Hi, it's Eric Prystowski, and welcome to another edition of EP on EP. We have part two of this today with Dr. Andrea Natale. We started the discussion on his approach to persistent atrial fibrillation, and he's done a beautiful job elucidating not only what he does, but how he got to that point. But there are other parts of this that I would like to ask Andrea to discuss. So Andrea, thank you for doing a second part with me, and we're going to go on to some additional areas. Thank you, Eric. There must be some people, even you, who are probably one of the best ablators that I know around, say, I'm not taking this person on. When people come to you for second and third opinions, there must be some that you say, this is just not worth doing. Can you give us some of your thoughts on that? It depends. It depends. There are people, I mean, we see a lot of people that come to us after two, three, four, five, even more failed procedure, and we kind of see what they've done, and we kind of explain them, you know, those are the areas that we've seen in our experience being responsible in patient IQ, you know, it's going to take two procedures, all this sort of stuff. The only reason for me not to try is if patients are really not very symptomatic, and they're very old. If they're a younger patient, probably I have a lower threshold to try to do the best I can to keep them in sinus, but if I see, obviously, an 80-year-old that is functional, is not very symptomatic, then what is the point? It's more about that, that people are symptomatic, even if I think this is going to be tough, and I explain that to the patient, say, well, you know, I think it's going to be a try. And in practical terms, at least it's been our experience, even if the ablation by itself doesn't totally do it, usually antiarrhythmic drugs take care of the rest, and the patient has a better lifestyle. So the future? Let you finish with that? Do you have any thoughts on where you're headed? I mean, electroporation, things like that? So when we talk to the patient about complications, we say, you know, we think we figured out how to avoid most of them, like stroke, we do an interrupted, with the esophagus, the pulmonary vein, with the intercardiac echo, we make sure we're not in the pulmonary vein. With the esophagus, you know, we have temperature monitoring, sometimes we move it. The only one we cannot completely abolish is steampop, which can lead to a perforation Unfortunately, it does not happen frequently, but it's the only complication that, even by following the impedance, keeping the contact force low, sometimes it happens, and there's nothing you can do about it. So there are two technologies that can potentially, based on some preliminary experience, prevent that. One is temperature-guided, there is a company that we've been working with, with their multi-center study for paroxysmal, now they're doing the persistent study, and we haven't seen a single steampop by using their catheter, and the power goes up to 40, 45 watts, based on the temperature in the tissue, they sense the temperature in the feedback, and they drive automatically the power to keep that temperature, so that they achieve better lesion. Despite that, they don't, that technology has not resulted in steampop in the entire paroxysmal study, and now we are halfway through the persistent, still the same. So that's an exciting technology, and then obviously electroporation, although it's not sort of gotten heavily into clinical work, it is exciting, I mean I think we have to look at efficacy, but the safety profile is just unreal, it's completely unreal. Your blade in the vein, you don't cause stenosis, your blade causes, so there's no damage. The friendly nerve, you know, unless you use super high power, so the safety profile of this approach is just unbelievable, and I think once it becomes available to everybody, why should I use anything different, and because, you know, I think that's sort of the future. The other things that we are becoming more aggressive, since you mentioned the appendages, that now, yes, we're really advising, we're really advising our patient to consider... At the same time? At the same time, no, because as I mentioned, it takes two procedures in amphetamines, but once we know that they are fine, no arrhythmia, the appendage flow is low, we advise them to consider appendage closure, and we have, you know, good results. I wondered if you were getting to that, well listen, it's always, it's great talking to you about this, thanks for educating us on this, and as usual, we look forward to your future research. Thanks Andrea.

persistent atrial fibrillation

approach to persistent atrial fibrillation

patient selection criteria

electroporation in ablation procedures

appendage closure