Well, good morning. We are going to continue with the scientific sessions of the LARS. On this occasion, the joint session between the LARS and the Heart Rhythm Association of the Spanish Society of Cardiology. We are going to discuss new strategies for catheter-based speech. First of all, the first presentation will be given by of Dr. Ulises Rogel Martínez, obviously beyond being the president of LARS. He is the head of arrhythmias and pacemakers at the Arrhythmia and Pacemaker Center of the City of Puebla, Mexico. Ulises is going to talk to us about cerofloro, using the technology of the simple for the complex. Ulises, whenever you want. Well, thank you very much Roberto, thank you very much. Thank you all for being here. Well, let's talk about something we've done in the last few years, something we like and that I think has a very significant benefit for us. people who do invasive procedures and also for patients. How can we use technology to treat arrhythmias without using what is called fluoroscopy? And well, this slide is the day to day in many electrophysiology centers, in many hemodynamic centers around the world. Aprons, heavy things that go damaging the body, radiation, which we also know that any dose of radiation more than zero will always be harmful, until we take a chest x-ray always It is a degree of radiation that can affect us at some point. So, this is the topic today. We know that radiation has harmful effects and these effects can be deterministic or stochastic, it may be due to luck, because we are unlucky that it happens to us and that the radiation triggers processes within our body. And we also know that the higher the dose of radiation, the greater the probability that we will have of having some complication. In that sense, look at this slide What has always caught my attention is the amount of radiation we are exposed to. in each electrophysiological study or in each procedure. If we compare and do the analysis here and we see, for example, an electrophysiological diagnostic study, It is the same as taking 160 x-rays at that time. And let's not talk about an implant, a cardiac resynchronizer that can reach the amount of radiation to more than a thousand X-rays at that time, in that hour, in that couple of hours that we are doing those procedures. Radiation, as I have always said, does not hurt, that is why we often ignore it, but it is something that is present and it is something that impacts us in some way. This has been discussed for a long time around the world, consensus has been reached, European society many years ago made a concept about the use of browsers These are devices that reconstruct the heart in a three-dimensional way and that allow us to use minimal fluoroscopy or even not use fluoroscopy with the same result in the treatment of arrhythmias. Please see this slide where it deals with the occupational disease related to use of fluoroscopy and the use of lead aprons. As you can see here, the prevalence of diseases in these people who work in procedures carried out by fluoroscopy Well, there are several, from spinal problems, neck problems, cancer, etc., etc. So, as we become exposed to radiation, we have the possibility to have this kind of problems. This is another example and also, as I told you in one of the first slides, The range of the problem or the severity of the problem also depends on the length of time we have been exposed to this radiation. What about the equipment we use to protect ourselves from radiation? Well, it will cause us musculoskeletal problems, spinal problems, cervical problems. and this is important. Electrovisual specialists, radiologists, the patients who are in the haemodynamics and electrovisual rooms, well, in the end many of us end up with this problem after years of doing this type of procedure. One of the important things, we have all seen how a person, how a haemodynamicist, how an electrovisuologist stands next to the fluoroscopy tube and well, this has also been studied. You see, it is more common for us to have cancer on the left side of our brain simply because the tube that gives us radiation is on the left side. from our head and well, this increases us and we are more exposed in that part of the body. It has also been a long time since browsers began to be used and they began to be used In this sense. And in this sense, the first thing that was done paradoxically was to use them In complex arrhythmias and in complex arrhythmias, we speak of atrial fibrillation, to treat atrial fibrillation with little fluoroscopy and it was not initially considered to treat simple arrhythmias. What happens with conventional arrhythmias? Well, conventional arrhythmias can now be treated with this type of equipment where it is clearly seen that very common arrhythmias such as intranodal thecane, accessory pathways They can be treated with this type of system and this will avoid or greatly reduce the amount of fluoroscopy that we can use. A long time ago, back in 2013, a concept was published and it is a very interesting concept that tells us that as low as reasonably possible, there will be arrhythmias. and procedures where for access to the heart, through the veins, for some reason we are going to have to use fluoroscopy, yes, but we must always think about treating to use the least amount of radiation as possible without putting patients at risk. Different studies have been done, this study shows us that in its series zero fluoroscopy It was about 72% on conventional substrates and told us that using little or no fluoroscopy reduces the risk of cancer by 96%, particularly in young people and women. When we analyze and compare not using fluoroscopy with conventional procedures using fluoroscopy, we see that obviously the fluoroscopy time, Radiation doses are greatly reduced, as is speaking time or procedure time. are virtually similar after one passes the learning curves, the success rates for treating arrhythmias with and without fluoroscopy are similar, both long-term term as well as short term, the complication rate that one could say without fluoroscopy is not can it be done, no, complication rates are similar using and not using fluoroscopy and the recurrence rate of arrhythmias, which is not zero, is also similar using and not using fluoroscopy. Some other studies where a larger number of patients were included, 6 years, 266 patients, have shown that this type of technology helps us and is useful without putting us at risk. to patients. But what is happening in our media, what is happening in Latin America, recently it has begun to have more navigators, more equipment for three-dimensional mapping, but the questions remain the same, we do not have concrete data, how many public services or private companies have these devices, we do not know, we have some idea, but not very clear. What are the costs of using these systems? It would seem that they are more expensive, But studies where they have done economic analysis on this matter, it seems that this is not the case, It is not more expensive, only for complex arrhythmias, in this sense surely not, simple arrhythmias also benefit from this type of technology and in simple arrhythmias We also use fluoroscopy, so there is no reason not to think about using this type of technology in simple arrhythmias. And in that sense, in our daily practice, at some point we get a pregnant woman who cannot use fluoroscopy and who has incessant tachycardia and who It doesn't improve with medication, so that's where one thinks and where one uses these types of systems. Last year we published a case of a woman in this regard, in the world there are published cases of arrhythmias in pregnant women, which although it is not frequent When it is presented to us, it is a problem that we have to think about and solve. This being the case, what do we do? We started doing this in a simple way and using fluoroscopy and little by little we have gotten into the topic of not wearing aprons anymore to use fluoroscopy, It is not necessary and from the beginning we thought of not using any fluoroscopy. We insert a first catheter through the femoral vein, we paint the entire access to the femoral vein, the inferior vena cava until reaching the heart, once we reach the heart without using fluoroscopy, obviously the first thing we do is reconstruct the right atrium, when reconstructing the right atrium the next thing we do is an electrovisual study, see gentlemen electrovisual, we trigger the tachycardia that we think he has, we confirm what type of tachycardia is and that is where we think about reconstructing some other parts of the heart, the left atrium, the right ventricle, the left ventricle, depending on the type of rhythms. But the first thing we do is this, the access, paint the access and then rebuild it in a way three-dimensional view of the right atrium to see the basic anatomical parts, the gis, the superior vena cava, the inferior vena cava, the tricuspid ring and with that we can orient ourselves see where we are. This year we published a small series of what we do in our service, zero fluoroscopy, using no fluoroscopy, with these substrates, simple substrates, the vast majority of nodal input and input tachycardias and flutter are by far the arrhythmias that we burn the most with zero fluoroscopy, but we also burn arrhythmias such as accessory pathways, atrial fibrillation, atrial tachycardias, other types of tachycardias. It is a series and it is sadly the largest series published in Latin America, although it is not that big, but it is outside of this series, there is some other series with 10, 12 cases and There is no further data regarding this type of technology in Latin America. So, these are the things we need to see what is happening with us. What do we conclude from this study and what is our conclusion from the experience of doing this type of procedure? We believe that zero fluoroscopy has a broad spectrum in the treatment of arrhythmias, both simple and complex. What we use now and what has also changed electrophysiology is the use of intracardiac ultrasound, ICE, for its acronym in English, and that many times It helps us, but many times it is not even necessary. So, depending on the arrhythmia that is going to be faced, we can always have We must have the tool, but we can use it or not. The procedure times, in the end, when we pass that learning curve, are not greater. than the usual ones and in our series we did not have major complications compared to the procedures we normally do. The use of three-dimensional mapping, I believe, should be encouraged, it is safe and effective, it is the best tool to avoid radiation and its consequences, It is the ideal method in incessant arrhythmias during pregnancy, of course. This is another example, what I was telling you, we enter through the femoral vein, we paint everything access, we paint the atrium and after painting this we orient ourselves, we do the electrophysiological study and we do this. In this one, I'm going to show you two, three cases of what we've done, this is the constructed right atrium, this is the superior vena cava, the inferior one, we place the GIS which is for the Electrophysiologists of the most important parts of the electroconduction system, we do the electrophysiological study, we trigger the tachycardia, we see that it is a tachycardia by intranodal entry and then we go to the area of the slow pathway where we burn and it is even safer to burn, to ablate an intranodal tachycardia using this type of technology and with this the arrhythmia disappears. And this seems simple because we no longer rebuild, this we no longer rebuild and this It's something that I like a lot because we can virtually turn it around. heart to accommodate ourselves and to think about where the focus that causes the arrhythmia is. This is another case where from the beginning in the electrocardiogram the patient had a wallpark in some way, we see with intracavitary electrocardiograms where the accessory pathway is, we reconstruct, in this case it was on the left side, we reconstructed the right atrium, Later we go here in red to reconstruct the left ventricle, we are located in the part lateral of the left ventricle and with that without using fluoroscopy, accessing through the aorta, we finish and can treat this type of arrhythmias with complete safety. More complex cases, yes it is also possible using this type of technology, this is an example of a focal tachycardia in the posterior part of the left atrium, It is a case that we did a year or so ago, where we obviously see the ectopic focus that is here in this part and as I was telling you, for me it has always been impressive to be able to turning the heart virtually while the patient is lying down, we see electrical signals, Obviously we have to locate ourselves with electrical signals and with this the catheters today They allow us to see the catheters virtually, reach the site where the ectopic focus is and with that apply radiofrequency and end the episode of tachycardia. So, in conclusion, does treating arrhythmias without fluoroscopy carry a risk? less? Yes, of course. Is it possible in most arrhythmias and procedures? Yes, and every day I should encourage you more to use this technology. Not using Fluoroscopy obviously reduces the risk of diseases such as cancer, reduces the risk of spinal injuries and the results are similar and even in many cases are better and certainly, well, this creates a more pleasant environment within the electrophysiology rooms. Thank you very much. We thank Dr. Ulises Rogel for his participation. Next, Dr. Tomás Datino, cardiologist, electrophysiologist, president of the Association of Cardiac Rhythm of the Spanish Society of Cardiology, belongs to the Quirozalud Hospital, Pozuelo, Madrid, Spain. Next, with its theme, new solutions for mapping and atrial fibrillation ablation. Please begin, doctor. Hello, how are you? Can you hear me okay? Hello, can you hear me okay? Yes, go ahead. Perfect. And can you see the presentation too? Excellent, yes you can hear it. Okay, I'll tell you, If you see the presentation that I am sharing, you can see it. Go ahead. Okay, perfect. Thank you very much. I'm delighted to meet you. I'm Dr. Datino, as I've already been introduced. Thank you very much for the invitation. I am very sorry I could not be there to make it. There are more people who have not been able to attend, but well, we are lucky to be able to replace it this way, doing it online. It's a fascinating and very broad topic, so, well, we'll touch on a few things and I hope I don't spend too much time on it, so let's get to it. We start with the topic of pulmonary veins, of atrial fibrillation ablation, which is what we are talking about, since it was written 25 years ago and we simply had fluoroscopy. and in the beginning even these circular catheters to map the veins. So we move on to the evolution of what our bonus includes, making these maps with the CARTO system, for example, pointed, with these little tubes that were the veins and that evidently helped us a lot to be able to grow in the technique, But we have evolved a lot since then, we are very lucky with all the new technology that is out there. And that's why I'm going to try to summarize it to see what we can benefit from. On the one hand, we would not only start by making the map with the ablation catheter itself, but with a lot of catheters, I will not be able to represent them all, I'm sorry if some are not represented, I'm just putting some images of multipoint catheters, On the one hand, since it is not with the tip of the ablation catheter, you have less risk when mapping. and on the other hand they give you a lot of points at once and a much more precise structure, As you can see here, for example, in a map of a right flutter, they are almost resonance images. and also with incredible precision when it comes to seeing where the slow driving zone may be, that is, we have made great progress in this regard. For example, what does Ensight bring? We started with the HDGrid, which was this multipoint catheter, which initially made the maps comparing whether the best signal was longitudinal or horizontal. and assigned it to that bipolar point, to what is now the unipolar signal, which what it does is at each point it compares the monopolar signal with the two that are next to it and it does a 360-degree sweep to decide at each site what the direction is, what the vector to use is, So that gives us much more precise signals, for example in the NFA mapping it allows us to better distinguish what are the scale zones and which are like the sinus rhythm, As I say, it gives us these point-to-point vectors of where the signal is going, even speed, which we do not know very well what it means and we will have to see in the future what use it has. We would have the equivalent or something similar in Biosense, which is the Octarray, which is no longer just 5 legs but 8, That's good, compared to the Pentarray it shortens mapping times a lot more, time is always an important limitation in the area and apart from this, It allows us to distinguish the fil much better with an electrode that it has in the handle, as we can see for example here in an upper left pulmonary vein, This is important to distinguish it from the signal from the ear appendage, for example, and it also greatly reduces the noise signal. This is in terms of signal recording. Regarding radiofrequency ablation, point-to-point ablation, one of the most important advances in recent years has been the ability to have a contact signal, They were talking in the previous talk about trying to reduce the fluoroscopy, about trying to map alone without using fluoroscopy, using the catheter itself, the navigator itself, and we see how having this contact signal gives us much more security so as not to press with the catheter, so as not to injure the tissue. and also at the time we are doing the ablation to know if we are in good contact with the tissue. That is why each company has released its contact signal, In the case of, as we see in the cartoon, it gives us the distance to the neighboring signal and above all it has brought us a very important thing, which are the algorithms, which integrate not only the power that we are using at that ablation point, but also integrate elements such as the contact itself and the time, The aim is to standardise what we are doing and to be able to compare results in a much more precise way. Here we are seeing it, it is performing the ablation at that point and we see how it gives us what is called the Ablation Index. And that information allows us to decide when to stop or when not to. How has that been evaluated? Well, with studies, as always. Once we knew these algorithms, in the case of Biosense, some parameters were established that could be suitable cut-offs, which are a series of studies that you will always see mentioned in Biosense, the Close parameters, which are those of this study, the distance, as I say, we could see the distance between the points, less than 6 millimeters. A power of 35 watts is initially set, Before this we usually used 25 on the posterior side and 30 on the anterior side, but here it is now increased to 35 to achieve an Ablation Index of at least 400 on the posterior side. and 550 on the anterior face. With this, a first step is achieved in this study, that is, only by making the crown when I finish, 98%, that is, 256 of 260 veins are already isolated, Going with those parameters, and it does not appear that there are any more clinical complications, especially what is worrying when we talk about increasing power. It will be the case of the posterior face and the esophagus. With similar efficiencies, you already know that the result in the follow-ups depends a lot how it has been evaluated and the type of patients. Well, they say, since we have gone up to 35, we have already cut the times, why not go up more? If we already know where we want to go, If we already know that our objective is to reach those 400 on the back side or those 500, 550 on the front side, well, the power was increased. In each study, as people have been asking above, comparing already 40 watts in the whole crown, there were also 45 and even 50 watts, More or less in these series that are not very large, less time is always achieved, that is, we cut the procedure and it seems with similar security. In the case of Styros, in the case of Abbott, there is a similar algorithm, there are two parameters, the one that is most used now is the injury size, here I have corrected it in Spanish, sorry, with accents, injury size index, which is what, well, They are always complex algorithms, but in the end they include the same parameters, power, time and contact. There have also been studies done, I cannot mention all the ones in which the parameters are also increased, until reaching that 50 watt crown to establish what the optimal parameters are. In some cases they do it simply by looking at the sites with which parameters the vein was isolated in the first step or looking at where the capture was lost. Well, it has been established more or less between 4 and 5 on the posterior face and 5 or 6 on the anterior face, in a very summarized way. And this has already been evaluated in a randomized study, which is the Shortayers, which basically looks at comparison, they are very few patients, this always has a limitation, compare in those 60 patients, use this, what we call high powers, 50 in the entire crown, versus the classic, which was 25 posterior, 30 anterior, with these close parameters or with what we just defined for the test. And they see that what is most shortened are the procedure times. We used to go from two hours, but now on average, the procedure is cut by about half an hour, By increasing the potency, there were no more clinical complications and here they even give better efficacy. I always put this in quotation marks, They are very few patients and, well, we would say that at least we achieved similar results by shortening the times, increasing the power. Before moving on to what is high power, I would like to mention two things. One, which is also seen in the Shortayers, although there were no more complications than those that worried us Initially, it was esophageal, neurophrenic, etc., in this study, something that is not done in all studies, they look at doing resonances to assess if there is asymptomatic embolisms. There are, indeed, more asymptomatic embolisms using higher potencies. It is not known how important this is, because this does not provide data. stroke clinicians, which is always one more piece of information that probably tells us about more charring when we use high powers. And that brings a little bit of care with the 50 watts, if that was to shorten times. And then, another issue that is not mentioned here, is that when we use high powers, When we are using these algorithms, it takes a few seconds until we get the first value, depending on the stability of the catheter. It can take 3-4 seconds, which sometimes takes up to 10 seconds. When one is on the back side with 50 watts, the first value that the algorithm gives us is already above what we wanted to achieve, for example, above 400 on the back side. There is some publication saying that you can hear some pop there and you might even want to be careful about injuries or sickles. My recommendation is to increase the power. We are already always doing high power, 40-50 watts on the front side. And I probably, on the back side, I don't think it's necessary to go up to 50 watts. Probably 35-40 is fine to have better control of the first values that the SLS index lesion gives us. But, well, we'll see. Moving on to what we would call, then, very high powers, right? Which is, in the case of the most developed catheter, It is the Biosense Q-dot, the Q-dot micro, which basically what it does is directly go up to 90 watts, this thin catheter with 3, it has 3 electrodes at the tip, and what it does is 4 seconds and it controls it with temperature, it is no longer a power control, but it will give a fixed 90 watts and if at any time it goes over 65 degrees, it stops. Which most of the time doesn't happen because it's only 4 seconds. In this case, since they are smaller lesions, a distance between points of 4 millimeters is required, right? This would therefore be an ablation with the Q-dot. We are therefore looking at the dot. We also have the interelectual distance. In this case, there was also control in the esophagus. and we see how it is getting those points in just 4 seconds, which is very fast. The important thing is to have good stability, that sometimes a deflectable sheath is needed in that sense. The surprising thing is that when animal studies are done, also so that we know, The thing is that the lesions that are really seen at high power are different. That is, they are smaller, less deep, and the largest diameter is on the surface, noticeably. This would be a comparison of the 90 watts, 50 watts, and 30 watts. It seems we were concerned that when we went higher in power we would get more depth. And it is not like that, but we begin to compare them to lesions made without irrigation, as when we made a non-irrigated catheter. In the end, this is doing a temperature control, no longer voltage, and it looks more like an injury. So why do we go back to all this? Well, because this type of catheter allows us, As we said, we need to provide a lot of power and very short applications. But let's not think that we are going deeper, but quite the opposite. That distance between smaller lesions would not be required. And, in any case, on the contrary, it seems that it would be more appropriate for areas where, for example, the carapostera, where it can be finer. This has also been studied in records. This would be record Q516. These are two very recent studies, as you can see. Basically, what I wanted to see was that the isolation was done well in the first step, that it was optimal, that the complications were not greater than with the usual techniques and that there was a similar recurrence rate, since what was achieved in many hospitals, similar results. So, the next step was to evaluate it in a randomized study, which is the PowerPlus, with 180 patients. And here it compares what we were saying, the very high potency with the high, with a CLOSED protocol, which, as you can see, despite the fact that we already mentioned the 50 watts, in the test itself they are going to 35 on the back side, what I was saying before, and 50 on the anterior face, reaching the Ablation Index of the CLOSED. So, with this comparison, what you see, this exam has been presented very recently, These results are from a Dutch group that promoted the trial, and what you see is, in other words, in the publication it says that the times are reduced, even beyond what we already achieved with high power, but hey, it's only 5 minutes. It's significant, because it's 75 to 70, but the advantage is already small, For what is an importance in the room it does not seem to have such a significant impact. That is, they cut the ablation times, but the first step is minor, That is, when I finish the ablation, I have to go over it, especially in the carinas, where there seems to be less stability, sometimes I even have to lower it. and go to normal powers at those points. And that in the follow-up, the effectiveness is similar. That is to say, well, it would be a valid strategy, with similar security, which might cut the time a little bit, but that's basically what it gives us. We could say, then, the very high power, what I just said, I'm not going to repeat it, which are more superficial versions of injuries, be careful with charring, and above all, in that sense, if there has been any data on the subject of cerebral embolisms, We will have to keep following it and see what happens with it. But well, it could also be a valid technique, which is worth learning. With this we would finish. with point-to-point radiofrequency. I'm sorry to have to go so fast, but it's a lot of information, we can cut it wherever you want. I'm not going to say much about the single shot. First of all, and we know that the most widespread is creatulation, this is, together with point-to-point radiofrequency, the most used technique, there are already millions of patients. those who have been treated. Initially with Medtronic, now we also have Boston's Polar X. They are two equally valid techniques, very standardized. and with short ablation times. So, I'm not going to say much more about this, just that, well, we are participating now, we have been promoters of a registry In which what we intend is to analyze that instead of using contrast when seeing the occlusion of the vein, that we already know the contrast which can cause nephrotoxicity, allergy, and also requires more fluoroscopies and especially if you record it, do it with pressure control. We have seen that this is the case. There are already some series showing that it is equally effective and in this case what we see is that when you occlude you go from having a signal that would be a typical left atrial recording. with its A wave and its V wave to have only a single monophasic wave of systoleidiastole typical of the pulmonary artery when it is well occulted. That is, when we see this signal It indicates that it is necessary to apply and we would not need to contrast. I assure you that it is much simpler, less cumbersome, the catheters do not stick to you and now we are doing a national registry with many centers and we are having very good results so far. I recommend them to you. And we come to the star technique That would be a bit like what everyone is talking about and what has been published the most. It has taken off in recent years, which is electroporation and well, we are all very excited. Not everyone has access to this technique because they have had very limited sources and that is where we are. Let me tell you a little about the data at the point we are at. Electroporation is like a new world. We leave behind what is called thermal injury to move on to what would be an electrochemical injury. It seems that we are going back to the beginning of electrophysiology when what was done was to give high shocks to cause injury. Well, this is the same thing. It is actually a very short electrical pulse with high voltage that instead of generating increases in temperature what it generates is an injury to the cell wall itself, especially more selective at the level of the myocyte, which are pores. And these pores, that's why it's called electroporation, would cause the cell to die. and it is probably thought or already being seen that it could be quite selective of the cardiac muscles without damaging the surrounding tissues so much, fat, esophagus, nerves, nerve cells. This, as I say, has been studied up to this point, already seen in... Sorry, Tomás, sorry to interrupt you. Dr. Keegan will speak to you for a couple of minutes and we can finish. Okay, let's go, perfect. Thank you. Very well. As I say, in the animal studies it is seen that it was more selective, that there were no lesions in the esophagus, There was no pulmonary vein scenosis and we have the techniques that we have right now in the available catheters, they would be the Boston catheter, This is the one that is capable of being shaped like a flower or retracted and made like a basket. The data from this study, first the first series was to validate What type of electrical signal was used and the signal has already been optimized, the best one is a biphasic wave and with that very high insulation data is obtained, of more than almost 100% and when those veins were revisited a few months later it was seen that most of them were still isolated. This was basically a study, We could practically say, in terms of dose and that he also saw what we were already talking about, that there are no lesions in the neighbouring tissues and only the typical complications. of any study inherent to the technique, the puncture, the transseptal, etc. Not because of the technology itself that we use for ablation. This is the Manifes registry, which are also already more than 1,500 patients, and we return to the same thing, good results using this electroporation that has the same, no esophageal lesions, which is the most important thing, but data are beginning to appear on what we call coronary spasm. It does not injure the vessels, but be careful when applying near the arteries, especially in chaotricupid isthmus and mitral isthmus, which may cause vasospam, that most cases say that they have been resolved with mitroglycerin. Another European registry, Leuporia, more than 1,200 patients, as you can see there are already many patients included in records with Boston electroporation. Similar results, also a case of vasospasm. This vasospasm has already been studied by the Americans, even trying to do corneography while the electroporation application is being done. In the veins, no vasospasm is seen, but when, for example, it is applied in chaotricupidism, 100% of the time coronary spasm is seen. And it is always resolved with mitoglycerin, But we must know that there are no ossic lesions, but we have another type of substitute that we must be aware of, especially when you leave the pulmonary veins. We also have Medtronic electroporation, which has two types of catheters, one that is the same as the old PIVAC, which you see you have to do, rotating around the vein to make those pulses. It has also already been studied in a multicenter registry. Similar results were presented by Boersma. There may not be any injuries around. There are phrenic injuries in some of the studies, especially in the farapus, so the fact that they do not injure the nerves is relative. There is some phrenic paralysis. They are rare, but they can also occur. And the newest thing from Medtronic is the acera. The acera that the Sphere 9 has, This catheter is like a tiny grid, with these 9 millimeters, which above all has the three very important things, which allows, not that it does not It has a tip, that is, it is a small sphere, which allows you to apply combined, it already gives you the complete, radiofrequency or electroporation and it also has associated a browser, if you want, that also allows you to make exceptional maps, so in these studies what is being evaluated is to apply with electroporation on the posterior side because of the esophagus and for stability reasons with radiofrequency on the anterior side and the results have also been very good. good on the records, although it is still less advanced and less available than the Boston Farapulse. So we have some comparison, two very chiquititas, a randomized study that has now come out in New England, 600 patients, compares thermal lesions with radiofrequency or CRIO versus electroporation, similar results, similar complications, that is, electroporation would be equally valid and this is another comparison in a registry in which similar results are also obtained. The times may change depending on the operator's skill, but in the end the results are similar. What would be the Conclusions? Those of electroporation, that there is no scenosis of the pulmonary veins, that there is less injury to non-street tissues, especially at the level of the esophagus and there may be injury to the crinic nerve and there may be coronary spasm, be careful with this, you have to know it when using the technique, you have to use general anesthesia because it produces muscle contractions, this should be known for people who do not have an anesthesiologist, they are not yet the optimal parameters have been perfectly defined, we are almost passing that phase, but you have to know it, it is not so widespread and well, if you do not have a browser, For example, in which we were talking about Medtronic, if you don't use a browser, then the scope time is another thing to monitor and we would end up, although this I say, it would be an endless conversation, which we can then comment on in the discussion, what I have said is only for the veins, that is, not We hope to have better results, in the end in all cases you are isolating the pulmonary veins, you are not going to improve the result in your FEA ablation, but Yes, you are going to do it faster, more safely and with fewer complications, which is already quite a lot, right? So, everyone will decide in their own room, hopefully in a in the near future, what technique I am going to use for which patient depending on what I am looking for. I do not put anything outside the pulmonary veins because if not We never finished, but well, it would be for another day. Thank you very much. Well, thank you very much Tomás. I would ask you, please, in case we get to have some minutes for the discussion, please stay connected. Thank you. Perfect. Well, now we will give way to Dr. Alberto Alfi, he is Argentine, an electrophysiologist. Argentine, he is an electrophysiologist at the Posadas National Hospital and the Adventist Cardiovascular Institute of the City of Buenos Aires, and he is going to to talk about something interesting, which is the complex accessory pathways, a great challenge. Roberto, whenever you want. Thank you very much, Roberto, for the words, Many thanks to Lars for the invitation and it is an honour to be at this session, together with the Spanish Heart Rhythm Association. So, well, let's get started. With this talk, I am passionate about the subject of what accessory pathways are. Let's go, these are my conflicts of interest. Well, this is what I want to present to you, let's go Seeing cases, this is what we all like, we are going to see interesting cases. This is an eight-year-old boy, with recurrent paroxysmal seizures, very, very infrequent, which makes him unable to do physical activity, refractory to medication and, well, as you can see, there in our circle in chalk refractory, tachycardia due to orthodox entry, as you can see. So, there we have to try to get rid of the coronary sinus. This ablation, unfortunately, was unsuccessful. So, what I'm showing is the second procedure. In the first procedure, the earliest region was the anteroceptal, anterior region, there was a great similarity in the activation, as you can see, see in green the chalk catheter and in light blue is a halo catheter placed, covering the anteroceptal part of the tricuspid ring, the anterior part and the anterior lateral part. Doesn't it strike you that it is Is the activation pattern very similar? That is, the VA is similar throughout the tricuspid ring, from all the way to the front, like, say, a sun setting in the horizon, right? It's the same in the anterior part of the tricuspid ring. And this caught his attention. So, I call it a vanishing effect, because there has to be a remote point to the place where we are taking all those similar activation points, is where we grab the vanico. That remote point is where we grab the vanico must be giving us, by anisotropic activation and conduction through the muscle tissue, very similar activations. Where is that point? And Well, this, then, we are going to see with a high definition map, using a Grid Edge. You will see that this is very interesting, like these images impressive, see the density of points there are and the entire tricuspid ring is activated at the same time, the anterior part, it is at the same time. So, this when We see this, it's a sign that there must be something we're missing on the map. It's a distant point. An accessory route is, let's say, something, let's say, thin, where you can activate, let's say, the entire ring. Well, what we did then is change to the ablation catheter and map, let's say, thinking about a remote point. And what we think, we are going to look for places near this site. So, what we saw that the fan, the fan sign, the point remote, and there you can see the point that I'm going to show you now, where we ablate. The white catheter, the white channel, is the ablation channel and there the VA is much more precocious. We are there. Well, where are we? And where we are is the very atypical place. This is an eight-year-old boy who is the base of the rejuela right. It's a very atypical connection of the base of the right appendage to the right ventricle. And, well, we decided to ablate here in this eight-year-old boy. years and, as you see, the ablation is successful and it is completely dissociated. This is the first case that I wanted to show, which is a very challenging path. Moving on to the Second case, we see, this is a 20-year-old girl with undocumented palpitations and who has what appears to be a anteroceptal. I'm not going to dwell on the analysis of the electrocardiogram, because the talk is too long. I'm going to move on to the discussion, okay? But, as you can see, it's a anteroceptal, okay? That is, by location. The most important thing, as I was saying, Dr. Josephson, mapping begins with the 12-lead ECG, right? That's the most important mapping. Well, but it's an anteroceptal pathway. But, strikingly, we do the study. Now, look at it, on the left half it looks like what is an anteroceptal pathway. On the right side there is a change in the morphology of the delta wave, in the polarity of the QRS and we see a left pathway now. What is important to recognize in this and learning is that When we see the first part, almost always, we are actually seeing a fusion of tracks. It is not the track pattern. Now, now that we discover that there is two pathways, when we see the first part that looks like an anteroceptal pathway, in reality that is a fusion of pathways. The second part, if there is not one The third way is the pure way, which is the left way. But the first part is two ways. But this is important and crucial. If it is an anteroceptal pathway, well, we have to be very careful because we can be at risk of AB block. So, it is important to have the exact pattern of this pathway, because As we said, mapping starts with the success of 12 leads. So before I stick a bunch of catheters in and start... I have to know where that pathway is. perfectly located. With maneuvers we could not normalize, sorry, have the pure activity, the pure creation of this pathway that seems anteroceptal. So, what What we did, what we actually do today, I used to do more, but what we did is induce auricular fibration. We induced this on purpose, to see a needle in a haystack and see if we could discover the pattern of the pure path, which was the straight path. And look how striking it is. I don't have a pointer now, I don't have a pointer now, You can, but look at D3, in the second half of the right, which is there three times, it falls like a W in D3. That W in D3, that is the pure activation of this pathway. right. And notice how striking it is. Follow the cartogram that has the 12 derivations in a line, all together. Now, in D3, see B1, B1, B2, B3. The transition is smoother in the precordials. So this is not an anteroceptal pathway, it is a more anterior pathway. This transitions smoothly. This is not It is anteroceptal. Knowing this, we convert the patient and, well, we are going to do pathway by pathway now. So what we did was we mapped the right anterior pathway. And obviously we mapped anteroceptal, but we were far from here, because we already saw it with the 12-lead text. And there we are relating it. Look below, how we are percos and then it separates into the local section, into the talker, but we do not normalize the QRS, but it goes to the left pathway. Pay attention to this, not to cut off the conversation, because, well, we do not normalize the QRS, but the sealing pattern changes. And then we move on to the second route, which is a very rare location, having a left anterior route. At 12 o'clock in the mitral annulus, we place a stabilization sheath to bring more contact force. It is very difficult to have good vector and good contact in this anterior left location. And, as you see there, we are percos, the local section, And then we completely normalized the QRS at the end of the tracing. As you can see, these are the patients who are at risk of death. All series have 2 pathways and had pre-excited RR. less than 200 milliseconds, okay? These are the patients who are dying. This was a challenging case, luckily you can do everything right. A third case, and for those who do not know this pattern, is very nice. Look how nice in the precordial leads, as B1 is negative, in the total priority of the QRS, B2 is positive. and B3 there is a lowercase R S, it kind of becomes negative again. This was described by Dr. Isaac Ehr many years ago, and the first abstract was presented at HRS in 2009. That's when it really caught my attention, we started looking for it and we really saw a lot of these patients that we put it in a cupboard. And this is a very specific pattern, but entirely specific to a vacation, which is the region of the tricuspid cape. It can be postero septal, posterior, posterior lateral, but it is always in the tricuspid cape. and it will never be left posterior septal, stained glass or in the coronary sky and tributaries. It is very nice to know this pattern, because the map is really with the elector of 12 derivations, then with more pre-excitation the pattern is maintained, then it is not a issue of fusion with node AB. That pattern is true, okay? Here, the shorter the cycle length, the less fusion with node AB, but see how it maintains the pattern. And this, well, I'll go quickly with this, there's an algorithm, if B2 is positive, it's more septal. If B2, the sum of RS in B2 is more negative in B2, it's more anterolateral. Even with the voter we can determine where it is. And I tell you, it is very specific, but unfortunately it is not very sensitive. It is not that the entire path of this location goes to have this pattern. Surely some have not seen it, this pattern, ever. But well, there is the ablation. That is the three-dimensional navigation equipment. Always It is in the ism, it is a very fast ablation. Section number 2, because we already know where the path is, okay? A very nice electrodrama, the fusion is early, that ablation of the first section in 4 seconds. This is a very interesting electro to share, we want to publish it. There really aren't many. Look how interesting. This is a challenging electro. We're looking at an electro where we see a pre-excited tachycardia, okay? It's an activation, a programmed atrial stimulation where we induce a tachycardia with wide QRS pre-excited. And it's very interesting because we see the morphology, it's a postteroceptal pathway, okay? In the whole arm degree. And well, it seems which returns through the AB node, right? Look at the GIS channel, as the earliest, it is precisely the GIS channel, so we could say that it goes down the postteroceptal pathway and returns by node AB. I want to ask someone in the audience if anyone thinks that is so. Is this so? Nobody answers, but someone brings the answer. Well, I I tell you that there is a second way, because look at the GIS electro. The GIS, the activity is completely dissociated. It has passive activity. The GIS is a bystander here. It has anarchic activity that is passively activated at times. Look at the GIS channel where you see the dissociated GIS. I don't have a pointer, but you can see it, please. I don't have a pointer, but there are several GIS activities, sometimes outside the QRS, sometimes separated, outside the atrium. In three, four occasions there is a separate GIS. Do you see it? So, This is a tachycardia, they call it accessory pathway tachycardia. One accessory pathway, another duodromic tachycardia, okay? So, there are two accessory pathways. The map is done. We have two ways. And the second way will surely come back, it is an anteroceptal way. The pointer appeared at the congress, how nice. You have the pointers at the congress. Well, See how it comes back through the anteroceptal pathway. There is the earliest atrium, okay? The upper right atrium is the furthest away. So, without further maneuvers, which are rarely we achieved in the geology book, there is a definitive diagnosis. Duodromic tachycardia reentrant via via. And well, this is very interesting. It is a via, the girl is also young, with a failed ablation of what you are seeing there, a right lateral pathway. These pathways They are really challenging. It is one of the places where most failures occur, because it is not possible to identify. Maybe this is a map in circular rhythm, using the open window technique, as you can see, you see the corridor, see where the track is located. And we also do it, let's say, during ventricular marking. There is no mismatch A, B, B, A, but it is a path that there is no obliquity here. So, we are going to ablate it. We already know where it is. We are going to place you Now, after we have placed the pentarray, we are going to place the ablation catheter. So, we're going to ablate it, but notice that it looks like we're ablating in the atrium. Look at the recording, what it is. So, ablate, on the first shot, we normalize the QRS. And when we normalize, the QRS appears in a ventricle, as if it were an act of magic. What happens is that the right pathways are what I call the pseudoatrial signal. They are the signs where we see the A, B closer together. If you look closely, the A, B closer together They are free-walled. Ablations often fail because we lose this potential. Look how it separates. You have to be very careful how you stick it. We have to normalize the QRS, we have to induce tachycardia. There is a lot of troubleshooting to attract and be able to differentiate the electrological ones that we are seeing. If we are not going to fail, we are going to fail. Because the little map on the navigator is fine, very nice, but if we don't then We're finally going to find the way, we're going to fail it. Okay? We can't bomb like the faces of the tachycardiacs of the Wolf, because it will come back. Okay? This This is the message of this, the pseudo A signal in the right free wall pathways. And well, I have the posteroceptal pathway in a 15-year-old girl, without tachycardia, we go to pediatrics a little, without tachycardia or anything. There was the posteroceptal pathway. So, we do the study and the QRS normalizes in 350,000 seconds. What do we do? Do we ablate it? We're going to ablate it. the AB node maybe. It has a risk of AB blockage. The node, the location is as Dr. Cabrera presented. We are right next to the Cardiac Rhythm City, with A very nice paper, where the AB node is compact and there is a lot of dispersion. Do you agree? Analyzed in specimens, let's say, of humans. A very nice work by Dr. Cabrera, by Professor Cabrera from Spain. So, what do we do? Do we not ablate it? So, it has little risk. Well, we ablate it. And it is not a question of, let's say, attitude that we want to ablate. See how in two heartbeats this pathway is gone. It seems as if The posteroceptal pathways are the easiest. And that's not really the case. This pathway, luckily, we mapped it and it went very quickly. But, really, the posteroceptal pathways are the ones that are most They offer a challenge, because they are the most oblique routes there are. There is a lot of variation. But the challenge in this case is whether to ablate or not. And, well, here you see how in two heartbeats we normalize. Very good unipolar signal. We can also differentiate the atrium and the ventricle here. The ventricle goes down. Very good signal. Here we are, let's say, look how opens. Very nice. So, well, to show the ablation. But look at the time they spend. 1.5 seconds. But the interesting thing about the challenge is not the ablation, but deciding to do the ablation. We are related by this. This is the 2018 study by Ettrich. Collaborators, there are 95 cases of arrhythmia with golf, arrhythmia of risk of death, with suicide represented as death or high-response FAA due to accessory road driving. And what was seen, everything traditional about this binary risk classification, less than 250 plus 250 milliseconds in the dispersion of the RRNF, the NFA, or the cycle stimulation at less than 250, or also the refractory period less than 250, This is not the case in pediatrics. There is no such work in adults, but this was done in pediatrics. 95 cases from 24 countries collected over more than 20 years. Look at the red dispersion of the refractory periods and also the earliest recited RRNF. There really is no binary risk number. There is a total dispersion. In fact, 50% would be considered not at risk and would have sudden death. So this, you pass, the society that is in charge of making the guides, you have to work to change the guides because this is no longer the case since 2018 with this really large study. So we have to change the way we think in pediatrics because a comforting hug to the father, to the parents, is not going to save the child from sudden death. OK? As an example, I don't have the slide, I had a patient last year who comes to the clinic, a 15-year-old rugby player without symptoms, by a wolf, an ergometry that did not normalize the QRS, but it is called up to 180, rugby player, now that the World Cup is on. I asked for the ablation and the mother called me saying that the boy had a sudden death at his desk at school and died. And the boy had never had arrhythmia. So, they see sudden death as the first manifestation in pediatrics. So, that's why it's important to change our thinking in pediatrics. And this is the challenge, because it is a talk about guides, challenging accessories. It is a challenge of decisions, okay? JUAN MANUEL LUCERO: Alberto, we are already on time. I can give you the last one, sorry. The last case I want to show you, this one that we posted on Twitter and the question was, what was your diagnosis of this? And a taquera with long RP, was a 40-year-old woman who had negative P in lower charge and, but the strasystole, sorry, in the taquera is cut with atrial strasiteles of other morphology. And everyone said that the diagnosis, most thought it was Kummel's tachycardia, but we have to prove this. If you see the intracavitary, this was always a short one with auricular strasses. Auricular strasses, you can cut both, An atrial tachycardia, a reentry that is not typical or a Kummel tachycardia, okay? In other words, maneuvers must be performed to make a definitive diagnosis. So, here we put a refractory G shunt, you see the G on the polygraph as it is, it is well marked on the polygraph and this anticipates the activity of the tachycardia. We make the diagnosis and we are going to do the ablation. The ablation is successful. The woman has 25 ejection fraction, she has been all her life with these bursts of what seems to be a atrial tachycardia. And the ablation is performed. See how it is not always so simple. And here I show you all the points of visit that were made. There were 4 previous points to achieve successful ablation, very close to the mouth of the coronary sky, but it was not on the first shot. All the lessons we had to go around, because there is obliquity in this area. It is not always that simple. You have to map very deeply and here, well, there is the ablation and the ablation as a short cut of the successful ablation. And if I can give the last example, I can't do more. We are on time, Alberto. We are way overdue. I apologize a thousand times, but we are way, way overdue. Thank you very much for your attention. Thank you. These are really very, very challenging cases. We appreciate your participation and your excellent cases, Dr. Alberto. Next, we will welcome Dr. David Calvo. He is the electrophysiologist from Spain, who belongs to the University Hospital of Asturias. What's next, doctor? Hello, good morning. Good afternoon, depending on which side of the ocean we are on. Well, even so, it's a pleasure to share this afternoon with you. I want to give, I'm going to start by sharing the screen and putting up my presentation now. Can you confirm that you are watching the presentation? Yes. Go ahead, Dr. David. Excellent. We are there watching your presentation. Perfect. I am going to make a change to this. Well, as I was saying, thank you very much for the invitation to be with you on my behalf and on behalf of the Heart Rhythm Association, both for Tomás and for me. It is an honor to share this session with you, even if it is telematic. And I also want to start by apologizing, asking Sorry, because when we talked about new solutions for mapping and ablation of ventricular tachycardia, we initially thought of it as catheter-related ablations, because I have decided to move away from the topic a little and I am going to apologize to Dr. Ulises, because although he has convinced us all that we must, in some way, reduce the number of radiation that we use in our electrophysiology rooms, well I'm going to move, and I'm convinced of this, I'm going to move to a different topic, which is Probably one of the most challenging and groundbreaking aspects that we have experienced in recent years in ventricular tachycardia ablation, which is the Incorporation of radiotherapy as one of the tools and technologies that we can currently use in our refractory patients with tachycardia ventricular. Tomás has told us, for example, about beautiful cases and technologies for the treatment of ablation and ablation of atrial fibrillation, all of which have in It is common that we use new technologies, new developments, also new catheters, new catheters that are often difficult to obtain, expensive, costly, that are not available in all centres, and yet this is not the case with radiotherapy. Radiotherapy is available in most hospitals, there is a accelerator where we are treating cancer patients and we just have to start working together with oncology radiotherapists to put this technology to use. disposition of our patients. Well, this is a little bit the leitmotiv, the leitmotiv because I have moved to this presentation. You know that this jumps in the year 2017 with the work directed by Dr. Filipko Kulic. Here you see a patient in this video with ablation of ventricular tachycardia. He walks into the room, performs the ablation procedure, completes the ablation procedure, and walks out of the room on his way home. It is obviously a paradigm shift, it is a paradigm shift and it is not against catheter ablation. We have We have to start seeing it as an additional technique, a tool, a new tool that we have at our disposal to treat our patients. We already have clinical evidence of the effectiveness of this tool, but it is truly something new. in cardiology to the use of radiotherapy. When I approached this topic, the first thing that surprised me was finding with work from a long time ago, in the 70s, where we already saw how radiotherapy was used for the treatment of different heart diseases, such as for example Application of radiotherapy in coronary lesions to prevent plaque progression after lesions, angioplasty procedures. Well, all this did not have much future, it was a little bit, it was a little bit in nothing, but it laid the foundations of what could be, of what could be the application of radiotherapy in other contexts within cardiology. And here I present a work, a work that From my point of view, it is one of the fundamentals for understanding how radiotherapy behaves in cardiac tissue. Experimental, animal, objective work on the ablation of the isthmus cautricuspid using contact catheters with radioactive charges at the tip, access to the cautricuspid isthmus, application of radiotherapy in the cautricuspid isthmus and, as you can see In the table on the right, serial electrophysiological studies over time in the animals that were used. It was observed that at the beginning, at the start of the application of radiotherapy, all the animals presented a conduction bidirectional by the cautricuspid ism and as serial studies, serial studies over different days, because different Animals gradually developed a bidirectional blockade of the ism after 1, 2 and 4 weeks. cautricuspid until finally, approximately at 4 weeks, almost 90% of the animals had developed blockage of the cautricuspid ism. Therefore, radiotherapy is capable of creating effective and long-lasting lesions, but with a characteristic very important and very different from what we are used to finding in electrophysiology laboratories, which is its delayed character in time. There are also some pioneering works, for example, some developed in our country, in Spain, for the treatment of pulmonary vein ablation, which today, well, we cannot say that this catheter technique has a future, but it does lay down a little of the foundations of how these types of lesions are generated and what their pathological anatomy is. Therefore, The pathophysiology of radiotherapy-induced lesions in the heart has a number of features. We know that it destroys tissue, but the mechanism by which you do it, by DNA damage, breaks the chains of the cellular hypothesis. Therefore, we cannot expect an acute, physical, histological injury to the human heart when we apply radiotherapy. Regardless of whether this may have functional results on ionic currents that can explain some observations, such as the effectiveness of radiotherapy that has been shown to treat some specific contexts such as arrhythmic storm. These results are already known You guys are the results of the 2017 New England, I don't want to dwell on it, they were replicated in 2019 and some evidence new, very recent, published in 2023 by a different group in this case European, as it shows us that radiotherapy is an effective technique when it comes to reducing the arrhythmic burden of patients with ventricular arrhythmias. In the context The arrhythmic storm also seems to have its uses and this goes a little against that delayed effect, which seems to be that radiotherapy could have ionic effects, ultrastructural effects, which could modify electrophysiology tissue acutely, perhaps maintaining and helping to stabilize our patient until the fibrotic lesion is generated that we were ultimately looking for. And it does all this at the expense of a low profile of complications, which we will discuss later. because there are certain things to talk about. Well, this is a little bit of what we can expect, it is a little bit of what we can to achieve, but it is a challenge. It is a challenge because we are just beginning to learn about this new technology that, as I say, depends on certain tools. which we already have in many cases available in our centers. But we need a coordination effort and we need a multidisciplinary work effort with groups and people with whom we are not accustomed to working in physical hospitals and radiation oncologists. To those of us who have to sit down and explain something as simple as what ventricular tachycardia is or why we want to to apply radiotherapy and what we want to achieve with that radiotherapy. But when one faces this problem, the problem is that Those who are, let's say, lacking sufficient knowledge are not only radiation oncologists and physicists. As for the physiology of ventricular tachycardia and what we want to achieve, a new world is opening up for us as well. We started talking about PTAs, ITVs, a series of concepts, planning target volume, internal target volume, a series of concepts that we have to start implementing in our, let's say, algorithm in order to be able to correctly carry out and define these procedures. I'm going to go a little fast because we are very short on time and I don't want to stop too much. Therefore, we are faced with a totally new workflow, a totally new workflow that has little to do with what we do with catheter ablation in our patients. We are talking about adequate delimitation of the lesions, respiratory compensation, definition of volumes, planning of radiotherapy procedures, verification and, finally, alignment and corrections. And this takes up practically 95-99% of the time we have to spend with the patient. In the end, the treatment is 3, 4 or 5 minutes of patient time. in the room with the accelerator to receive their dose of radiotherapy. Therefore, it is a group and a job, a completely new workflow where we have to have the anatomical techniques to locate the scar, the arrhythmogenic substrate, through multiple modalities, CT, resonance, nuclear medicine. The electroanatomical mapping that we perform in the electrophysiology room is essential to accurately delimit What we want to radiate and then integrate all this information with the colocalization systems in the radiotherapy units because the patient must be immobilized, we must locate our area of interest very well and, finally, as I say, this part here It only takes 2 or 1% of the time we dedicate to the procedure. Something that is totally contrary to the paradigm we are used to in electrophysiology rooms. We are also not used to the complication profile because we have complications in the heart, we have to think in collateral damage to the heart in ways that we are not typically used to thinking about with catheter ablation procedures. We have to think about pericarditis, we have to think about pericardial constriction, we have to think about coronary stenosis, vulvular dysfunction. and conduction system disease. And we have to think that this can occur in the long term, which means that the patient profile also changes and our ideal profile For radiotherapy treatment it probably changes and complements the group of patients that today is the elderly man that we treat with a catheter. But we not only have to think about a different profile of complications at the heart level, but we have to start electrophysiologists to think about complications in places we had never worried about before. When were we going to think or when have we worried about a catheter ablation procedure for ventricular tachycardia? In inflammatory responses that may occur in the lung or in disorders of the spinal cord or disorders of the gastrointestinal or liver. However, radiation volumes may never include extracardiac tissues that may be injured. We need to incorporate this whole philosophy into our new working group and into our new multidisciplinary working group. I don't want to dwell on this for too long because, as we say, we are short on time. Just a very simple case, a very simple case recently from my hospital. where a patient with ischemic heart disease underwent coronary bypass surgery, lateral scar, recurrent ventricular tachycardia, two endocardial ablation procedures. As you can see here is a very nice map with good delimitation of the faces, some beautiful late potentials. Nothing. We tried systematically with long procedures. Eliminating the patient's clinical tachycardia was not possible. Epicardial access. We had a clear suspicion that we had an epicardial substrate due to the behavior of the ventricular tachycardia. during the electrophysiological study. We had it closed due to pericardial adhesions that we were unable to release in this entire area. Probably due to the previous surgery and early recurrences, we decided to plan a radiotherapy procedure. It was essential to have a very well analyzed substrate of our patient to plan and exactly colocalize the area in which we should apply our radiotherapy. Our patient's progress was very good. We managed to control the rhythm and stop all arrhythmias. ventricular over a period of 10 days and over the months the patient has not presented new recurrences. This is a new technique. A new technique that we have started to register in Spain and as a result of the registration it is expanding. in its use. This is the approximate map that we currently have of the procedures practiced and it is growing. And it is growing because, As I say, many of you probably have CBRT techniques available in your hospitals to treat your patients. The only thing I recommend is that you have an open mind and above all take the lead together with your colleagues in radiotherapy oncology. to offer a new therapeutic modality to patients with ventricular tachycardia that does not compete with what we electrophysiologists do, but rather increases the arsenal that electrophysiologists have available to treat our patients. I'll just finish with that. Thank you very much. This concludes the new strategies for speaking with a catheter. We would like to thank all of our speakers for their magnificent presentation. Thank you very much.

LARS scientific sessions

catheter-based strategies

arrhythmias

fluoroscopy usage

radiation exposure

three-dimensional mapping devices

electroporation

atrial fibrillation ablation

radiofrequency ablation

ventricular tachycardia

collaboration between medical specialties