I welcome everyone. Welcome to the, I guess, the first rhythm theater for today's HRS. I'm Devi Nair. I'm one of the cardiac electrophysiologists in Jonesboro, Arkansas, and it is my privilege to moderate this session that will discuss AI and PFA and how they can be a complementary approach to treating arrhythmias, not just atrial fibrillation, but ventricular arrhythmias as well. And I have a great panel here with me today, and I hope I get to learn a lot from these guys because I am very new to this and very eager to learning a lot about AI and vector medicals. So, Anisha Meen, Ben D'Souza, and Gary Tomasani will share their insights and we hope to keep it very engaging, so please send your questions and we'll have a Q&A at the end. So, without further ado, I would like to invite Anish. Anish comes to us from Ohio Health and he'll talk to us about, actually give us an intro on VMAP and tell us what it's about and integration into AF ablation procedures. Thank you so much, and thank you to the folks at Vector for inviting me to talk about this. So ultimately, I think Ben and Gary are going to talk about what has changed, what is transforming our environment, making therapy delivery easier, more efficacious, certainly more efficient. What we need to do is we need to transition all the gains that we have in efficiency and understand from a diagnostic standpoint what it is that we should be ablating, why it is that we should be ablating that. And Vector is one mechanism that we have to understand arrhythmia etiologies, tailor, focus our intention so that the patients ultimately have better outcomes without necessarily a horseshoe and hand grenades type strategy that we've been employing for all these years, right? So, why? Why is this important? So, many of you are probably familiar with this data. This is the Advantage Phase 1 assessment that was presented at AF Symposium earlier this year. We all recognize that our thermal ablation technologies have had limitations. Even with our next generation technologies, we see limitations in efficacy. These are outcomes out to six months looking at arrhythmia recurrence. And you can see we ultimately wind up hitting the 60 to 70 percent benchmark that we're all familiar with, despite the therapies becoming more and more durable, despite us becoming more and more efficient at delivering them. So, we have to change something. And we know that for a group of patients, particularly as we think about atrial fibrillation, PVI only is going to be sufficient. But the more complex cases, our redo patients are going to require us to have a deeper understanding of the arrhythmia mechanisms in order for us to get effective treatments. So, how does VMAP fit in? So, VMAP is a simulation-based algorithm that helps us understand not only focal arrhythmias, but fibrillatory arrhythmias, drawing on the power of over 1,500 commercial cases that have been done and over a million simulated arrhythmias that have been reconstructed. What's interesting about VMAP is that unlike traditional or what we think of as algorithms to understand arrhythmia mechanisms, which have all been invasive, this is a non-invasive tool. So, we can use it in a continuum of locations. We can counsel patients in the clinical setting, in outpatient ambulatory settings. We can utilize it in intra-procedural settings. And we can do it over and over and over again. So, we can, because it's so fast and it's relying only on the surface ECG, we can take a ECG in the lab, ablate an area, take another ECG, reanalyze the arrhythmia, ablate a different target, onward, and so on. How does it work? So, we take the 12-lead ECG. We identify the location of interest, which on this graphic is the blue-shaded bar. We're talking about atrial fibrillation. So, in this particular case, the more fibrillatory waveforms that are available for analysis, the better. So, the slower the heart rates, the better the algorithm works. We put it into the proprietary algorithm, and then we ultimately describe an output, which you can see rendered as a location, conventionally called a hotspot, that serves as a trigger of atrial fibrillation, in this case, any other ectopic arrhythmia. So, how does this work? So, I mentioned over a million sampled and simulated arrhythmia subtypes. The models in arrhythmia simulation basically provide the link between the inputs, which is a 12-lead ECG, and the arrhythmia source, which is displayed graphically on the map. The impact to us day-to-day, I said this before, over 1,500 commercial cases have been completed. What we're trying to do, yes, we want to check the box about becoming more and more efficient. We do that with roughly a 25% reduction in the procedural time for focal arrhythmias, as well as for atrial fibrillation, but we want to change the outcome. That's the most important part, right? It's not enough to be fast, we have to be good, and we can see and we can demonstrate, and I'll show you here how we, the clinical data as far as efficacy. If we think about two years ago, a abstract that's, that was presented looking at AF outcomes, if we look at 75 patients who underwent, who have persistent redo procedures, and you say use VMAP, don't use VMAP, what you're going to basically see is that there's, you're two times as likely to have arrhythmia-free patient populations at a year out. So, what are we trying to do? We're trying to take our, we're trying to leverage all of these innovations that we're seeing every single day here at HeartRhythm in the therapy realm, apply a diagnostic algorithm to them to make us more and more consistent and efficient. When we think about using vector and VMAP in particular for AF, the idea is to identify non-PV drivers, including the posterior wall, interlateral ridges, and support an ablation strategy that's more tailored rather than more substrate-based. It helps us counsel patients ahead of the procedure, lets us make some decisions about how much time we need in the procedure, what potentially the patient should expect. For instance, we have several examples of patients who have had prior ablation, and we look at them and we say, listen, we want to go back in, we want to do a redo, it looks like the veins are not your primary drivers, so we're going to focus on posterior wall or we're going to focus on SVC, etc. So, we can counsel them ahead of time, makes patients feel like we're not just going into a black box. This is a brief description of how this works, so let's see if this plays. When we acquire the fibrillatory waveform, it's presented in several different ways. This is the beat summary page, so it's looking in multiple segments, so previously I showed a long-running ECG with multiple acquisition sequences being acquired. Those are laid together as an average of where the ectopic origin of an arrhythmia is. So, it's not just, you can showcase just one beat, you can also look at the average for multiple sequences identified. This is the case that I was describing, a patient who had had a hybrid ablation. You can see he's coming back, you know, Debbie knows this because I did the ablation, of course there's non-durable ablation in one of the veins, but we're also showing that for this patient, and we know this, patients even with non-durable PBI, clinically can do quite well, but as this patient's coming back, we know that we can't just focus on the previous ablation lesion set and tack that up. We've got to do something different. That's the reason that they're coming back. So, what do we see here? We see that this particular patient has identification of arrhythmia origin on the floor and over on the SVC. That's what we target. It's nice to have large focal ablation available for us, so now we can, you know, go address these sites without much inconvenience. And that's what this map shows, so we're hammering away at the floor of the left atrium. We'll wind up doing the SVC. I'm happy to report this patient's doing quite well. We did this around Thanksgiving. He was a previously persistent patient. He's got a loop recorder in place. He has roughly about 10 hours of atrial fibrillation from Thanksgiving to now. He's not exactly working on the risk factors like we talked about, but that's okay. That's why we have Vector, right? We want to overcome the risk factor piece. No, no, no, I'm just joking. So here's what we're going to do. So we're going to bring this patient back. We're going to counsel them about the fact that the pulmonary veins and the previous poster wall ablation are not the primary source. We're going to identify new sources of origin for his atrial fibrillation, ablatum, and I told you about the clinical outcomes. That's what I got. Ben. Thank you, Anish. So I guess, you know, we'll keep the questions to the end. I actually want to, I'm going to skip Ben and go to Gary. We're going to actually have Gary Tomasani give us insight into VMAP's role in non-PV driver ablation. We heard from Amin how he addresses around PVs and, you know, I've always wondered, you know, we talk, we call this atrial fibrillation, we just look at the left atrium, you know, I want to see what you can tell us about maybe the right atrium and maybe give us some insights into what upcoming clinical studies that's coming. Thank you. Great. So my discussion today is going to be looking at advancing atrial fibrillation treatment, mainly looking at the non-PV driver ablations with VMAP and then a few slides showing an upcoming randomized control trial. These are my disclosures. I do have some with Vector including consulting and advisory. So we all know in patients who have persistent atrial fibrillation and using radiofrequency catheter ablation, if you look at the overall challenge, the problem is that they all have a very poor single procedural success rate. In this systemic review in 2018 of 113 studies, close to 19,000 patients, in the blue you can see that a single procedure goes anywhere, gives you a success rate anywhere from 45 to about 58 percent and that's irrespective if it's pulmonary vein ablation, if it's WACA, if it's basically posterior wall PVI lines and CAFE. And unfortunately most of these patients will have multiple procedures in order to get to the 60 to 70 percent success which is shown in the red. So how do you target these patients knowing that basically they're a high risk patient for failure and recurrence? One strategy is to look at empiric ablation and basically there's been two studies that we look at the results of such a strategy where they are landmark clinical trials included to star AF2 which is on the left, which was in 2015, which in patients with persistent atrial fibrillation, three arms were looked at, PV alone, PV with lines and then PV with highly fractionated signals. And we all know that at a year or 18 months there was really not a lot of significant difference in any of those arms for reducing AFib recurrence. And then the CAPLA trial which is a more recent trial again in the radiofrequency ablation error at 2023, that was a trial that looked at posterior wall PV isolation versus PV isolation alone and at nine months you really don't see any major change in again the overall success rates. So empiric ablations for persistent atrial fibrillation using RF energy probably is not the solution. So what's the other option? Well, Amish already talked to you about it which is personalizing the ablation strategy for that individual patient. And there have been two recent studies that have been excellent as far as the design and the results to discuss. The one on the left is called a flow AF trial which was in 2024. And this was in a population of patients who had recurrent pulmonary vein after a pulmonary vein ablation in a setting of persistent atrial fibrillation. And there were two arms in this trial. There was the PV isolation only arm and then the treatment arm included extracellular flow analysis which is a way of measuring away from propagation to see if they become organized, i.e. drivers, re-entrant waves, etc. They did it with two basket catheters, one in the right H and one in the left, where they required intracardiac signal analysis to determine where these sites were coming from. And if you did a PV isolation and then targeted these sites, there was a dramatic difference at a year of success, over 51% difference between the ones that were personalized ablated versus a random PVI. And then the other study on the right is a tailored AF trial which is another trial that looked at PV alone, but this was not in a redo population, but these were in persistent AFib patients alone. And again, the strategy of PV versus another way of trying to look at these non-pulmonary vein sources, which was an AI-generated spatial temporal assessment of dispersion, that was done by using intracardiac analysis, mostly signals that are already available during the studies. And there was a difference of 18% improvement in AF and I think it was at 9 months or 12 months that was seen. So again, both situations were evidenced that you can actually tailor this procedure to individual patients trying to find these sources and if you target those sources with success, the patient will do well. But what's the problem with the two studies? Well, if you look at the data, the studies show that it was, by doing this type of therapy, you added substantial amount of time to the procedure. In the flow AF trial, it was 90 minutes additional, 90 minutes to the study. And in the tailored AF, the average time was about 50 to 60 minutes. So a lot of work, more catheters in the body, more sampling of intracardiac signals, and that all led to basically a prolonged time of procedure. So this is where VMAP comes in. VMAP is great because it does allow a personalized ablation strategy. Number two, it's non-invasive, so you're not putting basket catheters and other catheters inside the heart and basically allows for very rapid mapping. If you look at it, it requires 12 lead EKG. There's no catheter-based situations. It's less than a minute to do, as Amish mentioned, and it tries to locate arythmogenic substrates that are outside the pulmonary veins that might be important, not only for the triggering of atrial fibrillation, but more importantly for the maintenance of atrial fibrillation, especially in this population of patients. So I just want to conclude with a couple of slides on the upcoming randomized controls trial that we're all excited about. It's called Improved AF, which is Artificial Intelligence Mapping and Ablation of Non-Pulmonary Vein Electrical Drivers of Atrial Fibrillation. It's a multi-site international randomized control trial that is going to look at 334 patients, and this patient population are persistent AF, as well as patients who had recurring AF from a previous procedure, and we are using pulse field ablation rather than radiofrequency ablation for this study. The objective is to evaluate the clinical outcomes in this population using VMAP to guide ablation of non-pulmonary vein targets in accordance with the FDA-approved indications. As I mentioned, it's a one-to-one randomization. It's going to be PV isolation versus additional – I'm sorry, versus PV isolation with additional driver ablation information, and the control arm, of course, is only going to be the PV. The primary endpoint is listed there. It's going to be freedom from AF, both on or off antiarrhythmic medications for 12 months, and then typical secondary endpoints that you see in these trials today, freedom from AF and AT, the total procedural time, total VMAPing time, which should be pretty short, and then assessment of AFib burden, which you all know now is a very important endpoint for these studies because it's very hard to get 0% AFib in this population, and then the percent of patients with a spontaneous AF termination that happens, as well as overall fluoroscopy time. As mentioned, it's going to be in 15 sites across the United States and Europe, and the first patient is expected to be enrolled in the upcoming few weeks. I just wanted to show you an end on two kind of cases that we recently did. This was a case of a redo pulmonary vein ablation, and we used VMAP for AFib ablation, and it was using pulse-filled ablation, so it was a 75-year-old female who had six sinus syndrome and a preexisting pacemaker with symptomatic AFib. She had a previous ablation. Initial bipolar map on the left, CARDO, showed that the right upper pulmonary vein voltages were still present and significant irregular scar in the septum and anterior wall. After we isolated the right upper pulmonary vein, the patient remained in atrial fibrillation, so we acquired a VMAP, and it showed, as you see, sort of a red hotspot, which is a higher rate of probability that the driver might be coming there at the base of the left atrial appendage. Then PFA was performed with ferropulse, and it terminated the atrial fibrillation, and then the bipolar map on the right shows that we have now isolation of the veins, roof, and part of the anterior wall. In this particular patient, we didn't want to do a line down to the anterior mitral valve because the patient had posterior scar in the back of the valve, and I didn't want to isolate her appendage. And then I just wanted to show you that the two systems can be superimposed, sort of integrated, so this is a CARDO map on the left, and then you basically have your VMAP, and this is a very common location that we see for these sort of non-pulmonary vein sources occurring below the appendage, above the mitral valve, and in front of the ridge of the pulmonary veins. Thank you. Thank you, Gary. So I'll move on to Ben D'Souza. Ben comes to us from Penn, and Ben is going to talk to us about the ventricles, and so this is not just AF management, this is arrhythmia management, and I think that is important to have tools that can address everything and every arrhythmia that comes to the lab. So Ben's going to give us an overview of VMAP's role in VT ablation, focusing on improving procedural outcomes for VT ablation. Ben. All right, thank you, Devi. As I said yesterday, I'm very unhappy that I have to be the last speaker, and you guys are so much better at this than me, but I'm gonna do my best. I continue to be an equal opportunity employer. So we're gonna talk about some ventricular work, and in this case VT storm, which is something that I enjoy taking care of, but truth be told, you know, as cost per case, and I never used to have to care about cost until I became the director of a program, by the way, and I've met with the CFO and the CEO of our hospital way more than I want to. But the modern medicine has moved towards, we have to get as many procedures in the lab as we can, and truth be told, we want to be able to get these patients and take care of them carefully. So I'm super excited to present this case because I presented it last year before I knew what the results were going to be, sort of proof of concept. So this is a 65-year-old gentleman coming in with multiple shocks, obviously a very low ejection fraction, who almost died from a previous valve surgery requiring impella, so sick, right? These patients are sick. And so when the patient came in, essentially what we did was, traditionally, the way that I learned to do this procedure that Dr. Marsalinski and Dr. Cowens taught me for many years was to elegantly map ventricular arrhythmias, find the critical isthmus, terminate VT. It's one of the favorite things that we get to do in the field. However, it's very difficult to do that, and these patients are sick. And I can't tell you how many times we've had bad things happen to these patients. I remember a couple of years ago, just from induction of anesthesia, patient died. That's it. We didn't even get to do anything. And it's really unfortunate, but these patients really need our help. And so how can we do the procedure safely, efficaciously? And we talk about time, and it's not just time for my administrators. It's time for the patients. All of us know the longer we keep these patients on the table, the more likely something bad's gonna happen to them. So this was a patient in which essentially we induced VT and was able to localize a hotspot, similar to what Dr. Tomazoni had shown instead of in the atrium, but in this case, in the ventricle. So you can see this VT morphology here, and using VMAP. So again, a sick patient, A-line went to nothing. The patient needed to be shocked out of it. Everyone needed to take a deep breath, make sure that the patient was okay. This patient was floridly in heart failure, by the way. So their LA mean pressure was 40. As soon as I crossed, I did this transeptal. I'm like, okay, this is not gonna go great. This is the VMAP and cardiac MRI that I showed last year, actually, when I sat on this podium. And so I didn't know where this patient's VT was coming from. This is kind of interesting. I had vector there for an atrial case, and I was like, hey, while you guys are here, can you tell me where this is coming from based on this? And we did. And so this was, again, the case last year before I actually did the VT ablation. So now I got to do it. So again, I was not thrilled about keeping this patient in any ventricular arrhythmia. Truth be told, anesthesia wanted to stop. Everyone was like, Ben, are you gonna continue to do this? We can't keep this patient on the table for hours. And so again, we've moved towards trying to look at non-mapping targets for ablation. Of course, we look at scar. In this case, this is a ILM map with GRIB. I really like this technology. It's pretty neat. I know Dr. Tong and folks have sort of shown this stuff in the past, so this is me doing the map in sinus. So my goal for the rest of this case is no more VT. I can't have this patient in an arrhythmia anymore. I have to do this case in sinus, and I have to do this as quickly as possible. And again, I love doing long ventricular cases, but I also love my wife and my four-year-old and my seven-year-old and getting home to them for dinner if I certainly can. And honestly, all joking aside, these patients, we really need to get them off the table and do a good job of what we're doing. So you can see here, this is just me doing a map with the GRIB and looking at these areas of abnormal conduction and ILAM as well. So again, the whole procedure, sort of looking to be able to do this and find these areas of interest. This is a propagation map showing sort of the same thing, and you'll see sort of over and over again these interesting areas in the septum that we were looking at as well. Again, the whole case done in sinus after the initial induction. So put the patient into VT, found the area of interest, put the patient asleep under anesthesia, felt comfortable, and then did the rest of the case in sinus. Again, continuing, there we go. So this is just a combination of the voltage maps and the ILAM maps. Now, I've been on several podiums before where folks will say, let's just scorched earth, burn all of the scar. And I've said, and this is somewhat controversial, it's not very elegant. I mean, the hand grenade approach is doable, but is it the right thing to do? Besides the fact that it's a lot more ablation, it's more fluids, it's longer procedural time, it is not elegant at all. I mean, it can be done, and we've seen outcomes in these patients that actually are fine with just homogenize the scar, just burn everything. But if I could get away with not having to do that, patient's ejection fraction's 10. How about I keep some healthy myocardium in this human being moving forward? It's very important that we can actually tailor the approach for any arrhythmia. So again, this is that sort of scar looking at the isochronal chroning that sort of all correlates with the area. And so, again, I'm not too thrilled about doing pace mapping in really any ventricular case, but this was actually us doing pace mapping with VMAP. So the nice thing about VMAP is you can do it over and over and over again, and it runs very quickly. So it is a really nice tool for honestly any arrhythmia. So this is not the case I actually hope next year I get to show a primary VF case. So I don't know how to map primary VF, none of us do, but I think it's really fascinating. PACs are a real pain to map and find. So single beats from anything. I'm also super interested in left bundle pacing because I think I know what I'm doing, but I don't really know what I'm doing, truth be told. And so I think that these are all conceptual things that are super interesting and in the space. And I think that's where AI is gonna certainly help us. So again, this is just looking at the localized VMAP with pacing to be able to try to find that interesting spot. And so again, just lots of fun pictures and showing, again, this is the sparkle map, just showing an added sort of way front, looking at that interesting area. So multiple ways that are telling me, Ben, go to this spot, don't spend your time ablating every part of the left ventricle, spend most of it in this area of interest. So I listened, again, this is just looking at peak frequency and looking at these sort of high frequency reasons of scar that again, all correlated with slowed conduction, right? We're looking for the critical isthmus, but I wanna look for it without having to search while they're in VT. Because as I said, this patient would have died if I continued to do the procedure or I would have to put them on ECMO, just to be able to continue with what we were doing. And so while these are options, it would be nice not to have to do that. And so again, continued, this is just looking, I mean, I'll quote Dr. Garcia, dude, look at these signals. I mean, look at that. And so this area of interest where I really was like, oh, wow, I gotta oblate that. It's up to the point where like, you wanna switch out the catheter right away just to start burning in these areas. And so all correlated exactly where the VMAP told me, a year before I even did the procedure actually. And so I think that's really neat. And so I sort of had the concept that this is where this area was coming from. And again, just look at these signals. I'm super excited to be able to burn these areas or pulse these areas or whatever we're gonna be doing in the ventricle moving forward. And so again, just continuing to look at the areas of interest. Just here's another example of the same thing. So again, if I did this, just scar based substrate modification, I would have spent hours and hours and hours burning. I remember when I was a fellow, I was doing a case at HUP and we terminated VT and I burned this one spot. And then I'm like, oh, that was awesome. And then I asked the attending, I'm like, it was like six o'clock at night. And I was like, so are we done? He's like, no, we're gonna be here for hours homogenizing this scar. And then I called my wife and I said, yeah, I definitely am not gonna be home for dinner. And so my point is that I thought that that was enough. And the question is how much is enough? Certainly an atrial arrhythmia is now that we have pulse field ablation, we can go to town in terms of doing what we're doing. But again, I'll continue to say, how can we do it more elegantly? So continuing to look in these areas. And so here's ablation again with TactiFlex, which I really like it in terms of a RF catheter. And as we get better ablation tools, the combination of pulse field and RF in these areas, I think is a really fascinating concept. And so you can just see me sort of spending time specifically in the area that both VMAP and my mapping done in sinus was able to sort of tell me where to ablate. And so, again, this is just showing exactly sort of the area that I ablated. I didn't do that much ablation for a patient who is a VT storm patient who traditionally I would have spent hours and hours ablating the scar. Non-inducible from multiple sites, he's doing great. He's not had any more shocks and is still alive. And the procedural time was less than an hour and a half. So for a VT storm case, that's pretty darn good. And so I was very happy with this concept of being able to use AI mapping tools to go to a specific area, show me how the important areas are and not waste time. I've seen colleagues spend hours mapping an area and not spending the time ablating. And then, again, these patients don't do well. It's really a ticking time bomb in terms of how long they are until they will completely decompensate and die on the table. So I'm gonna finish by sort of pointing that I love showing cases, but we don't make decisions in electrophysiology or really anything in medicine based on a case, right? We do it based on data. This is a research conference. And so I think that I will continue to beat up Vector and everyone else who's down here today about doing more trials, whether they be registries, retrospective or prospective. This is how we show what we do is appropriate. So this is the vital registry, which I think all of the registry stuff that I've participated in, I'm super excited about. And it's looking at not just endpoints, but efficiency, time. Time is very important now more than ever in terms of getting these cases in. Because truth be told, if I have to get as many PFA fib ablations in and I can't do the VT ablation because it's gonna take me too long, that's really a hard place for us to be. And I'll stop there and we're happy to answer any questions. Thank you, Ben. So I encourage you guys to send some questions, but let me just ask with you, start with you Anish. Just walk me through your workflow. I mean, this is fascinating. I look at, for forever we thought that we were not getting the therapeutic effects because we just didn't use thermal energy well. And then Advantage proved it all wrong, to me at least, that there are patients that we just go with just an anatomical approach and here we are still struggling with the 60% success rate. So today when you have, say, a persistent patient walks into clinic, I understand you're doing the VMAP in the clinic, but then what happens in the lab? So I'm assuming you're doing PVI on everyone? We're doing a PVI. We're doing a posterior wall on that persistent patient based on our Advantage data. And I showed Advantage phase one, but also Advantage phase two that was simultaneously published in CERC earlier this week. And then we do a pre-VMAP, we do our PVI posterior wall, then we do another VMAP. And what we're really looking at is we're saying, where are reasonable targets for us to address? We need to understand more. Dr. Tomasoni talked about what Improved is gonna deliver for us as far as the data about where to target, how many of these hotspots to target. And yeah, I am making like a clinical judgment, a gut check to kind of say, okay, I'm looking at this, it's showing me something close to the SVC, I'm gonna go ahead and do an SVC isolation or something close to the CTI, I'm gonna add a CTI. There are cases where maybe it'll show the entire intracable line. I'm not sure if I have enough confidence to do that yet, but we're gonna learn more. And what's interesting, as Ben pointed out, is that we wanna push for organizations like Vector to validate these technologies and they're delivering for us. Gary, I think one of the things that Aneesh highlighted is just a persistent patient, but when you think about, you start getting all these hotspots. Now, what does this hotspot mean? I'm getting a lot of questions from the audience as to is there a physiologic mechanism to that hotspot? Is it one of those that you are mapping and you kind of see it and say, oh, this is gonna be a place I'm gonna ablate. And then of course, this was a hotspot as well. Is there a mechanism to it? And if you have 10 hotspots, how do you decide which one to ablate first? Is there an order that you pick? No, that's a really good question. And the man to ask is Dr. David Crumman since he's a specialist in this. But the fact of the matter is you've seen all our maps. It's very rare outside of the ventricle when you're in the atrium and you're in AFib that you have a single little red spot. There's multiple spots with varying grades of color degeneration. And the spots basically is the best knowledge that I can explain is that gives you a probability curve of what the highest chance that that red spot represents that the most likely success that you're going to get from an ablation standpoint. The fact of the matter is that, when you look at those spots, it's looking for organized reentrant activity or repetitive focal firing or what we call drivers. And that's based on the probability curve that you're looking at that. That's gonna be in that location. But we don't target when we see a very hot red one and then some lower or cooler ones, basically target that area. And in the setting of PFA, I think this is gonna be great, right? Because with PFA and the large fin catheters, you can destroy a ton of tissue. But what Ben says is really true. I mean, we wanna destroy the right tissue. We wanna destroy the tissue that's causing the problem. We don't wanna go in and do a substrate assessment in the pulmonary veins. We wanna tailor this to where they're coming from. So even though we have great tools now that we can really do quick PV isolation, posterior wall isolation, take down the appendage, do the anterior wall, do the coronary sinus, this is not what we wanna do with the tools. We wanna be scientific, academic and best for the patient. I mean, and so that's why I think that these things will allow us to be more personalized and more local with our ablation. Ben, you know, the ventricles are challenging, right? They are the ones that keep you up. Do you feel like when you have a V-map from Vector, you can say, just go focus just on one part. I saw the map you did was a true pen map. I didn't see the right ventricle and I was gonna ask you, but outside of that, would you feel comfortable just going to the part that Vector is highlighting, see if that makes sense and go after it? Yeah, it's a good question and we have to answer it. You know, it's sort of the antithesis of, don't do these cases, send them to the University of Pennsylvania so we can spend the time doing them. But truth be told, the penetrance of doctors who are doing VT ablation is incredibly low. And we really need to have tools to help our colleagues be able to do this. So the answer to the question is, I don't know. I'm cautiously optimistic, but that's why we're going to need to prove it with things like registries and prospective trials. And I think, you know, both atrial and ventricular arrhythmias are, you know, they're a struggle and certainly in certain things. But I think that I do believe that we can do it, but we need to prove it. So if we did a Vector-guided VT ablation, strategy saying, all right, based on where this is, just target these areas. Don't target the other areas. And how does the patient do? It's very, very interesting study that I would love to participate in. And this question's for any of you guys. I mean, do you think there's value? Because one of the things that we worry about with PFAs, we just, we get acute, you know, acute stunning or loss of signals, and we just don't know whether we've done what we need to do. Is there value with a technology like this to when you run the analysis again, Aneesh, after you've done your PVI post-treatment wall, does Vector ever light up the areas that are ablated or in suggesting that you've not probably gotten transmural or do you see any of that? That's a great question. And anecdotally, we have not seen that. So the areas that we've ablated are no longer identified as, you know, triggering activity. Areas that have been previously ablated that may be durable or non-durable are often also not identified as triggering activity. So it's really looking at what is the new areas that we wanna focus on. That's been our experience. Yeah, I agree. The interesting thing that I think that this technology, as opposed to many of the things that we use, is that it's non-contact. So it's a 12-lead ECG. So imagine if you had a patient who's in clinic who has recurrent atrial arrhythmias, and you can just take their 12-lead and figure out where you think their AFib is coming from and potentially advise the patient on what you're going to do before you even put them in the lab. That is extremely novel, not just for any arrhythmia. And again, I mentioned, you know, PACs are a nightmare for me to be able to map. VF is not mappable currently. So I think that, you know, all of this technology that we can utilize at any certain point in time, I'm, you know, also interested in certainly looking at for those redo, redo cases before I say, all right, let's sign you up. Because they always ask why, what are you going to do differently? And, you know, I said this yesterday and continue, the top two things that patients are interested in is pulse field ablation and AI. You know, they're using chat GPT. And when you say that you can apply AI to their heart, they're like, okay, I'll sign up for this again. So, you know, we're almost out of time, but I want to ask one practical question, which has come up a couple of times about the variability of EKG. And, you know, it's not, you know, depending on the body habitus of the patient, you know, Anish and me, you know, we're on the part of the country where we, I'll be in my average, be a miser of over 40. And, you know, there's a lot of variability in this. The Philly Desi. Is that, do you see that that could become a struggle point or do you think that that has been mitigated? Yeah, I mean, I actually am very impressed with the localization of where you put the 12 lead EKGs and especially in the lab, because you have all these other patches and everything else going on. And really it has had very little effect in our experience as far as helping decide where the sites to target and those types of things. So it doesn't have to be exact the same, like if you do it in a clinic and while they're in a patient the model, I think compensates for these types of things. And so I've had seen no problems with that. All right, well, I think we are out of time, but again, you know, I have tons of questions that have come through, couldn't get through them, but there's a, you can catch these folks and there's a lot of folks from Vector in the audience. So please stop by and talk to them about all the questions that you have about the technology. I want to thank our speakers for sharing their insights. It's a great time to be an EP. We have great therapeutic tools, but I think it is time for us to spend some time understanding the mechanism of arrhythmias a little bit more and maybe spend a little more time in the lab focusing on that. So with that note, thank you very much.

AI

PFA

arrhythmias

VMAP

atrial fibrillation

ventricular arrhythmias

ablation

ECG analysis