First, here as a panelist, there will be Dr. Juan Carlos Alejandro Chávez, who is a cardiologist, electrophysiologist, who is in Zapopan, in Guadalajara. Here is Juan Carlos. Then we have Dr. Néstor López Cabanillas, who you know very well, who must be around here. Here it is, here it is. Nestor is vice president of LARS and is well known to everyone. He is at the Buenos Aires Institute, at the Adventist Cardiovascular Institute of Buenos Aires and is an expert in all these device issues. We also have Juan Felipe Betancur, who is also a cardiologist, electrophysiologist, Chao Clinic, in Bogota, Colombia. And finally we have, well, there's Dr. Mauricio Cortés, who is a cardiologist, electrophysiologist in Monterrey, but he is in the case and those who are in the clinical case, in the transmission, are Dr. Ulises Rogel, already known to all of you, Dr. Juan Carlos Diaz, who is a cardiologist, electrophysiologist from Medellin, Colombia. There is Dr. Martin Ortiz Abalos, who you also met yesterday at the clinical case, which he has written to them at the National Medical Center on November 20. I don't know if we have the transmission to start with. Can you hear us in the auditorium? Very well, Ulysses, tell us how things are going. Well, here we are already ahead. First of all, first of all, because I forget later, I want to thank the authorities of the 20th of November, from the ISSSTE Hospital, from the National Medical Center 20 de noviembre, for their kind acceptance to bring these cases live from here. And well, especially to Martin Ortiz, to you Gerardo, who are the ones who intervened in this. And well, I don't know if you have the case there for present it or we present it here. If you want we can put it. I'll tell you who the panelists are, Carlos Alejandro Chávez, Néstor López Cabanillas, Juan Felipe Betancourt and I. And I don't know if, well, I already introduced you here, you who are operators, but if you raise your hand and we see you, Even if it's with a mask, it would be great. Ulises Rogel is there, who is from La Voz, Martín Ortiz. Raise your hand, Martín. Juan Carlos Díaz is there, where are you? Perfect. And Mauricio Cortés. Okay, very well. We're going to have to charge you for the robes. Go ahead. We are going to present the clinical case, it's two or three slides. Gerardo, if you want, do us the favor of presenting it. Yes, thank you. I'll grab it on the fly, of course. He is a 75-year-old male patient, he is retired, he is a resident of Mexico City. He had cardiac revascularization surgery, he was given four bridges in 1997, has classic risk factors, diabetes and hypertension and the consultation was due to deterioration in his functional class, as well arrived at the hospital. The symptoms were particularly fatigue with effort, with minimal effort when walking a few meters and inability to walk more than 10 meters without history of syncope or dizziness. Of course this started two weeks, well two months before, but in the last few two weeks, this effort with exercise was increasingly noticeable. And the physical examination, regular cardiac risks, etc., Everything was fine and this is the electrocardiogram. I don't know if anyone on the panel wants to comment on the electrocardiogram, obviously not, but but in relation to heart failure and blockages, first-degree blocks. Nestor. What is the function of the electrocardiogram? No, I would like to say at the beginning that we are dealing with a patient with coronary disease, with myocardial revascularization. And I was not clear about the ejection fraction issue, I don't know if we already have that data. We don't have it, it is normal, it is above 50 percent. So no, there is not much comment so far and the question is, well, how does it continue, what are we going to do? What pharmacological management was he receiving, doctor? Pharmacological management was the usual for ischemic heart disease, so he had beta-blockers, management for telmisartan, for hypertension, diabetes and ischemic heart disease. He has a holter, which I think is the next slide, can you come in? No, well, this is the echocardiogram, no abnormalities contractility, valvulopathies or other relevant alterations, ejection fraction 59 percent and this is a holter that was done to the patient in a private medium, which is observed the same as the first degree blockage, but the next one, here it is and it is a first degree blockage that progresses and makes a second degree block. So, there is a detail that is very important to take into account, that in the face of clinical data of heart failure, Patients, if they have first-degree AB blocks, which can progress to second degree and have these symptoms of dyspnea, which are resolved for us Very easy, by putting in a pacemaker. This disorder was described in Argentina by professors, as pacemaker syndrome, and it was described about 30 years ago. And it is very important to keep this in mind. One, because I think we are all electrophysiologists here, but it is a reason for frequent consultation, just take a look. the above trace, anyone would say it is a nodal rhythm, no, in the previous one, in the previous one. So, one says, could it be that the dysfunction is of the sinus node or the dysfunction is of the AB node? And what we have is a P in T phenomenon, where the PR is so long that the T wave hides the P and its problem is in the node AB, is a dysfunction of the AB node and not the sinus node. Yeah, well, I don't know if this one, well, if you want us to start seeing where we are going. Yes, the decision is to put in a pacemaker, That's obvious, but what pacemaker? Dual chamber, okay, that's obvious, but where? Why physiological stimulation? Let's, let's, I would like to describe first what we did, what we are doing, where we are at and if you want we can discuss later. who and why. What did we do? Well, with what they already presented of the case, we decided to put a branch on it. Why? Because this is a person who has conduction disorders and obviously will need a lot of stimulation, a very, very, very high percentage. So, here is one of the questions for All of you, an initial question that you will later answer will be which pacemaker would you prefer? At the apex, septal stimulation, at the pacing in the tract, a pacemaker without leads or a physiological stimulation, a stimulation in the branch, in the normal conduction system? That is a first question. What do we do or what is the technique that we use to put these types of devices? In my center, in my public center, what we do is What we do is put this type of device in 100% of patients. We are already abandoning putting them in the tract, in the apex and we do everything So what do we do? Well, what we do is always have a safety electron, as you can see in fluoroscopy, I don't know if we can see the fluoroscopy on the screen. We always do the two functions, like any normal pacemaker, then by the electron that Finally it will go into the atrium, we lower it and put it into the ventricle and we put it in safety. You can see it there at the tip of the right ventricle and that pacemaker is useful to us in case of any eventuality, to stimulate at any time. Once we have that that electron, we move a sheath. The issue of physiological stimulation is that for the procedure to be very effective and quite successful We need to use pods. And today there are pods of all commercial brands, from all commercial houses. I don't know if we can focus here. We use a pod to show you what the pod we use on this day looks like. Well, I'll show you here. This is the pod we use. It's a pod that is used, It is preformed, with a curve and two, right? This helps us by making clockwise and counterclockwise rotation movements to get to the seventh and stick the electrode, stick it to the seventh, stick it to the seventh and with that impact the electrode. We already did this there, you see in the fluoroscopy. This is the sheath that we used today. You see it in the fluoroscopy. I don't know if we can get through the fluoroscopy. There is the sheath. We can get through it. There is the sheath and through the sheath we pass the electrode through. It is a conventional electrode, let's say, a little longer than the electrodes we usually use, but it is a conventional electrode. The first thing we do is, in the polygraph, I personally, Juan Carlos will tell me right now what technique he uses, personally I always I'm looking for the branch or the seventh in right oblique. In right oblique, I don't know if we can pass the right oblique branch, looking for that morphology in B1, which is a W, that morphology stimulating through the electrode with unipolar stimulation, I look for that W in B1 to know that I am in the seventh and I am heading to the left branch. Can we have a polygraph, please? The polygraph is not visible, what you are describing is not visible. Yes, we will see right now. the polygraph without stimulation. One question, Ulysses. Do the pods come in one size? Do they have different sizes? It depends on the commercial house. There are houses There are commercials that have only one size and that one can preform them a little more, depending on what we see in the room, patient by patient. There are other brands that They have small, medium, large curves. Generally, I use the large curve sheath in almost all patients. Why? Because generally That is what needs stimulation in older patients, who have some dilation in the heart. So, with a sheath of a medium curvature, many Sometimes we fall short and what we use are the tiny curves. These curves may be useful for the GIS or we always fall short. So, I occupy 80-90% of the large curvature and the rest occupy a medium curvature. So, there in right oblique, what we do is to look for that image of W, stimulating in a unipolar way in B1, I always look at B1, and where I see the W, well, there, that was also described a long time ago. many years, that's a good place to be able to stimulate. Obviously, below the tricuspid valve. And then, since I have that position, I What I do is go to the left oblique, I don't know if we can go to the left oblique, and in left oblique, I look at left oblique, why? To see that the electrode is seeing between two and five. Between two and five, I look at left oblique, why? I assure you that I am very surely attached to the seventh, looking at the seventh and I will be able to hit it. Once I see that, I go back to the right and that is when I impact. What do I see or what do I like to see when I impact it? Well, that W becomes a right branch morphology, a QR morphology or a r small QR, a right branch morphology. That is what we have already done and in the end, once we have that morphology, we make measurements in person and I'll give the floor to Juan Carlos right now. I like the QR to always be less than 0.12 seconds, less than 0.12 seconds, and the time of the spike in lead B6 to the top of the R is around 80 milliseconds. Those are the parameters that I generally use day to day to say that I am in an acceptable position for that. And that is what we did now. The patient did have a narrow QR of 0.7, 0.8 and was left with a QRS of 0.10. And that is also described. Those patients who have a narrow QRS, when this is put in, it becomes a little bit wider. It does not happen Nothing. Those who have a wide QRS, patients who have bundle branch block, this makes them have a narrower QRS. But the mechanical issue, regardless of the issue electrical, it is the same. By making the QRS a little bit wider or thinner. And finally what we do is that injection of medium contrast. We pass the previous one, the injection, where we can see where the septon is and how far we stuck the tip of the electrode. The tip of the electrode, if We make measurements in a very simple way, from the tip where the screw is to the electrode ring, more or less they are 1.2, 1.4 centimeters. So I estimate that we are within the septon one centimeter or so. So there, with that left oblique projection, I Day by day I see that I am with the electrode inside the interventricular septon. And with those parameters I am satisfied and then I put the atrial cable and do the rest. I don't know, Juan Carlos, you. Give me the right one, please. We already use an approximation. There, pause it. Pause it there. And the injection of better contrast. On the right. We already use a more anatomical approach, rather than looking for the W, because not all patients have the W. So we simply give an anatomical location. If you believe me, while loading the second staple from bottom to top, in the oblique Right. That one, that one, that one. We are at 20 degrees there. Normally we work more towards 30 degrees. So, more back, more back, more back. There. There you can see Okay, on the second staple from bottom to top, from the sternotomy, you can see the tricuspid valve. There, at that point. And the idea is to be 1.6 to 2 centimeters ahead of it, but 2.7 centimeters, less than 2.7 centimeters to avoid the coronaries. So, more or less, it would be from the staple, from the tip bottom of the staple, down and a little further forward. That would be the landing zone and we no longer look so much for the W. At that point, well, We have the device on all the time. If we see it well, if not, we also try to be as perpendicular as possible with counter clock. And at that point We start drilling quickly, looking at various things. If we have continuous stimulation, like with this cable, which is very good for that, we go Seeing the change in morphology, we see how the W gradually rises until it makes an R, as you see in this case, and be very aware of the branch stimulation beats. That is, when we irritate the left branch, mechanically we are going to produce some beats, some extrasystoles that are going to have a complete right bundle branch block morphology. And that's where we're going to slow down a bit and start taking measurements. If they're just starting out, they start running the contrast injection. Please, the contrast injection helps you a lot because you will be able to see the tricuspid valve behind, you will see the infundibulum and they will be able to orient themselves very well towards where the arrival site should be. And I wanted to show you about the unipolar. There is something that the houses have to start to understand. work very well. I want you to look at the morphology. If you can see the B1 and the R, please, that leather. No, not that one, polygraph. If they can see the R in B1. If we are going to put a CRTD, in this case, most of the commercial houses do not are able to do true unipolar. So, they do extended unipolar where they go against the right ventricular coil. So, I'm going to put them to stimulate at this point against the right ventricle. This one? Oh, well. Sorry, excuse me. I'm just dithering here, but here we go. I found the cable that was it. It stimulates with more output. Look at the change in morphology. Look at how that B1 looks. Can you see it? The B1 completely lost the R and the only thing we are doing is stimulating from the tip of VI to the tip of BD, which is similar to the coil. And look at it if you I put it back in unipolar, like changing the morphology again, to have R in B1. Can you see the R in B1? Thank you. And now I'm going to change them back as quickly as possible so you can see the difference on the same screen. Look at the change in morphology. And we haven't done nothing. The only thing we have done is that we put in a cardioresynchronizer that does not have the capacity to do true unipolar. So the companies are going to have to start working on that because if I am forcing the flow of electrons to go and force it to pass towards the casing then I am crossing the area of the left branch but if I am forcing the flow of electrons to go to the right side I will be avoiding the left branch Well, that's what we have so far, which is what we say is the most important thing. The next step is to place the safety cable that we have. Pass it to the auricle so that it stimulates the auricle and remove the sheath to remove the sheath because the commercial houses have these little things that are here. These are special knives that pull the sheath like any resynchronizer and the electrode stays with it, it is not that the sheath is removed fix the electrode like any other electrode and the procedure is over, right? Ulysses, one question. That's what I was talking about before another one, now as we are here with Martín and Mauricio have a plus, which is having the intracardiac transfer, where the plus is that we see exactly in the septum where the electrode was left. MMM I want to mention, sorry, while Juan was discussing this, I already removed the safety electrode that was in the ventricle, I already put it in the atrium, I already removed the and I already put the generator in. This is a bit of a critical step for those who are learning this. The generator is programmed in unipolar to stimulate the ventricle then then. They must be careful with those patients who are very slow, who have a very slow frequency, because as long as that generator does not touch the skin, they can have assisted insulation. It is a small step where one has to always be thinking about what It has to be done. It's not like pacemakers, where as soon as you screw the electrode into the generator It starts to get stimulated. No, this is a little different. If we can see the polygraph live, This is the final result of how it will look. The P is now synchronized with the QRS. We can remove the intracavitary electrode, the green one, and set all the leads to white. Ulises, if you allow me, I would like to mention two things about the ECG and to complement it. Although the QRS is not so wide, the patient did have a blockage of the posterior fascicle, because it was isodiphasic D1 and ABL was totally negative, which has now been removed. So, the point of stimulation is that you can do selective stimulation of the left bundle branch or non-selective left bundle branch, but even if it is non-selective, you can have narrow QRS. In this case, the target or the final objective is this, because it is not a right bundle branch block as such, but it is a QR of a W that I had, that is, totally negative, It goes to a QR and that is the objective to be able to selectively stimulate the left bundle branch. There are recently published criteria in the physiological stimulation guidelines. And the other point I was going to... No, no, go on, go on. Something that I always have in mind is, obviously in many cases we are not going to have a QRS completely normal. That is, we look for narrow QRS and there are different morphologies that we can obtain at some point. But one thing is the electrical issue. The electrical issue, QRS narrow QRS is better than wide QRS. That's a first. The mechanical point of view, which is the next point. The next point, no doubt, this is much better than stimulating in any other part of the ventricular endocardium. And, well, in a few years this will surely replace a lot to the three-chamber pacemakers in a short time. I don't know what you think, Juan Carlos, but this For us in Latin America it also turns out to be a bit cheaper than a pacemaker. tricameral. So, these are the issues where we see a lot of advantage. I don't know, Juan Carlos. Yes, absolutely. I just wanted to tell you something about that, that the concept of physiological stimulation has changed. We previously considered physiological stimulation as not having the electrode at the apex. The apex It is the worst point where we can put the electrode. And then we go up to the output tract, then we go up a middle septum. But in reality we are now doing physiological stimulation. Why? Because we are stimulating on the electrical conduction system. And to answer the question of the echo, I say, it may not be necessary, but just now and Dr. Llorente who is here with us will remember that a live case was done in Ecuador and the Dr. Alexander del Forno said that he really liked to see, perhaps not putting it in the ventricle crossing the left side, but seeing it with echo intracardiac or with echo to see how much it perforated, because yes of course there are times when you can go too far and reach the left ventricle and that was it. To be a question, what happens if they perforate and reach the left ventricle, they just delay it, nothing happens. I had never used the echo in my life intracardiac to put a branch, I never ever use it, it is not a habit of mine, I look at the anatomical question as Juan Carlos says and the question electric, I keep paying a lot of attention to that WI, I keep looking for it a lot and that change in morphology. What happens if I, how do I know if I've gone too far? Well, I always have mentions of impedance, morphology, loss of capture that tell me, oh, I've gone too far or something is happening and something is not right, So obviously using the two projections, it is a procedure that has to be used for both projections to locate you and as I said Juan Carlos, don't mess with the coronaries or don't mess with other things, if you perceive in some projection that you are ahead, you will surely hit it. some coronary and that has already become very complicated for you, then I look at the two projections, I see impedance, I see the electrical thing that we know, that already We know why we use pacemakers and that is enough for me, fortunately we have not had any complications in terms of perforation or hitting a coronary or not, if we have suddenly passed to the left ventricle, what we do is go out a little and generally it does not happen Nothing, I don't know Juan Carlos. Yes, there are people who have very thin septa, so you don't capture, you don't capture, you capture and you perforate and the perforation is immediate, so one You realize this because you lose your capture and the cable goes away, the important thing here is not to withdraw it and leave it behind because we can end up again in the area of the left branch capture it, but you have to remove everything, place it in a new position and make a new one, re-enter with the cable because there will not be a tunnel where the electro will be loose. And with respect to anticoagulation, here I take advantage of another topic, I love anticoagulants, so I don't see it The problem with admitting people with full anticoagulation is nothing more than taking a little more time with hemostasis and absolutely nothing happens, there is no greater risk of bruising significantly. Now, if you have anti-aggregants like Prasugrel, they, I don't know why, but they bleed very nicely in a layer all over, that's what they are more difficult to control than anticoagulants, anticoagulants do not cause any problems at all. Nestor. Another technical question, some groups impact the shirt, the sheath in the septum and once they achieve that, they advance the conventional electrode and take out the helix or the screw and only then do they They hit the septum and start to rotate to advance it. Others do like a common pacemaker, they hit the electrode on the septum and then they take out the helix. or the screw, I don't know if you like to remove the screw before or you do it like a common pacemaker, which impacts the electrode and begins to turn, remove the propeller out. What I do is prepare the electrode inside the sheath, inside the sheath you have to take out the propeller, you have to take out the screw and yes, I take out a a little the screw of the sheath, there are people like Juan Carlos that we saw today, he doesn't like to take it out, but he has it inside the sheath, inside the sheath We can also have a signal, so that's also good, many times if you pull it out a little bit it can get stuck and then you have to unclog it and everything, but Nothing really happens, I think it's up to each person to settle, there's no major issue, I think. Personally, I think that hitting the thing and then Screwing at that point is risky, because any movement of the sheath is going to bend the helix, so I find it much better to take the helix out of the sheath, leave it a few millimeters inside and map with the helix stored so that it does not get tangled in the tricuspid subvalvular apparatus and once we find a good place, then we support it well, we push the electrode that gives us a little resistance and we start drilling quickly, but I don't like that technique of supporting it and then giving it a curve because any movement can easily twist the helix. And the helix, well, I always take it out once I've already crossed the tricuspid, since I am a metriculus, not the atrium, because if it can get stuck in the tricuspid, the valve, then since I am a metriculus, I take it out slightly, I put it in the septum and I'm looking for the electrical part first and I'm looking at the anatomical part, I don't know if we can go back to the polygraph, look, this is the final result, leave it a little, it's the final result, the polygraph is running at 50, at 50, we can run it at 25, that's how we see it on surface electrocardiograms, you see, it runs that narrow, well very similar to normal, I always say, nothing to do with what we get when we stimulate any other part of the endocardium. And I don't know, we haven't recorded the obliques. We just recorded a left oblique. We can see the left oblique that was already recorded as end. Let's change the video there. We change, now. That's the left oblique, we already took out the bathtub, since the generator was connected, That's how it is, I don't know if you have any comments, anything in that sense. The doctor had a question, okay. I had a question, Dr. Nestor, the panel everyone, do you usually look at the anodal stimulation? Let's see if suddenly with the ring we have stimulation of the right septum, that is, it would be necessary to put it in bipolar, but do they usually do it? What do you say, Dr. Nestor? You always have to try unipolar to see how close to the branch we are stimulating. Anodal stimulation can cause the right endocardioventricular zone to be stimulated, so these are variables that need to be seen in each implant, I don't know if it answers the question. The two stimulations, initially as we are in the unipolar live case and later we see the bipolar to see if we are capturing right myocardium or not. If I don't have right myocardium and I don't see a pseudodelta, I leave the patient in bipolar, for questions that I can enter some type of different surgery and I will not have any problem, because there was no one who went, well I put a magnet or go and put it in asynchronous, then for that reason. But there is an article that came out a few months ago about what you mentioned about stimulation anodic, then they also see it as very feasible to leave it there and if the thresholds are low then they leave it that way, it is described in that article. What do you do Juan Carlos? I can always be bipolar and I don't know if Juan Felipe remembers that in Bogotá we had a very nice case where there was a threshold of left branch, right branch threshold in bipolar. First was the highest of the right branch threshold because remember that the anodic threshold is much higher higher and one has to evaluate if it is worth leaving it in bipolar for anodal capture and resynchronizing that right ventricle that we have always had left lying or else and then myocardial threshold and then left bundle branch threshold. Then one can find many thresholds but always the test and if it is relatively low and if it has a complete right bundle branch block I leave it in bipolar, if not I leave it in unipolar because with respect to that surgeries all houses are capable of having a stimulation configuration and another detection configuration and unipolar detection can give us problems but one can leave it detecting bipolar and stimulating unipolar then if the anodic bipolar threshold is low I think it is worth it especially if there is Complete right bundle branch block, if there is incomplete block I think it is not worth the additional battery wear that this will generate and it has happened to me that I leave them with good thresholds in the anode and in the follow-up I see the electro and I say I lost the left branch and it turns out that it is because I am stimulating bipolar the circuit is not the same and the morphology has already changed and I had to change them back to unipolar so I am not very fond of leaving them in bipolar unless that there is a compelling reason. I always try it in bipolar, always always, but I always leave it in unipolar and then I find out, always When the implant is finished we return it to unipolar and in the follow-up I see if it helps me to leave it in bipolar or not, it gives me more confidence and security to leave it in unipolar. One of the advantages of this technique is that one can connect an electrode with the generator of any commercial brand, that is Another advantage is the electrode input for this technique, one can use the electrode of one brand and connect it to the generator of another brand, which is what What we did today, connect, use an electric brand and connect to another different generator. We can do many things with this because as I said Juan Carlos, each brand, each generator has its advantages and disadvantages so we can play with this process in some way to obtain a greater benefit. Whenever patients have conduction, I also look for what is described as fusion, trying to optimize the QRS more, more the stimulation, but well, we do that post-implant to try to leave it with the best possible programming. I want to mention the audience that when the electrode was strictly left in the HISS, very high thresholds were used with a pulse width of 1 and often 2, 2, 5 or 3 millivolts voltage. Could you share with us in this case what the voltages are, how the thresholds were? How did the thresholds turn out? 1.2 with point 4 the ventricular, that is, as any electrode remains in any place of the endocardium. Which will surely go down now that the steroid. Sure, it's an acute threshold, they usually go down. Perfect. Ulysses, I know you leave it in unipolar, but because you are very Honest, but there are people who leave it in bipolar so that it is not noticeable that it is stimulating and so that they talk to you to say "oops! the pacemaker fell out." Can we move to bipolar? Don't you think so, I mean, they already said it about stimulation, etc., but is there really an advantage or not to leaving it at that? unipolar or bipolar? Yes, what I showed you just now in some patients, the electron cloud I want to force him to pass through the area of the left branch and in some patients when, we will see if it happens in this patient, but when we pass it to bipolar it is lost and the QRS widens. So you have to be aware of that, it's not whether it's the spike or not, but how do I get the best QRS? Because remember that's the only thing that we have in the room to know if the patient is going to resynchronize or not. Let's see if we can put the head on this patient right now and move him to bipolar. see if it changes or not, but in many cases it changes, because it achieves more capture of the septal myocardium than capture of the left bundle branch due to how it is moving and I just showed them to you, going from just unipolar to an extended unipolar, the morphology completely changes, simply because I am dodging the left branch. Another thing and changing the subject a little and being very didactic, when we started to do this it took us a little longer than an hour, two hours, we failed. One has to learn and go through a learning curve, to put a branch you need 70, 80 cases, but you have to start with the first one. Then, but after that, now we put these devices in less than an hour, 40, 50 minutes, standing on the skin. So, It is something that in all centers, not only in ethnoseology, but where they do stimulation, they have to change, they have to make the curve and surely As I have always said, this is the next step, a big step in cardiac pacing and where the pacing that obviously for six decades served and saved many lives, but obviously it has to be abandoned. Now we have new technology that can help us, that can help people much more. So, we all have to think about switching to this, because this is something very interesting, very good for people. We've already put the programmer on to see if we can switch it to bipolar and see what happens with the QRS. Perfect, we could see the polygraph so it's something direct. Shall we see the polygraph? Give us a polygraph and speed, please, so it's easier to see. Should we give 100 speed? Yes, yes, yes. Oh, no, you can't see the... There it is. Polygraph. At 25 it would be great, because then we have the image of the narrow QRS. If you want, leave it there for a moment and we can go on to see the wave changes. Can you tell us what you are doing? We are waiting for the device to change to bipolar. This is one of the four fastest reprogrammers on the market. That's when he became bipolar. In his case, it didn't change. Yes, it also has to do with how selective you are, but you can't know that until you see the schedule. Until you rehearse. The stimulation, of course. Of course. Will you put it at 25 soon? Give us 25, please. 25 on the polygraph. Remove the bipolar spike, please. Yes, please. Yes, please. And no spike. You're about three points away there. It's at 25 there. Perfect, there it is. Right now there? Of course, from a didactic point of view it looks better here because you can't see the spike. Exactly. And that's the comparison. Well, now we're on time. I don't know if you want to make some final words, some conclusions. You and I will close the table here. Juan Carlos. No, start rehearsing, don't lose heart. I did the first one, a success, I said this is very simple. Two and three times I failed, they were going to kick me out. I stopped for a while, tried again, more or less successful. Three and four, complete failure and passage to the coronary sinus. I have done cases lasting five and a half hours because I am stubborn to die. But once you simplify the technique and learn how it is, it is really simple. Yes. Well, I would just like to thank Martin Ortiz again, you Gerardo, to Mauricio Cortés, to Juan Carlos who dared to come to Caso en Vivo. And in general to all the people who do not see themselves there on camera, they cannot, Can you turn the camera a little, it's a bunch of people. Or come in here. Vero came from Puebla, she's my nurse too. I always say that you have to find a Vero who knows what you do and what you don't do. And you adapt and do it very well. Many thanks to all of you. And cheer up as Juan Carlos says, it is not so difficult, at first it seems so, but it is very simple, it is much more difficult to put a resynchronizer than this, In my particular point of view. Thank you very much. Thank you all. Thank you Jen Sala. Thank you, see you later. Thank you. Conclusions here, please. Néstor, Juan Felipe, Carlos. Well, in any order you like. Thank you very much. You have to start, don't get discouraged. And first read the guides, the European recommendations are excellent. There are all the measurements, the step by step that must be done. And start, because really all the magic that must be had to go through the coronary sinus, In the case of resynchronization, it is complex and this is quite simple, but there is a small learning curve to overcome. Complementing that learning curve, just don't despair about time, as the doctor said, there are cases that will take longer. And be a little calm. We are going to last longer and be a little stubborn in trying to achieve it so as not to abandon it. Because part of what was abandoned from the stimulation of ASDEGIS, that since many years before 2015 when more began to be done, it was that, that it took a long time to find it, having to map the area or having to use a navigation system. Well, here the steps are already being simplified. Another way would be to maybe measure the septum a little, if I don't have an echo to measure with, or someone who can measure me trans-thoracic, trans-esophageal or intracardiac as now, is to ask our technician, they have done all that with the semoyenamists, measure the sheath, how much is the diameter and with that they can measure how much we got into the septum, once we do the tattoo with the contrast. And I would add that this is the fusion of cardiac stimulation with electrophysiology. So, for those who are pure stimulators or those who are pure electrophysiologists, notice that we have a procedure that fuses the two major branches. of our specialty in a single procedure. Well, finally this is the physiological stimulation that we want to present, Because this is something very, very modern, it is the latest thing that is being done and I would not say that it is the future, but rather the present of cardiac stimulation. Thank you very much to everyone.

Dr. Juan Carlos Alejandro Chávez

cardiac stimulation procedures

heart resynchronization

Dr. Néstor López Cabanillas

Dr. Juan Felipe Betancur

Dr. Mauricio Cortés

unipolar stimulation

bipolar stimulation

physiological stimulation techniques