Hello and welcome and thank you so much. Thank you Nishant and thank you Brad for really organizing this webinar. It is truly an honor and privilege to be included among this very highly esteemed faculty, being able to share my experience about catheter ablation using mainly the no floral using ice as well as 3D mapping system. Of course, as you mentioned, you already perhaps watched the movie that watched the actual presentation of Paul earlier this morning, which was a fantastic presentation on using ice and basic of ice, which is the foundation of this technique, being able to know that foundation, being able to know how those. So here I'm going to step forward and we're going to show it during the catheter ablation procedure. Again, this is a movie I would be more than happy to pause in case anybody has any question if you would like to ask me Nishant, but otherwise, if you have any time for at the end of the presentation, I would be more than happy to answer. So we're going to talk about advanced ice techniques for catheter ablation. These are my disclosures. I'm a consultant for Abbott and Ellis Medical. The first thing I always want to talk about would be how to advance the ice inside the right ventricle. Why do we want to do that? Of course, because we want to make sure there is anything baseline pericardial effusion or not. So this is how we advance the ice inside the right ventricle. Let's look at it a little bit closely here. If you notice, we always want to see the aperture of the tricuspid valve as we try to advance this catheter through the tricuspid valve into the right ventricle. But if you look at it more closely, you would be able to see here that we have this is the distal part of the ice and this is the proximal part of the very ice at the tip of the very ice, the transducer. So when you see these two dots, you always would know ice basically is located in the heart. It makes it much easier to understand where your ice is basically. So the dot on the right would be the distal part, like that, and the dot on the left would be the proximal part of the very tip of the ice, which is the transducer. So here again, we would see you're trying to go through the tricuspid valve. As you notice, those two dots now are inside the right ventricle because we passed the tricuspid valve, and that is the tip of the ice catheter, which is, you see, if I advance it a little bit, you see that very tip is very close to the RV wall. So that is the tip of the ice catheter, that is the tip of the ice catheter, and you can appreciate that that is the RV wall. So that is very close to the RV wall. So you want to make sure that you don't advance it anymore. So then if you want to look at it one more time as to how this process is being done, this is the right ventricle, okay? So my ice catheter is coming from the left, from the IVC. I would like to, with this St. Jude system that I have been using exclusively, actually, I have all my experience with this catheter currently, you have to do anterior tilt to be able to dive inside the right ventricle. So when you do the anterior tilt, you dive into the right ventricle. And when you go into the right ventricle, it makes that ventricle look horizontal. Because remember, those two dots are always horizontal. So that's very crucial to know. So when we are inside the RV, we undo the anterior tilt and we go ahead and clockwise rotation to be able to see the left ventricle. So here you can appreciate that that is the left ventricle. And of course, this is a good view to be able to see based on pericardial effusion. This is my preference that I press the right ventricle. The reason I do that, you appreciate that right on the top, that is the icon. You want to bring the icon towards the right. Because it reminds me of palestine, a long axis view of the echocardiogram. So you can see the left atrium, mitral valve, and LVOT, and so forth. So now I'm going to talk about how we perform a transeptal puncture, a practical part, how we can go ahead and do this transeptal puncture. And we always need to first be able to find the SVC, as we all know. So first, we are going to have the home view on ice. The moment we put the ice inside the right atrium, as Paul mentioned earlier, this is the right atrium, this is the region of the his right ventricle, and this is the RVOT. So if you look at this, as soon as I start clocking a little bit the ice, so as I start clocking the ice a little bit, what I'm going to see, I'm going to see the septum, I'm going to see the left atrium, left atrial appendage, I'm going to see the mitral valve, left ventricle, and of course the coronary sinus is going to come into view. So here, if I perform a little bit more clockwise rotation, I'm not going to see the CS and appendage anymore. What I'm going to see, I'm going to see the septum, I'm going to see the left atrium, I'm going to see the left superior and left inferior pulmonary vein, and I start gradually seeing the SVC right on the top. If I a little bit do a posterior tilt and advance my eye scatter, I would be able to place this ice inside the SVC, and that is always what I do. I don't want to look at the SVC from the right atrium, I want to place the ice inside the SVC. So now we are going to advance the septal wire, the wire is going through the groin, right now here the wire is getting into the right atrium, we are advancing it further, and as you notice it just went to the SVC. So my eye scatter is inside the SVC, and basically I'm being able to see my wire is going inside the SVC. You want to always avoid pushing this wire inside the right atrial appendage. Let's take a look at it. So here, as you notice here, you're going to see SVC here, and this is the right atrial appendage. And SVC here. You really don't want to push it in the right atrial appendage because unfortunately these wires are very easy to perforate this right atrial appendage, so you want to steer it towards the SVC, and as you notice my ice here was in the right atrium to be able to see the right atrial appendage. And now my wire is inside the SVC, what I'm going to do, I'm going to advance the sheath and dilator over this wire inside the SVC. I can see my eye wire, I'm pretty sure that it's very safe, left atrium, SVC, and this is my wire. And I want to start looking at my sheath and dilator coming from here to here, and you can see that that is the wire now, and that's the sheath and the dilator. So here we are going to remove the wire, and we are going to leave the sheath and dilator inside the SVC. Let's go ahead and remove the wire, you can appreciate the wire is there, JJ wire is coming back, coming out of the body, and sheath and dilator sits inside the SVC. Patient with devices, it is very important to see this, to recognize this. If you think that this is your wire, unfortunately you see the left atrium, PA, and SVC, that's not the wire you're going to perforate. That is the lead, that is a pacemaker lead. So you've got to make sure where your wire is. Actually, look at the wire here. The wire is inside the liver right now, and if you think that is your wire, you're going to advance the sheath and dilator into the liver, and unfortunately you're going to cause a catastrophic complication. So you always want to see the entrance of this wire inside the SVC, that is very crucial. You can appreciate here, you can see that we have the lead and we have the wire. So you know that your wire is inside that SVC, and then you go then advance the sheath and dilator over the wire. So remember that, that is very important. Maybe 5% of time you may not be able to SVC, it is difficult, the wire doesn't want to go into the SVC. So you know what, always have a plan B. Let's see what is our plan B. I go then advance the transeptal wire into the right atrium. You know that it goes up somewhere close to right atrium, even if it is not going, you know that it went up a little bit, like about maybe 30 centimeters or so, but majority of time you would be able to see it that, okay, this is the wire, this is the right atrium, and basically I know that my wire is safely in the right atrium. What am I going to do right now? I'm going to go ahead and advance the sheath and dilator over this very wire, and I'm looking at the wire, I know the wire is still in the right atrium. I would advance the sheath and dilator like about maybe, you know, 20 centimeters or so inside the IVC. As soon as I do that, I just go then remove the wire and dilator, and I would keep the sheath inside the IVC. So you can appreciate that the sheath is inside the IVC. I would go ahead and advance the catheter such as CS catheter or an ablation catheter as such. As soon as this catheter comes out, you should be able to recognize it on your mapping system. So when you visualize it on your mapping system, and perhaps you have already created the geometry, you just go ahead and advance this catheter because you remember now you can steer it towards the SVC and chances are that you have already created that geometry. That's your road map. So the catheter went into the SVC. Now we are going to advance the transeptal sheath and dilator, I'm sorry, transeptal sheath over this catheter inside the SVC. So remember as soon as you start seeing some deflection artifact like distortion here, this is where you know that the sheath is over the catheter. You don't want to go any further. So you go ahead and remove the catheter and right now you were able to blindly advance your sheath in the SVC. Let's look at it in this view of it. The CS catheter went to the SVC right now and hold the CS catheter steady. The decoupler catheter advanced the sheath over this catheter and then going to remove the catheter. So the sheath stays inside the SVC. Here, this is during the procedure. You can appreciate we are advancing the sheath, holding this catheter steady and you can see that here you can appreciate that we have this deflection artifact. So you know that your sheath now is over the catheter. Now we are going to advance the wire and dilator over this through the sheath. But we want to make sure that we protect the tip of the dilator with the wire. So how do we do that? We bring the wire all the way out. So to check to make sure that the tip of the wire has reached the tip of the dilator. So pull it back a little bit and go ahead and engage it. As soon as we engage it and we go a little bit further in, usually we go ahead and advance the wire for about maybe three, four inches and hold them as a single unit. So now the wire is going to be proceeding the tip of the dilator that is as such. You can appreciate here this is as I'm going to advance them as a single unit. When this sheath and when the dilator and the wire is going to come out, so here when the dilator comes out, actually you're protecting the tip of the dilator by this very wire because you're coming out inside the SVC. So you want to be paying attention to that of course. You always want to advance it while you have a wire in it. So now you're going to remove the wire and again like the other case transeptal and you know the transeptal assembly is going to be inside the SVC. So here you can appreciate that we advanced the wire inside the dilator and here we are advancing the assembly as here my nurse is holding them together. I'm advancing it as a single unit so that is very important. At the very end they let it go so I can advance it over the wire. You don't want to have a lot of stiffness of the wire. You want to let the wire just do not hold the wire anymore. Now we are going to go ahead and advance the transeptal needle here. If a bailless needle is used these are the following steps we are going to take. This is a bailless needle. The reason I can I'm using this and I'm going to show you the tip of it is blunt so you may be able to you know show the tip of the lead and you may advance it while the tip of the I'm sorry tip of the needle is exposed. So first you're going to advance the needle but you got to make sure that you don't advance it all the way. You want to make sure the needle is not completely exposed. You don't want to push the needle out. What you want to do you want to unsheathe the needle. Means you want to pull the sheet and dilator back to expose the bailless needle and here it is. I'm pulling back the sheet and dilator as such and I'm exposing the needle on the other end which is right here. Because you don't want to advance the needle in the SVC. You want to expose it kind of you want to unsheathe and here you can see the needle on my mapping system. I'm pulling it back and you can see it went towards the fossa. Of course this is a luxury of looking at it. You mainly want to look at this with eyes of course but if you are using the BRK needle while you are dragging it down you can certainly show the tip but you when you are dragging it down there is absolutely you should not expose the tip of the needle. Here you can appreciate I'm pulling back the eyes and needle together. Here you can see that that's the needle just went to the left atrium and here is the sheet and dilator inside the left atrium. Pull back the needle and the dilator and you have the sheet inside the left atrium. Almost always for any left-sided procedure I advance the eyes inside the left atrium. Let's see how we do it. Here is the transeptal puncture. I'm performing the transeptal puncture and here the transeptal puncture assembly just went to the left side. Now I'm going to advance the wire inside the left superior for my vein. So I have a the left superior for my vein. So I have a transeptal puncture here and I pull back the sheet and dilator inside the right atrium as such and the wire stays inside the left superior for my vein. So what we are going to do right now we are going to perform anterior tilt to advance these eyes inside the left atrium adjacent to that very wire. Beside that wire you go to the left atrium and then you can go and advance the sheet and dilator into the left atrium as you see it there and go ahead and pull back the dilator and the wire out. So sheet as well as eyes are in the same through the same hole. So let's look at it during the procedure. We always do it with the second transeptal if I'm going to do an AFib. So the first transeptal here you can see the first transeptal sheet. This is my needle of the second transeptal. I just went ahead I did the transeptal puncture you can see the tip of the needle and I just advanced the sheet and dilator. So this is the second transeptal. I go ahead and advance the wire. This is the wire you're going to advance this wire into the left superior for my vein. Now what I'm going to do I'm going to pull back this sheet and dilator inside the right atrium. So through that very hole that we created we are just going to have the wire going through. So let's look to see what we have in this view. In this view we have a first transeptal sheet. This is going to be the wire of the second transeptal. Where is the rest of the assembly? Right there in the right atrium waiting to go back to the left atrium. They are sitting there dilator inside the sheet sitting back into the right atrium. So what we are going to do right now we are going to do anterior tilt with the eyes which will bring the tip of the eyes towards the wire. Let's look how we are going to see this one but on the on our echo machine. So this is the tip of the wire. That tip of the wire is supposed to go the tip of the ice right there. So it means that I have to bring the ice anterior tilt and bring this tip towards the wire correct. But as you notice these two dots are never going to move. The ice is always going to be here. So what you are going to see instead you're going to see that the wire is going to go towards this very dot. So when you see that as you are doing the anterior tilt you would appreciate that this wire is getting slowly closer to this dot. Let's look at it. This is a wire going up towards the dot right there. Still wire is here dot is here. So I have to do a little bit more anterior tilt to bring this one to here right there. I just made it and then I go to the left atrium. So if you appreciate here you can see that this is my eye scatter. Actually like about three fourth of it is inside the left atrium. One fourth of it is inside the right atrium because this is a septum. So you can see those two dots again left atrium right atrium. Some part of it is inside the right atrium. Now I'm completely inside the left atrium. I go and counter clock majority of time at this stage. Go then watch my wire. Find my wire and advance the sheet and dilator over it and pull back the dilator and the wire. So my sheet is now inside the left atrium. So now I would be able to see the ablation catheter going through the sheet inside the left atrium. Let's see what really sometimes we really have to do. I said I do it routinely but let's look at this. You can't see the septum. This is a needle but if I ask you to show me the left pulmonary vein it's going to be almost impossible to show it. And the reason it is is that because of the lipomatous hypertrophy of the septum. So if you notice here as this wave of the ultrasound waves are coming they are going to deflect. They are not going to go they are going to go back. They are not going to penetrate through that lipomatous hypertrophy of the septum. But if I just go then advance the eyes inside the left atrium this is the very same patient that now you can appreciate that you can see the left superior pulmonary vein. You can see the left atrial appendage. If I go ahead and start moving my I can just start looking at the left inferior pulmonary vein and then when I'm further clocking it I'm going to see that you almost always would be able to see the longitudinal aspect of this vein. So this is the right inferior vein. This is the right middle pulmonary vein. And if I clock it more you're going to see the right superior pulmonary vein. Let's look at it one more case. Again this case I went to the left atrium. Here you can appreciate I can see here the left atrial appendage. Then you're going to see the LAD and left circumflex arteries right here. And if I go down, counterclock it a little bit more, you can very nicely see the left main from the left atrium and that is the left coronary cusp. Okay. Now we are going to start performing some catheter ablation. Let's talk about catheter ablation of atrial flutter. This is a slam dunk case when you see this because there is nothing, there is no pouch, there is no Eustachian valve. I wish I could tell you that I see this often. I really don't see it often. This is maybe 20% of the time I see that. The rest of them I see a lot of abnormalities. So here you can appreciate that I start burning from the tricuspid valve junction and the CTI and pulling the catheter back towards the CTI and IVC junction. So very nicely, maybe a two minute burn and almost always you have a very nice, you know, conduction block. But here there is another issue. If you notice that there is a pouch there. So if I'm not going to see the pouch, chances are that I'm just going to come back and not going into the pouch. But when I see the pouch, I try to steer it towards that floor of that pouch. And as I do that, you can appreciate that the tachycardia terminates as soon as I go inside the pouch. There is another case that actually I did a couple months ago, very interesting case. This is ablation catheter. If I'm going to pull back this ablation catheter, let's see the trajectory. The trajectory is this way. It's coming towards the IVC, like from here to here. But what am I going to be missing here? What I'm going to be missing here is that very structure, which is that pouch here. So I would not be able to burn this area. So if I'm pulling back the ablation catheter right there, you can appreciate that this is coming back, but I'm going to be missing this area because it is going to come back like this all the way to here. I'm going to be missing that area. But if you would be able to see it very clearly with your eyes, what I would do, I would do this candy cane. I perform a candy cane with this catheter. So make a U-curve and go inside that very pouch and finish the procedure. And almost always, if you don't go there, chances are that you're not going to be able to get that CT smooth block. A Eustachian valve, Paul showed very elegantly today. So here you see that you can see that heart. This area is going to be very hard to access with ablation catheter right there. And this is the Eustachian valve. And many times you really have to burn all over this Eustachian valve because it contracts and you see a lot of electrogram on it. But if I'm going to ablate it from here, I'm going to come back here, but then I'm going to be on the air because this is not going to let me, this Eustachian valve is not going to let me to get to this area. But if I see it, what I can do, I can do a continuous ablation. This is a continuous movement. It is not movie after movie. This is continuous movement that you can appreciate that you perform again another candy cane here like a reverse candy cane kind of, and you continue the entire area to the very end, to the very last minute. So you can perform here. You can see that I'm right exclusively on the Eustachian valve part of it and we perform and finish that with single catheter ablation. This is a very interesting case. Perhaps you guys are the very first ones that are seeing this. I just added this a few weeks ago. This is a case of Parahysian. I wanted to show you how it is nice to be able to use eyes for that as well. Interestingly enough, you see that the transition is almost in V3, but I assure you that this was Parahysian. I'm going to show you. So we know that this is a region of the Hiss and you can see my, this is my HD grid and I make an open window, which means that I look to both atrium. This is my mapper, does map both A and the B. So my catheter is through the tricuspid valve. Half of it is in the A, half of it is in the B. And of course I tried to get this entire area. And when I do that, you can appreciate that this is my mapping system that's showing a very nice fast activation through this very area, which was very close to the region of the Hiss. And I have been using cryo for about 17 years now and thank God we have never had any issue using cryo. But here you can appreciate that this is my ablation catheter, cryo catheter. You can see A and B. I don't know if this is a potential or not, but very close to each other. And at the same time, you can see that I'm touching the Hiss catheter. You see this yellow one is the Hiss catheter, I'm touching it. You see the artifact. And here you can see that that is a very, a cryo catheter comes to the region of the Hiss. And later on, you're going to see just the ice ball is going to be starting there. But let's look at this. So we start here, you can see that this is some artifact here. So we went cryo on. We don't do mapping or anything. I just go cryo on. If I don't terminate it within 10 seconds, I redo it, I reposition it. If I mean that if I, accessory pathway doesn't go away. So here you can appreciate that, interestingly enough, look at this one, within seven seconds the accessory pathway went away. But you can see very interesting thing. You can see the Hiss on the Hiss and the Hiss on the ablation catheter. But again, if you are using cryo, as long as you keep looking at that and there is absolutely no increase in AH. So you would be able to immediately come off and you're going to be fine. So here you can see the ice ball here. And here you see now we got adhered. That time we were just not even adhered. So it was about maybe some degree close to zero or so. And here, as soon as we are done, this is after the ablation, you can still see a very nice Hiss on the ablation catheter. And this is what happened, interestingly, about four or five minutes ago. That's what you see, AH prolongs and you have the block. But please don't panic. Actually, the reason this happened, I gave 18 milligram of adenosine. I always give adenosine just to make sure that the pathway is not coming back. So 17 years of using cryo, thank God, we haven't seen any block, but with the antireceptal accessory pathway and parahysion, it is very forgiving. And here you can see that, here it is where actually you see that the accessory pathway was gone within seven seconds. Now we are going to switch the gears. We are going to talk about ablation of AFib. Mansoor, I'm sorry to interrupt. There was a question maybe you could answer before moving on. There was a question about candy caning your catheter for a CTI ablation. How do you do that just with ice? It sounds like most people are more comfortable watching that on fluoro, especially as you turn it around. So how do you do that with ice? Excellent question. Yes. Basically, so if this, I'm going to be showing it this way. So this is a CTI, this is ablation catheter. You just bring the ablation catheter into the CTI and you start gently pushing, gently pushing. And as you are gently pushing, you just go then curve it completely. Sometimes you can come towards the region of the hiss and curve it completely, but you have to be able to see it on ice. So in my lab, interestingly enough, the ice is in front of me and my mapping system is on my right-hand side. So I look at the ice almost 99% of time for everything and 1% or 2% on my mapping system. I'm so used to using ice. So you want to make sure that you position your ice catheter somehow inside the right atrium that at all the time you are able to see the ablation catheter. So you want to put it in the home view and you don't want to see a shadow of the ablation catheter. You want to see the ablation catheter very bright, means that all the waves are going through the ablation catheter, means that the ultrasound is nicely in the same angle with the ablation catheter. And by just looking at your ablation catheter, you just go then slowly. Either you go over the CTI isthmus and put a little bit pressure and because it is pretty thick and you're going to be fine, or you just can go towards the hiss region. And sometimes when you do that, it may want to go inside the right ventricle. And should that happen, if you're using the FJ curve, maybe the best thing is that to use the F curve as opposed to J curve so it doesn't keep going into the right ventricle. But should that go to the right ventricle, you can make it entire curve completely curve and then you pull back from the right ventricle and let the curve go. So you would be able to get the candy cane sitting on the isthmus. Great. Thanks. No problem. So I'm going to show you some basic LA anatomy to help with ice movement. The reason I'm showing you this is the use of the ice. Remember, we put the ice inside the left atrium, so during the afib ablation as well. So let's look at it. This is my mapping system. And here, if you appreciate here, you can see the left superior, left inferior pulmonary vein, right atrial appendage, right superior, right inferior. Let me break, let me go inside this structure and show you from inside because the ice is inside. So we are going to, as if you are looking at the ice, I want you to understand that image is this way. Left superior and left inferior pulmonary vein, correct? So if I go ahead and counter-clock my ice catheter, as I'm looking at the left superior pulmonary vein, if I counter-clock my ice, I'm going to see this structure. If I counter-clock it too much, I see the left atrial appendage. But if I counter-clock it enough that I don't see the left superior pulmonary vein, neither I see the left atrial appendage, I see this very wall. So that wall, I would be able to ablate. And that is the anterior part of the left superior pulmonary vein. So if I'm looking at the left superior pulmonary vein, I'm just looking, we are going one vein at a time. If I clock my ice, I'm going to see the posterior part of the vein. I don't want to see the vein. I just want to see the antrum of the vein. I want to see a wall. I'm going to show you on the ice. And I go ahead and ablate that area. So I know exactly I'm not inside the vein, I'm not burning inside the vein, I'm burning the antrum side of it. If I go ahead and continue clocking the ice, right there, what am I going to see? I'm looking at the posterior wall. I just want to hold it here. Remember, imagine that you are standing in the left atrium. You're sitting on the mitral valve and looking at the posterior wall. If you always think, and while you're doing this procedure, imagine as if you're sitting on the mitral valve. You're looking at the posterior wall. So this makes the movement, the maneuvers, much easier. Because while you're sitting on the anterior valve, you're looking at the posterior wall. If you look at your right, means counter-clock it, you're going to see the left superior pulmonary vein. Counter-clock it more, you're going to see the left atrial appendage. If you keep clocking, you're going to see the posterior wall. If you keep clocking more, as we see here, you're going to see the right pulmonary vein. You're going to see the posterior wall and more posterior wall, and I'm going to see the right pulmonary vein. If I clock it more, keep clocking, and now we are going to be able to see the right pulmonary veins. And this is the right upper and the right lower pulmonary veins. And we observe one pulmonary vein at a time. So this is the right superior pulmonary vein. Let's look at the right superior pulmonary vein. If I continue clocking my eyes, I'm going to see the anterior part or septal part of this right superior pulmonary vein, correct? Because I clocked it. So I burn it there. If I see the right superior pulmonary vein with the eyes, and this time I counter-clock my eyes, I see the posterior wall of the right superior pulmonary vein. I don't see the vein, I see the wall posterior to it. So let's look at it, we are doing an ablation of left superior pulmonary vein. Let's look at it. This is the left superior pulmonary vein. My eyes catheter is inside the left atrium as you notice here. I just went ahead, I clocked my eyes catheter. So when I clock my eyes catheter, I don't see the left superior pulmonary vein. What do I see here? I see that antrum of the left superior pulmonary vein. So I just need to put my ablation catheter there and burn that very wall from here to here. I'm done burning the posterior aspect of the left superior pulmonary vein. I know I'm not inside the vein because you cannot see the vein. You just see the wall. You were seeing the vein before you clocked your eyes. So since you clocked your eyes, you just see that wall, you do not see the vein. And you can see that very nicely. You can see that how tissue reaction here, and so it is going to be pretty safe. Of course, you are going to see here, of course, you have this one. It would help you, your mapping system, that you are in the posterior wall. And here, majority of the time, almost always nowadays, I go 50 watt. But I do not stop because I look at it with eyes, we continue burning. I keep moving. If the temperature probe of the esophagus shows the temperature is going up, I just go anterior. I keep burning. I go somewhere else, but I know I'm going to come back there. And I have the memory of it. I know where the eyes is going to look like, where I would come back here, there again. So here is the left superior pulmonary vein. If I go then counterclock my eyes, what am I going to see? I'm going to see a wall, that wall. You see, I am neither seeing the left superior pulmonary vein, nor seeing the left atrial appendage. I am just seeing that wall. That wall is between the left superior pulmonary vein and the left atrial appendage, right there. And I'm ablating that very well. And you see that ablation, you always want to see very bright. And here, if you notice here, if I clock it, I see the vein, but I don't see my ablation catheter because my ablation was anterior to the vein. So if I go then counterclock my eyes, I would see the ablation catheter right there. You see, that's ablation catheter. So now if I go then counterclock my eyes, I would not see the ablation catheter. I would see the left atrial appendage. So I'm between these two structures. I'm between the left atrial appendage, left upper pulmonary vein, and these two my thomps are the area that I'm burning, is the ridge between those two. And we are just burning here. So you can appreciate here, we are burning actually, this is a coumadin bump, kind of where the ligamentum martial goes through the ridge, left atrial appendage, left superior pulmonary vein. This is the ridge, and this is the ablation catheter sitting. And you can see how nicely I know that where I am burning. Sometime I just go to the other side and you have to burn on the appendage side of it. Because remember, this is all, this area has to be majority of time ablated. Right there. This is the venous side of it. Again, this is another case. You see my mapping catheter is inside the left superior pulmonary vein. Here I'm doing the crina between the left superior pulmonary vein and left inferior pulmonary vein. And this is a crina. Here you can appreciate again, left superior, left inferior, crina. This is ablation catheter. And of course, I have my mapping system as well. And I know I'm in crina. So we are looking at both images at all the time. So right inferior pulmonary vein, another example, this is right inferior pulmonary vein. So this is right inferior pulmonary vein, again. Now that I am seeing the vein, I'm neither posterior nor anterior. I'm just at the roof of the vein. If I bring the ablation catheter down here, I'm at the floor of the vein. I'm neither posterior nor anterior because I see the orifice of the vein. Exactly right there. I just brought the ablation catheter to the inferior part of the right inferior pulmonary vein, release the curve, going to the superior part of the right inferior pulmonary vein. Superior part, inferior part. Now let's look at it. We put the mapping catheter inside the right inferior pulmonary vein. Remember sitting on the mitral valve? When I'm looking at the right inferior pulmonary vein, if I counter-clock, I'm going to see a wall. That wall is the posterior part of the right inferior pulmonary vein. I just burn it. I don't see the vein. I have already done the superior part of it, inferior part of it. Now I counter-clock my eyes. I'm doing the posterior part of the vein. Right there. And of course, again, you see it on your mapping system as well, that you are in the posterior part of that very right inferior pulmonary vein. So if I'm looking at the right inferior pulmonary vein, this time I go and clock it. Remember, you're sitting on the mitral valve, you clock it more, you see the septal part of that right inferior pulmonary vein, which is right here. You don't see the vein anymore. You did the superior, inferior part of it, you did the posterior part of it. Now you are doing the anterior part of it. And sometimes you can see your lesion actually, the lesion formation, which is mainly because of the edema formation and stuff. So you see it. And of course, the moment you see that is happening, this right there, you want to move on and go to it because you don't want to cause a steam pop or so. So it makes it very safe to be able to see all this lesion formation many times during the catheter ablation. So here is the lesion formation, you just see it there. This was the right anterior part of the right inferior pulmonary vein. And here we are in the right inferior pulmonary vein, anterior part of it. And you can appreciate it here. Really sometimes I tell my techs, why did you stop burning? They say, oh, we didn't. It timed out. You can see that sometimes you can do all the veins with single burn from the beginning to the end. This is sometimes it really stops. And we have done perhaps all four veins with one burn. Here let's look at the roof line. My eyes again is inside the left atrium. I have the right superior pulmonary vein. I have the left superior pulmonary vein. What is the area in between? It's going to be the roof line, correct? So if I ablate from here to here, I can do a continuous movement of my ablation catheter and you can see lesion formation here. I just need to burn from here to here. So I see that how continuous my lesion would be. I see that if I'm missing, you know, I'm going to be able to come back to that area and ultimately make sure that I get clearly, you can appreciate here. This is another patient. Patient is already in AFib. You can see right superior pulmonary vein, left superior pulmonary vein. And this is the descending aorta and you can appreciate that this is the roof between the left superior and the right superior pulmonary vein. So you can make a roof line just by looking at your intraocardiac echo and burn from here to here and finish that entire roof line. Remember, you do have your mapping system as well, so that would help you as well. So you know that you're really burning there if you're at the very beginning, if you have any doubt. How about the floor line? So if you would be able to look at your left inferior pulmonary vein and get you, you know, to the right inferior pulmonary vein here, we are getting, this was a case that we are doing the geometry right now, activation with this grid catheter here. And you can see that my catheter is inside the left inferior pulmonary vein, right inferior pulmonary vein. So what is going to be in between? This is going to be the floor line and this is a descending aorta. So I just need to, you can see here, it goes from left inferior pulmonary vein, as I showed you on the mapping, just went to the right inferior pulmonary vein. And the area in between is going to be, of course, the floor line. And here you can see on the mapping system that you perform a floor line from the... So here, this is during the case, interestingly. This was in a fib. As we are trying to perform, we were trying to start a posterior wall. We were just getting a little bit more organized rhythm. And as we are trying to finish the posterior wall, you can appreciate that it went to a slow attack and some extra beats and terminated the tachycardia terminated here. But when you look at that, when you look at this interestingly, you can see that the posterior wall is dissociated here, but there is still posterior wall there. Many times it is epicardial. You've got to go down, find that area and then make sure that, you know, find the earliest spots, get rid of it and make sure that your posterior wall, of course, is completely without any voltage. In some cases, you may need to do ablation of the coronary sinus. Here, I usually don't go above 35 or 40 inside the coronary sinus. This is for persistent, of course. And here you can appreciate that the catheter is coming from the distal part of the coronary sinus. And, but with the ice, you can also look at it. This is the ablation catheter inside the coronary sinus. And this is my decoupler inside the coronary sinus. So I would be able to see that I'm really touching the wall. I know that bubble formation. And remember, mapping system may have more delay than the ice. So you can, even if it comes out of the CS, you can see it immediately. And here, I'm doing the endocardial aspect of the very coronary sinus that I was burning. So I'm doing the LA part of that. I was doing the epicardial. Now I'm doing the endocardial. Because of the shortage of time, I didn't put the LA appendage, but I'm going to just put a SVC appendage here. So you can see, this is the SVC. This is my circular catheter for mapping. Right atrial appendage, which means this is anterior part of the SVC. Ablation catheter here. So you know the septal area is going to be somewhere here. So we are doing the posterior wall of the SVC here, ablating it. If I advance it towards here, I'm going to be ablating the anterior part of this very SVC, like by the right atrial appendage. And if I go into the SVC, I usually have to use the F-curve, and you can do, again, a candy cane here, and just make it. And then when you have this candy cane, you can just go down, rotate it 360 degree, and perform this entire SVC with one circle of 360 degrees. We are going to now completely switch the gears. We are going to go to the VTAC ablation. I'm going to show you a few things of RVOT and RVPVC ablation here. Let's, again, look at the structure seen in the home view. You can see the CTI. You can see the region of the HISS. You can see the right ventricle and RVOT. So in order for us to go, of course, we are going to go place the ice inside the RV. Sometimes it really results better visualization, especially for the RVOT. You can see the RVOT from here, but if I place the ice inside the RV, here we went to the RV. You see that those two dots are in the RV. I just go ahead and clock it. I'm inside the RV with the ice. I can see the LV. If I continue clocking more, I'm going to be able to see the right ventricular outflow track. And here you can appreciate the RVOT here. So you can see here that this is RVOT and this is PA. So this is a kind of upside down view, like patient legs are here, feet are here, and patient head is this way. So this is upside down view, and you can see the RVOT. You can see the pulmonary artery, right coronary cusp and left coronary cusp. So you can appreciate the proximity of them to each other. Here you can see that the ablation catheter here, the PVC was coming a little bit inside the pulmonary artery, but the problem was that, you know, if I put the ablation catheter, this valve is not going to let me touch this tissue very well. So it would prevent from a good contact. So what you can do when you see that that area is above the valve, again, you can go in a little bit here like that, and you can perform the candy cane maneuver. Here you can pull it down, curve it, and right now I just bent right on top of the valve. As opposed to coming this way, I came here, and you remember this is upside down view. This is a pulmonary valve, RVOT, pulmonary artery, and this is ablation catheter. You may do, you know, when you do this candy cane maneuver and you curve, it give you a better contact. And you can also do the upside down, and now you can see a real view that head is this way. It is like a pediatric kind of echo, and the feet is this way, and you can see that RVOT, and this is a pulmonic valve, and this is my ablation catheter, a candy cane coming right above the pulmonary valve. Have a very good contact. Again, you can go back and forth, and you can see it here that I went back up, and you can see this kind of reverse view. You can go ahead and remove your U-curve, pull it back slowly, and here you can see that again, if you are in this area, let's look what is adjacent to it. So if you cannot get it from here, of course you can see the right pulmonary cusp right there. That's why we say that, you know, you have to check both many times, and look at that. You can see now my catheter is in the right pulmonary cusp, so this is RVOT and PA. The ablation catheter is in the right pulmonary cusp, and you can see the same patient, RVOT, PA, right pulmonary cusp, but this time ablation catheter is right on the other side of it, right here, right here on this side, and if you, of course, go a little bit further, you see the left pulmonary cusp is there. So, here you can see the longitudinal view of it. You can see my ablation catheter came to the right pulmonary cusp, as opposed to here, my ablation catheter going to the RVOT adjacent to the right pulmonary cusp. Here we have it here, here we have the ablation catheter on the other side of it, and that is in the ablation catheter, right pulmonary cusp, and RVOT is on the other side. So, it really helps you with the maneuvers. This is another case that, interestingly, you can see that sometime how you see that Dr. Asibatam very elegantly has shown us this, that this, you know, the muscles go beyond the pulmonary valve, and you can clearly see it. This is extension of RV muscle into the pulmonary artery, and I had to go above the pulmonary valve and go on the top of the muscle to be able to get rid of this PVC. This is an example of the PVC ablation, which is originating from the right ventricle. So, if you notice here, this is a V1, so transition is very late, two was positive, you know, three and ABF, I believe was a little bit still positive, but interestingly enough, you can see, let's look at this to see where this PVC was coming from. So, this is my ice catheter, you see the Eustachian valve here, this is, that was a CS, and my ice catheter is in the right atrium. You can see my ablation catheter, I have made a U-curve, and I'm at the lateral view of the tricuspid valve. So, this is a septum, this is a lateral, this is a tricuspid valve, this is a right atrium, this is a right ventricle. You can see the ablation is right under the valve, right there, and here you can see ablation actually came to the right atrium, you see? Then you say, oh, I just saw that atrial activity. Yes, because the ablation just came to the atrial side of it, I released the curve, go back and go inside the right ventricle under the valve. So, this is a right atrium, this is a valve right ventricle, and I'm right under the valve, and this PVC was interestingly, was coming from this very area, which was lateral part of the RV, right there. And of course, you have your mapping system, and you can create the geometry as well as the voltage mapping, which is very crucial. So, here you can see the medial side is CS RV RA, and this is the lateral side, and again, you see the RA, and here you can see that that was the very early activation which was right under that tricuspid valve. Again, this is a right atrium, this is a right ventricle, and that is a very area. And the medial AV were very late, so, and this is the CS, and this is the right atrium and right ventricle. Here you can see during the ablation catheter, during the ablation, interestingly, the patient developed a lot of nice PVCs, and I've been following this patient for several months and he's doing pretty well. So there are no more PVCs at the end. So another example of the ablation of PVC, this time originating, again, originating from the right ventricle, but I want to show you how ice is so crucial to see this stuff. Look at this, RA, RV, and RVOT, and this is my ablation catheter. You shouldn't be satisfied with this view. Why? You see the ablation catheter, but you have no idea where your ablation catheter is touching, where it is. You just know that it is at the base of the RVOT, but you don't exactly know what it is. Don't be satisfied. This is my ice catheter. Why shouldn't I just go ahead and put this ice catheter inside the RV by performing anterior tilt? And as soon as I perform the anterior tilt, I was able to see this is my ablation catheter. And you can appreciate the ablation catheter was right by that papillary muscle inside the RV. And I was about 20, 25 milliseconds early, but I said, let me go to the other side of it because we had a small R-wave on the unit. And then as soon as I put my ablation catheter on the other side of it, I was able to get another 10 millisecond earlier, and there was no R-wave on the unit, and this happened to be a very good, very successful procedure. Actually, this was a redo procedure from another hospital. It was noted that they had done it in the RVOT, but if you notice here, this is way at the base of the RVOT, and you can see that the catheter is sitting very nicely snug there. How about the catheter ablation of the coronary cusps? If you're doing the coronary cusps, so you're going to advance your ablation catheter straight towards the coronary cusps. You are not going to perform a candy cane in the descending aorta as I'm going to show you next. So you're just going to go straight towards the coronary cusps. Here you can see the ablation catheter is right there. So my eyes is showing the non-coronary cusps, and you show the left coronary cusps, and this is the left main. So if you clock the eyes, you always see the left coronary cusps in the kind of home view, but you have done a little bit advanced. You see your eyes catheter is close to the aorta. So on the top, it is always non-coronary cusps. Why? Because the septum is here. The hiss is here. But if you counter-clock your eyes at that view, you're going to see the right coronary cusps. This is we had clocked it, and we saw the left coronary cusps. You can also see that short view from the RV and short axis. This is again another left. You can see the very left main here, and you can put the color Doppler, and being able to see the color Doppler across the left main. You can also see it from the left atrium. I showed you just earlier today that if you put the eyes inside the left atrium, you can also see the left atrial appendage here again. You can see the LAD and CERC, and if you go ahead and counter-clock it, you would be able to see the left main coming to the view. Why is it important to see them? Because you can put your ablation catheter there and tag it on your mapping system so that you know how much away from it, so you don't need to do an angiogram. So non-coronary cusps here, we counter-clocked the eyes a little bit, so you see that we see the tricuspid valve stop. And now you're going to see the right coronary cusp. The other one was non-coronary cusp and left coronary cusp. So here you can see the right RCA here. And again, as we mentioned, if you go ahead and advance your ablation catheter towards this RCA, you can tag it on your mapping system here. Just quickly put it at the osteum for a second or so, tag it on the mapping system, and believe me, I have seen some physician actually they try to do the U-curve in this area, and very likely there is a likely that you can dissect this arteries and stuff. So this may happen. So if you are very careful and look at it, you can just put it and tag it. So here you can see a short access view, non-coronary cusp. Why is it non-coronary cusp? Because the septum is here. You don't need to memorize it. Why this is left coronary cusp? Because left atrial appendage and left atrium is here. So the remaining one is going to be the right coronary cusp. Where is my ablation catheter here? Actually here, I just performed a little bit more clockwise rotation, and I see the non-coronary cusp and the right coronary cusp. And my ablation catheter was in the right coronary cusp, such as here, right there. I'm sorry, it is the right coronary cusp. My ablation was in left coronary cusp. And then here you can see the ablation is at the junction of the left and the right coronary cusp. Here you can see the ablation is at the junction of the left and actually non-coronary cusp. And next you are going to see the ablation catheter actually is in the non-coronary cusp, which of course, as we know, you know, atrial tachycardia comes from that very area. So this was actually a patient with atrial tachycardia coming from the non-coronary cusp, and you can appreciate that ablation catheter is inside the non-coronary cusp. Here you can see the non-coronary cusp, this is ablation catheter, and this is atrial tachycardia. And we were very early on the ablation catheter. And as soon as we start burning, so the atrial tachycardia terminated into sinus rhythm. Here you can see that No more atrial tachycardia So last we are going to talk about ablation of the LVPVC's Either you can go retrograde approach, of course or antigrade approach depending on where you think your PVCs are But I almost always perform the U-curve and candy cane inside the descending aorta I believe it is much safer to do so. How do I know that I performed it? I am able to see that green mark goes down. So when I'm advancing towards the ascending aorta I'm going to be able to see this tip of the ablation catheter looking up means that there is going to be a U-curve ahead of it. So another example in a different patient again, you can see that ablation catheter is going up You're going to be able to perform You know U-curve here and you're going to see that 1, 2, 3, 4 is going to become 4, 3, 2, 1 So as I'm going to advance this here you can see that it's coming towards the Ascending aorta and of course, you would be able to see through your eyes image that this catheter goes You can prolapse the catheter through the aortic valve into the left ventricle So PVC from endocardial part of the LV summit. This is one case I would like to show you. You can appreciate that this is a PVC. It is a nice R wave on V1, 2-3 wave are positive. And if you look at this, you can appreciate that this is here. This is eyes view of it and you can let's compare them with this. This image was adapted from McAlpine. It is a courtesy of Dr. Tong. He gave it to me. So this is aorta, aortic valve, pulmonary artery, LV. And you can appreciate here that this is the left main. So you can see the pulmonary artery here. You can see the left main. So you know that that is the territory of the LV summit, but that is going to be endocardial aspect. This is a very area of the left main. This is a very left main without any color. Here you can see that ablation catheter goes in. I go ahead and perform a U-curve, come back and sit right under the left coronary cusp right here. So if I want to just go then compare these two images, you can appreciate this is ablation catheter. This is ablation catheter. This is that triangle of the, you know, epicardial aspect of it. But here we are doing the endocardial aspect of it. We are just doing in the under the left sinus valve salvo. Here you can see this is ablation catheter and we are performing, you know, ablation. And here this is the PVC and we just went RF on here. And interesting, we didn't have many beats, just, you know, no PVCs after that. And you see that PVC was eliminated. You can see that here and you can see that how this tissue becomes white here. So it means that, you know, I'm very nicely snug with the tissue. You have to make those changes in the tissue wall, especially in the LV, to be able to get rid of these PVCs. Look at this. You can see how nice this lesion is. And you can see that ablation catheter is very snug with the tissue. Of course you can release the curve and go straight on top of it and touch it this way. And here you can see that my catheter is straight going. So I pull the curve back. I release the curve and pull it back. So this is one case of ablation of PVC from aortomitral continuity. For this one, usually, as you know, we go retrograde. But for this one I show you why I had to go and integrate through the mitral valve. Here you can see that this is a left atrium. This is a left ventricle. This is a mitral valve aneuplasty. And this is my ablation catheter going through it from the left atrium through the mitral valve, LV, here. And actually the reason I went and integrate because this was a mechanical aortic valve. So as you notice here, I'm just right under the mechanical aortic valve. But I have a distance. I see that I'm not touching it. So it makes it very clear that you can see how close I am to the aortic valve. You can appreciate that this is a St. Jude mechanical aortic valve. And that's my ablation catheter. I'm very close to it, but I'm not touching it. And here, this is my ablation catheter. And then you can see that as soon as I move the ablation catheter, I release the curve, you can see that lesion formation here, which was right by the aortic valve, mitral valve. So aorto-mitral continuity happened to be a mechanical aortic valve. And lastly, we are going to talk about a PVC ablation of papillary muscles. This is a retrograde approach. I'm going to show you first. So to visualize the papillary muscle, of course, we want to place the eye catheter again inside the right ventricle. As soon as we go to the right ventricle, you release the anterior curve. You want to make sure it is neutral. And you go ahead and clock this eye catheter. The first one you're going to see would be the posterior medial pap muscle, because it is on the posterior wall. If you clock your eyes a little bit more, you're going to see what? You're going to see the anterolateral pap muscle, because it is not on the posterior wall. It is, there is a distance between that and the posterior wall. That is a septum. So if you prefer, again, you can do the right and left, toggle the, you know, to toggle the mirror image, you can press the left, right, and left button. Again, the reason I do it, I'm used to it. You may not want to do it if you are not used to it. But the reason I do it, when you be used to read, you know, parastenal long axis view of the 2D echo, this reminds me of that. So I understand the view a little bit better, LA, mitral valve, LV, and pap muscle. And here you can see that that is anterolateral pap muscle. But as we all know, it's not a good option to go retrograde for this anterolateral pap muscle. Why? Because it is not going to be sitting. You see that my catheter, there is a distance between the catheter and the pap muscle. It is not snug on the very tissue. You can see it's just playing. It's just touching and coming back. So it is not snug on the tissue. And we all know, perhaps the best approach would be the transeptal approach for the anterolateral pathway site. So here, left atrium, mitral valve, you can see that ablation catheter is going through the mitral valve. Here you can see the very papillary muscle, but this time my ablation catheter went through the mitral valve. And here you can see that how this tissue, transeptal approach, I'm sitting on that very tissue, as opposed to retrograde approach. So you can see how snug the tissue is here, as opposed to a distance between that catheter when we went retrograde. Another example of ablation of PVC originating from anterolateral pap muscle. You can appreciate here, actually if you notice that this patient is in ventricular bigeminy, you can see here, you can see that that is the junction of the chordae and the pap muscle, and the PVC is coming from here. I have gone anterograde, and here you can appreciate that this is that very PVC. Here is the V1, V2. There is an M shape, 2,3-ABF are positive. So this was coming right from this very spot. We had a very good contact, and you can see ablation catheter here is very early, and as soon as we started burning, you can see the bigeminy went away, and the PVC disappeared when it was eliminated. How do we visualize the papillary muscles? For the papillary muscle, if you clock your eyes, you're going to always see the anterolateral pap muscle, and you know that there is a distance between that pap muscle and the posterior wall. It is not sitting on the posterior wall, so you know that this is your anterolateral pap muscle. If I go ahead and clock my eyes a little bit while I'm inside the right ventricle, I'm going to see, I'm counterclock eyes a little bit, I'm going to see the posterior medial papillary muscle, which you see that it is sitting on the posterior wall. So that is how you can differentiate the anterolateral pap muscle from posterior medial pap muscle of the left ventricle. There is no distance between the posterior medial pap muscle and the posterior wall. Here you can see another case. Interestingly, this patient has two posterior medial pap muscle heads. So this is one and the other one. So there are two posterior medial papillary muscle heads. If I go ahead and clock my eyes, it's going to be two more pap muscle, which are the two more heads, which are the heads of the anterolateral pap muscle. So if I ask you, show me on the kind of Google map, where is this PVC could be coming from? It could be coming from any of these spots, if you are going to look at it, anterolateral pap muscle. So there is no way that an x-ray would be able to help you to be able to go into those territories and look at it to see where it is coming from. So you can just go then, look at it, and here we are going again, antegrately, and you can see that that is anterolateral pap muscle. My ablation is on the anterolateral pap muscle by the posterior head of it. So this is the posterior head of the anterolateral pap muscle. As I counter-clock it, I don't see the ablation catheter anymore. I see the posterior medial pap muscle. Why don't I see ablation catheter? Because ablation catheter is not there. Ablation catheter is by the anterolateral pap muscle. So if I go ahead and clock my eyes a little bit more, I'm going to see the ablation catheter, and I'm going to see that it is sitting so nicely at the junction of chord A and the posterior head of the anterolateral pap muscle. This is a PVC ablation from posterior medial pap muscle. So I showed you the anterolateral pap muscle. Here you can appreciate that my eyes catheter is actually inside the left H ventricle. Why? So I went through the left atrium into the left ventricle because you don't see any septum. There is nothing in front of the eye's catheter here. So you can appreciate that my eye's catheter actually is inside the left ventricle. So I could see it very clearly. I had gone anti-grade into the left ventricle. Here you can see that ablation catheter is actually this one as a distal side of the posterior medial pap muscle. I go ahead and toggle the mirror image and you would be able to see that this is my ablation catheter, posterior medial pap muscle, and I'm embedded actually at the very insertion side of this pap muscle and the posterior wall, distal to the pap muscle kind of. And here you can see as I'm burning here, you can see this is a posterior medial. This time you see V1, V2, V3, they are M, but there are negative in 2, 3 AVF. So you know that it is posterior medial pap muscle and as I'm burning you can see the lesion formation here and subsequently you can see the elimination of the PVC right there. And then this is the last case, left ventricle. This is the posterior medial pap muscle and you can see how eyes is going to be helping you. This is my ablation catheter in the posterior part of the posterior medial pap muscle. When I look at my eyes, beautiful, I'm sorry, my electrogram, it is very early. But there was a problem there. The problem was that there was a small R-wave on the unipolar, even though I was very early. So I said why shouldn't I just try to go, maybe it is coming from inside, maybe it's coming from other end. So ultimately I just went on the other side of this pap muscle, which is again the same posterior medial pap muscle but on the other side of it. And I was able to burn and actually we didn't have any R-wave in the unipolar here, but here we just were able to eliminate the PVC and ultimately actually I burned both from this side and went to the other side of it and both burned from both sides to be able to eliminate that PVC. And with that I would like to thank you so much. I know it was a long talk but thank you so much for being patient. Thank you, those were incredible images. Let me just ask a couple questions that came through. There's a common theme on a few of them. It's mostly related to discomfort pushing without looking at fluoro. So how do you assure yourself that you're not gonna perforate when you're not looking on fluoro and you're advancing your ice catheter? Excellent question. So initially, interestingly enough, the movie that I showed you today, actually I have about three terabyte of data. So this movie is almost getting to four hour movie. So that part is a completely a separate movie that I would be able to show you. So what it is, basically you don't, when you know the tip of your eyes, the eyes are at the tip of the ice catheter, so when you look at the ice and move and maneuver, by looking at the echo free space at the very leading edge, remember I showed you those two dots? That dot is your ice catheter. So when you see, if you have time, actually this is my own computer app at home, I can just show you but I don't know, I don't think we have enough time, it's gonna be too long, but I can show you that you want to, if you give me a metal that I would be able to not to look at that, if you look at that metal or if this catheter for that reason, if it is very stiff, if you look at the x-ray you perforate. If you look at the x-ray actually you perforate. Why? Because you have no clue where that catheter is going, where the ice catheter is going, by looking at the x-ray. So you don't see a wall of the IVC, especially when you are going from the left side, sometimes you know you have to maneuver and go. So by just looking at the ice itself, by looking at, so this is ice, kind of this is IVC, you look at the echo free space and you keep moving. So you would, even this is actually the reason it is, I love this catheter because of being stiff. Do you know why? Because first of all, I don't, majority of time, I'm by myself, my tech may or may not scrub with me, I do everything myself and I hold the catheter, the ice catheter, so because it is a little bit stiff, you can just overdo it. Let's say if I want to 40 degree clock it to be able to see one view, I make it 70 degree clock and I let it go, it comes back to that 30 degree, comes back, sits there and I would be able to see that wall and do my ablation. But you, you know, using the ice and using photo less technique is like a martial art. You have to start with the white belt, then you have to earn a yellow belt, a kind of, then a green belt, then a blue belt. You are not going to be like, I have cases that you know, these cases they have IV, patients have valves, all those things and you would be able to do it, but that is perhaps for a black belt with few stripes on it. So you want to start slow, but you have to learn the ice. Paul and I, we edited a book which was published last year, all those questions are answered inside the book. The book has almost two and a half hours of this kind of movies in them, so that it would show how you would be able to manipulate the ice by looking at the ice itself, being able to see the ice in correlation with neighbors. So you would be able to advance the ice by looking at the blood around it. If you see a TQ, see where the other blood is going, where the other structure which you are supposed to go, steer it that way, so you would be able to go. But if you're just purely going to use x-ray to put the ice up, unfortunately it's going to cause complication.

catheter ablation

ice catheter

3D mapping systems

ablation procedure

transeptal puncture

complications

left atrium

visualization

safety

efficacy

lesion formation