over here, is that instead of the lead going forward, the helix continues to grab on to trabeculations in the right ventricle or fibrotic myocardium. And so if you're not making the progress that you ought to, you need to stop. Now, it can occur in normal hearts without fibrosis just because of the trabeculations that are normally found at the RV endocardium. But you certainly can have failure to progress deeper in the septum in patients who have fibrosis like this patient or scar. So in general, my practice is if I've had difficulty getting to the main trunk of the left bundle, I'll then transition to targeting the left posterior fascicle. It is a larger target. The myocardium is thicker, probably lower risk of dislodgement, but you do have the benefit of trying to recruit the conduction system more distally. And it's possible that in some patients, particularly those with more diseased myocardium, you may end up with a slightly inferior result. But it's clear that I'd spend enough time targeting the main trunk in this case. So as you're in a case where you had multiple deployment attempts, it's important to not only think about moving to a new position, but also think a little bit more broadly about patient safety. How is the patient doing? What is the indication for this patient? Is this a patient who's got bradycardia or who has a class one indication for CRT? Is left septal pacing appropriate, or would it be reasonable in this patient? So a patient, for example, with a normal ejection fraction, relatively low anticipated RV pacing burden, left septal may be an acceptable place to stop. Then also, again, think about the underlying subject, like this patient, and then what are the alternatives? And those alternatives could be his bundle pacing, or probably more often this day and age, things like biventricular pacing, because of the higher level of reliability. So this is a series of paced morphologies at the final site of deployment. You can see you've had a kind of a bizarre W in V1. And over time, we do develop that R prime in V1, indicating that we're at the left septal region. So then the question is, am I capturing the conduction system or not? Oftentimes when you've got significant myocardial and distal hysperkinesia disease, it can be hard to apply a lot of the criteria that we use, specifically the absolute R-wave peak times in 1 or AVL or 1. And so I like to try and rely on other methods, none of which are perfect, really aside from mapping the left septum for left bundle potentials, which clinically is not usually feasible. In this instance, I identified the fact that the R-wave peak time in V6 was essentially stable at high and lower output pacing. At this point in time, the threshold is 3 and 1 half volts. So this actually was just a little bit above capture. Here's a sense signal. So maybe a hint of a far field Purkinje potential, but certainly not certain. And here is an image of threshold testing in that final lead position. And here's where you see loss of capture. And one thing I want to draw your attention to is that right before loss of capture, you actually do see a slight change in the pace morphology. And in a lot of the papers that we read, we hear about these output-dependent changes being essentially the gold standard for left bundle branch capture. But you need to be very mindful that if you've got a very diseased septum, one with significant fibrosis and infarction, you can actually have some subtle changes that are not related to transitioning between conduction system capture and septal-only capture, but actually because you end up capturing different quantities of myocardium that are isolated by these areas of scar. Dr. Vijayaraman has an interesting case where he identified, I think, four total transitions, most of which, of course, could not be a non-selective left bundle to left septal transition. So at this point in time, you know, I was feeling like this probably was left septal, although, you know, not perfectly diagnostic of that based on the available data. In this patient, since I knew it was going to be a difficult case to start with, I had actually planned on almost certainly putting in an LV lead. Here you can see the coronary sinus venogram. Based on the pace morphology, where I was in the infraceptal region, I anticipated that a higher lateral branch would probably give the best resynchronization, because even if I did capture the posterior fascicle, we're going to likely see the most delay in the anterolateral LV. So, I was able to target that nice, large anterolateral branch, and I put a standard quadripolar lead in there. And I did a maneuver that probably doesn't get enough attention, but could be very helpful in situations like this, where you're trying to determine, do I need a coronary sinus lead or not? And what that involves is putting, you know, your left bottom branch area pacing lead in, putting either a coronary sinus lead in, or you could also use a, you know, an O1-4 wire that has the ability to pace and sense. You could put in a decapolar catheter. There's a lot of options here. So, the intervals that you can measure and compare are the interval from the stimulus at the LV epicardium from the coronary sinus lead to the sensed signal in your left bundle branch area pacing lead, and compare that to the opposite, where you're pacing at the left bundle branch area pacing lead and sensing at the LV epicardium. And there's a nice paper that was published about, I think about April of last year, that suggested that if that delta was greater than 20 milliseconds, then that was highly suggestive of capturing the conduction system, whereas if it was less than 20 milliseconds, then you're more likely to be capturing the left septum and not capturing the conduction system. So here's the final fluoroscopic shot. The final paced 12-lead ECG in the lab, and here's the post-op day one ECG programmed with a VV offset of zero, sensed AV delay of 160, so it looked quite nice. So, in the last three seconds, my conclusions for challenging implants are pay close attention to the pace morphology at the RV endocardium and during septal penetration to improve the safety and efficacy of the procedure. Consider that the left posterior fascicle is a larger target, more removed for the tricuspid valve and basal septal scarring that can oftentimes make these challenging procedures. Consider if left septal pacing will do, and consider the alternatives, like biventricular pacing. I do think you should always strive for left bundle branch capture, but there are situations where the best choice for the patient is to leave it with left septal. And finally, the pitfalls of current left bundle branch area pacing criteria are going to be more common in these difficult cases, and so you do need to be more creative. You can consider left septal signals, measuring retrograde HISS potentials, and again, the coronary sinus can be invaluable for both diagnostic and therapeutic purposes in these difficult cases. So, thank you very much. Thanks very much. That was a tough case, for sure. If anyone in the room has questions, if you wouldn't just come up to the microphone in the middle, it's the easiest way, or else you can put them in the app. I'll just ask one from the app while people are getting their thoughts, which is my thought as well, is if you expect septal scar, do you prefer statlet-driven lead versus lumenless? And I'd add to that, any thoughts about maybe using a different lumenless, or using a different statlet-driven lead for this particular case where you anticipate it's going to be, you're going to need maybe more tensile strength? Yeah, so, I think you can make an argument for switching from one lead type to another. I think from a lead delivery perspective, the statlet-driven leads are overall pretty similar, so, you know, in some instances, you know, it's worth switching lead types altogether, and Haranburi's group published some data suggesting that that can be a very helpful transition, and it can increase the likelihood of procedural success, but in general, switching between statlet-driven lead vendors is probably going to be lower yield than considering an alternative lead design. You can ask more questions. In a difficult case, would you ever consider LV endocardial pacing, putting lead on the left side? I think, yeah, okay, so, like, transeptal MV endocardial pacing, or why is CRT, I suppose, available? So, it's a great question, you know, truthfully speaking, left septal pacing is LV endocardial pacing, it's just at the septum, and so, you know, particularly for some substrates, that can be helpful, and there's some reasonable data, all retrospective at this point, suggesting that, you know, left septal pacing is relatively equivalent to biventricular pacing. I'm very excited for hopefully the YCRT system to be approved and clinically available soon. I would certainly look to use that, rather than take a transeptal approach with, you know, any of the current leads, just because of the necessity for long-term oral anticoagulation. So thank you very much, Dan, for presenting this case. I just have a couple of questions for you, as, you know, someone who does these procedures. Based on your approach, how long and how many times do you actually try to achieve a main trunk capture, versus then shifting to below on the septum? So that's the first question I have. The second question I have is, at what point in your cases do you decide, oh, I really need to consider a BIV, and would you do it if the EF is preserved, if the EF is normal, and you're really not happy with the left bundle capture that you get, left bundle pacing area capture? At what point do you start thinking about biventricular pacing? Great questions. So in general, I'll usually give the main trunk two attempts. It depends a little bit on why I'm, you know, not making progress. So there are some instances where I'll try more if I think I just need to make a minor adjustment and I can get it. But if I'm starting to do it and it's just really not going the way that I'm hoping, then I'll transition to the posterior fascicle after two attempts, usually. And in terms of when to think about a BIV, you know, the evidence for biventricular pacing is excellent. And if I'm not very confident that I've got left bundle branch capture, then I will always put in a coronary sinus lead if the patient has an indication for a biventricular pacemaker. Because as you can see from this patient's EKG, even in a very complex substrate, lot CRT with a left septal lead can give an excellent result. One thing I'll mention, too, is, you know, so some people could reasonably ask, well, why did you even bother continuing to try and get a left septal lead should you've just put in a standard RV endocardial lead? And the reason why I kept on persisting this patient is because when you think back to the RV endocardial pace morphologies, there was so much notching and slurring indicative of significant substrate. And so this patient would have had, you know, much less efficient LV activation with a conventional RV endocardial lead. A very tough case. Congratulations for achieving at last. I mean, the EKG is so good. So my question is that, have you tried his bundle pacing? I mean, if you try his bundle pacing and you can have, you know, stimulation to LVAT, and then you can compare as LV pacing is at maybe 17-something milliseconds, it's OK or not. Have you tried it for his? You mean as a bailout strategy or as a diagnostic strategy? From the beginning. I mean, just using the leads to try his bundle pacing to see. No, I mean, you know, the long-term lead stability data so much strongly favors left frontal branch area pacing. I know there's a few folks who seem to be, you know, outliers, and they can achieve, you know, levels of lead stability that others can't. But I think in general, based on the lead stability data, you know, I'm always starting with left frontal branch area pacing. So what about using, you know, 3830, using, you know, the C315, his, the she's, to achieve a relative proximal LBB pacing? Yeah. So I use a lot of that. This case just happened to be a silot-driven lead case. But no, absolutely I use that, and I think it's a fantastic combination. It just wasn't what I had selected in this case. And have you had the experience of using a she's, he's, she's strategy, I mean, just using a CS she's for the support, then using a C315 to have a good location? I mean, because you tried for several times, maybe from proximal, then at last to the physical posterior physical. So for, for these cases with scars, I think maybe we can go proximal for first time and trying to use different tools to get penetrate and see what I think that the QRS duration or the similitude to LBB will be better than the physical one, right? No, I agree completely. And that's why I always start off trying to target the main trunk. In terms of, you know, how do I troubleshoot that? Usually I reshape the sheaths, whether it's a C315 or an SSPC sheath. I know that Dr. Wong has done a fair bit of work with the telescoping approach for left bone branch area pacing, but that's not something that I've personally tried. But it sounds like a very promising technique. Okay. Thank you. Thank you. Yeah. Another question just from the app is how to get left bundle area pacing when the lead is going obliquely, or in other words, how to kind of resolve, I think the first issue you had where it was coursing apically. Yeah, that's, that's a great question. So there's several different techniques that you can use. One approach is you can reshape the sheaths to try and get more of a posterior bend on the distal curve of the sheath. That can be helpful. Sometimes you can actually pull the lead back, engage the septum with the sheath, and then actually advance the sheath forward. And that can actually functionally create a more posterior bend. And then as long as the sheath is well enough engaged with the myocardium, you can then advance the lead through. If you've got a stylet driven lead, which is a larger body, that can sometimes be a little bit more difficult to maintain that posterior curve. And so you may need to actually advance the lead and do the initial helix deployment with the helix, or excuse me, with the stylet pulled back just to reduce the amount of rigidity of the system. But there's, there's several different techniques. And Boston Scientific has got a new sheath line, the NXT sheath line, that actually has a more posterior bend on that distal curve compared to the current version of the SSPC sheaths. Fantastic. Thanks very much. Thank you. All right. Our next speaker is Dr. Siva Malpuro from the Mayo Clinic, and his topic is venoplasty for upgrade, when the best way forward is through. Good morning, everyone. Thank you, chairs, the organizing committee, for the kind invitation today. OK, I do have an audience response question. So you may have to use a QR code for the response. No relevant particular disclosures for this talk. So I'll start with a case. I have a 53-year-old gentleman with history of Wegener's polyangiitis. He had chronic renal insufficiency, was on dialysis for many years, eventually underwent two renal transplants. So he subsequently developed ischemic heart disease. He underwent bypass surgery around 2000. Developed severe mitral and tricuspid regurgitation. He had bioprosthetic valve replacement, subsequently developed bioprosthetic valve degeneration requiring a valve-in-valve procedure. So with all this background, with prior history of dialysis, he had bilateral subclavian occlusion. His right femoral venous system was also occluded. He was noted to have symptomatic bradycardia, inducible monomorphic VT on an EP study. EF is still low. On good medical therapy, he is NYHA class 3 with a very wide left bundle branch block, 162 milliseconds. So good candidate for CRTD therapy. We bring him to the lab, and here is his venogram. This is a non-selective venogram, little bit of contrast injection from an IV in the left arm. As I can point out to you, there are some collaterals. We see some stasis, and we don't really see a continuous flow of contrast into the central veins there. So we go to the right side. Inject contrast on the right arm, and you can see collaterals there. And this is a non-selective venogram. We see all these extensive collaterals on the chest. Again, not enough contrast flowing into the central veins. So with this venogram, what would you do for this patient? Stop the procedure and call the surgeon. Maybe do like a femoral. Use the one side that is still open to do a femoral CRTD implant. Maybe be novel. Do an SICD with leadless RV pacing, or think about an IJ CRTD implant. There's no right or wrong answer, just an opinion here. So some of you said that you would try to do like a IJCRTD implant, OK. So I'll show you. So in this patient, we wanted to have a little bit more information. So we obtain venous access over the first rib on the right side. And here we have like a wire inside the vein, a vein finder catheter in the vein. And we do a selective venogram, injection of the contrast selectively where the occlusion is, gives you a little bit more definition so you understand more details about the obstruction. So we pass this particular vein finder. Here is a shepherd hook-shaped catheter. And we inject contrast. So here you can see the SVC or the subclavian confluence of the central vessels is around this area. And you have a lot more collaterals. Maybe this is the closest way to get to that area. So we pull this catheter back and actually exchange it to like a hockey stick-shaped catheter. And then we inject contrast. And you can see there is flow into the central vessels through this collateral. So this is in the anteroposterior view. A little bit of the area of view to understand the separation of the collaterals. So we're going through this branch, through this curved collateral, back into the central vessels. So we try to navigate that with a combination of a hydrophilic catheter, hydrophilic wire. Eventually, the wire goes through that. We were able to establish central venous access. And once you are in the right atrium, we try to advance this vein finder or a microcatheter into the right atrium and place a stiff wire into the IVC. So you have a better rail for any of your balloon procedures. So here you can see we initially started dilating all the way from the right atrium back into the area of obstruction. So we use a smaller profile balloon first, and then a larger profile balloon. Eventually, we're able to implant the CRTD through that occluded vein. So when you're thinking about venoplasty, this is one of the skills you probably want to have in your armamentarium. The first step is to start off with a non-selective venogram. So this is just contrast injection of vein. Most of the times, it will tell you that there are other collaterals there. May not show the real region of the occlusion, how far it is and how severe it is. So we try to obtain, once you identify that there is an obstruction, try to obtain venous access more distal, away from the occlusion. So in this case, we obtain venous access over the second rib. And we do a selective venogram by injecting contrast through that sheet. Oftentimes, using a five-fringe or a six-fringe sheet, you have access so you can continue to probe with wires and microcatheters. So we try to have that wire away from the obstruction, a small sheet, introducer sheet, five or a six-fringe. Through that, we use combination of various microcatheters. See these are the hydrophilic tip-coated catheters, various shapes. Sometimes, one shape works better than the other, in particular anatomy. So you try to cross that occlusion with a combination of the catheter and the wire. Once you're across the occlusion, then you try to exchange it to a stiffer wire in the IVC or the PA. You want to make sure that you are in the venous system before dilation of these occlusions. So some words about what kind of balloon to use. So in this top picture, I'm illustrating a scheme of an occlusion. And if you use a compliant balloon, so compliant balloon is a balloon that can stretch. So in the area of obstruction or fibrosis, this balloon applies little pressure. And in thinner areas, you have much more pressure. So you can see this dog boning. So some of the coronary balloons are compliant balloons. We try not to use this for venoplasty procedures. We always try to use like a non-compliant balloons, where the force is kind of uniform. So you're much more likely to open up that particular occlusion. Sometimes, even with an uncompliant balloon, you may not be able to open up the occlusion. In that case, we do something called a force vein venoplasty. Essentially, you place a wire outside, a second wire outside of the balloon, which acts like a cheese cutter. So it breaks up that fibrosis, so you can eventually open up that occlusion. Now I want to play a video for you. Many of you may not be using like end deflators, prepping the balloon. This is a short video that I've prepared with my fellow Dr. Ward to give you an idea of how to do it in your practice. So the balloon has two ports, one for the wire to send the balloon over, and then the second where you insufflate the contrast into the balloon to see expansion under fluoroscopy. So we begin by using a lure lock syringe connected to a three-way stopcock. And that has about two or three cc's of diluted contrast in there. We place the balloon under vacuum pressure to get rid of any air. So we fill the end deflator with a little bit of contrast, maybe 10-15 cc's of contrast there, as you can see. Now basically we connect the end of the end deflator to the stopcock. We open up the stopcock to the end deflator, and we open up the stopcock, and I'm going to put a negative suction so there is more vacuum that pulls the balloon. So at this point you can take the balloon out of the casing. And this particular balloon is a non-compliant balloon, meaning, as you can see, when it is prepped, it's kind of thinner profile, and it's placed on the wire, which is already passed through that obstruction in the venous channel. Yes, so we use a shorter length balloon that's specifically designed for venoplasty in the brachiocephalic system, and the idea is to not have to use exchange length wires, which can get long and lengthy and difficult to use on a relatively short table. Yeah, and we get the tip of the balloon almost into the right atrium, and we want to inflate the balloon. And, Dr. Ward, what numbers, what kind of atmospheres are we looking at? Is there a guide that you use? How would you decide that? Yeah, so each balloon typically comes with a guide with numbers, nominal and then rated for burst. In the venous system, we often feel comfortable going just underneath the rated for burst pressure to allow for adequate expansion, given it's a low-pressure venous system. Yeah, so here, once we have it in the distal right atrium, so I press the side button, take the suction, and slowly I inflate the balloon. As you can see here in the picture, the balloon slowly inflates. Obviously, this is going to be in the body, and you will be watching it under fluoroscopy. This is a non-compliant balloon, which means that there is uniform expansion of that balloon. There won't be any dog boning here, which prevents any, you know, damage to the vessels, especially thinner vessels like veins. So once you have performed this serial dilatation from the right atrium, you will be able to see the balloon in the right atrium. So in our practice, you know, we don't really call interventional radiology or cardiology. Most of us do these procedures in the lab. So some things to consider for ergonomics in your lab. Dr. Worley has really advocated this use of this T-table. You know, it helps you have your wires flow on the table, having another set of monitors in front of you, so you're kind of working, looking at those monitors. So in most cases, we try to use a long balloon, about 8 millimeters to 10 millimeters. We start in the right atrium and come more peripheral. The reason for this is once you inflate the first time, the balloon becomes high profile. And if you have an obstruction, it's difficult to advance this forward. Now here's a case report that's actually presented as a poster at this particular conference by Dr. Tan. So he can see that this is a patient requiring a device for a heart block, and there is a long segment of occlusion. And in this particular case, we do a venogram from below, so we understand, and a venogram from the top, so we understand the extent of obstruction. So we place a snare in this inferior venous segment and use a powered RF wire to be able to navigate that. So you're essentially exiting the vessel and entering the vessel back. You catch this RF wire, externalize, do a little balloon dilatation, and then place a coated stent, essentially creating a neoconduit so you can place your leads. This particular patient did not have other venous access for the device implantation. I'd like to summarize here. It's a pretty safe procedure when you follow certain rules. Here the key is to know your tools. Get your venous access distal to your obstructions and place and introduce a sheet so you have ways to rail to advance your wires and microcatheters. And once you're across the obstruction, place a stiff wire into the IVC, use a long noncompliant balloon to dilate that obstruction. And the idea is to give you some space so you can advance your leads. Many patients won't have an open vein after this venoplasty procedure. And think about this option of creating this neoconduit in difficult cases. Thank you for your attention. Thank you. Thank you very much for this review here. And great job with that case, by the way. Clearly it was not easy at all. My question to you is, had you tried the approach that you tried and you didn't work, you gave us the answers. I mean, the different answers and people gave different, I mean, the different options in terms of answers and people gave their answers. What would you have done if you couldn't do it this way? So certainly going through the femoral approach, the only vein that is open is certainly not an option. And it's technically would be challenging to have a good defibrillator system. So that would be out. So then the only option would be to try an IJ, to have three leads through an IJ and tunneling them to a pocket would also be challenging. So if I was not able to do this, I would take a pause and then reconvene with the surgeons and see, you know, many of these patients have, you know, their valve docs, surgeons are involved, get their opinion, put our minds together and then proceed. The third option could be the hepatic approach. We've done it a number of times and it works quite well for venous access and CRTs. Yes, that's an interesting approach. So obtain hepatic venous access and try to tunnel. Yeah, and those are all, again, as you meet as a team to hash it out and figure out what would be the best for the patient. Any questions from the audience? Can you please walk up? Can you please walk up to the mic? I'm so sorry. While you... Yeah, so ideally, we try to use like a longer length. Can you repeat the question? Sure. What is the length of the non-compliant balloon that we use for this subclavian venoplasty? Typically about four centimeters and eight to 10 millimeter is the diameter of the balloon. And we start in the right atrium and you do it backwards. You don't want to start in the subclavian and try to go forwards because once you open it, you cannot advance it forward. Sana, I'm being a good citizen, all right, I came all the way for this, all right. What is the wire on the neovascular, neovain creation? What kind of wire are you using? Are you using an 014 and then, you know, applying radio frequency at the back end of it, or are you using a 32 wire as in a bailless? Yeah, it's a bailless system, it has a powered RF, there's a little marker at the tip of the wire, so the RF is delivered just at the tip. But do you think it would be safer to use an 014, I mean, do you fear about going outside of the confines, you're in the mediastinum in the end, right? I'm just asking, I'm not... Yeah, I think it's certainly possible being in the mediastinum, you can expect a little bit of bleeding, but it will be a controlled bleed in the mediastinum, so you have until you put in your neovascular stent. Thank you. Great, thank you very much. Wonderful, and it's my great pleasure to introduce Dr. Maggie Infeld from Tufts, who is going to talk to us about, hot from another Backman's Bundle session, is going to talk to us about Backman's Bundle pacing. Thank you. Thank you very much for the chairs and the meeting organizers for having me, and thank you all for being here. So I will be discussing how to place a Backman's Bundle area lead. So first, we'll discuss why we think it's important to pace as physiologically as possible and why this should be also extended to the atria. We'll cover anatomy relevant to the paceable right atrial endocardial insertion site of the Backman's Bundle and how to find it. And finally, we'll describe how to place a Backman's Bundle area lead, breaking down each step with recorded case, pieces of a recorded case. So cardiac physiologic pacing is currently defined as any form of cardiac pacing intended to restore or preserve ventricular contractile synchrony. However, if our aim is to pace as physiologically as possible, shouldn't we think similarly about the atrial lead and aim to restore or preserve atrial contractile synchrony? Although a specialized conduction system doesn't exist in the atria as it does in the ventricle, in the atria, preferential conduction is determined by myofiber orientation or anisotropy. Impulses propagate more rapidly over parallel longitudinal arrayed fibers than in the transverse direction. The sinus node happens to be located conveniently next to two such bundles of parallel longitudinally arrayed fibers that facilitate efficient atrial conduction. The crista terminalis runs between the superior and inferior vena cava on the endocardial side of the sulcus terminalis, and the Backman's Bundle connects the right and left atria superiorly. Under normal conditions, the crista and Backman are activated very quickly by the sinus node and are responsible for activating large portions of the right and left atria simultaneously. No single lead spot will completely replicate normal sinus nodal behavior as it has complex autonomic input. However, pacing in the region of the Backman Bundle should improve atrial conduction compared with the appendage, which is a trabeculated area that's pretty far from the preferred conduction pathways of the atria. These images explain why we think Backman Bundle pacing is preferable to the traditional appendage site. These anatomic maps show right and left atrial activation while pacing from the traditional right atrial appendage lead in panel A and then from the Backman Bundle area in panel B in the same patient. Here with appendage pacing, you can see that the initial impulse is quite lateral in the RA, and it results in first the right and then the left atria being activated in series. In the same patient, when you place the lead in the Backman's Bundle, you are activating both atria simultaneously, and that is how we define atrial resynchronization. You also cut the total atrial activation time down by a third. This is a second patient who has baseline intratrial conduction delay, and we map during sinus rhythm in panel A and then during Backman Bundle pacing in panel B. Similar to the right atrial appendage pacing example on the previous slide, you can see that in this patient, the sinus nodal exit site is quite lateral and caudal, as has been described in patients with sick sinus syndrome, AFib, and heart failure. And so you have first the right and then the left atria being activated. When you pace this patient from the Backman's Bundle area, you're able to resynchronize the atria. Why is this important? Well, when parts of the left atria are activated very late, there is intraatrial and atrioventricular dyssynchrony that can result in adverse hemodynamics, including increased left atrial pressure and stretch, which we know is anitis for atrial fibrillation, and left atrial hypertension is also the kind of common final pathway for pulmonary congestion and heart failure exacerbation. So next we'll discuss how to find the paceable Backman Bundle site. Anatomical studies have shown that the right-sided endocardial insertion site of the Backman Bundle is pretty reliably located between the superior limbus of the fossa ovalis and the inferior border of the SVC. There is, of course, inter-individual variability, and this is a great paper by Dr. Lesgarten that I encourage everyone to check out when it comes out in a few days. In 15 patients, we mapped the right atrial endocardial insertion site of the Backman Bundle, and I also draw your attention to the double and multi-component potentials that we mapped in this area, which is the kind of electrogram signature we're looking for when pacing the Backman Bundle. This is one patient, here's a second patient, and here's a third patient that we mapped at Tufts. So these are the SVC-RA junction areas of the right atrial endocardial insertion site of the Backman Bundle, that's a mouthful, in LAO. Just a few examples, but when you flip this image up, so you're kind of looking up the barrel of the SVC, like here, if you imagine this is kind of a clock face, and this is 12 o'clock, this is 6 o'clock, the mappable portion of the Backman's Bundle is typically between 2 o'clock and 5 o'clock on the septum, as you can see the fibers inserting here. I'm trying not to replicate too much of what was already covered in the atrial re-sync session. Next, we will describe the implantation steps, kind of one by one, using recorded case examples. So most commonly, I use the 3830 lead and the S4 preform sheath from Medtronic. If the right atrium is very large, or I need additional reach, I'll sometimes use the C304 deflectible sheath. And here we're flushing and prepping the preformed dilator and sheath, and the 3830 lead is here, and a TRUMA wire here. This is one of our Starr Fellows, Munim Khan, and our camera is positioned in RAO, Munim is advancing the dilator and catheter over the wire into the mid-to-low right atrium. We already have our left bundle lead in, so you can see him advancing the dilator and sheath over the wire. Then he'll remove the wire and dilator so that the catheter is sitting in the mid-to-low right atrium. And next we'll insert the lead, and then we're gonna hook up our alligator clips. I apologize, this video is not cooperating, but we're gonna hook up our alligator clips to the lead unipolar tip so that we're able to map atrial electrograms during lead placement. And so we have our red alligator clip in the pocket and the black at the end of the lead. Now we're gonna switch, once the catheter and the lead are in the mid right atrium, we switch to an LAO view. And with the lead inside the preformed sheath, we'll kind of drag the S4 sheath up over the limbus of the fossa, kind of like a reverse transeptal under fluoro, so that it, until it slides nicely into that area that you wanna target between the SVC and the superior limbus of the fossa. We make sure that the lead is inside of the catheter, so it's not dragging up on the septum. And we map atrial electrograms to make sure that we're in the atrium, not in the SVC, because that's really the dangerous thing that could happen with Bachman's bundle pacing. You don't want to screw the lead into the SVC, obviously. That would be a no-no. So this is just showing, again, that you're dragging it up over the fossa into the Bachman's bundle. And this is just one way to do it. We then adjust the camera from an LAO view to an LAO caudal view in order to look up the barrel of the SVC and map the electrogram potentials in this region. This would be an example of an area where you would have inadequate sensing. Everyone's different, so I'm not trying to say two o'clock is the best, or is the worst for everyone, but it's important to do gentle clock and counter-clock motions on the sheath to map the potentials. And it's also helped save time to see if you have a good amplitude potential that will likely have adequate sensing. And this is us putting the camera into LAO caudal. And then using gentle clockwise and counter-clock rotation on the catheter, mapping between two and five o'clock at the base of the SVC-RA junction for the Bachman bundle area potentials. I have to give credit to Dr. Leskarton who's standing over there who developed this technique and taught me how to do this. And this is a live screen showing us gentle clock and counter clock to find, you know, this is a better potential than the first one that was too low amplitude. We find one that looks adequate, and then the next important step is to pace map. Notice the native P wave, it's long and low amplitude, and when we pace at the site of this potential, look what happens. And this is really important to notice the paced P wave criteria. I think a lot of the early studies of RVseptal pacing and Bachman bundle pacing were somewhat limited by not looking at the electrical criteria of the P wave, and that would be kind of like putting a RVseptal lead in and saying it's left bundle without looking at the QRS morphology. So we think that that's really critically important. And the Bachman bundle paced criteria are pretty simple. We want the same axis, so this is the native P wave, and this is pace mapping unipolar tip before you screw the lead in. You want the sinus axis, or the P wave axis during pacing the same as sinus, so upright in 1, 2, 3, ABF, and usually a bit by, what's the word, I can't think of it. You also want normalized or higher amplitude P waves compared to sinus, and a reduction in the P wave duration. This comes from Dr. Lesgarden's paper as well. So when you are prior to active fixation of the lead, it's important to ensure that the catheter is nicely opposed to the septum. In this view here, as you advance the lead out, you can see it kind of sliding down the septum. That's bad. You want the catheter kind of more perpendicular, having purchase on the septum, so when you advance the lead, you can see that, oh, I see you can't see my arrow, sorry. On the improved version, you should have the lead abutting the septum. And then this is the active fixation technique that I use. I do a couple quick turns where the lead meets the catheter, and then I have my hand kind of at the back, and with one hand, I'm advancing the lead and holding the sheath steady, and with the other, I'm turning the lead into the sheath. When you withdraw the preformed sheath, you just push the whole system forward and advance the lead while you're withdrawing the sheath. It's important at the end to try to have the lead facing like panel B so that your tip and ring are abutting the septum. This will enable improved capture and sensing thresholds compared to panel A where the lead is kind of twisted on itself. Now when we're slitting the sheath, I usually check parameters one more time before we lose our venous access. Then you have an assistant hold the safety sheath while you're slitting the S4 sheath. Then we tie the lead down, check parameters again. I'm okay with capture thresholds of 1 volt at 1 millisecond as long as there's a good current of injury on the atrial lead and the threshold is kind of coming down throughout the case because usually by the next day, it could be like 0.5 at 0.4. This is a summary. Usually this lead placement technique is very quick, so I wanted to break it down step by step, but this is what it's kind of like in practice. This is borrowed from Dr. Yang with the exception that I would have the lead inside the catheter when you're dragging it up the septum. They're gonna say here five turns. I do a little more than five. You're not gonna hurt anything as long as you're below the SVC and you're in the right atrium and you determine that by mapping atrial electrograms. And especially if you have to do a little half counterclockwise turn of the lead to get it to be that J shape at the end, it's okay to do more than five. Thank you very much. These are our star fellows that were in these videos. Our EP lab techs helped film this. These are EP lab co-directors and the folks that taught me how to do this. Thank you very much. That was fantastic, Maggie. Thanks so much. I'd encourage anyone to come to the microphone if you have questions or else put the questions in the app. I'll just start off with one. When I talk about this with colleagues, the concern is often about the aorta, which is just anterior to your position. So although you should be posterior to the aorta and not kind of endangering that, I suppose my question is how would you describe how you are reassured fluoroscopically that you're not in the region of the aorta? Oh yeah. I mean, I think the area that we're screwing in is typically pretty thick, like as long as you're above the limbus. And since we're targeting two o'clock to five o'clock, we should be more posterior to the region of the aorta. I've never had that issue. That makes me nervous. As a new attending, everything makes me nervous. And what about stylet-driven leads for Bachmanns? Any experience with that? I don't, but did you publish a paper with Dr. Israel where you used stylet-driven? Right. Because I would love to, it's good to like learn all different ways to do things. Yeah, I've done it with stylet-driven leads, but mostly with 3830. But you can hand-shape stylets, you can use the Locator Pro, which is a deflectible stylet, which just comes in limited curve sizes. And you can also use, I think Dr. Luskart mentioned the C315 His sheet, for instance, in the prior session. The other companies also have shaped sheets that could be used for this purpose as well. I have three questions for you, by the way, but we'll let Dr. Luskart go. Go ahead, please. Well, just real quick to the aorta point. In order to perforate, you have to be pretty high in the SVC and very anterior. In the ILEO, as long as you're mapping on the septum, you can't be at the aorta. And one thing I would challenge is that I think we are in the SVC proper. And I think it's fair to say that. Because when you're at the infraceptal aspect of the SVC, it's very, very thick tissue. And essentially, nothing is completely impossible, but it's really, really difficult to imagine perforating anything when you're at that level of the SVC. It's a little bit of a semantic issue. It's kind of like deciding what the pulmonary vein orifice, what's pulmonary vein, what's atrium. But I think we're actually, if you look at the Damien Sanchez-Quintana histology, it's pretty clear that the insertions are at the level of the SVC. So it's fair to say that, I think, but it's slightly semantic. Great. Thank you very much. I have three quick questions for you. The first question is, based on your own experience and what's been published in the literature, what is the dislodgement rate of this lead compared with traditional positioning of the lead? And my second question is, are all your atrial leads, Buckman bundle pacing leads at this point? And if so, what do you do when you're using a non-metronic device? Because you mentioned you use the 3830 for that. So if you're using a different type of device, what type of atrial lead are you using? I'll start with those. The third question is a bit tougher. So go ahead. So dislodgement rates, we had a retrospective series of like 300 patients and trying to rack my brain to see if we looked at dislodgement rates. So we did a prospective 80 patient randomized study appendage to Buckman bundle, which should be out in the next 12 months. We're analyzing every, like the double in the details data for this pilot study. There was one dislodgement in the appendage group and one in the Buckman group. I've had maybe throughout our training, and we did pretty high volume devices at UVM, maybe like one or two dislodgements, like not very many. And so I do all my atrial leads in the Buckman bundle because unless, like I just recently had a case, it was actually a friend's parent, which is a risk factor, where they had really severe electropathy. And so I just couldn't really get adequate sensing anywhere. And the appendage didn't have great sensing or capture either, but it was a little better than mapping extensively in the septum. And then she's an elderly, you know, thin lady. And so it perfed within the appendage. And I'm actually surprised the appendage leads don't perf more often, because it's hard to know where you are. It's so thin. And so I just feel so, as a new attending who's, you know, just doesn't want to hurt anyone, I feel so much more comfortable putting it in the septum because I know that it's not going to perf. And in terms of the, what else I'm going to say? Using non-metronic devices. Oh, thank you. It's rare for me to do that, I think, just because I am such a fan of the Bachman Bundle pacing, and I haven't tried many other companies' sheets for Bachman Bundle. So my question, that's a bit harder, is linking these approaches with improvements in patient outcomes. In terms of do people feel better? Do they do better? Can you comment on that a little bit? Right. So yeah, that can be difficult to suss out in terms of, like, it makes so much sense to me that we would want to pace kind of, and homage to Dr. Leskart in saying, you know, we want to pace as physiologically as possible. Like, we evolved in a certain way. And when we do put the leads that these people have into the rest of their lives in places that replicate normal activation, that makes you be able to individualize the programming so you can have a normal, you can, you know, resynchronize intraatrial, atrioventricular, interventricular. And so it makes sense to me that over time, if people are, parts of their left atrium are contracting, it's the higher pressure left ventricular and diastolic pressure system, or it's causing diastolic mitral regurge. Over time, it might be subtle, but we should be able to suss that out. So we do need outcomes data. That's the key. Yeah. That was my point. Thank you. Go ahead. Just a couple of quick questions. In these days of AFib ablation, do these leads interfere with your transeptal axis if you're going to go do an AFib ablation? And second, very related question is, since these are all metronic devices, are any pacemaker that collects AFib burden data, can you show that this leads to reduced incidence of AFib once you do with Bachman's versus traditional atrial stem? Yeah. So the first question, the transeptal, when anyone has either an appendage lead or a Bachman lead, I tend to do my transeptal under fluoro in addition to ice. So I can just watch it carefully go over the limbus and fall into the fossa. And I haven't had any issues with lead dislodgements doing that. I'm just careful like you are when you're mapping around anywhere people have leads. The second question, we did a retrospective study because Dr. Leskarton's been putting leads in the Bachman bundle area since 2006 and so have many of the operators at UVM. And so we had good data or we had retrospective observational data where we compared appendage versus Bachman and then also nonspecific rAseptal pacing. And the point of that study was to kind of challenge the prior rAseptal pacing studies that when you combine them all into meta-analyses, they look equivocal. But just like we talked about, if you put a lead into the rV septum and called it left bundle area pacing, that wouldn't really work. And a lot of these early rAseptal pacing studies put the lead under fluoroscopy in the septum but didn't look at the resultant P wave criteria. So our point of this retrospective study was does P wave matter? And so we looked at Bachman bundle based on those electrical P wave criteria versus nonspecific rAseptal pacing that didn't meet those criteria versus appendage. And when you separated them like that, the Bachman bundle lead, people with those leads had less incident AF if they didn't have AF. They had less recurrent AF if they'd ever had AF before. And their burden of AF was lower over time. We do need prospective studies. I've heard some murmurings from people that are doing those that they've seen similar results to our retrospective study, which makes me really happy because obviously retrospective has so many confounding variables. And hopefully our pilot RCT will be out soon. But more people, we need to study this more rigorously. Go ahead. Congratulations, Laskartan. This is a wonderful thing that you've put together. We have done a randomized trial several years ago on epicardial surgically visualized Bachman bundle pacing in patients who undergo rheumatic valve replacement. And there's a dramatic reduction in postoperative atrial fibrillation in terms of outcomes. We randomized to three groups, one no atrial pacing, the second one atrial pacing 10 beats above the sinus rate, and the third one is Bachman bundle placement about 10. So three groups. There's a dramatic reduction in AFib rates. This is a prospective randomized trial. But the only problem was after two to three days, these are surgically placed leads. We had poor sensing, high capture thresholds. So there are technical issues then. But nevertheless, the outcome was excellent. That's great to hear. Thank you. Thank you so much. Thank you so much. Fantastic. This brings our session to a close. Thanks to all our speakers for wonderful presentations on these very complex and difficult CID cases. And thanks for attending.

cardiac implantable device

leadless pacemaker

internal jugular vein

venous occlusions

left bundle branch pacing

biventricular pacing

venoplasty procedure

CRT-D

Bachman Bundle pacing

atrial resynchronization

anatomical details

innovative techniques