Thank you so much, Nishant, and thank you, Brad, for the opportunity to talk. And I just want to thank you all as well, the audience, for taking your time out to take a listen to hopefully what I think will be an informative talk. So as you saw on the schedule, we sort of got this teaming up today with a talk on general approaches to a fluoroscopy-free EP ablation procedure that you may have heard already. And Mansoor Osmania and I sort of teamed up to do basically a two-part series. So I'm going to sort of give an introductory talk on ice basics, something that I think has become ubiquitous, at least in the United States and now beyond, in the EP lab. And then Mansoor is going to sort of go into more detail on the advanced topics. So it's sort of like ice 101 and then ice 201 or 301. So without further ado, I'm going to get started here. Here are some disclosures. So here's an outline of what I'm going to talk to you about today. The rationale for why we use ice in EP, very basic principles of ice catheters, the nomenclatures for views and catheter movement, basic intracardiac views, and some case examples that I think will be illustrative of some of the important concepts I want to talk about today. So of course, it's a catheter-based technology, allows real-time 2D echo imaging of cardiac structures and blood flow. The ultrasound transducer is mounted onto the catheter tip. The catheter is inserted, usually through the femoral vein, and then maneuvered into the heart, typically somewhere between an eight and nine French diameter. And why? Why is this an important topic? As you heard about, I would advocate that reliance on fluoroscopy has significant limitations. Ice allows visualization of structures that you otherwise cannot see with fluoroscopy and even with mapping systems. And ice allows visualization of catheter-tissue relationships in particular, which can be critical for a safe and effective procedure. And then it helps you in the process of elimination of fluoroscopy for your procedures, which there are a multitude of benefits from. And I think I would advocate that we haven't perhaps demonstrated it rigorously yet, but I would hypothesize that ice imaging may improve our success in procedures. So getting more detail into the pros and cons of doing this. So it is really, if you think about it, is perhaps the one real-time imaging modality that we use in EP today. And we can, as a result, image not only the cardiac tissue structures, but all the stuff we put into the heart, into the cardiac chambers. And so as I said, it may improve safety as a result and eliminate or reduce fluoroscopy use. There are cons, of course. Nothing comes without negatives. It does require a new catheter manipulation and interpretation skill set, which hopefully our talk here today and Mensoor's later this evening will help you out with moving forward. It does require an additional access site for vascular access. And there is, of course, an added cost. So here are the available devices in the United States. So many of you are familiar with the CARDO sound device, which is really an adaptation of the GE Acunav platform. And then Abbott St. Jude has their own device as well here. And I'll show you images from both. So I don't really think there's a significant substantive difference between the two. There are some important differences, and I'm happy to go over those as I have experience with both. But basically, I want to go over things more in a generic principle sense and help you understand the principles to get you to that next level of using ice in your EP workflow. All right. So the first thing you want to do is, of course, understand how you move the catheter. So the basic principles of that are, as you can see in the schematic here on the left, your ice catheter has the imaging sector coming out of the tip. Now one thing that's maybe a little peculiar if you think about it is that the fan of imaging comes off from the side of the catheter rather than the front. So the analogy I always like to use is imagine you're trying to drive a car and you're only able to look out the side window. You're not really looking out the front windshield. So you have to be able to drive by doing that, and that does require a little bit of learning. But otherwise, the catheters move very similarly to other catheters that you're familiar with, but in fact, perhaps with a little bit more options for movement of the catheter. I'll go over that in the next slide. But basically, the other issue to know about is, of course, the standard display. So most labs in the U.S. use this type of display. Even though the catheter, we think of going into the body in this direction, we sort of turn it 90 degrees, and as the catheter moves from left to right, the image moves from left to right. So generally speaking, the left of the screen is more inferior in the body and the right is more superior. In particular, you might see folks from the Penn Group, they like to flip that image around, which there's some rationale to that in terms of how it orients with the actual body. All right. So in terms of manipulating the catheter, this is a little bit of a complicated slide, but I think if you walk through this, you'll understand pretty easily what we're talking about here. So like most catheters, you have the basics of, of course, advancing and retracting the catheter. You can rotate clockwise or counterclockwise, but the added features here I've pointed out in all the catheter platforms have this, there's an anterior and posterior tilt and a left and right tilt. And what that does is it gives you a full range of motion. And then there's a friction knob often that lets you lock that catheter into position. And the general nomenclature, as I showed in here in the schematic, is that with the ice fan sector, looking in this direction towards the right on the screen, anterior is towards that sector and posterior is away from that sector. And that's an important, that's an important thing to keep in mind. Sorry, I'm trying to move the pictures out of the way here. All right. All right. So, so here's just a very short video. When you do anterior-posterior tilt, you're moving the catheters left and right, or so your anterior to posterior, depending on the fan is, and left and right to move in an orthogonal direction. And they all come into play, but I'll say in general, I'd say most, most of the time when I've observed this, most folks are just focusing primarily on the AP movement. The left to right is more of a subtle fine tuning kind of a movement where, but there are important places where that isn't an important move to be able to understand and use. So first things first though, getting the ice catheter into the heart. So especially if you're using a procedure that does not utilize fluoroscopy, you have to be able to drive that catheter safely into the heart. And that part of that is understanding anatomy. And the other part is understanding that concept I mentioned earlier, where as you can see in the schematic, it's like driving forward while looking out the side window. And the key there is you have enough of a view on the side window to see the vascular space. And as long as you see that your vascular space and the walls are running parallel to your catheter, generally speaking, it's going to be a safe direction to move. You use tactile feedback as well. And as you move through the vascular structures, you should be able to identify things like venous branches, the liver, and then eventually get yourself into the heart. One very small tip that I'd suggest is we often put the catheter through the left femoral vein. And I did a literature search on this, and there's actually a surprisingly high prevalence of an anomalous connection between the left iliac vein and the left renal vein, which then creates a 90 degree or greater angle between those two structures. So oftentimes when we see on fluoro, you have this very sharp turn, and the catheter doesn't seem to want to go well in that direction. If you anticipate that possibility and you make a very sharp turn, that often is the answer as to why that happens. All right. So once you get in the heart, we all use a standard nomenclature, like a lot of things we do that are rotational, a clock face anatomy. And so this is a schematic that shows you the overarching and sort of clock face view and the different views in that home view that I'll go over. So going from 12 o'clock to 3 to 6, of course, and then to 9. And I'm going to go over step by step each of these. So starting with the upper right quadrant from 12 to 3 o'clock, this starts with what we call a home view. So once you've entered into the heart, this is generally what you land on, a home view. And you can identify the home view by knowing that you're in the right atrium. And we should all, of course, recognize this when you sort of extrapolate from our understanding of transthoracic or even TE echo. And then you have a tricuspid valve, right ventricle. And you should be able to often get a glimpse of the aortic valve. A few tips here. So the heart almost invariably sits a touch anterior to the IBC, so you have to create a slight anterior tilt of your ice catheter to enter the RA in many patients. And once in the RA, you then release that, and in fact, sometimes you need a slightly posterior tilt to see most of the right atrium. All right. So our talk is not going to be free of audience polling questions. So I tried to throw in a few questions. I kept in mind this is a basic talk, so I'm not trying to go crazy on the questions. But I think things that will illustrate the anatomy. So this is our first question. What key anatomic structure can be usually located very near the X mark on this image? So Bachman's bundle, bundle of hisc, CTI, right coronary artery. I see the answers showing up here. I'll give just a few more seconds. I see some answers still rolling in. Okay. I think we've reached steady state. Yep. Okay. So if you can see here, most of you got the right answer. And this is what I expect to see on all the polling questions here. I'm keeping it simple. But this is the bundle of hisc. And I wanted to introduce the anatomic relationships that you can identify through ice and understand better through ice, in fact. So that sort of brings us to these home view variants that we can see. And as I mentioned, you have your RA, tricuspid valve, RV, and all of these views, the aortic valve. But depending on the anatomy, you may see more or less of the aortic valve. You may see the aortic valve more in a short axis or a long axis or even a skewed view. But those are all sort of considered your home view that you can use to manipulate and get into the right views that you're looking for for your purposes of your particular study. And getting to that question I asked about. So the importance of that anatomic relationship for EP in particular. So when we're in the home view, keep in mind seeing the aortic here where it's juxtaposed against the tricuspid valve. We're looking at in this anatomic cutaway you see here a relationship between the aortic valve and in particular the non-coronary cusp of the aortic valve and the proximal conduction system. And why is this important? You know, sometimes you can see your catheter sitting there and you might be thinking, is this where I can find the hiss? And the short answer is this is often the time. I find often you can, it's a parlor trick, but you can often just put your diagnostic catheter based on ice right in that location before you even look at the electrograms. And when you turn and look at the electrograms, you'll find the hiss right there. So it's quite useful to augment your catheter placement. And it'll be very useful, as you can imagine, and I'll show you some examples at the end of this session, where ablation in this region becomes, of course, as we know, some of the hairier ablations that we perform. And that can be quite helpful to understand the ice relationships of that anatomy. All right, so we already went over this, but the correct answer is the bundle of hiss. All right, so we move from the home view, and this requires, if we're just going systematically through this clock face, a slight clockwise torque of the catheter, usually not much more than doing just that. And there are some slight adjustments that you need to make, and you often end up with a view where you can see something like this. So that leads us to another question. So if you could correctly identify, I know that the stuff's moving a bit, but if I can freeze this here in a spot that gives you a nice view. Okay, here we go. So there's structures 1, 2, and 3. So is 1, 2, and 3, which I'm going to go over these because these are, I'm just going to be repetitive here, but look through the answers of identifying the correct coronary cusps. And again, I tried to keep this all very simple, but just to make sure we are all on the same page with the anatomy. I'll give a few more seconds for the polling. Okay, so as you can see, a majority got the correct answer, where number 1 is the non-coronary cusp, number 2 is the right coronary cusp, number 3 is the left coronary cusp. And I'll go over how that, I'll just actually go ahead and keep moving forward, but I'll go over how that relationship can be identified and actually taken advantage of on ice as well. So, but that gets us to this view that I said with just a little bit of a clock, it's essentially the anterior views of the atria and then with a view of the aortic valve. It can be quite similar to a view you can get just on the other side of the valve in the RVOT, and you can often see the proximal coronary vessels. In this right-sided view, you're a little closer to the RCA, so it's more likely that you'll see the RCA as opposed to the left main, which is in the opposite direction from on the opposite side, excuse me, on the aortic valve. And this can be a quite useful view if you're mapping and ablating near the aortic cusps. And just to clear the way, as importantly to note, you can see the relationship here between the aorta in these views and the left atrium. And speaking of the left atrium, then as you move forward a little bit, so actually before we get to that, this is just the answer that we talked about. So how do you identify all that? So here are the hints from this view. First of all, we're viewing from the right atrium. So you need to understand that in the aortic cusps, the non-coronary cusps will be the cusp that is most closely abutted to the right atrium. The left coronary cusp will be the one that's most closely associated with the left atrium down here, number three, and then the RCA is the one over here far to the right. And as I said earlier, another hint is as you see the takeoff of the RCA in this view. All right. So again, with a little bit of further rotation from that view I just showed you, you start to see these other structures. So these are views where some advantages can be taken here. So one is you'll encounter often the ostium of the coronary sinus. And as you can see here, a lot of folks who use ice a lot will actually place their diagnostic catheters in the coronary sinus using ice alone, or at least in augmentation with a mapping system. You can often in this view get a view directly across the anterior interatrial septum, see the mitral valve on the upper right here, as well as a glimpse of the left atrial appendage. And you can see I'm showing a lot of variants. And the other thing to highlight about this is, of course, every patient has a different anatomy, and you have to sort of take advantage of what their anatomy gives you in terms of views in order to let you see the structures you're trying to see. And you have to have in your toolbox different views that say, you know, if I can't see the appendage, well, in this view, what's the other views two or three that I can take advantage of if I'm trying to see the appendage, for example. And hopefully after we've gone through some of these views, you can sort of assimilate all those different tools that they can use to try to image whatever structure you're trying to image. Oftentimes in this view, you can see not just the left atrial appendage, but you can see here not just the mitral valve, but this is the appendage ridge that you can see here. And this is possible to even visualize thrombus in this view, although it's not as clear as some of the other views that I'll show you a little bit later. So with a little bit of clockwise rotation, then you get into a little bit more posterior aspect of the atria, and this allows you to see the interatrial fossa and septum and some of the left atrial structures. So here's another quick question. So correctly identify these anatomic structures. So we're looking at the posterior view of the left atrium. So choices A, B, C, or D. And again, because they're long answers, I'm not going to read them out. A few more seconds for some answers to show up here. All right, so this one's a little bit more distributed. I guess I'm a little surprised, but that's OK. So what we're seeing here is the posterior view of the atrium. And how do we identify structures here? So again, when you make a little bit more clockwise tilt, you often will see the thin portion of the interatrial septum. And if you're posterior enough, you'll see these structures that are posterior and far away from the septum. And what are those? Well, those are your left pulmonary veins. Now, this is an idealized view that we don't always see. But a lot of us call this like a pants view, because it looks like a large person wearing a pair of pants here. But what you're seeing here is, if you keep in mind the orientation, so our catheter is inferior here, superior on the right. This is then the left superior vein, and this is the left inferior vein. So that's number one. And sometimes you can, if you really want to, you can Doppler and say a redo a patient that you're worried about, PV stenosis. You will often see, you can see the relationship between the left inferior vein and the descending aorta. And then you might, in the more leftward sitting esophagus, you might see a view of the esophagus. And this is a useful view for sort of identifying an ideal, a typical location for performing a transeptal puncture, for visualizing the esophagus, or performing a wire exchange, if that's something in your workflow. All right. So moving on from that, then as you continue to rotate, you'll get more and more posterior with your catheter. You start to see even more posterior structures. And this gets to the second part of that question I asked about. As you go more posterior, you will then often align with the esophagus. And you'll notice the esophagus, you'll often be able to visualize, as in these four different examples, a double stripe, or at least a slightly echolucent stripe. And in that, when you see it adjacent to the posterior wall of the left atrium, and you know your posterior because you see your interatrial septum opposite to it, then you can correctly identify that as the esophagus. And I don't do this workflow, but there are many who, in a fluoroscopy-free approach, for instance, will keep an eagle eye on the esophagus while they place a temperature probe. And you can often identify the temperature probe as it passes into view, and in fact move it back and forth up and down along the posterior wall to track your ablation and esophageal heating. So this is also a useful view for especially left atrial ablation. So then getting back to our question, the majority did get it correct, but the idea is that with these different views, you can identify the left pulmonary veins often, which are sort of a good landmark for transseptal puncture and other interatrial steps in your procedure, and then often identify the course of the esophagus. So that's that sort of posterior view. Now, if you keep rotating, then this gets to be a little harder often to see because of the way these veins take off, but you often can't identify one or both of the right pulmonary veins. So when you rotate very posteriorly, the right pulmonary vein, if you think about it, you're in the right atrium, so the right superior pulmonary vein will take off above you and just abutting you, especially if you're heading up towards the SVC. And this is another one of those understanding the anatomic relationships, especially if you're up in the SVC region. As you know, oftentimes this is where we can capture both phrenic nerve from both sides of the septum, and so these tend to be very close structures to each other. And then if you see this, these are a couple of other different examples. And then once in a while, you can also identify taking off from below the right inferior pulmonary vein, as you see down here. And you can see here trying to engage the right inferior pulmonary vein with a mapping catheter where that can be useful. All right, so you keep turning. Of course, we sort of complete the circle. And as you keep turning, you're going to sort of leave the views of the left atrium and come back to your right atrium. And once you're back in the right atrium, you're going to see the more anterior structures of the right atrium. So that can include the right atrial appendage, the crista terminalis, at least the anatomic marker of it, where the change from the pectinated tissues from the smooth tissues can be observed. All right, so I think there's a last question. So what is the typical best view during ablation procedures for evaluation of pericardial fusion with, I should say, with ice? Is it the RV free wall from the RA home view? Is it the RV free wall from within the RV? Is it the LV inferior wall from within the RV or the RA free wall from the RA home view? Paul, maybe I'll use this as a chance to ask a question that came through. If you could go over the relationship between the aorta and where you do a transeptal puncture. Oh, yeah, absolutely. So if I could shelf that for like a few slides, the first case example I wanted to just quickly go over, I think we'll give you some answer to that. That's okay. Oh, yeah, of course. All right, great. So remind me if I forget to mention that specifically, but yeah. All right. So in terms of the poll answer, so there's a little bit more distribution here as well, but most said LV inferior wall from within the RV, and I'll explain to you why that is correct in a few slides. All right. Okay. So that gets us to the next view. So I guess I wouldn't call this 101 anymore. We're starting to get to ice 102 perhaps. I wouldn't necessarily call this 201 yet. So what are the images we can get now we move beyond that home base of the right atrium? So we can see things if we get the catheter into the RV, and that's not just the RV and the LV, but we can see all these other structures, as I said here. I'll show you how we can look at the outflow tract, the left atrial appendage, and even the coronary ostea. So how do you get there, though? So that's important for understanding that one of those earlier slides I showed about how to drive yourself when you're looking at the side of your catheter. So you start out in your home view here, as you see in the left image, and you can then sort of counterclock a little bit so you see instead of at the home view, now you see the tricuspid valve right in front of you. So you know that your tip is right here. Your tricuspid valve is just under your catheter right here. And then as you slowly advance forward, you'll basically see yourself cross the tricuspid valve, and I'll show you a little bit of a longer clip here. So the idea is when you flex anterior from the home view, you're aiming for that tricuspid valve, and you can see here I've had to do a little bit of clock adjustment to keep the tricuspid valve in view. And once I'm seeing the valve, I push forward, and again, you have to keep tactile feedback to make sure there's no resistance. And then once you're in the RV, you release a little curve and perform a little bit of clock. It's very similar to the kind of move to get to the outflow tract to do either outflow tract ablation or even to float a swan. You're sort of climbing up into the outflow tract essentially and then once you do that you're gonna pass the septum and this is looping again so you can see once you're in the RV you see the the valvular apparatus this you're sort of transecting the septum in your ice view and eventually you get into a view where you see the LV and a long axis view and you can see here there's a nice view of the LV inferior base and the epicardial space so these are there are a lot of variants again get back to that principle I mentioned earlier where different anatomies present themselves in different ways you sort of have to take advantage of what you can see and these are just sort of variants that I've written collected over time and this can be a very useful you view especially for LV mapping and ablation so looking from the RV and different this is a very basal view of the RV but you almost see like a two chamber view with a nice view of the septum in cross-section so you can often get that kind of a view this is a different view of that where you can also see a little bit of the papillary apparatus this is a more classic view of the LV chamber where you can see very clearly the papillary muscles in the mitral at the rest of the mitral apparatus then you can also of course get a good assessment of when you have dilated cardiomyopathy and and then if you just continue on a little bit and continue to rotate you start to look upwards more and more you can start seeing the outflow track and the aortic valve apparatus up higher and this is this this is to answer the question and I think in most people's opinion the best view to evaluate for pericardial fusion and that's you have to just think about physics so in our typical EP procedure where a patient is supine presuming a new effusion is is free-flowing it's going to collect in the dependent space and if you think about the way the heart typically sits while a patient is supine the space behind the LV at the base in particular is going to be the the most likely place that a free-flowing effusion will collect of course the caveat is we often we do see not often but there can be loculated effusions in different spaces so if you see hemodynamic issues you you can scan through other spaces to look for that especially if for whatever reason for instance that effusion starts to clot off and such but this is typically the best view for a free-flowing effusion and in my workflow at the end of every single case I'll stick the ice catheter back in the RV and take a quick look in this area it really lets you relax in and not be as worried about any any post procedural hypotension that you might encounter so getting to your the answer to this then the LV inferior wall from within the RV especially towards the base is your best view for that effusion so beyond that LV view then if as I said if you then continue to clock your catheter just like you're going to the outflow track which you actually are then you can start seeing those structures in the outflow tract and this left upper view is sort of the typical sort of view you land on where you can see here this is a glimpse of the aortic valve and as you look with your sector out into the aortic valve you can see the relationship between the aortic valve and the pulmonic valve and this is a really nice view to let you see you know when you perform for instance septal RVOT ablation the relationship between the left-sided and right-sided outflow tract regions and in particular when you see that you can't get it from the RV outflow track you can often see how close you are when you go in from the left side and when you're when you then take a retrograde or even transeptal approach which which is often not as effective of course then if you look over here you can get if you advance the catheter carefully often you can get a much clearer view of that outflow tract I'm not going to keep going past the outflow into the pulmonic arteries that's going to be part of ice 201 that that where you can start seeing all kinds of interesting stuff as you get out farther farther that way but suffice us to say that that I think I'm in sore is going to be talking to you about some of that kind of stuff and then if you change the views a little bit with a little bit left or right twill sometimes you can get a long view of the aortic root and other than just looking interesting and cool there's actually quite a good use for that so so say you're performing a retrograde aortic approach to get into the LV and to try to prolapse your catheter well this is actually a really good view to see the loop that you make the catheter prolapsing and this is a typical view I try to look at for performing that step and then oftentimes again you take what you can get with the anatomy but in the correct type of patient anatomy you can often see as you can see here a glimpse of the left main ostium all right time I think we're doing well all right so then so then if you just keep pulling back a little bit and and then now rotating just a tad from that aortic view some you know sort of just just go clock counterclock until you can start seeing it in view as you pull back you'll start to see the left atrium sort of as you scan across the aorta as you can see in the upper left here and look into the left atrium now why is this view useful and interesting well this is one of the other views where you can often visualize the left atrial appendage reasonably well these are a few examples of seeing the left atrial appendage and in fact you can see here a nice view of the ridge and what I've been I've been sort of taken by is in this view is how often you see a really thick ridge there and it's no wonder that this area is at least at least perhaps until recently with some of the ablation approaches we use this is often an area of typical reconnection that we can see but that relationship is very useful and in fact you can often see your ablation catheter I think I might have an example of that later on sitting on one side or another of that Ridge all right all right so then to the last part of this I just wanted to show you some case examples that really illustrate how you can leverage your ice skills this is this is some basic stuff still though and so this is a case of a 69 year old woman with hypertension dyslipidemia or failure preserve ejection fraction PAF failed meds so refer for catheter ablation with RF we're using and a zero fluoroscopy approach so how is ice useful for this you might have seen this in the previous talk if you were there for dr. Singh's talk but there are many ways to skin a cat but this is this is the approach I use for transeptal and this reminds me of the discussion or the question about the relationship between the aorta and the septum so before I answer that so so what I typically do is to take a view where you can actually you can see on the top here what is this structure here so we see the left atrium chamber here we see the upper portion of the inner atrial septum here because we're in the right side and so this structure that's going up linearly is the SVC and what you see here is you can use this view to advance the wire without using fluoroscopy and using the wire as you can see in the bottom left panel you can advance your sheath over the wire you can see that sheath passing over the wire right there you can see right there where the sheath ends and the wire begins and then you can remove your wire as you can see in the middle panel here and as you pull the wire back then you have your sheath in place and then as you have that sheath apparatus up in the needle up in the upper portions of the septum in the SVC you can perform a drag down and then land in your in the appropriate location of the inner atrial septum using that more posterior view and what I like about this view is then you can try to identify a an ideal position to perform your puncture and you can see a glimpse of the left pulmonary vein system here so we know we're posterior enough to be able to to direct the needle and that's a I'll advocate that with ice this is one thing that's a huge advantage over fluoroscopy in that you can you can much more precisely direct your puncture site whether it's anterior posterior high or low depending on the application you're using and then and then once you are in the right location the location you'd like this is this is I use an RF catheter and you can very well see this is another nice view of how what you can see is is a very clear relationship between the tip of your needle or dilator and the the walls of the endocardium so you know you're very safe with the sheath and dilator in this position you're not going to puncture the posterior wall because you can see that relationship very clearly now you might ask what about the if what if you're sort of abutted against the wall out of the plane well you can obviously move your your ice catheter back and forth to see the relationship between the sidewalls and as you can see here blowing a few micro bubbles lets you know that you're in free space territory and then once there you can continue to use that view to move your sheath in place as you can see in the left and then advance your mapping or ablation catheter down at the left atrium you can see there or use this for a wire exchange as you sort of cannulate the left inferior pulmonary vein in this case all right so actually I'm gonna before us just go over this next case just mentioned let's see let me think of a good example of that I'm gonna have to go back a little bit to show you maybe at the end I'll show you but the in terms of the relationship I'll just stop here and just talk in terms of that question of the relationship between the interatrial septum in the aorta so if you take a traditional fluoroscopy approach we all do so we all learned at least those of us who still were old enough to learn a fluoroscopy based transsepal puncture as we do us as an SVC drag down and and we look for that sort of those those couple of hops that first hop lands us we learn traditionally on the aortic knob and some folks will even put a pigtail catheter in the aortic root to identify that on fluoroscopy and then the second drag down puts you into the interatrial septum well you can see all of that on ice and you don't of course need a pigtail catheter in the aortic space and what is invariably true with the anatomy even if all the variants that that that humans have the aorta tends to sit more interior and superior to the interatrial septum and depending on how vertical versus horizontal the heart is it can be completely just a relationship of anterior to posterior from the aorta to the septum or completely superior to inferior in a more vertical heart and and and the way I sort of judge that is you sort of do a you do a dry run so to speak not pulling the sheath and needle down first but just pulling your ice down and you can see as you pull down and you see the aorta does it require a clock to move posterior to see the septum which tells you it's more of a horizontal approach or just a straight pull down which tells you it's more of a vertical relationship between those two structures so hopefully that's answering that question but this is the second case where I wanted to show you some of the leveraging of ice that we can use as a more even more simple cases 74 year old woman with hypertension no other significant medical history atrial fibrillation and flutter had three catheter ablations before perform before before at another Institute with including CTI ablation with block confirmed 20-30 minute waiting period at those other procedures but a year later actually vexingly developed recurrent atrial flutter and referred to us for repeat ablation and this is to highlight this issue that ice really gives you an advantage of over every other modality so given so in this kind of a case what I do is is you know I don't use de novo CTI ablation ice I will actually avoid that if possible just for cost and access savings but in a patient who is coming back for now fourth procedure you know you throw the book at them basically and what I find is invariably ice will identify the problem and in this particular case it's a it's a very common problem that you're seeing here so so so what do you see is the problem here I didn't do a polling question here but I'll just ask I'll just ask rhetorically so so so what the issue here if you go on to the next slide here is in the CTI the CTI CTI ablation we all like to say they're really easy except when they're not and and those not cases are the ones that vex us and take hours and hours and more often than not the reason for that is illustrated both anatomically here by drawing and and here on ice you can see two examples of this that I've collected and and what they're what we're showing here is that here is our trust in the bottom one tricuspid valve CTI and what you're seeing here is a eustachian ridge and sometimes it can be so prominent and you can see them actually sometimes contracting so you know there's conducting myocardial tissue there and more often than not you'll find that that is the area that you need to ablate additionally to to confirm CTI block and so in this case that I showed you an example of this we're happy to use a visualized catheter but you almost invariably will need to then create that that Shepherd's crook or loop to get and tug back or tuck back into that eustachian ridge and and in this case if I showed you that map here no okay so so in this case then ablation here I actually had this early in an earlier version but in this case you could see a conduction pathway through that zone and just a little bit of ablation that within a few seconds of turning on RF the patient's CTI reblocked and and patient has had not not had recurrence now ice can also let you see some weird things so what is what is this what does this show you so again didn't have a polling question but this is a home view RV RA tricuspid valve so this was a de novo diagnosis of an Epstein anomaly that we diagnosed with with ice and how do we know that well this there's that apical displacement of the valve but also we were recording nice ventricular signals on the the anatomic atrial side of this valve so so so you can see all kinds of things with ice and these are just some more of a flavor kind of things as we're wrapping up so some other ideas of where you can use ice this is a parahissian 80 that we ablated using with ice as a very important part of our fluoroscopy free approach to this of course that's this is one of the hairier places to ablate but what we found is marking mapping on the right side the ablation spots that we want is a plate were as often as the case sort of overlapped with our hiss recordings so we went retrograde aortic and you can see here on ice that we were able to visualize placing the catheter directly in opposition to the best sites from the right atrium and did not see a hiss signal there and were able to successfully ablate here and just as a note to do we just marked here the the ostium of the coronaries so that we knew where they aren't were and also a sort of skeletal view of each of the aortic cusps so so so one example where ice can be quite helpful and this is another one where we performed I'll be summit ablation using ice and I didn't have a good recording here but this one was sort of a cool one because this is a patient we did without fluoroscopy who had dextrocardia so using cardo sound which is a registration of the ice images to your electroanatomic map we could see all the chambers before we performed our transeptal so we know where everything is in relation to everything else in a patient with dextrocardia and you can see here this is this is actually rotated as you can see so everything's pointing right word as is typically the case all right so to wrap up I hope I've given you a few a few highlights here so we talked about how ice utilization requires a new skill set we went through some of that skill set at least the basics of it I hope we could I could illustrate how ice use uses real-time visualization of cardiac structure is really the only modality we have currently to do that and use of all cardiac structures to significant detail can be easily achieved from basically to two locations of the catheter with with slight rotations from the RA or within the RV slash RV OT we have to keep in mind that we only see one 2d plane one sector so we have to be able to have the skill sets to move that catheter around know where it is and and and know where to go and ice along with mapping systems of course really helps us get to that point these are the key tools to allow us to both either reduce or eliminate our use of fluoroscopy during our EP procedures and so I'm going to wrap up by just acknowledging and thanking my colleagues here at the Brigham we have a wonderful team and I think you've heard talks from at least a few of our other faculty members and and I'll wrap up here here's my contact information if any of you are interested and want to reach out to me for any any questions or anything all right all right thank you so much Paul that was great there are a few questions here I guess some people want to know what types of cases are you routinely using ice for it sounds like not for CTI ablations but what cases do you go into where you say I'm definitely going to use an ice catheter yeah so so so for sure all complex ablation so anytime I'm going to be performing a transeptal puncture you know ice is essential for my workflow there are folks who use mapping systems for transeptal but I find ice so helpful for for the transeptal and then beyond once we're in the left atrium for mapping identifying structures for more or less all ventricular mapping and ablation I'll use ice and then I don't use ice as I mentioned for first-time CTI ablation basic CTI ablation and I don't use ice for most SVT's certainly if we know we're going to be forming a left-sided pathway ablation then then I'll use ice for the transeptal portion and then how confident are you in your ice imaging would you skip a TEE before a left atrial procedure because you think you can clear the appendage would you skip an angiogram for a cusp ablation you can see the corners so those that's the that's the great question that's that's I think we need to answer as a field right now I feel confident that I can visualize the appendage very well and reliably in nearly every case but frankly I don't think the data are out there to support doing that standalone and if you ran into some trouble even if you had a stroke that was likely completely unrelated to a left atrial thrombus if you if you if you then are standing in the courtroom and saying no I didn't do a TEE in this patient with a high CHADS VASc score I don't think you were going to be you're gonna have much to stand on now in terms of the coronaries that's another situation I think just as a start you know the typical locations you're often ablating and say the aortic root are generally reasonably far from the coronary ostea but I think that even with that I use ice very carefully to try to evaluate and define the relationships between where our catheters are going to be likely ablating in the coronary ostea and so so I rely on that and for most of those afloat tract ablations I am NOT performing coronary angiography anymore I feel I feel a fair amount of confidence with that but but that's I know from you know from talking to other colleagues that use ice extensively there's there's some variation to that approach and maybe this is someone graduating trying to buy equipment for their labs but can you talk about the benefits of the st. Jude versus Acunav yeah so so let me tell you I want to start with the caveat so of course I don't I really want to try to remain unbiased between them I'm not trying to sell one company or another I use both catheters currently with the what's available right now the Cardo the big advantage of the Cardo mapping catheter or ice catheter of course is that it integrates the ice image into the mappings image so you can create an anatomic shell with your ice image and that can be quite useful especially I find for like afloat tract ablation but even for some left atrial ablation some folks like to use it in that way but I will say that the image quality is inferior to the st. Jude image quality the st. Jude clearly has a better image quality now it's and then a disadvantage though of the st. Jude system as well is it's very clearly a stiffer catheter so you have to be very careful about manipulating that especially in the vascular system before you get into the heart and even into the heart of course but I think frankly and you'll hear a lot of that from men sore later today but he uses the st. Jude system extensively and he has a terrific you know safety record with that I think is it's it's all about you know obviously experience and knowing what you're what the tool is and how to use it so I use both and I think you can you can do fine with either one honestly okay great and then there was one more question here about monitoring the esophageal temperature probe for floralist procedures how do you do that yeah that's one of that falls under the category of there's many ways to skin a cat so I mentioned during the talk that some of my colleagues will try will visualize the temperature probe on ice in the esophagus and when you can see the echo brightness of the the recording electrode the temperature of the thermistor you can identify that and move that up and down on ice I don't do that what I do is I actually fix a quad mapping catheter to my single electrode temperature probe and then then plug that quad capital catheter into the mapping system and I know there's you know I don't know if Will Sowers on the line here but but he has some really interesting data about the potential antenna effect of the metal electrodes whether it's the temperature probe or the quad catheter so I actually purposely ops offset the electrode at least a centimeter away from the recording electrode so that at least theoretically you're minimizing that the risk and then as a result you can see the you can see the the mapping catheter and and by extrapolation the temperature electrode location on your map your systems sorry long no that's great all right I think I got through most of the questions here if anyone else has any other questions you can unmute or if anyone else has comments feel free Sean my unmute it can you hear me yeah we can thank you for doing this that was great good introductory talk on ice we agree with your points of relying on ice and thank you for doing this I have a question about 3d ice I think that's coming there's some availability already and I know that's not a nice one-on-one question but it's very impressive what it can do I guess the question is with the added cost it will come with that do you feel like there will be a significant role for 3d ice that's a great question as well I mean I think we are we're still in the the steep slope of where technology is going to come out with an industry is going to come out with all these really cool tools and toys and we have to as a field I think justify that it's going to actually improve our procedures and I've seen a lot of that that work and it's very cool actually and and I think the other thing that that's underlying your question about that with 3d ice in particular is is if you those of you who already use ice it's the one thing I didn't mention my talk also is especially if you're creating an anatomic shell it's a it's a manual process so it can be quite tedious the the mapper has to has to create contours and that's that can introduce inaccuracies and it slows down your procedure and I think one important step to get that to where it might be actually useful for our workflow is an automated contouring which which I think is something that's going to happen in our near future and I think once we put that together with 3d imaging I think the possibilities are going to be quite interesting for what how we can apply that to our EP procedures yeah thanks so it may not even be the 3d aspect of it as much as other features it'll be digital steering to make 3d but that digital steering will you know avoid all that catheter manipulation potentially yeah exactly because there's another thing I didn't mention is the practicality so there's a for obviously in the audience they're gonna be a variety of they're gonna be a variety of settings in the EP lab you know if you're in an academic setting you'll have a fellow and one of you can try to be assigned to the ice one to the ablation catheter but you know if you've done that already you know the hands get crossed over and in the way there's you know there's there's a lot of stuff we're trying to manipulate and so I think things like automated catheter manipulation might improve that and certainly if you know private setting where you're standing there by yourself you know it's it's your to you to your two hands are not enough often for all the stuff you have to move around yeah yeah thanks Paul you're welcome

intracardiac echocardiography

ICE

electrophysiology procedures

2D ultrasound imaging

catheter-based technology

fluoroscopy

mapping systems

visualization of intracardiac structures

catheter-tissue relationships