Indiana University, I'm one of the fellows. I'm just going over this case we have that involved a chest trauma involving a gunshot injury to an ICD. So there's approximately 150,000 ICDs that are implanted, over 150,000 ICDs that are implanted yearly in the states. And certainly firearm-related injuries are quite common in the states and unfortunately present quite a problem for public health and can lead to death as well as other non-fatal injuries. But gunshot injuries that involve ICDs or other intracardiac devices are quite rare. And the data behind how to manage such injuries is pretty scarce in the literature. So here we present this unique case that involved the patient who had a self-inflicted gunshot injury in which the bullet penetrated an ICD. And I go over the management of the patient as well as the outcomes. So we have a 69-year-old man. He has a history of ischemic cardiomyopathy who had an ICD implanted in 2018 for primary prevention. As I said, he presented to the emergency department with a self-inflicted gunshot wound to his left chest. This was an accident. The patient had been asked by his uncle to clean his gun. And apparently this individual was pretty versed in firearms, but I guess he had forgotten, I guess, to check to make sure that the chambers were empty. And he was cleaning his uncle's hunting rifle and had a face towards him, and that's how he sustained the injury. But his prior history was otherwise notable for a coronary disease with a CTO involving his LAD. He had a severe LV dysfunction with an ejection fraction of 15%, paroxysmal AFib with a prior ablation, hypertension, and hyperlipidemia. So on presentation, he was hypotensive. His blood pressure was in the 70s over 40s. He was mildly tachycardic at 101 beats per minute. This was in sinus rhythm. And he was setting 93% on a 15-liter non-rebreather mask. His physical exam showed an intact airway with diminished breath sounds on the left side. He did have that visible gunshot wound near the ICD pocket area that did not have any active bleeding. And he had a normal neurological exam with a GCS score of 15. His labs were notable for a white count of 25, and his hemoglobin was actually 13.2, so pretty normal there. Here is a photo of the injury that he sustained. This was when he first presented. As you can see, there's no active bleeding. Clearly, you can see his ICD scar up. Sorry, I'm not pointing that way. But you can see his ICD scar up here, but clearly over the area of the ICD pocket, and there's no evidence of active bleeding. He subsequently had a chest X-ray that was obtained, and this showed a pulmonary contusion that involved his left mid-lung field as well as a small left hemothorax with some rib fractures as well as some metallic fragments near the area of the ICD, and I'll show that in the next slide. Along with that, he subsequently had a chest CT that confirmed those findings but also showed a pneumatic seal with active bleeding as well as evidence of the bullet penetrating the ICD with a track that contained metallic fragments as well as gas and evidence of hemorrhage. So, moving on here, this is his chest X-ray, as you see here. Just to point out here, there's evidence of the contusion he has. Here are some of the metallic fragments. And going to the next slide, this is just a few cuts from the CT scan that he had. And you can see here, there's clearly a compromise of the ICD, as you see here. There's fragments of bullets and clearly some air that's been introduced into the pocket. And the bullet trajectory, it's not quite apparent just in this view, but clearly it was going from a superior to inferior aspect and then going anterior to posterior. And then this just shows also the hemopneumothorax that the patient had suffered. So, he ultimately had a left-sided chest tube that was placed. Once the chest tube was placed, he had a significant amount of blood that came out. As a result, they gave him two units, two-unit transfusion just preemptively. He never had a significant hemoglobin drop, but he was able to be stabilized. His respiratory status improved significantly after having the chest tube implanted. And then afterwards, electrophysiology, we had been consulted for management of the device and the ICD couldn't be interrogated. Luckily, other than what we saw on the CT imaging, he hadn't sustained a lot of other injury. He was stabilized, but there was certainly concern given the fact that the ICD had penetrated the device, that the pocket had been compromised. There was concern for infection, as well as concern for possible battery leakage from the generator itself. So, because of that, he was scheduled for device extraction the following day. And so, he went to the OR. CV surgery was involved in the process just because this was clearly a case where there was a trauma involved. And they were the ones who removed the pulse generator, did some excision of the pocket, as well as removed some of the retained fragments. But EEP were the ones who took out the atrial and the ventricular leads in the OR, and they came out fairly readily. On the next slide, I'll show, but once the pocket was opened and exposed, it was apparent that there was a fragment of the bullet that had become embedded in the ICD, in the pulse generator circuit board. And I'll show that in this next slide. Here's the photo of the ICD removed from the pocket. You can see clearly here, it's clearly penetrated the pulse generator. And coming out of the back, there's some fragments of bullets of the bullet, but you can also see clearly here the broken circuit board as well. And here's another photo just with the device cleaned up. I don't think it adds much more, but just showcases here how the bullet just kind of penetrates right through. There's a little bit of a fragment in there, but also how it just breaks through the circuit board as well. Post-operatively, he developed a left-sided hydranumothorax, and ultimately required a thoracic surgery involvement as well. They ultimately performed VATS decortication for him, and removed additional bullet fragments and some of the debris from the circuit board. A few days after his extraction, he underwent a right-sided single-chamber ICD implantation without any complications. He ultimately recovered, was discharged, and at six-month follow-up was doing well. Afterwards, the generator was sent to Boston for additional analysis. And what they found was clearly the bullet had penetrated the case of the device and caused significant damage to the circuit board. But they did find visual evidence of electrolyte leakage. So the battery had been compromised, but there wasn't any damage to the high-voltage capacitors. Because of the extent of damage that the device had obtained, they weren't able to do further analysis, unfortunately. And here are some pictures that we obtained from the company, showing here the kind of broken-up circuit board, as you see here. And this is just showing a little bit of a dent in the compromise that took place to the battery. So this was our case. Clearly, any case like this where there's a firearm injury involving an intracardiac device can be quite complicated, and many factors need to be taken into account. Luckily for us, the patient hadn't suffered a significant other injuries as a result of the gunshot wound, and was stabilized fairly readily. And on top of that, too, he wasn't pacemaker-dependent. But those are all factors that need to be taken into account before the device would need to be extracted, as well as when and if it needs to be extracted. Certainly, if he was to be dependent, we'd have to make sure that he'd have some temp wire in place or some chronotropic agent to support him. Or with his ICD, if there was some damage to the leads in such a way where it introduced significant noise and led to inappropriate shots, we'd have to certainly put a magnet on board. And also, there is somewhat of a rush in trying to get this device out in this guy's case, just given the fact that there was compromise to the pocket, there was a risk of infection, as well as possibility of any chemical reaction with the leakage of the battery that we found out about later. So certainly, this is a case, and other cases like this would need a multidisciplinary approach, as we saw for our case, CV surgery was involved, as well as thoracic and infectious diseases were also involved afterwards in terms of when, if it was okay to implant, and how long antibiotics would need to be administered. This is just a recap, but I don't think I have anything more to add, and I'm running close to the end of time, but any questions? Yes? Why did you feel you had to extract the leads? So there wasn't really, there wasn't significant damage to the leads, but given the concern that the pocket had been compromised, and the introduction of infection was the main reason. On top of that, too, I guess, there could be, with the fact that we couldn't interrogate the device, certainly I think when they went in there and checked, the leads were working appropriately, but given the concern for infection, they wanted to get everything out. How long after the gunshot injury? After the gunshot injury? How long would it have been? It was probably a few days. I think at least two, three days. At least between the time of when he sustained the injury and when he was taken to the OR. And the lead plant was on the other side? Other side, yeah, right-sided device. It was done, we got the OK from ID, but it happened a few days later, later on in the week. So the device, I think the extraction took place on a Wednesday or Thursday. It ultimately got implanted on the Monday of the following week. Last question, I need to hug you there. Oh, no, of course. You got cultures? You got cultures? Yeah, they were, nothing grew. Any other questions? One question that could raise up is that it could lead to a BT storm, because if you damage the circuitry, it could have like over-sensing and a BT storm, so it was more or less lucky the guy at the end. It was quite lucky. Yeah, quite lucky. Okay, so thank you very much, good presentation. Thank you. Okay, so thank you, and we ask the next speaker, Mohamed Atire, to talk about a case about sinus node spurring ablation technique. Hello, good morning. My name is Mohammed Atare. I have nothing relevant to disclose. Okay, I'm going to talk about a novel sinus nose-pairing ablation technique for inappropriate sinus tachycardia using pulse-feed ablation and an endocardial-only approach from Kansas City Outputting, KCHRI, slash Overland Park Regional Medical Center. So, as you all know, inappropriate sinus tachycardia, though not as prevalent as maybe the other tachyarrhythmia, but usually, like, more prevalent in, like, females and in younger patients. Well, we all know the first management usually using conservative management before we can go ahead to proceed with our ablation. So, just a little background. Hybrid sinus nose-pairing ablation is an emergent technique for inappropriate sinus tachycardia. It can be performed with an epicardial and endocardial approach in which areas adjacent to the sinus node are ablated to avoid dysfunction and pacemaker implantation. PFA is also a rapidly emerging technology that presents an opportunity to decrease complications further. As you all know, PFA is cardioselective. You all know the ablation is usually done in the right atrium area, and there's always a concern of maybe ablating the phrenic nerve. So, PFA is a good technology where you can avoid collateral damage. So, the objective was for us to, like, manage a case of an IST with hybrid sinus-pairing ablation performed with PFA. Give you a little background about the patient. So, this was a 50-year-old female with history of IST. She has had it for, like, years. She had it prior to endocardial ablation a few years ago. I can't really remember how long it was, as far as the patient. She has also tried medication, beta blockers, ibuprofen, calcium channel blockers, but she really had, like, side effects with hypotension, and sometimes the artery is not controlled, and she kept on having this debilitating fatigue. So, average heart rate was between 105 to 150 beats per minute, most of the time at rest without really doing anything. So, after a shared decision-making, she agreed to go for this hybrid sinus node ablation. So, upon presentation, her average heart rate was about 130 beats per minute. So, she was taken to the hybrid lab after we obtained consent and things like that. She was intubated. We got intervenous access. So, we mapped the right atrium using the HD grid to create a 3D activation map and also a voltage map. We used the NCITE mapping system. This is the baseline of the 3D mapping. On the left-hand side is the voltage map. You can see it's essentially normal, and on the right side is the activation map. This area here is where the sinus node is. So, the sinus node was identified at the superior lateral aspect below the superior vena cava and adjacent to the right atrial appendage. This hybrid case was done in conjunction with CT surgery. So, they performed the 3-part thracoscopic approach using simultaneous access to the pericardium with an NCOX1 tissue sealer. Once confirmed, the sinus node was epicardially marked with methylene blue for surgical reference. As you all know, the main concern is to avoid ablating the sinus node, particularly this patient that's 50 years old. We don't want to give a sinus node dysfunction. So, we used the endocardial ablation was done using the Boston Scientific Farawave Slash Viral Pulse PFA system. So, we ablated from the superior vena cava area, the inferior vena cava, as well as the posterior lateral crystal terminalis. There were some further atrial activities in this area of the crystal terminalis, so she was re-ablated again. No epicardial ablation was done. for this patient. By the time we completed the ablation, the heart rate was around 60 beats per minute. The sinus node function was preserved. There was absence of an inducible tachyarrhythmia. As you all know, if you take a patient, young patient to the EP lab, for whatever you are taking the patient for, you always want to check to make sure they don't have any other SVT or things like that. And there were no complications. The heart rate remained stable. She was discharged on an Iverbrodin 2.5 milligrams BID as needed. So this case was actually submitted, I think, one month before the closure of the abstract submission. And any time you have a patient, you must always follow up with the patient. So I'll give you an update of what happened post-submission of this case report. So after about three months, she was having this tachycardia, so she was taken again to the EP lab, where she was discovered to have an infra-atrial reentry tachycardia. This ablation was done at the crystal terminalis and at the IVC junction. We also did a typical atrial flutter ablation at the CTI line. So we used the Medtronic Afferasfer 9 PFE slash RF system. So we used the RF portion to perform this ablation because it's, sorry, we used the PFE to perform the ablation because of the area we had to avoid maybe damage to the phrenic nerve. Additionally, before presentation, she was having some intermittent sinus bradycardia, sinus pulse, sinus arrest, with some junctional escape redeem. So we decided to implant an atrial lidless pacemaker at the IV. The reason is because this is lidless, number one. She's young, number two. This AV is something you can always explant. In case you run out of generator life, you can always extract it and also always implant a new one. So this is just a comparison on the left. This is when we did the IST ablation. The left is a normal voltage map, and on the right here, you can see this area of scar where we did the ablation with some preservation of the sinus node here. And here, this is the activation map. On the left here, you can see this area here is where the sinus node is, and if you compare it to the right here, you can see areas of scar due to the ablation that we performed. So this was, this is a picture of the faraway power pulse PFA system that we used. There was not a signed number of applications before we went in, so it was based on able to like eliminate extra activities in this area while preserving the sinus node function. So yeah, this is just X3 on the left here. This is the PFA system. This is almost all into the SVC. In the middle picture here, this is the PFA system, the faraway power pulse system in the crystal terminalis, and on the right here, this is the area of the IVC junction slash crystal terminalis. So in conclusion, in summary, this was a 50-year-old patient who had debilitating inappropriate sinus tachycardia, despite the fact she had a prior ablation, who had side effects because of conservative management with medication. We ultimately took her for a hybrid sinus node sparing ablation, but we should note that there's always a potential for sinus node dysfunction and development of atrial tachyarrhythmias, particularly if you don't really ablate those areas, you can have some atrial flutter there. So for this kind of case, since PFA is a new system, I think for us to know the short-term and long-term benefits overall, and also to assess for possible complication, perhaps a randomized controlled clinical trial, which is really the best evidence that we have to help determine some of these benefits and potential complications. Thank you. Thank you very much. Any questions from the audience? Okay, so nice presentation. I have one question for you. Looking after the case, you punctured where you access to the epicardium, but you didn't ablate it, right? Yes. So, considering the result that, after this is such extensive endocardial ablation, the interatrial endocardial cure, do you think that, looking ahead, it could be in the future better just to go epicardial and ablate the sinus node immediately? Yeah. What would you do differently? So, I think for looking at this case, perhaps consider also epicardial ablation in this process, and also maybe avoid delivering too many applications, because I think, during that time, the sinus node was preserved, but then again, when you do ablation, vision goes on, and things like that, perhaps we may have extended some of the applications into some of the cells, area of the sinus node, where we cause some dysfunction. But I think avoiding too many applications, and perhaps including epicardial approach as well, too, may be something that we need to do. Yeah, that's a danger to your pain, you feel safe in terms of training nerve, and then you feel like a brave, and you can destroy the area, and it can work for sinus node disease, but it can have this kind of effect. I think it's a good example. Exactly. Thank you very much. Thank you. Thank you. Okay, so if there are no more questions, I'm not sure the next speaker is here, but I call the speaker just in case, Dr. Mao Xuxuan. Ah, okay, great. So he will present a case about left bundle branch area pacing. Thank you. Good morning, everybody. So I'm presenting a case entitled When Perfect Becomes the Enemy of Good, a case of left bundle branch area pacing lead causing severe mitral regurgitation following subacute LV septal perforation. So this patient presented with symptomatic sinus, sick sinus syndrome, and she is elderly, 82 years old. She has a past medical history of CAD, ESRD, and I highlighted breast cancer on chronic aromatase inhibitor, which I'll expand on later in the case. She had a low BMI, and pre-imaging TTE showed that her septal thickness was 11 millimeters, normal EF, and also had what's very commonly found in patients with ESRD, mild mitral regurgitation, MAC, and calcified leaflets. So we routinely implant dual-chamber pacemakers aiming for selective left bundle branch area pacing in these cases using luminous leads. In this case, it was easily achieved and satisfied all the parameters and criteria for selective left bundle branch area pacing, and you can see the x-ray lead positions. The patient was discharged after post-op date one when re-interrogation showed parameters were all stable. Intra-procedurally, we can see that this is the initial mapping of EGMs and surface EKGs, and we progress to the final position here with the typical QR, and here is displayed the unpaced, filtered left bundle branch signal where you can begin to see a QR pattern as we reach the left septal area. And she did have output-dependent transition from non-selective left posterior fascicular pacing to selective. And unfortunately, a week after implant, this patient presented with heart failure, flash pulmonary edema. We re-interrogated her device, and the amplitude went down dramatically, impedance went down dramatically, no longer had unipolar capture, bipolar threshold was very high, and the EGMs on interrogation were profoundly different, very wide. And the echo showed septal perforation, and unfortunately, severe mitral regurgitation. So this is a comparison of post-op day chest x-ray versus re-admission chest x-ray, and you can see that the tip has migrated more basally, and this was her echo showing the lead in the LB cavity, and there's a thin strand of chordae right here that you may be able to appreciate that is adjacent to the lead tip. And this is the TEE that shows the lead was protruding about two centimeters into the LB cavity, and you may be able to appreciate that there's a flail segment there. And this is just a diagram showing the flail posterior leaflet and chordae adjacent to the tip of the lead. And these are transgastric TEE views, and on the short axis you can see that it is impinging on the medial commissure aspect. So hospital course, this patient was actually developing cardiogenic shock, was in the ICU, was optimized then on post-op day 12, had complete device extraction. She was unfortunately too complicated for surgical mitral valve repair, and she did have a mitral clip on post-op day 20, and eventually discharged to rehab with plans to re-implant a pacemaker after recovery. So is delayed LB perforation rare? If you look at the MELOS registry that we're all familiar with, it's quoted around less than 0.1% incidence after over 2,500 patients. Recently a paper was published in Jackie P. by Cato et al, which showed that perhaps it's more common than we think if you just look at incidence of partial perforation, and they used these criteria here of a non-filter EGM with QS morphology, had a specificity of 100%, and in the patients who achieved left bundle branch area pacing, this is where they found this type of pattern, and the incidence rate was up to 41.7%. So is this just the tip of the iceberg? Obviously a really bad outcome that we really need to look into, and during the procedure there weren't any traditional intraprocedural findings of such a risk, so what are the pre-procedure risk stratifications that we can potentially identify? Are there any other nontraditional things to look at, and how can we optimize intraprocedural risk mitigation, and what can we do for post-procedure monitoring? So in terms of risk factor stratification, you know, the traditional risk factor of a thin septum, elderly lady, this patient did not have a thin septum, and now in her case she was on chronic aromatase inhibitors, and our hypothesis is that the inhibition of estrogen production chronically reduces, has been found to reduce myelocyte hypertrophy, collagen synthesis in the extracellular matrix, and therefore decreases wall strength and increases penetrability, which makes us think of other nontraditional risk factors such as connective tissue disease that decrease collagen levels in the myocardium, and of course genetic collagen diseases such as Erlose-Danlos. Now in terms of how severe potential complications can be after LV septal perforation, this patient also had risk factors including ESRD MAC leaflet calcification, which increased the tension and the stiffness of chordae, which potentially can increase rupture. What would be other risk factors of septal perforation and also severity of complications? I think more work needs to be done here. And with better pre-procedure risk stratification, it should help us identify patients where perhaps we shouldn't be too aggressive with achieving perfect left bundle branch pacing. So lots of things to think about also during intraprocedural risk mitigation. I personally feel that tactile feedback is perhaps the most important in this case. She had what I consider a butter septum. It was very easy to get to the final position. And if you think about it in a quantitative sense, the distance traveled by the luminous lead or any lead is a function of rotational translational forces. In this lead in particular, the lead tip is, the screw is 1.8 millimeters and from the tip to the proximal ring is 1.1 centimeters. So if you have perfect mechanical energy transfer, the pitch of each screw turn is 0.9 and it would take at least 12 turns to get to the proximal ring. If it takes less than 12 turns, then the septum is very susceptible to translational force. And this lead in particular, compared to stylite driven leads, has a smaller diameter which increases the translational force per unit area. In terms of anatomical considerations during the procedure, I would avoid perpendicular orientations of the lead to the septum. Just to guide us with intraprocedural ECGs, we often look at lead to growth, for example. If it continues to grow as you're screwing the lead in, that's perhaps telling us that it's going more superior in basal and vice versa. And here's where I think imaging adjuncts could help. We moved away from contrast, but perhaps in some cases we should use contrast to help identify how deep we are and so forth. And from the EHRA Clinical Consensus Statement, it was said that the left vesicular pacing is the most commonly achieved left bundle branch area pacing. And that's what happened in our case, however the myocardial thickness is less as you approach the basal posterior fascicle myocardium. And on the opposite side of that is the mitral valve and subvalvular apparatus. So that's something to keep in mind. And lead two and three would be negative in that case. And another consideration from an electrophysiology perspective is continuous monitoring would be very beneficial. Again, going back to the CATO paper, the myocardial current of injury, less than 14.5 millivolts, was identified as a highly specific finding in partial perforations. And non-filtered unipolar EGMs during the case should be considered because it has 100% specificity for partial perforation. And finally, lead management during the case. This is the fluoroimaging of the final position or lead. You want to minimize excessive slack, which could transmit to forward force. But that's kind of something that's hard to quantify and needs more work. And finally, what kind of factors would trigger post-procedure monitoring earlier with earlier device checks? And we have to check unipolar and bipolar. So in summary, this is, as far as we know, the first reported case of a left bundle branch area pacing lead causing LV septal perforation, mitral chord elasteration, and severe mitral regurgitation. It occurred despite lack of traditional intraprocedural findings of these perforation risks. And just highlights the fact that more work needs to be done to help re-stratify patients, better mitigate intraprocedural risk, and monitor post-procedural complications. And thank you so much, and I'd like to thank my mentors as well. Thank you very much. Any questions? Yeah? Yeah, I have a couple, actually. First of all, thank you for sharing this. This is important. It's obviously, it might be the first with MR. Well, I'm going to thank you again for presenting a great case and being thoughtful about it. I appreciate it. This is certainly not the first report of perforation of a septum. As you point out, it might be the first with the mitral valve getting involved. I had a couple of questions. One was the notion that the lumenless transmits more. I think part of the reason why people went to stylet-driven was the difficulty with advancing with the lumenless, so that's number one. And I'll remember the next one when you, I got too busy thanking you, so. Yeah, that's absolutely, I agree with that. So, you know, we at our institution are primarily trained using the lumenless lead, and I agree in a lot of patients it can be hard to drive that lead into the septum. What I was thinking is that, you know, it's a complex interplay of multiple factors when it comes to LV septal perforation, and if the translational force during cardiac motion is transmitted in just the right way after the lead is already in place, then perhaps, you know, given equal force vectors, the lead with the smaller diameter would be able to transmit more force. But thank you for the question. Thank you very much. Sorry, because we are out of time. So, I call the next speaker, Dr. Badri Kayli. In the meantime, just a short comment. I think the outstanding presentation, I think the first comment of this presentation is the indication. So, sinus node disease, 82-year-old, so no need for ventricular pacing at all, and if he needs ventricular pacing probably will be less than 40%, so probably I like your title, the best is enemy of the good. I don't know why the slides haven't come across. I've checked them on Orchestrator. I checked them here yesterday. Really? Yeah. These are just the abstract ones. So, can I use these or I can go to the next feature? You want to go to the next feature? Okay. I can't see... I can't see any other thing for me. So if you click My Files... Okay. Great. Thanks. Thanks. Okay. So thank you very much for the opportunity to present our case. My name is Barrett Cayley. I'm an EB fellow based at Imperial College London. So our case describes an unusual approach to AF ablation in a gentleman with anomalous pulmonary vein drainage. So the structure of this talk will spend the first half describing the case and the approach we took, and the second half will be contextualising why this was such an unusual approach, even amongst a rare population of patients with anomalous pulmonary vein drainage. So this was a 64-year-old gentleman referred from another hospital with persistent AF. He had no significant comorbidities, and we undertook a cryoablation procedure, during which we were unable to identify the left-sided pulmonary veins, and so we carried out cryoablation to the right-sided veins alone. Given the issues in locating the left-sided pulmonary veins, we organised cardiac imaging. The patient underwent both cardiac CT and cardiac MRI. The cardiac CT shown here showed a dilated right atrium, and suggested the left pulmonary veins were reported to drain into the right atrium rather than the left. This was corroborated by cardiac MRI, and here we have MRI and CT images at slightly different levels. They demonstrate the left pulmonary vein, and one can appreciate in the right image that there is a very thin layer of myocardial tissue separating the left atrium and the left pulmonary vein bundle. Interestingly, apart from this thin layer of separation, anatomically, the left-sided pulmonary veins were at the correct site in relation to the left atrial body, but their drainage was reported to be into the right atrium via the coronary sinus. Therefore, altogether, the imaging was suggestive of anomalous pulmonary vein drainage, which in itself is rare, and as we will see, both left-sided pulmonary veins draining into the CS would represent a very rare subset of an already rare condition. So he represented two years later with symptomatic persistent AF, for which we undertook a repeat ablation procedure. We took a penta-array multipolar mapping catheter and carried out mapping of the left atrium. Unfortunately, sinus rhythm could not be maintained, so all mapping was performed in AF. The right pulmonary veins were located and were found to be reconnected, so a redo right-sided pulmonary vein isolation was performed. And here we can see the AP and PA bipolar voltage maps of the left atrium, with the red lesions depicting ablation undertaken to re-isolate the right-sided pulmonary veins. And from the PA view, one can appreciate where the left pulmonary veins should be, demonstrating that they could not be found or accessed from within the body of the left atrium. Now the right side of veins were isolated we tried to cardiovert once again however we were still unable to maintain sinus rhythm therefore we sought to map the left side of pulmonary veins and the imaging had suggested the connection to the right atrium was via the CS. So we started mapping within the CS and for this we used an SLO and Penta Ray catheter. So here we can see PA and AP views for 3D electroanatomical bipolar voltage map of a dilated CS at the end of which we have located both the upper and lower left side of pulmonary veins. As shown in the maps they're both electrically active with signals recorded from both and we therefore made the decision to proceed with a circumferential lesion set to isolate both pulmonary veins from within the body of the CS. Technically reach was difficult and therefore a gillis catheter was used with a smart touch ablation catheter. After confirmed electrical isolation cardioversion was again attempted and this time was successful with maintaining sinus rhythm and pulmonary vein isolation was reconfirmed through both entrance and exit block. It was especially interesting to see both maps overlaid. So both maps here are displayed PA views which show that though the left pulmonary veins were anomalous in their drainage their anatomical site was to a fair extent where one might expect them to be in relation to the left atrium. And on this slide we have a video of both maps overlaid. So to orient it in the glass view we have the left atrium and the right-sided veins and the non glass view we have the left-sided veins arising from the CS. So I'll just let this play so we can appreciate the lesion sets and exactly where the left-sided veins are in relation to the left atrium. So here we come to the left lateral view and now moving around to an anterior view and it shows how the left-sided wacker is in a surprisingly conventional location despite being carried out from within the CS. So now we're going to review the literature to help contextualize our case. Firstly what does partial anomalous pulmonary venous return mean and what are the subtypes? Partial anomalous pulmonary venous return by definition refers to only one or two of the pulmonary veins draining oxygenated blood back to the right-hand side of the heart. This is in contrast to total anomalous pulmonary venous return which is a different congenital syndrome that must be usually surgically corrected at birth. Partial anomalous pulmonary veins are often picked up incidentally, do not often require surgical intervention and are rare with a quoted incidence of 0.2% and as we'll see most cases involve just the right upper pulmonary vein and the most common subtypes are supracardiac draining into the SVC, the infracardiac subtype drains into the IVC and the rarest form cardiac involves anomalous pulmonary veins draining directly into the RA or via the CS. So what about ablation? Should we ablate these anomalous pulmonary veins and this is an important consideration given they require a different approach to conventional PVI and therefore may carry a higher theoretical procedural risk. So one must first consider how likely these anomalous pulmonary veins are to be the drivers for our patients AF. Unfortunately data on AF ablation in patients with anomalous pulmonary venous return is limited to case reports and a single case series. So here we have tabulated the first all the available case reports and the case characteristics and one can appreciate that most cases involve the right upper pulmonary vein draining into the SVC and of these 12 reported cases only three showed confirmed electrical activity and four out of 12 underwent ablation to the anomalous vein and all four of these ablation cases were supracardiac draining into the SVC and therefore underwent SVC isolation as their ablation strategy. Moving on to the published case series here 20 international centers were contacted yielding just nine patients. A higher proportion five out of nine patients had electrically active vein and only two cases reported ablation directly to the anomalous veins again in the form of SVC isolation and here is an image from one of these cases showing anomalous pulmonary veins draining into the SVC and in pink and white we can see the lesion sets that constitute SVC isolation in this case. And so here finally I've summarized all the case reports and case series with some useful takeaways to help contextualize our case. So the first pie chart on top left you can see approximately three quarters of all cases reported cases are supracardiac draining into the SVC with the next largest portion also being supracardiac draining into the brachiocephalic vein. Only two cardiac subtypes have been described with one draining into the CS one into the right atrium. Moving on to the second pie chart in terms of which vein all bar one reported case involved just a single anomalous pulmonary vein and again in three quarters of all cases this was the right upper pulmonary vein draining into the SVC. Moving on to the pie chart at the bottom left there with regards to electrical activity about half of all cases reported that these anomalous veins were found to be electrically active and however direct ablation is not often pursued and we can see in the pie chart in the bottom right only five out of nineteen cases reported ablation. All of these were SVC isolation with three using RF and two using cryo. So what's a learning point from our case? This is a rare condition with limited data especially on whether direct ablation is useful. Ablation has only been reported in those in whom electrical activity is seen in the anomalous pulmonary veins and if you are to encounter partial anomalous pulmonary veins in your practice it will most likely be a supracardiac right upper pulmonary vein draining into the SVC. All reported ablation thus far involves SVC isolation and therefore with respect to our case this truly was a rare rare subtype of a rare condition and the first known reported ablation strategy isolating the pulmonary veins from within the CS and I'm pleased to say the patient remained free of AF for over 18 months now. On that positive note I'd like to conclude my talk and take any questions. Thank you. Thank you very much. Just time for a very fire question. Okay so just one comment. One clue that you had at the beginning to suspect any abnormal thing is a dilation of the right atom. That probably in the echo was already stated but sometimes we forget the right atom so that that's also a learning point I think. Thank you very much. So I call the last speaker Daniel Nelson for a first surgical implantation of an extravascular ICD lead in patient with by your sonatomy. Thank you. All right well thank you guys so much for having us. We appreciate the opportunity to present. All right so like I said I'm Dan. I'm a EP fellow at Aurora St. Luke's in Milwaukee Wisconsin. I'm going to present the first surgical implantation of the EVICD lead in a patient with prior sonatomy in the United States. So the extravascular ICD lead was called the EVICD lead is the only extravascular outside the vascular space lead approved to pace and defibrillate. The only other one is the sub-q ICD lead but that one can't pace. It can only defibrillate. So the EVICD lead is contraindicated in patients who have had a prior sonatomy. So we described the first reported surgical implantation of the EVICD lead in a patient with Epstein's anomaly during repeat tricuspid valve surgery in the United States. There was a case in Italy where they did do an extravascular EVICD lead placed surgically and that was published about a year ago. So this is the first one in the United States. So I do want to give a shout out to the Italian group who've already published the first reported case ever. So in our case is a 49 year old male with history of prior sonotomy, diabetes, and tobacco. He developed exertional dysthmia over two weeks. He came to the emergency room was found to be in 2 to 1a flutter with incomplete right bundle branch squawk right right axis deviation. The echo was was obtained. It showed severe right ventricular dilation with severe systolic dysfunction and an apially displaced tricuspid valve with torrential TR consistent with Epstein's anomaly. Let's see if we can play the video. So here you can see the apially displaced tricuspid valve, severe TR. We'll show you on the next slide. But you also have massively dilated RV and RA as well. This is consistent with Epstein's anomaly. Okay here's his presenting EKG showing 2 to 1a flutter, right axis deviation in that right bundle branch block. Here you can see the apially displaced tricuspid valve. I don't know if I can point. No you can't really see it. But there's apially displaced tricuspid valve here, dilated RV, massively dilated RA, and then you see the torrential TR on the bottom right. All consistent with Epstein's anomaly. Outside records clarified the patient's prior sonotomy was for tricuspid valve repair. Despite medical optimization including diuresis and rate control, he continued to have New York heart class 4 symptoms. So the decision was made to perform a redo surgical tricuspid valve replacement. Prior to the surgery, the patient went to a sustained ventricular tachycardia that terminated on its own. This was seen on the tometry. So EP was consulted. Preoperative EP study was performed to ablate the known a flutter and to assess for the risk of accessory pathways. Patients with Epstein's anomaly are increased risk for accessory pathways in addition to ventricular arrhythmias. So that was the main reason EP was consulted. We had a multidisciplinary meeting so the decision was made for the surgeons to place the EVICD lead to avoid passing the lead through the tricuspid, the newly placed byprosthetic tricuspid valve. So during the EP study no accessory pathways were identified. The CTI line was performed and the patient the patient converted to normal sinus rhythm. During the ablation though of the well we were giving the lesion over the fibrous ring. It caused some PVCs that sent the patient to a VF and so the patient was successfully defibrillated. Here's where we were. Those are the lesions that caused the PVC that sent the patient to a VF. It is because the tissue itself is ventricular but it was atrialized because that tricuspid valve is more apially displaced so that's what we thought caused the PVC because it's actually a really ventricular tissue. So the patient was taken two days after the EP study. This patient was taken to this for reduced rhinotomy. So the decision like I said was to place the EVICD lead to avoid traversing a lead through the tricuspid valve. There's the surgeon's decision that they did not want any leads going through that newly placed byprosthetic tricuspid valve. So he ultimately underwent the byprosthetic valve in the tricuspid position, the Lehman LED, and the RV placation in addition to a right-sided maze with epicardial RF ablation from SVC to IVC. And then at the end of the case after he was taken off cardiopulmonary bypass and he had the EVICD lead sutured to the RA, to the anterior RV I should say. Here's the video. You can see he's already off cardiopulmonary bypass and this is the surgeon suturing, putting a couple 4L-proline sutures to the anterior RV. This is just a close-up view of that video showing the anterior RV with these the 4L-prolines suturing the lead to the anterior RV. The lead was then tunneled through the mid-exterior line to the serratus anterior muscle for future generator placement. The surgeon wanted to wrap up the case and so the decision was made to take the patient back and have the pocket formed by EP and EP lab. After the byprosthetic tricuspid valve replacement, the patient had persistent complete heart block so a transvenous dual chamber pacemaker was placed with an atrial lead and a coronary sinus branch lead to avoid placing a lead across the byprosthetic tricuspid valve. Prior to discharge, the ICD generator was placed in that lift mid- axillary pocket. The EVICD lead showed no over-sensing during CS pacing. That was one of our concerns but it didn't show any over-sensing. Defibrillation threshold testing was successful at 30 joules as you can see in the strip below. At one month all the patient was doing very well. Both the EVICD lead and the pacemaker were functioning normally. They had to drop the output of the atrial lead because that was actually picked up by the EVICD lead so it was DDD but the atrial pacing output was decreased but he didn't really need to be atrial paced anyways because of the heart block so that's that's eventually how he was programmed. This is the final chest x-ray and discharge. You can see the dual chamber pacemaker in that left subclavicular space with the atrial lead in the appendage and then you also have that CS branch lead with that white arrow and then you have the EVICD lead over the anterior RV and then you have the can in that left mid-axillary space in that pocket. This is the first reported case in the United States of a surgically placed EVICD lead in a patient with prior sternotomy. Like I said that group in Italy had published a year ago the EVICD lead placed for a patient they had infection and so they had to have removal of ICD leads and they eventually ultimately underwent placement of an EVICD lead in Italy in 2024. So this is the first one in the United States. From our experience the surgical placement the EVICD lead was safe. It was done under direct visualization and this case overall highlights the importance of collaboration between EP and CT surgery and the innovative treatment of complex arrhythmias in patients with in patients with like Epstein's anomaly or complex congenital heart disease. So the EVICD lead is an appealing option because it combines the valve sparing profile of the sub-QICD with the same defibrillate efficacy ATP capabilities and battery longevity of the of a transvenous ICD lead. And like I said the surgeons did not want a lead through the newly placed bioprosthetic tricuspid valve so that's why they didn't want to place the transvenous ICD lead. The prior sternotomy is in general a contraindication during percutaneous implant because when you tunnel the EVICD lead beneath the sternum you'll be hindered by the sternotomy wires and fibrosis and this can lead to inadvertent injury to the to the artery. So but in our case because the EVICD was placed in the OR it was done under direct visualization so the procedure was safe and like I said it was done after cardiopulmonary bypass so it didn't really add much procedure or too much time to the to the OR so it was safe it was quick and it was it was elegant because it spared the spared the bioprosthetic valve and it can provide that ATP pacing unlike the sub-Q. Yeah so that's kind of what I already said it's it was straightforward minimally increased procedure time the defibrillation threshold testing was successful at 30 joules and there was no P wave over sensing. Obviously there was sensing when we were pacing the atrial lead but like I said we decreased that output so that the EVICD wouldn't see the when we're in the patient didn't need any atrial pacing. Obviously continued follow-up is needed to ensure appropriate device function but I think the patients with complex congenital heart disease this is an appealing option you spare the valve you can provide ATP pacing obviously successful defibrillation is paramount and so I think other you know it opens the door for future future options for patients with you know ventricular arrhythmias needing pacing who have bioprosthetic valves. Thank you very much very elegant case any question from the audience yeah so yeah the EVICD lead very low risk for infection and so we thought that the infection risk would actually be lower with the EVICD lead because it's not in the vascular space so that that was would be a pro to using the EVICD lead compared to a transvenous ICD lead. At the time the patient was going for the EVICD lead the patient didn't have any pacing requirements so we didn't know that the patient would then subsequently need the dual chamber pacemaker. It is a risk of doing bioprosthetic tricuspid valve replacement but at the time they didn't need any additional pacing it was until after the procedure after the surgery that the patient developed a complete heart block so that's why then had to go and place the pacemaker so when we were placing the EVICD lead it was just going to be the EVICD lead and unfortunately they developed a complete heart block after. I'm sorry what was the first question again through the valve oh yeah that was the surgeon's decision there's been reports of being safe to place leads through the bioprosthetic valve but large meta-analysis have shown increased risk for tricuspid regurg especially with the ICD leads because they're a little bit bigger so the surgeon didn't want any leads going through the valve so that was that was why we had the multidisciplinary meeting between EP and CT surgery and they it was really the decision of the surgeons to avoid placing any any lead through the valve because of that concern for increased risk for a TR and we the guy he already had you know severe TR you know large RV large RA we didn't want him to have to undergo another surgery if he had developed RV failure in the future because that would be a third sternotomy so they thought the best option was to avoid any lead through the valve whatsoever so it was kind of the decision of the surgeon but yeah. Thank you just last one sent no no no it was not checked during the implant what's that yeah exactly yeah it wasn't till after we brought the patient back to the EP lab like a couple days later they checked all that just one last question I'm also scared about the infection in a seizure cable in the epicardium so not considering the needing for pacing would you consider the subcutaneous ICD in this patient the patient the patient did have monomorphic PT on the floor so during that multidisciplinary meeting we wanted to provide an option for ATP pacing so the subcutaneous ICD lead wouldn't provide any ATP pacing so that was the main reason we wanted to do the EVICD because it could ATP the patient out if he developed probably in the short term you will have the option to do with subcutaneous ITD and with the leadless Boston device so that could be also yeah that would be a good option so thank you very much I will close the session session to thanks to all of you to be here at 8 a.m. the last day and have a nice end of the Congress

electrophysiology

cardiology

ischemic cardiomyopathy

Implanted Cardioverter Defibrillator

surgical extraction

pulsed-field ablation

sinus tachycardia

mitral regurgitation

multidisciplinary approaches

cardiac surgery