If you're interested, there's a great podcast on Radiolab called Octomom. I heard it a couple weeks ago and just thought it was great. Okay, so I don't have any financial disclosures to report related to this presentation. This is an audience response. I'd love to get your feedback here. So I'm doing the conference today as a cardiology fellow, as an EP fellow. And four, because I was forced to join. Okay, so mostly EP fellows, a couple of cardiology fellows, a few practicing EPs, and there's some poor souls who were forced to join. So I apologize. I don't know who you are, but hopefully it'll be worth your while. And then let's go to the next one here. Over the course of my EP training, I've had no exposure to practicing with low or no floor techniques, minimal exposure, some exposure, a great deal of exposure. Great. So, you know, I think times are changing. When I came out of fellowship, I mean, the idea of not using fluoro was crazy. I mean, I don't think even a single minute was devoted to the practice of fluoroscopic reduction, but it's very clear that probably because the technology is changing and because this is becoming more and more mainstream, a lot of you as fellows are exposed to low fluoro, which is great. If you're not, honestly, and I think this is probably true for your life as an electrophysiologist after training in general, which is that most of what you'll be doing as an attending electrophysiologist 10 years from now will be stuff that you learned after your training, right? So all of this low fluoro stuff, I started a couple of years into my training from scratch. And I think it just goes to show most of us that are practicing, if we look back on what we knew as a graduating fellow and how we practice now, so much of what we've learned is actually on the job. So I'm not going to spend a lot of time on this. I think justifying why no fluoro is fairly straightforward. Radiation is bad. We know that the risks of potentially cancers are increased in practitioners using radiation, interventional cardiologists, EPs. All of my interventional attendings as a fellow had cataracts after being exposed for years in the lab without wearing lead glasses. And of course, exposure to the patient, right? So the ability to minimize our exposure to the patient is really important. And usually the radiation effects are what we stress in terms of the benefit of not using fluoroscopy. But I cannot understate the importance of the ability not to wear lead. My first case as an EP fellow in San Francisco was a nine-hour VT case. And they kept calling in different attendings. And finally they called Scheinman in. I'm like, oh God, it's really bad if you have to call Scheinman in, right? Because that's like sort of the final frontier. But I was standing in that room alone because all the attendings sit outside in the control room where we trained for nine hours with lead on. And I went home and I felt like I couldn't walk for several days after that and thought, I don't think I can actually do this. I don't think I can do it. It was so physically painful. I got used to it. But the reality is we know that orthopedic injuries are actually extremely common amongst invasive cardiologists. When I was interviewing for jobs, a lot of the spots that were opening up in these EP practice groups were people that were retiring because of back pain. They just couldn't do it anymore because of back pain. So even though this is something that you have to think about projecting to the future, wearing lead for 15, 20 years for a lot of people is actually a really big deal. And it can really significantly impact your longevity as an electrophysiologist. So not being able to wear lead, for me, has actually been a huge, huge game changer. I actually have more energy. My stamina has gone up in cases. It really can't be overstated. So again, we know that this is a little bit of an older slide. I suspect these fluorotimes are probably not, these doses are probably a little less now. But even so, if you look at a standard AF ablation procedure, that's like the equivalent of 830 chest X-rays to the patient. So we are able to essentially, for many of these procedures now, completely eliminate the use of fluoroscopy. I'll come back to this, but I think the next frontier really is going to be in device implantation. It's great. You can do a four-hour, five-hour BT and not wear lead. And then you do a IV and you're getting blasted by radiation. So the technology is here. I just think it's a question of innovative people and industry working together to make that happen. This is a paper that many of you may have heard about. It was a paper that was basically a case report where they looked at nine cases of brain cancer in an interventional cardiologist, and then received an additional 22 cases from around the world. So they had 31 cases in this cohort. And they found a high percentage of head and neck tumors, the majority of being GBMs, which is obviously super bad. The really interesting thing is the malignancy was left sided in 85% of these physicians. And we know that the left side of your head is exposed to more radiation than the right in a standard lab setup. So the suggestion here is that this is probably not just a play of chance and could be related to occupational radiation exposure. So it's serious stuff. And now we have the technology to wean ourselves off radiation and fluoroscopy. I think it really is paramount for us all to try and do that. So where did this begin for me? So this began very early on. I just want to pay homage to two of my mentors, Shepal Doshi, who is in Santa Monica, and Brett Gidney, who's in Santa Barbara. You know, very early on in my career as an attending, I went to go visit their lab. And they were doing zero fluoro stuff at a time where not many people were doing it. And I think it's worth recognizing that these guys and many others were really the pioneers in developing these techniques. And they were doing it at a time when people didn't take it seriously or thought it wasn't that important. So I say that only to acknowledge their contributions. But also, you know, reiterating the point that you're learning as an electrophysiologist never stops, right? You're always going to be learning. In my job, you know, I'm lucky enough to have the ability to take a little time every year. I try to visit at least one or two labs every year just to see what other people are doing. And, you know, it's amazing how different practitioners are in their approach, even with respect to low fluoro. This is one of the things I want to stress is that the technology is so good that your low fluoro workflow or zero fluoro workflow may be really quite different than mine. And it's about what you're comfortable with, maybe how creative you are. So there's a lot of room for creativity here. And that's actually one of the things that makes it quite fun. But I would encourage you, you know, for the EP fellows that are graduating to really make a point to not get locked into your ways as you do things and seek out, you know, other colleagues and see what they're up to. It's been really helpful for me. Okay. So this is just a graph that I put together of my fluoro times when I came out of training for AFib. So if you look, I came out of training in 2011 and you can see I was kind of all over the map. There were some cases where I was using 70 minutes of fluoro and, you know, sort of maybe got a little more comfortable. And then in 2013, you know, I will be honest with you. One of the main reasons I started doing this is because AFib ablation just became quite tedious and boring. Yeah. Give me a good pathway any day. I think many of us went into EP because like the satisfaction of mapping a pathway or figuring out like an unknown SVT, something that makes you think is really rewarding. And then all we do is sit around isolating veins all day. Not the most exciting thing in the world. And once you become technically proficient at it, you know, PBI is actually a pretty straightforward procedure. For me, it was actually becoming quite boring. And I thought, well, you know, what can I do here? And, you know, that's when I started focusing on fluoro reduction. And I will say that in my experience, the single most important step in reducing your fluoro time is saying, I'm going to reduce my fluoro time. Just that simple cognitive switch in your brain about paying attention to fluoroscopy, asking yourself, do I really need to step on the pedal? That results in really great reductions in your fluoroscopy time. Just the simple awareness. When we started moving forward, you know, we really started trying to develop workflows that were very specific. And we were able to get our, you know, fluoro times down 10 minutes. Then we were hovering around five minutes. For a while, you know, for me, the transeptal was kind of the final frontier. That was the step where I felt probably the least comfortable as far as not using fluoroscopy. So for a long time, for my AFib cases, I would keep my lead on in the beginning, do the transeptal, and then when the transeptal was done, I'd take my lead off and be lead free for the rest of the case. Eventually, we got to the point where we started doing our transeptals without fluoroscopy. And so, you know, I haven't worn lead for an AFib case in many, many years. So again, I would say that getting back to this idea that the most important thing really is just being aware of your fluoroscopic usage and just being committed to trying to not use it as much. That'll get you very far as far as reductions are concerned. Okay. So I know you guys have a lot of lectures that are going to be coming up by some really esteemed teachers, and there will be some redundancy, which I think is great. I'm, you know, really curious to see what other practitioners will be sharing with you as far as ice and so forth. It's really hard for me not to talk about ice when we talk about a zero fluoroscopic protocol. Obviously, you have to be proficient with ice in order to do this properly. Now, I will say, like, if you look at someone like Brett Gidney, I've never, I mean, when I saw his ice skills, I was like, I can't ever do this. I mean, he's able to, you know, map out, like, you know, small tributaries of coronary arteries with ice. He's just sort of a Jedi master with it. And, you know, I found that to be very intimidating. So my ice protocols aren't, you know, as heavily influenced by ice usage as his are. But again, that just goes to show that there are lots of different ways to skin a cat. The technology is such that you can choose many, many different ways to reduce your fluoroscopy. No matter what you do, obviously, though, ice is going to be critical. I'm just putting this here because maybe some of you have already started using 3D ice. We have not done that just yet here in Hawaii, hopefully soon. But I think this is going to be another game changer. You know, things like Watchmen and left atrial appendage occlusion, I think using 3D ice will be very useful. So I think this is going to be one of those disruptive technologies that actually makes the whole process of, you know, understanding anatomies, visualizing the heart, et cetera, et cetera, even easier. So I think things are only going to get easier with respect to being able to be less reliant on fluoro as time goes on. Okay. So this is just a point that I want to make about ice. What I've done here is I've taken a CT that we used preablation from several years ago, and I've merged it with my left atrial anatomy. And the point that I want to make is that, number one, I think many fellows coming out in training now are probably extremely capable with ice. When I came out of training, my ice skills were really quite rudimentary. So I suspect this is old hat to many of you, but I'll just reiterate it in any case, which is that the best way to really become comfortable with ice is to use ice. You just got to use ice. I'm agnostic as far as technology is concerned. This is not meant to be a CARDO talk. I will just share with you that, you know, we use CARDO here. I don't actually have the same gene mapping system. If anything, going low fluoro using the Abbott system is probably easier. But some of the things I will talk about today are unique to the CARDO system, and that's not meant as a promotion of CARDO, but more just as a reflection of my own experience. So one thing that I found to be very helpful, if you do have the opportunity to use this SoundStar catheter, is the ability to use this fan. Some of you are probably really adept at being able to translate two-dimensional structures into three-dimensionals. I'm not. That's never been a really great skill of mine. So I really want to rely on as much technology as I can to really understand what I'm looking at. And I found the fan to be extremely useful because it shows you exactly what you're looking at. And one of the really key things about ice that is important to know is you can look at the same structure from different vantage points, right? So this is a very traditional view of the aortic valve and cross-section. And most of you probably know, if you put your catheter, your ice catheter, into the RV, right, just across the valve, and you look up, you're going to be staring at the aortic valve. And you can see here, what I've done is I have the CTL lined up, so you can see exactly how the ice catheter and the field of view is cutting through the aorta here. You can also get a very similar view of the aorta by staying in the right atrium and posterior tilt, right? So almost always, if you're in the mid-right atrium and you posterior steer your ice catheter, oftentimes the aortic valve will come right into view. And you can see you're looking at the aorta here still, but you're just looking at it from another vantage point. And then you'll begin to notice little things, and I'll show you this later, but what I found is actually, if you're trying to visualize the coronary arteries, you see the right coronary artery much better from the right atrial view of the aorta, and you see the left coronary artery and the left main much better when you're in the RV. And you can kind of appreciate that here, you're cutting right through the right coronary artery here. So the more you look at these structures, you'll notice little nuances that will allow you to understand where you are and use the technology for your advantage in your ablation. So again, I think most of you are familiar with it. This is like ice 101, but as you put your ice catheter into the right atrium and you clock it, you're going to start rotating the beam posteriorly. And as you do that, you'll encounter various structures. So from your home view with the tricuspid valve in the aorta, you'll get to the left atrium, the left atrial septum. If you keep clocking, you'll have the left-sided veins come in, keep coming, you'll see the right-sided veins eventually. And then if you come all the way back, you'll be looking at the crista. So this is just an example of that. Here you can see I'm clocking the catheter. You'll see me cutting through the veins here. This is the left-sided veins. If you look on the right, you can see the carina in the middle and the two veins. And as I clock, you can see how you're sweeping through the posterior wall. That was the right lower pulmonary vein there. And if you keep clocking, you'll usually bring in the right upper pulmonary vein. So this is, I mean, everybody's anatomy is a little bit different, sometimes maddeningly different. But for the most part, if you sweep through this sequence, you should be able to predictably see structures that you would be expected to see. So I'll tell you, when I started doing this, I feel like the right atrium is like having the training wheels for most things in EP. It's perhaps the most forgiving chamber of all, or at least I think of it as the most forgiving. And so I started my low floral stuff just in the right atrium, and it was really simple. I just decided to see whether I could place my CS catheter without using fluoroscopy. This is my own personal workflow, and I know others don't necessarily create a right atrial map, but I like to have an entire map of the chamber that I'm in. I find it to be useful. Even in an AFib, having a right atrial map, I find to be useful. If I have to come back and do a CTI line, I have a right atrial thread. My map is there. If I want to see the relationship between the SVC and the superior right atrium and the right upper pulmonary veins to see if maybe it's like a far field signal, I just pull up my right atrial map. So it takes very little time with our current technology to create geometries, and I just like really having a structure to look at and utilize. So basically, I'll go up to the IVC, straight up to the SVC, drag down toward the hyst and the annulus. I'll usually try to get my catheter into the CS and then in the lateral wall after that. So I use the same sort of workflow every time as far as creating the geometry, and it takes maybe two or three minutes. It doesn't add a lot of time. Once I have that map, I'll go ahead and place the CS catheter. So this is just an example of that. Let me play. Sorry. I had this set to music way back when I thought that was cool, but I think without music is just as good. So you can see basically I'm just painting. I'm using the pen array here, but really any multi-electrode catheter would be acceptable. And I honestly find when I go back to trying to place a CS catheter using fluoroscopy these days, actually I'm like really bad at it now. Having the ability to actually see where your CS is, see it in three dimensions, you can look straight at the os if you want to, you can understand the takeoff of the CS. I find it to be so much easier in terms of being able to place this catheter. Incidentally, I've started doing this for biVs as well. I actually fam using like a DecaNav catheter. I fam the CS from the axillary vein, and my median time to CS cannulation is about 30 seconds. So it's really transformed, I think, my ability to not only reduce fluoro, but to create a more efficient workflow. And one of the arguments that I hear is that it's really important for fellows to learn the fluoroscopic way first. And I think that's probably still true. But I'll tell you, we have a general fellowship here, and since I don't use fluoro, I'll oftentimes let them place the CS catheter or place catheters, especially if they're going into EP. And with very little supervision, I found that fellows can pick this up very quickly. As long as you have a good map, and you're able to see the CS, putting a CS catheter in without fluoro is really quite straightforward. So the next step was, OK, how do we get from there to, let's say you're doing an SVT study, you don't want to necessarily break out an ablation catheter, but if you don't want to use fluoro, how are you going to place your catheters? Well, we're going to do an SVT study, at least in our lab, what we decided to do is I use a Decanav, which is a multi-electro catheter, and basically create my geometry using the Decanav. With CARDO, at least, you do need to have enough matrix to visualize catheters that are going to be using impedance primarily for visualization. So it is important to get a pretty adequate matrix. And once you do that, though, it's very easy to place diagnostic catheters as well. When I use the Decanav, the advantage of that is because it's a decapolar catheter, I'll just use this as my CS catheter. So here you'll see basically coming up with the Decanav. This is obviously not real time. But again, it just takes a minute or two. I end up placing that into the CS, and then I just come up with my diagnostic catheters, RV, HRA, and HISS. And so a simple SVT study can be done without any fluoroscopy using this technique. And like I said, there are other techniques as well, but it really has aided our ability to not rely on fluoroscopy for our SVTs. So what about Flutter? I don't know. I've heard different things. I've had a chance to go and talk about low fluoro stuff, and I get different responses. But I find that more and more people are just using ice routinely for their typical Flutters. And I don't do that myself, but I will say that I have really gone to a very low threshold for breaking out an ice catheter. All of us who are in this business have probably had the misfortune of saying something like, well, it's just a typical Flutter. It'll be really quick. And then six hours later, you're wanting to pull your hair out because it's the worst case you've ever done. So typical Flutters, in my opinion, can be some of the most humbling cases you'll encounter. And ice can actually be an extremely valuable tool if you're having a hard time. So if the anatomy is challenging, if you want to, obviously, we have contact force catheters now, but you can use it to see whether you have adequate contact. I find it particularly useful in patients who have prominent eustachian ridges, if they have pouches, trabeculations, and it's very easy to visualize the CTI using ice. So basically, here's an ice image, and you can see here, this is the IVC, and this is a prominent eustachian ridge here. So you can understand if you're trying to do a CTI line, and you're dragging back, how this will behave as a fulcrum, right, and actually can prevent you from getting good contact into this region right underneath it. And without ice, you might not know that it's there, and you might be burning all day trying to figure out why you can't get block or termination, whereas if you have an ice catheter, you'll know immediately why you can't. So what you're probably familiar with is if you have this prominent eustachian ridge, or even if you don't, it's useful to prolapse your catheter. So you can see here on the ice image how the catheter is prolapsed, and I'm actually curled underneath the eustachian ridge here, or eustachian valve, that allows you to get into that region and burn in an area where you otherwise might not be able to burn. So I find ice to be very useful in typical flutters. Like I said, I don't use it routinely. I'd be curious to know from the audience if others are using it routinely, but it certainly can be very helpful in challenging cases. And again, you know, the view of the CTI is really just your home view. Sometimes you need to clock it post your anterior a little bit just to kind of get the ideal view, but you should be able to see your catheter drag all the way back from the matricular side of the CTI all the way back to the IVC. So just being able to have that visual feedback is incredibly helpful. Left atrial appendage viewing, I'll just say a little bit about this, but I think most of you know that, you know, you can get really good views of the appendage from the PA or the RBOT. I find the left PA to be very useful if you can get your catheter up there. I found it, I don't know if others have this experience, at least for the SoundStar or for the ice catheters that we use, it comes in either eight French or 10 French. I find it very difficult to get the eight French ice catheter up into the PA. I don't know if it's the stiffness or, you know, the maneuverability. I find it much easier to use the 10 French, and actually that's why I've gone back to using a 10 French. But whichever catheter you use, if you get it out into the left PA, you'll actually be looking down at the appendage. You can see here the beam looking straight down, and on the right you can see a nice view of the appendage here, and you can see the circumflex artery coming in and out near the top. So, you know, I don't do this. I know some practitioners are using this to rule out left atrial appendage thrombus prior to their case. I think, you know, if you're comfortable getting these views, it can be a really valuable tool and could save you some time, maybe prevent your patient from getting a TE if they don't need one, or certainly if you're ablating and you want to appreciate where your appendage is. And, of course, more and more people are starting to use ice for left atrial appendage occlusion. I think 3D ice will probably make that even easier, but even with our current tools, visualization of the appendage is really quite achievable. The cusps are another really important structure that you can visualize beautifully with ice, and, you know, obviously, you know, I don't know when the last time I saw, like, a run-of-the-mill RVOT PVC or VT. It's been probably a year. It seems like every one of these summit VTs are coming from some other region other than the RVOT. So my approach, and, you know, I think many of us probably in the meeting now would echo this, is that I, for any outflow truck, you know, case, I plan to map the RVOT, the cusps, and the AIB as well. So I just have a good idea of where the PVC is coming from or if I need to sandwich the lesion, consolidate by approaching it from two different regions. So we all know that these can be very challenging cases. So having the anatomy is really critical. So, you know, ice is standard for any of my outflow truck cases. You can see the right coronary cusp, the non-coronary cusp, and the left coronary cusp very, very nicely. As I mentioned, you can see the relationship here between the cusp and the posterior RVOT. Depending on the anatomy, the posterior RVOT will be often close to the right coronary cusp. Sometimes the anatomy varies a little bit. But one thing I have noticed is that if you want to, rather than doing a coronary angiogram, you can use ice to delineate your coronary arteries. As I mentioned, I found that seeing the origin of the left main, it's much easier for me to see it by taking my catheter into the RV, whereas if you pull back into the RA and go posterior, I can visualize the right coronary artery much easier. And I'll show you a picture of that in a second. But suffice it to say, you know, creating a good map so you really understand these relationships, number one, you don't need FLIRO to do it. You've got all the tools here between ice and your mapping. And two, having that ability to visualize this really complex space in three dimensions is critical. So this is what I wanted to show you here. Here you see I'm in the right atrium and you have a beautiful view here of the right coronary artery. And then oftentimes if you're using, you know, CARDO sound, you can actually have someone take a contour of the right coronary artery. So you have a good idea of where the takeoff is and that will make your ablation safer if you decide to burn in the cusps. So I'll talk a little bit about floralis transeptal. You know, I'll say the floralis transeptal was sort of, for me, the final step. I mean, obviously the transeptal, you know, for a-fibs or really any other case where you're doing one is a potential for a really, really bad complication. And so I was pretty comfortable using low floral before, you know, taking this on. But I will say that, you know, it's really not that hard if you follow a few basic rules. And obviously this is one step where you really can't do without ice. I mean, you absolutely have to have ice and a comfort with ice, you know, you have to be able to trust your ice skills in order to do transeptal without fluoro safely. So, you know, we started with the BRK1. I know probably many people are still using that needle. Later on I switched to a Baylis, which I'll explain in a second why that is, but you really can do this with either one. I found it helpful and again, it's not necessary. I know plenty of zero fluoro operators who don't need to visualize their transeptal needle on their mapping system. For me, it's just an extra bit of information that complements the other information I have to make me all the more confident that I know exactly where I am. I know how posterior, how anterior I am, where I am with respect to my target, where I want to cross. So I really find it to be useful. But again, certainly not essential. The Baylis, I won't go into this much, but basically the Baylis, as many of you probably know, is set up in such a way where you can actually plug it into a pin box and it allows you to visualize the tip of the Baylis on your mapping system. So you're kind of tricking the system into thinking it's a bipolar catheter when it's really just a unipolar signal, but it gives you a nice discrete sort of icon, which I'll show you in a second, that allows you to see exactly where your transeptal needle is. So before doing that, we were doing something similar with a BRK1. I don't know if folks are still doing this, but again, this was part of the fun of trying to figure this stuff out. And I don't purport to be much of an engineer. I know some EPs are like really great engineers and can figure this stuff up on their own. I happened to have a someone, a tech, that was just like a genius with this stuff. He was sort of like MacGyver and he was always trying to jerry-rig things and, you know, really push the limits of how we could use the system to its full advantage. So initially, actually, we were able to visualize the BRK1 by basically hooking up an alligator clip to the stylet in the BRK1 and then jumping that to one of the CS poles. Again, I wasn't as comfortable with this technique. I don't use it anymore because it does mean that your stylet has to be out while you're dragging it down. That means the stylet is actually what, you know, you're sensing off of. I had never had any complications from it, but the stylet, as you guys know, is pretty sharp. So dragging that down can make people a little nervous, but it is possible. And again, I did this for a couple years really without any trouble whatsoever. So you don't necessarily need the bailless. If you want to visualize with the BRK1, you can. The bailless, you know, there's some different options here. Obviously, the needle is an RF needle. So, you know, I like it because it doesn't jump. Like if you have a atrial septal aneurysm or, you know, a thick septum, you know, it doesn't tend to jump as much. So, you know, if you worry about, you know, perforating, it just gives you a nice clean entry point into the left atrium. And I choose to use this bailless wire, which is a low-profile wire that's curved. Before we use this, I just took a 032 and actually made one of these myself. So I would just take a J wire and I curled it around a bunch and basically created a very similar situation. I just use this now because it's just one extra step that I don't have to worry about. But either is fine. You could also just use a straight wire and put it into the left upper corner vein. But I like this curve because it's very easy to visualize on ice. You know, you can see it very clearly in the left atrium and it's big enough so you're not going to perf through the appendage and it gives you a rail to have your transeptal sheath go over. Especially if you have a thick septum, it's a little bit challenging. Not COVID. I tested negative. Okay, so what's my transeptal access workflow? The first thing is, how do you get your wire into the SVC? Well, this is like, you know, there are times when you are doing a zero fluoro protocol when you're pushing a wire without seeing it. And you know, that was like heresy, you know, when I was training. Like the rule was you should never push a wire without seeing it and there is some truth to that. What I will say is, and this seems maybe self-evident, but one of the most important things I think you should honor if you're doing zero fluoro protocols is never push anything if you feel resistance. And again, that may seem really obvious, but you just have to train yourself. If you are pushing and you feel resistance, then you have to stop. And that starts with access, right? So when I get access, if I use a long wire to get up into the RA, I'll push. And if it's going cleanly and I don't feel any resistance, I'll continue to push. But if I feel any resistance, I'll stop. Now, usually what I'll do is I get access and I take that wire to the SVC. But that means that I have my ice catheter, and I'll show this to you in a minute, basically focused on the SVC. So I actually don't see the wire until it appears in the SVC. If you have weird anatomy or something, that wire can go into the right atrial appendage. You know, these wires can perf. It doesn't take a lot. So you just have to be really careful if you're using a wire and you're not actually seeing every step of the way where it is. Once I get the wire into the SVC, I'll advance the sheath. Now I have a rail. I know it's safe. I can take the sheath from the groin into the SVC over the wire, and I visualize the sheath going up into the SVC. Once the sheath is in the SVC, I'll put the transeptal needle into the sheath. And this is a really, this is a nuance, but you, and I'll show you on some pictures in a second, but you need to make sure that your needle is pointing in the right direction. So you can confirm that on ice, or if you're visualizing your transeptal needle on mapping it, you can really see whether it's pointed toward the septum or toward the lateral wall. Obviously, you don't want to be pointing toward the lateral wall. So that's, that's really critical. Once I'm in position, I will do the transeptal puncture, and I'm using the intra-atrial septum view on ice. It's critical, and I'll go through this again, but maybe this seems obvious, but you absolutely have to see the tip of the needle on ice. It's not good enough to just see the shadow of the needle. Before you puncture, you want to make sure you actually see the tip of the needle pressing into the septum. That will tell you exactly where your needle is. Anything less is really not, not a good situation. You want to make sure you know exactly where that needle is. So once I'm comfortable with the needle, I will go ahead and come on RF, if you're using Bayless, that's what you do, and this is a really key point. When you come on RF, the needle will jump across the intra-atrial septum, but your dilator may just be a little further back. So just because the needle is across doesn't mean that your dilator is across, and one of the complications that I'll show you what can happen is, even if you're back just a millimeter or so, you can actually dissect the left atrial wall. If you're not truly across the septum, you can get into a tissue plane, and you may think that you're going into the left atrium, and even on ice, it may look like you're going into the left atrium with a wire, but you're actually going through the plane of the left atrium. So that's one like minor point, but it's a very important one. As soon as I get that needle across, I will just advance a little more with my sheath, just to make sure that the dilator is across. Once I pull the bailless back or your BRK1 back, I'll inject a little saline and make sure that I see little micro bubbles in the left atrium. That tells me, that confirms, really bubbles are your friend. Those micro bubbles shouldn't cause any issue. Once I see those bubbles, then I know that the tip of the dilator is engaged into the left atrium, and the other thing you should notice is, if you're in the left atrium, you should always be able to aspirate. Okay, so if you're actually not quite there, no blood will come back when you aspirate. That's a clue that you may not actually be fully across. So you want to make sure that blood is coming back, and then you want to make sure, I double-check by injecting some bubbles, and I'll show that to you in a movie in a second. Once I know that the dilator is across, and again, you don't necessarily need to do this. I know some people are comfortable just pushing and visualizing on ice. Sometimes ice, you know, images aren't great. You know, everybody's a little different in terms of their anatomy. So I like advancing the sheath over a wire, and like I said, I use this curled wire that Bayless makes, or you can, you know, use a wire that you've shaped yourself. But that just gives me an additional step, or layer of confidence, that when I push across the septum, I'm not gonna, you know, push into the posterior wall or the appendage and end up perforating. It gives me a rail in order to safely cross the septum. Once the wire is in the LA, I'll advance the sheath over the wire. And once you have that wire in your LA, you can push. If it's a thick septum, you can, you can give it a little push. So here's our workflow. I will often use Cardo Sound just to tag the area that I want to cross. Again, not totally necessary, but it's just a little bit of extra information that I have that shows me exactly where I want to be. So I'll have our staff, basically, I'll get a quick ice view, and then they'll tag this area. So when I'm coming down, I actually have a landing zone in terms of where I want to land my stylet. And this takes, you know, not even 10 seconds to do. So how do you get the SVC view? So once I've got my septal contour, the SVC view is really pretty easy. So if you're in the mid-right atrium with your ice catheter, if you poster your tilt, you'll almost always get the aortic valve and short axis. And this is that view that I said where you can oftentimes see the right coronary artery very nicely. Sometimes you have to play a little bit to get this view, but it's almost always there. Now, once you have the aorta and short axis in the middle of your screen, if you left steer, that will almost always get you a view of the left and right ventricle. So the first thing I'll do from here is I'll left steer and I'll just check for an effusion. This is like one, it's a good habit to get into. You know, if you have an effusion later on your case, you know, I've had cases where the effusion actually was there already, but you know, if you didn't know that it was there, you might freak out. So it's always a good idea. I think, you know, most practitioners will agree with me. Get a baseline sense of whether there's an effusion or not. That way, if you do see an effusion later, you can be sure that it's something new and you can act upon it. So from here, again, I will left steer. That will bring the left ventricle into view and then right steer from that view or, you know, from this view here back to neutral and then to the right will bring the SVC in. So, short axis of the aorta you get by posterior tilt, left steer gives you the ventricles, right steer will get you the SVC. And once you have the SVC, I'll just show you here. So you can see here, I'm posterior, this is the aorta here, I'm posterior tilt, and then you can see the SVC coming into view here. And you can see there's a, probably my CS catheter is there already. So this is a view of the SVC. Sometimes, you know, it's a little more angled. Everybody's a little bit different. I like to be able to see part of the septum here. So remember, with your septum is going to be here, so you're dragging down this way. So you want your sheath to be pointing towards this wall. If you're pointing to this side, you're pointing lateral, and that's not good. And so you can very clearly see, so I'm pushing the wire up from the groin. And again, as long as I don't feel resistance, nine times out of 10, that wire will just show up in the SVC. If it doesn't show up there, I don't keep pushing, because I know that it might be getting caught somewhere. It's going to end up in the wrong place. And so there's really no shame in using fluoro, that's the one thing. I think for many of us that are zero fluoro, we feel like we're defeated, you know, if we have to come on fluoro. I should just say, like, especially if you're starting out, there's no shame. Like, put the lead on, like, make sure you feel comfortable with what you're doing. There's no reason to push the limits if you're not comfortable. So, you know, there are different ways around this if you are, you know, having difficulty. One thing you can do is you can put the long sheath in just a little bit, then take your ablation catheter through the long sheath, and then you can watch your ablation catheter go up on mapping into the SVC. And then once you have your ablation catheter up, then you can track your sheath over the ablation catheter, and then you can, you actually don't even need a wire, right? So there are different ways of doing this. I will say nine times out of 10, you come up from the groin, you have this view, you'll see your wire show up. If it doesn't show up, take a step back and come up with another approach. So here's just the full picture. You can see I have my wire up in the SVC, and eventually I'm going to come up with my sheath. You can see the sheath coming up here, and again, you can see that it's pointing toward the septal side, septal side. You can follow it, you can see how it, you know, you can follow it dragging back if you want. I usually switch to a traditional view because I can see this on mapping. I'll come back to this in a second, but here you can see tenting. There I've injected bubbles, right, so I know that my dilator is across. Now I've come out with the balus wire, and once that wire is there, I feel very comfortable pushing. And then you can see the sheath go across. So I'm going to play that again because there are a few different things to look at. So if you look here on this side, you'll be able to see, once he turns the fan off, you can see the actual transseptal needle visualized by a balus. And like I said, I find this to be very helpful because it gives me a sense for how, like, anterior or posterior I am. There you can see it behind the fan. I think he, no, maybe he left the fan. Oh, yeah, we usually take the fan off so you can see it, but you can see this number one, and oftentimes it will disappear. I don't think, yeah, it did disappear here. The reason it disappears sometimes is because you actually don't have matrix out here. So it's very common to come down, and as soon as you hit that zone where you're about to want to cross, the visualized tip will go away because there's no matrix. If that's the case, you really should be able to see it on ice, right? So that's just another little nuance about this. But for the most part, I find this visualization to be very helpful. Another little thing, there are lots of different ways that you can mark where your transseptal is. You can take a contour if you're using cardosound of the actual sheath, as long as it's in plane. You can actually take a point right where you've crossed. So if you do lose your transseptal, you can come back to that point. I used to get so upset if I lost my transseptal. It doesn't happen that often, but if it does happen, it's really not a big deal. Almost always, if you've marked where you crossed, either by famming it, you can pull it back and do an anatomy of where you crossed, or you have a contour. It's so precise that you basically can go up with an ablation catheter, and you can almost always probe that area, line yourself up anterior-posteriorly based on your contour. Line yourself up anterior-posteriorly based on your contours or your fam, and you'll be able to cross again. So losing a transseptal really isn't a big deal, if you just take a little extra time up front to make sure that you've delineated exactly where you've crossed. So what are some of the complications from transseptals? I'm sure many of you are familiar with this. They can be quite horrific. Obviously, the one that we fear the most is aortic perforation. So with ice, it's really hard to perforate the aorta. If you're looking at the septum, and you see that needle tip on the septum, then you really shouldn't ever perforate the aorta. I think where people maybe do get into trouble is they maybe get a little comfortable or a little lax. Maybe they think they see it. They're not getting the perfect view, but they're sort of confident, and they'll go ahead and push. That's how complications will happen. You can't be too overly anal about really knowing exactly where you are before pushing that needle. Aortic perforation is obviously a really bad thing. You may get away with it if your needle goes into it, but once you've dilated and you put a sheath in there, and you haven't picked it up by that point, then it's time to call a surgeon. You don't want to pull that back. I mentioned left atrial dissection. I don't know if any of the other practitioners... I actually didn't know about this until I was proctoring a case, and somehow it doesn't really reflect well on me as a proctor, but I've never seen this complication. He basically did what I described earlier, which is that his needle was across, but his dilator wasn't. Then he advanced the wire, and it basically dissected through a tissue plane. The weird thing is, I'll show you a picture of it, but it looked like on ice that the wire was in the left atrium. You can be misled. Fortunately, if this does happen, if you pull back the wire, usually you're not going to get tamponade. Unless you've frankly perforated, this is a complication that you can actually potentially even continue the case with, but it's really important to recognize it. What might be some clues? Again, if there's no blood coming back from your sheath, or you can't aspirate, then you're not in a good tissue plane. You could be in a tissue plane. You may not be in the left atrium. If you are using a contact force catheter, and you cross, and your forces are in the red, that doesn't make any sense. If you're in an open space, you shouldn't have super high force, unless there's something wrong with your force measurement. One clue that you're in the atrial wall is if your force is super high. Another clue is if you have a vector, like the catheters have vectors on, and it's pointing out toward the outside of the left atrium, that also doesn't make sense. You really shouldn't have much of any vector if you're just in an open space, or at least it should be pointing in the other direction. Those are some things that you can look for to see whether you might be not in the left atrium and actually in a tissue plane. Obviously, left atrial perforation, if you have an atrial septal aneurysm, if you're too posterior, once you cross, you can go right through the posterior wall. Thrombus formation. I think most providers have gone to full anticoagulation before we cross. I certainly have been doing this for years. It takes seconds sometimes for a clot to form, especially in a high stasis state. I have them fully anticoagulated with full-dose heparin. I continue to use heparin. I'm not doing these on DOACs. In any case, you really should make sure that they're anticoagulated before you cross. If you do it safely, it really shouldn't be an issue. Obviously, tamponade is a complication. That can occur at any point during your procedure, but probably the most high-risk point is when you're crossing into left atrium. Again, this may sound really elementary, but I can't reiterate enough. Don't push or come on RF unless you're absolutely sure you're in the right place. You know where you are and you know you want to cross there. If you don't see it completely well, just don't do it. Take the extra time to get the right view and convince yourself that you're in the right spot. This also may seem self-evident. I don't know if this was more of an old-school thing, but when I was a fellow, we didn't manage our own complications when it came to tamponade. We would maybe have tamponade, call the interventionalist. It's the worst feeling in the world having one of your patients crumping and having to wait for someone else to come help you bail you out, basically. I think this is probably less of an issue now, particularly because many of us are doing epicardial. We're trained in epicardial. Getting into the pericardial space isn't such a big deal. Your confidence as a provider will be much, much higher if you're able to manage most of your own complications. Certainly, feeling comfortable getting pericardial access and draining an effusion is really critical. If you haven't had an effusion, you just haven't done enough ablations. You will have this happen to you. It's important to be able to recognize it early and to manage it. Most of the time, if you do have tamponade in one of your cases, you can manage it conservatively without having to take the OR. Being able to be comfortable with this, I think, is really critical. In our lab, we have a cell saver ready to go. This took some time. We had the cell saver in the room, and then we had a tamponade situation one time, and then no one knew how to actually use the cell saver. Having it in the room is obviously not enough. You need to make sure that people know how to use it. There's tubing. There's all kinds of stuff. I would encourage you, wherever you end up practicing, or if you are practicing, have these protocols written down somewhere. Have people that are designated to deal with this. In a crisis situation, you're not running around trying to figure out where the instruction manual is. There's someone that actually knows how to use this thing. The cell saver, I find to be very useful. It can buy you a lot of time. It allows you to get blood back to your patient. A lot of times, if you just give it enough time, the bleeding will stop. You reverse them with protamine or whatever. You give them their blood back. A lot of times, it will stop on its own, and that will spare your patient from having to go to the operating room and have their chest cracked open. At least in my lab, we find this to be very useful as a security blanket. Obviously, you're going to get protamine. If you're doing patients on DOACs, you may want to use one of those reversal agents as well. Obviously, there are rare instances where you can't stop the bleeding, and that might happen to you. It probably will at some point. Having a good relationship with your surgeons, knowing that there's a surgeon around, to help you, no matter how simple the case. I've seen or heard about SVT cases that have gone south. It's just always good to be on good terms with your surgeons and have them available to help you if you need to get them to the OR. This is that example of the left atrial dissection. It's kind of hard to see, but the sheath is actually not in the left atrium here. It's actually in between two tissue planes. Injective contrast, you can see the contrast is basically just going into the wall of the atrium. Fortunately, actually, we were able to pull back here. In this case, we stopped the case. Again, this is one of those complications that I hadn't really heard about until I encountered it. Once you do the transeptal, honestly, the rest is really quite easy. Some of us aren't getting CTs or pre-imaging anymore. I think the fidelity of the maps that we create is so good that you don't really need to worry too much. You can ablate right on top of your map. Taking the time to do a good map is really critical. I know I'm running short on time, so I'm just going to say ablating here is once you have a good map, I think the key is just giving yourself a good map. Take the time to make a good map because then everything else is easy. If you are in the right spot, you're ablating on top of a very high fidelity structure. Just some tips, philosophies about low floor ablation. Again, seems obvious, but never push if you feel resistance. Just don't push. One thing I found is that my hands have actually become better. I don't know if other providers have experienced this. I don't want to liken this to becoming blind, but in a sense, you're taking away one sense. You're taking away your ability to look on fluoroscopy. I found that my hands are actually better. They're more tactile. I'm able to feel things more. It's almost like my hands have taken on a more sensitive role and developed more sensitively as I've become less reliant on fluoro. I'd say for some people that are used to doing things a certain way, it's really hard to change. Maybe you've been doing ablation for many, many years, and it's uncomfortable. I would say change is uncomfortable, but lead is way more uncomfortable, so the incentive to change is really there. I think respecting your limits is really important. Everybody's different. I met people that said they were able to jump from fluoro to no fluoro in five cases. That definitely wasn't me. This journey took me probably over a year and a half to really feel comfortable with it. There's a fine line between pushing too far and not getting too comfortable. Knowing your mapping system, whatever mapping system you use, is really, really key. These mapping systems are so sophisticated now. There are so many features that I'm still learning about. The more you know about the mapping system, the more you can harness the various tools that are embedded in them to make your ablation safer and allow you to do this. There are lots and lots of different ways that you can use various features of the mapping system. The more you know about your mapping system, the better. I would say evolve at your own pace. Don't rush it. Again, learn from your colleagues. Come to Hawaii. Compliance has not allowed us to be set up as a tech site, because sending people to Hawaii to learn EP seems a little suspect. There are plenty of good centers, including Northwestern and others in the country where really innovative things are happening. I'd encourage you to learn from your colleagues, not just at conferences, but go spend a day in someone's lab or two days in someone's lab. Again, if you don't see the needle tip on ice, don't cross a septum. It seems obvious, but don't do it. Workflows should really be dynamic. I mentioned at the beginning of the talk that we're always changing our workflows. Right now, we're doing a single transeptal for AFibs. We're constantly trying to figure out how to make this easier, more streamlined, safer. As the technology changes, and as you change as a provider, your workflow should also evolve. Lastly, this doesn't really apply to just low fluoro, but just in general, don't be afraid to question dogma. I remember when we started doing this, people thought it was kind of silly. It wasn't real EP. People thought Schaeffel and Brett were just kind of out there. It was really interesting. I felt pretty passionate about it. Whatever it is, don't be afraid to question the status quo as you go forth in your careers. Sometimes the biggest discoveries, the most interesting innovations, come from taking something that's accepted and turning it on its head. I think I'll stop there. I hope I didn't go over time too much. Nishant, I'll turn it back over to you.

cardiologist

low-fluoroscopy techniques

electrophysiology procedures

radiation exposure

technological advancements

fluoroscopy usage

intracardiac echocardiography (ICE)

left atrial appendage

transeptal access