together and for HRS for continuing to support this. Looks like we have a plan next year to have this same meeting again. So bring your friends and we'll try to keep growing this. We talked a lot as a group about what types of cases we should present, recognizing we had a diverse group of people from experiences and from different fields. So my goal was to present not an easy case, but in for this 10 minutes I'm going to talk about a particularly challenging case that highlights problems with devices, ablation. You can imagine yourself as the patient going through this history as well. This is a 45 year old man who I've gotten to know pretty well, although he had fortunately most of his care elsewhere before he came to us. He's got muscular dystrophy. That's a problem in and of itself to contend with. He has hypertrophic cardiomyopathy and he had intermittent atrial fibrillation. He had a prophylactic implantable defibrillator for primary prevention of sudden death implanted in 2002. I'll tell you in 2020 he still never had an appropriate shock, so this was all a device implanted for primary prevention, but yet he's had multiple inappropriate shocks for atrial arrhythmias. So take-home message one is that we continue to struggle with how to manage patients with inappropriate shocks, whether it's in a transvenous device, as we talked about earlier. This is also a problem with subcutaneous devices, particularly in young patients and particularly with atrial flutter and atrial tachycardias that conduct one-to-one and are very difficult to rate control. He underwent his first catheter ablation in 2011, I suspect with a PV isolation with radiofrequency. He had a repeat ablation, presumably for recurrences, about four months later, again quite a while ago. He then had another ablation a month later. He then had a surgical ablation that, again I don't have all the details, but it required a minimally invasive epicardial ablation for both atrial fibrillation and atrial tachycardia. So you can imagine what the patient's gone through already and you can imagine what his insurance company has paid at this point. He did pretty well, but he started having inappropriate shocks, despite having four atrial arrhythmias, but to address that, because he had never had an appropriate shock, people felt comfortable increasing the VF cutoff rate to 222. At this point, he's really got post-traumatic stress disorder and his biggest fear is getting a shock. So although he may not continue to have sustained atrial arrhythmias, as you'll see, he has enough that he's terrified of getting in a shock and has reached that point. So this whole issue of recurrent ablations, atrial arrhythmias, and how do we manage their devices can become a problem. Here's an example of an inappropriate shock, but this was a atrial tachycardia with one-to-one flutter at a rate of about 250 beats per minute. It's very hard, unfortunately, even though we could all look at an EKG and probably tell this was VT. The device only sees a very rapid regular rate with a one-to-one AV ratio and errors on the side, as these all tend to do, of giving a shock in the hope that it's an appropriate shock. So he's continuing to get shocks. What would you do next? Would you give him amiodarone? He's in his 40s. Would you do a repeat ablation, which would be his fifth? Would you redo cardiac surgery? He's already had an epicardial ablation. The surgeons are not going to want to go back in. So we talk a lot about epicardial procedures, but there's kind of a small window of numbers of procedures. Would you change the device programming, or would you do something else? Who would give him amiodarone? We do it short-term for young patients, but it's certainly not a good long-term plan. Who would recommend another ablation, a fifth ablation? You could ablate his AV node. David Haynes is recommending we just give him heart block. It would solve the problem. He would no longer be feared about getting shocked, and it's a good idea. He absolutely did not want that, and he's... He has a narrow QRS. I can't tell who asked that, but yes. You're gonna induce... Yeah, the other downside besides pacemaker dependency is you're gonna introduce some ventricular dyssynchrony, although he's got hypertrophic cardiomyopathy, and we often intentionally do that in patients with gradients, but it's a great option. But what else would you do? Would you reprogram the device? His whole issue is he doesn't want to get shocked. He's not worried about having 10 minutes of atrial arrhythmia. So we brought him in. We turned his rate cut off to 260. I begged him not to let us take the device out, and then we also scheduled him for a repeat ablation, and this was his fifth ablation, and Chris would appreciate this. We used a powered transeptal needle to get through. For those who aren't familiar, this is a intracardiac echo ice image from the right atrium. This is the intraatrial septum, and this is a one centimeter marking. This was the thinnest place we could find. We had trouble even getting through here. We had trouble dilating it. We put a second catheter through that hole to try to dilate it with this sort of shoehorn technique, but again, transeptal catheterization is something that we're super comfortable with. Most of the EPs in this room have probably done it over a thousand times, but you're going to continue to run into these outlier difficult transeptals. Let's see how thickened and scarred that is. And so this is kind of the response to what David brought up that could potentially be a problem with pulse field ablation. Everything on this electroanatomic map is depicted as red, as low voltage, and presumably scar. There were no electrical signals anywhere in the posterior left atrium or in the pulmonary veins. His left atrial appendage had been amputated, and he had, again, another take-home message, the limitations of our mapping system. We could only induce slightly regular, mostly irregular atrial tachycardias, and we recorded mid diastolic potentials on the left atrial septum and ablated at those sites, and then just ablated as much as we could on the left atrial septum. So there becomes a point where destructive ablation really doesn't solve these very difficult to manage left atrial flutters. Our colleague Susan Kim had a case in the last week where there was hardly anything left recordable in the left atrium, and yet she still had this atrial flutter that we couldn't terminate with ablation. It was probably involving the coronary sinus and other left sided structures. So a message here is to come up with non-destructive ways to eliminate atrial fibrillation, whether it's with gene therapy, whether it's with neuromodulation, but destroying atrial tissue isn't always the solution, even if you destroy that much. A few months later, we get a phone call that I'm continuing to have episodes of atrial arrhythmias. So this is after five ablations. Again, they're only three minutes, two minutes. The rates are below, certainly the ventricular rate on average is below 260. He's not going to get a shock for these, but he's terrified of getting a shock. So this was kind of a cluster here, July 28th, August. I guess that phone call couldn't have been in July. It probably was in August. He wants to have his device removed because he doesn't want to get a shock. So aside from removing the device now, what would you do? Would you start him on amiodarone? Would you do a sixth ablation procedure? Could you take the device out? There's devices that have atrial therapies, which he doesn't have, which was somebody else's suggestion that I put on there that might be at a pace to terminate these, but his problem really is not sustained episodes of arrhythmia. You can send him to Detroit. Dr. Haynes might ablate his AV node. You can turn his device off and say, this is your real issue. These are brief episodes. We'll turn off your defibrillator. Or would you do something else? So A, amiodarone. Isn't it amazing how like terrified people are of amiodarone now? Legitimately, but like 30 years ago, he would have gotten amiodarone. Another ablation. I got a case report to review the other day of an interesting electrogram that occurred during an ablation procedure, and we accepted it for publication because I was stunned that it was the patient's 10th ablation procedure. And it was in England, of all places, as 10th ablation procedure. How many people want to do another ablation on them? Wow, not... Aaron? Who wants to give him a device with atrial therapies? Anybody from Medtronic here? Raise your hand. AV node ablation. Yeah, I've had most electrophysiologists over like 55 would say AV node ablation. No, I'm over that age. No, I think, you know, to be honest, some of the most grateful patients we've seen. I know the patient that gave the most, the biggest donation when I was at University of Michigan was a patient who had an AV node ablation. It changed his life. He really benefited from it. Who would just turn off his ICD? All right, that's tempting. Who would do something else? Well, something else is the answer, and again, we got lucky here, but the take-home message here is that all these little details matter. You can't just put patients in different buckets based on their presentation. You got to look at everything, so I don't know how this came about because his device was followed at another hospital, but I started looking at his arrhythmias to make sure they were flutter and not fib, and we quickly recognized that every one of them, including the ones before his last ablation, all of his episodes of atrial flutter are triggered by a device problem. His PVARP had been set so long, I either suspect because they were worried about pacemaker-mediated tachycardia. At some point, his PVARP was set so long that when he got his sinus rate to a certain point, it would stop detecting this and pace the atrium. If this was repetitive, this is RNR-VAS. This is repetitive non-reentrant VA synchrony, but in every case that he had, it was triggered by this pacing stimulus, so we got lucky. We shortened his PVARP. He hasn't had PMT, and since last August, he's never had an atrial arrhythmia, so it was an example of all these issues with devices, ablations, and some of the limitations that we have, so take-home messages are we have inappropriate shocks. This creates major problems, psychiatric problems with our patients. There's limitations to multiple catheter ablations. It's difficult when you create and transfer a fib to atrial flutter. When you create an atrial flutter, those can be more difficult to manage, and then the next take-home message is, you know, you do what's right for the patient and look at every single detail, so hopefully this will generate some comments for discussion. Thank you very much.

muscular dystrophy

hypertrophic cardiomyopathy

intermittent atrial fibrillation

inappropriate shocks

treatment options