Thank you, Atric, here for holding this conference. My task today is to discuss criteria in patient selection, and I think what my real job here is to try to operationalize how you select patients. Ultimately, this talk is about providing guardrails, but the real task is on basically up to you at your institutions to find what the best approach of navigating a patient in your system locally is going to be, because it's going to be different from region to region depending on what resources you have available. So here are the hard stops. On this slide on the left-hand side, these are absolute contraindications, the most obvious being that if you've had open-heart surgery, convergent is probably not the best approach. I am sure that there are people in this room, and you'll hear stories of people attempting to access the pericardial space after open-heart surgery. It's difficult. As my surgeon says all the time, can I do it? Maybe. Is it advisable if I get into trouble to have a closed chest that is bleeding out to get in there emergently is dangerous. So not advised. And then some of the other things are quite obvious, having a thrombus in the left atrial appendage and some other things that you see on the left-hand side. And then there are relative contraindications to convergent. This list will grow and collapse as you get more experience doing the procedure. So when we started off, we were hesitant to take a patient who had advanced COPD or hypertrophic cardiomyopathy or heart failure. Now we do all of these things. So it really depends on what your experience is with the procedure as you get more agile and expert at a convergent approach. As was previously mentioned, there are, as Dr. Eldada says, accelerants or comorbid conditions that will ruin your outcome. So why not address this in the beginning? There's been a lot of studies that look at the relationship of obesity and uncontrolled hypertension and all of these things to decrease your ultimate efficacy. So might you address this before engaging in a procedural approach might be a good idea. So this is something to consider. And then what Andy used to laugh at me when I started the referral process, things that probably should not be treated with convergent ablation, like a patient with wide-open mitral regurgitation. There are other more effective class 1 indicated approaches of managing a patient with concomitant mitral valve disease and atrial fibrillation. This really should be managed in the operating room, the cardiothoracic surgical operating room most efficiently. So this has become a great referral program to Andy, is having the patient as their initial manifestation of mitral valve disease, atrial fibrillation, only to find that they have surgically correctable disease. So obviously, this is not the ideal patient to be managed with the convergent approach. Now, having said that, there is a relationship between atrial fibrillation and mitral valve regurgitation. It's hazy, and this relationship is still unclear. I throw this slide up because it is definitely an emerging topic. We don't quite have the sophistication to identify what AF-created mitral regurgitation is. Nevertheless, there is this entity, and we have seen this in our practice of patients that have mitral regurgitation that improves over time, whether that is the remodeling process of the left atrium or some other effect that keeping patients in sinus rhythm has on mitral valve geometry and regurgitation. So this is an emerging topic. Now, I'd like to provide a case presentation that will kind of make more concrete this process of patient selection and how we have evolved to our approach in Tampa, and I'll end with this presentation by showing what our algorithm is. But let's walk through this initial patient presentation of a 56-year-old patient with paroxysmal atrial fibrillation that has already had pulmonary vein isolation and now presents with a recurrence, and the question is, how do we manage this patient most effectively? I can guarantee you that everybody in this room has had to deal with this. It's quite common. So here are your options. You can bring the patient back to the EP lab and do a posterior wall isolation. You can add a mitral isthmus line. This is like going to a fast food restaurant. You want to add this, add that. Here are all the different options. I can tell you that there's an individual at our hospital that does D, which is posterior wall isolation, mitral isthmus line, vein of martial ablation, CTI line, SVC isolation. All of these things begs the question, just because you can do something, should you be doing it? But these are all the options, and of course, we're going to talk about hybrid ablation as the last algorithm. You've seen this study. Dave presented this in the beginning of the talk. The failure of adding posterior wall isolation to PVI in doing any better than just pulmonary vein isolation, we still do this, despite not having any evidence from an endocardial standpoint. But how does the evidence inform decision making when selecting patient criteria? Well, when it comes to electrophysiologists, we are devoid of using any type of evidence to guide our procedural approaches, because we know that there's no evidence to support endocardial posterior wall isolation, and yet we still do it. Nevertheless, here it is. And even if you blame technology. So maybe the reason that we didn't do so well with posterior wall isolation was because of the technology that we were using. Well, this is Dr. Reddy's most recent publication, came out a couple months ago, looking at manifest 17K, all of the pulse field ablation that has been done in Europe, comparing patients who have had just PVI to PVI plus posterior wall with the latest technology. This is the latest that we have in the field of electrophysiology, and yet the success rate is just the same if you were to just do a PVI. And yet, I have just done this last week, a PVI plus posterior wall isolation with PFA, yet not having any evidence to support my process. Nevertheless, we still do it. How about adding an anterior mitral isthmus line endocardially? Here again, this has been tested in a randomized control trial fashion, showing that you can add all of these extra lesion sets endocardially, and it will still not improve your success rate over just doing a PVI. No evidence. And yet, the only amount of evidence is in this beautifully created manuscript published in Jack last year that reviewed all of the hybrid approaches, TT, convergent, and pooled, and looked at the success rate. This is the highest level of success that we have in our fields, our combined fields, in managing non-paroxysmal AF. And yet, we still have a hard time convincing all of our colleagues that this is something that you should consider, despite the evidence being there. Now, I was really happy to see Dave's electroanatomic map showing the presence of epicardial activation, because the more sophisticated we have of mapping systems, the more we're starting to see that the left atrium is actually a complicated structure. So what I'm showing you to the surgeons in the room that may not be expert in looking at maps is an electroanatomic timing map. So we've got the posterior wall of the left atrium, and with color, we can see the electricity as it shoots out in the left atrium. And what you're looking at is that electricity is emanating from the center of the posterior wall. Well, how can that be? Electricity is supposed to start from the sinus node, then go transeptally to the left atrium. The activation is always right atrium to left atrium. So how is it that electricity sparks from the center of the left atrium outwards? Well, you know the answer to this already, which is it is an epicardial structure. To compare what it looks like, if electricity is going from the right atrium to the left atrium is on the right-hand side movie. It's supposed to go from the septum, the atrial septum, over the anterior wall and the posterior wall and activate from top to bottom as opposed to emanating from the center of the left atrium. So this is evidence indirectly that in this patient, despite doing a pulmonary vein isolation, that there's activation that is conducting over an epicardial structure. And this is what it looks like from an electrogram standpoint. So what do we do? Well, we ignore the level of evidence, which we're very expert at our hospital in doing, and we ablate the posterior wall to manage this patient's recurrence. And what happens? We are rewarded with mitral annular flutter. And in fact, in our series, our 10-year series, the incidence of mitral annular flutter after posterior wall isolation is as high as 20%. So you can address the pulmonary veins. You can address the posterior wall. You will be treated with a mitral annular flutter. And now the question is, how do we manage this patient? Well, we have the tools. We have the know-how. And we have the ignorance of managing this endocardially. So that's exactly what we did, is we created a mitral isthmus line. And the patient told us that they're smarter than we are, at least their left atrium is. And the activation skips right over that endocardial mitral line. And the question is, how does this happen? Why are electrophysiologists not expert in creating mitral annular lines? And the answer is the epicardial structures. We're ablating from the inside. What is happening here is electricity is going around the mitral valve in a clockwise fashion, goes right to our mitral endocardial annular line, laughs at it, skips right over epicardially to join the left atrial appendage. This is what this movie is showing. So now we are on the third procedure of this poor patient who was managed with just the PVI endocardially. And the question is, is there a block? And the answer is there is not block in this patient. And the answer is further informed by the presence of Bachmann's bundle that creates a nice electrical highway that skips right over the epicardium. So we finally head towards the convergent procedure that actually ablates epicardial structures. And here are all of the kind of add-ons in the accoutrement that come with a hybrid ablation. Not only do you get an endoepiposture wall, you get isolation of the left atrial appendage electrically, you interrupt the ligament of Marshall, and you ablate epicardial structures. So you really get a value-added procedure. So here is my endocardial mitral line. We're looking at the anterior aspect of the left atrium. All of these little globs are the number of lesions I've deposited endocardially in trying to get a mitral annular line and still failing. And then this is what it looks like when Andy just ligates the left atrial appendage. He just puts a clip, interrupts the ligament of Marshall, and I've got instantaneous block. I don't need to do anything else. So it is really a slick procedure when it's done correctly and in the right patients. So to summarize, these are all the different structures that we've addressed with a hybrid ablation. You really get a comprehensive approach. So how do we operationalize this? And I tip my hat to my colleagues from the National Health Service, because the one thing that I really respected and appreciated when I went to the UK is that every institution manages their own enterprise independently. So just because you're in the same country doesn't guarantee that there's consistency from one hospital system to the other. They maximize the resources of what they have locally in creating an algorithm. I believe this is called an MDC, if you guys can correct me. Is that correct? Yes. I think this is brilliant, because as much as we can create an edict and tell everybody to do all the same things in Miami as compared to Tampa, as compared to Wisconsin, the reality is we have different resources available to us at a hospital, and we have to use what we've got. So the moral of the story here with this presentation is this is what our approach is locally, because we have our resources. It might be different in your hospital. Here's an example of what we do. So let's walk through this. Here is a patient with paroxysmal AF, or stage 3A in our new guidelines. This is how we manage them. We reassess their atrial fibrillation severity, because we all know that once a patient gets a medical diagnosis in Epic and Cerner, it lives with them to their last dying day, and it's probably wrong. So when a patient comes into our office with the label of paroxysmal atrial fibrillation, we say not, we're going to reassess you, I'll put an event monitor, I'll do some sort of ambulatory monitoring to make sure that that paroxysmal AF patient hasn't turned into a longstanding persistent or persistent. So we reassess AF severity. If they're going to cardiac surgery, let the surgeons handle it. They have class 1 indications for doing this, and they do it very smartly. So if a patient has cardiac surgery planned, they get a surgical PVI and a left atrial appendage ligation. There's class 1 evidence to support that. If they're not going to cardiac surgery, they go to the EP lab to get a pulmonary vein isolation. We have class 1 evidence to support that as well. We at our institution now use non-thermal energy to isolate the veins, and then we look for symptomatic recurrence. Now here is where life gets complicated. If you have symptomatic recurrence, so this is our second procedure now, they've had recurrence after their pulmonary vein isolation, here are your options. You can bring them back to the lab, which is a class 1B indicated procedure to re-isolate the veins. You can bring them to additional targets, which is a class 2B indication, so it's expert opinion. There's no level of evidence to support this. Or you can do the convergent, which is what our algorithm is for all patients with non-paroxysmal AF. So in our hospital system, we have paroxysmal AF and non-paroxysmal AF. We don't mess around with early persistent, late persistent, long-standing persistent. If the horse is out of the barn, then it is what it is. We're going to apply the same therapy. So this is what our dichotomy is at our hospital system. So if you've got non-paroxysmal AF, or stage 3B, 3C, and you have cardiac surgery planned, here again, Dr. Cox has and his colleagues have validated COXMAZE-4 as a class 1 indicated procedure. For heaven's sakes, if the patient has an open chest, let the surgeons manage this with the most comprehensive tools they could possibly get. So this is what is done in our institution. And we have inserted what we call this TAMPA 2 procedure also in the mix. We're starting to understand how to apply this in our patient population. But the moral of the story is you're going to get cardiac surgery. If you're not planned to get cardiac surgery, and you have not had a prior sternotomy, then you'll get the hybrid procedure. Unfortunately, if you have prior sternotomy, there's nothing that we can do about this. We'll try to manage it as best as we can in the EP lab. But if you haven't had any prior instrumentation, then we do what we call the convergent 3.0. The convergent procedure itself is a class 2B indicated procedure in the latest guidelines. So there is robust level of evidence to support this, and it's only building. At our institution, we apply convergent 3.0, the extra lesions that we talked about earlier this morning. And then we look for symptoms. So in our patients who are non-paroxysmal, our mode of monitoring is a loop, or anything that provides AF burden. We do not use 30 seconds of recurrence of atrial fibrillation to document failure. This is important for our referral physicians to understand. If you've been sitting in atrial fibrillation for two years, and you have three minutes of atrial fibrillation, it does not constitute a point of failure. So we use AF burden monitoring, despite there not being significant evidence to support this, but we use that as our endpoint of measuring success. And then if you have a left atrial size that is significant, or we've tried multiple times at trying to maintain sinus rhythm, yes, there is a possibility that we just cannot get this patient in sinus rhythm, and we have to give up. So we have also included in our algorithm permanent AF or stage 4 atrial fibrillation. And there is stuff to do there as well. You can ablate the AV node and put a pacemaker, conduction system pacing, biventricular pacing. So we still don't give up at managing the patient, but we do give up with rhythm control. And so here is how we have evolved our treatment algorithm that works for us at the current time. I have a very interesting conversation, and we were just joking about this earlier this morning that some of our colleagues still like to do things endocardially, and I remind them that there are even more interesting indications for ablating patients, including heart failure, early atrial fibrillation diagnoses. I mean, there's a ton of patients out there. There's no reason to fight over every single patient. There's enough patients that we just don't, we can't manage them effectively as a system. So with that, I will close.

atrial fibrillation

ablation techniques

patient selection

mitral valve regurgitation

evidence-based decision-making

tailored treatment algorithm