Well, thank you all very much for joining us in this session of the Latin American Society of Cardiac Rhythm and the Colombian College of Electrophysiology, a very interesting session on physiological stimulation within the concepts of heart failure management. We are going to We should also talk about whether or not it is an option for cardiac resynchronization therapy in Latin America and also what complications we are going to have. For this session, I am joined at the table by Dr. Eduardo del Río. Doctor, thank you very much. Dr. Eduardo is a cardiologist. electrophysiologist here in Mexico City and I have the honor of introducing Dr. Jorge Romero as the first speaker. Jorge, Jorge is Colombian, he is Cascaleño, but he looks like a gringo, he is an electrophysiologist cardiologist and works in Boston at the Brigham and Women's Hospital and he is going to talk to us about the left bundle branch pacing in heart failure. Dr. Jorge, thank you very much for joining us. Left bundle branch pacing in heart failure in patients with heart failure. I want to clarify that most of the data that we are going to show today and that Juan Carlos will also show data from observational studies and perhaps perspective records, but we only have a small randomized control trial. And we're only going to have large scale randomized controlled trials probably four or five years from now, because it's going to take probably two to three and a half years to enroll patients to assess heart failure hospitalization and all mortality caused, as the studies that we have on biventricular rhythm. These are my disagreements. I want to start with this deal. We all know this deal. In 2009 We read the CRT MARID and based on that study we started to do biventricular rhythm in patients with heart failure. In that study the The author showed that the composite outcome of heart failure hospitalization and all-cause mortality was significant in all patients, patients with ischemic cardiomyopathy and non-ischemic cardiomyopathy, but failed to demonstrate any mortality benefit at all costs. We realized with this treatment that only patients with biceps ventricular ejection and a left target block of more than 150 milliseconds really would benefit from this therapy. And we have extended the MARID CRT to 7 years and then we were able to show that biventricular pacing improves survival and mortality at all costs only in patients with left target blockade. In patients with right target blockade or interventricular, there was no difference. We also had the RAP study published a year later in the New England Journal of Medicine and that study had a longer follow-up, 6 years, and they showed an all-cause mortality and a heart disease hospitalization benefit. And for 13 years we've been doing the same thing. We have been trying to get good results with that therapy because we have solid data. However, we know that many patients They do not have a suitable CS branch to put the CS lead in. We are going to have up to 40% of patients having complications with CS stimulations. brain, slips and high levels. And almost 30% to 40% of patients with left white block are not going to benefit, they are not going to improve ventricular ejection fraction. Now we have patients with conduction system. We know that your patient with left target block for patients with heart disease should probably be abandoned at this point. We can put these leads on the septon in three different positions. We can currently pass the left target block. We can make the left ventricular septal passage or we can do the deep septal passage. The beauty of this technique, and this is why everyone is doing it, is because it is so much easier and much faster than putting a CS lead. The problem is that we don't really have clinical results on randomized treatments. As you can see, most of the These patients, most of these patients, on paper, are supposed to put This lead in the left white blocking, but most of us will put the lead in the phasers, whether it's in the anterior, septal or posterior phasic, and that's going to be a lot easier to do. This is a beautiful paper showing that in this white block on the left There are not three distinct structures and they have several anatomical variations and this is important to understand the data I want to show you. Let us not forget the passage of the left ventricular septum and the white on the left. The left white blocking passage is composed of the left white blocking passage, the left phasic passage and the left ventricular septal passage. The deep septal passage It is something we should not use to treat patients with heart cancer because It is a slightly deeper passage, but more in the right ventricle rather than the left or septal ventricle. These are the latest European instructions showing how to define whether you are capturing the left block, probably capturing the left block, or just doing the septal passage deep. The main thing we have to understand is that all these criteria have not been validated in patients with heart cancer because patients with heart cancer have different sizes in the left ventricle, they have different amounts of wounds, so Most of these criteria were validated for patients without structural heart cancer. The main criteria that most people use is the transition from non-selective to nonselective and nonselective to the left ventricle or septal during septal passage. So that's a good way to know that you're actually capturing the driving system. Another useful criterion is the left block at B6, B5. Here in the instructions, we define it as less than 80, but in the study that we are going to show you with Juan Carlos Díaz, we found that the majority Of these patients, where the left ventricle is less than 100, it is most likely that you are capturing the driving system. So 100 milliseconds is the number when you are making the cases that you have to keep in mind to decide whether it is a success or not. So this is the randomized deal that I showed you. This was introduced in 2022 at HRS as a left-hand block deal posted on JAK. And this was a very small randomization control deal, 40 patients, 20 and 20 patients randomized to left ventricle versus B6 ventricle. And they evaluated the change in the executive fraction of the left ventricle. It was significant, a small improvement, 5.6% in the executive fraction. They didn't test for any change in left ventricular volume, but you can see the difference between the two arms. This is our paper. I want to thank Juan Carlos Diaz again. He is like the main author of this project. And he has made great contributions to all these papers that We have published on this topic. So we presented this as a left block treatment this year at HRS. And it was published simultaneously in JAK, Electrophysiology Clinic. And the beauty of this study is that for the first time, we are offering left block as an initial strategy to treat patients with left ventricular dysfunction. So we offered these patients, it was not randomized, it was a prospective registry, and we give patients the option to choose. Of course, most of these patients They chose the left ventricle because we have robust data on patients with left ventricle, but we were able to enroll almost 125 patients in this registry. So five different centers participated, Brigham and Women's in the United States, three centers in Colombia, and Néstor Cabanillas in Buenos Aires, Argentina. 128 patients. in left ventricular block and 243 in left ventricular block. And we used inclusion criteria standard for cardiac resynchronization therapy. And we excluded only patients with tricuspid mechanical wings. We used this technique, there are many techniques for left block, but we use the 9-part technique. We use these two criteria, as you can see. We want the air wave in the distal part of the QRS in V1, so that's the thing that we want. And then when we're doing the price lock, we want to go from unselected to selected, or unselected to ventricle morphology of the ventricle. as well. Important, as I mentioned before, the STIM 2 peak in V6 of this patient was 86%. Important because the guidelines, if you read the guidelines, it says less than 80, okay, and likely left bundle branch area pacing is less than 100, so I would use 100 for the cases when you're doing these cases. The V6, V1 inter-peak interval probably is overlap. I'm going to show you, so probably it's not a good measurement to use when you're doing these cases. This is the primary efficacy outcome. It was a composite of all-cause hospitalizations and all-cause mortality, and it was, of course, better for left bundle branch area pacing with a relative risk reduction of 37% and absolute of 18%, and this is each component. It was the main difference was driven by heart failure hospitalizations, but we didn't find any difference in all-cause mortality. The primary outcome, only using the patients that we found a left bundle branch pacing that it was 84% of the patients were successfully on the left bundle. Of course, it's even better with a relative risk reduction of 57% and absolute relative reduction of 26%. In medicine, especially in electrophysiology, to find an absolute reduction of 26% is very dramatic. And also, when you divide the composite outcomes, also it was driven just for heart failure hospitalizations without any difference in all-cause mortality. More complications in By-B, but they were not different because probably a small sample size. A secondary outcome, the post-procedural left ventricle ejection fraction and the change in left ventricle ejection fraction also favor left ventricular branch area pacing. The improvement in more than one class in NEHA was also better for left bundle. The PACE-QRS was narrower for left bundle branch area pacing. So that was the study. We presented that as a late-breaking. Dr. Vijay Raman also, at the same time, he presented this late-breaking trial. This was a much larger study. It was a retrospective analysis, but they have 1,800 patients with several centers in the U.S. and in European centers. Pretty much the same results. They found an absolute difference of 8% in heart failure hospitalization and all-cause mortality. We found 18%, but still significant. And those results were driven by heart failure hospitalizations without any difference on mortality. But you can see the trend in all-cause mortality. Also a major difference in QRS duration, NEHA, left ventricle ejection fraction before and after the procedure was different and between left bundle and by ventricular. And important is also the rate of echocardiographic response and hyper-responders was higher in the left ventricular area pacing group. So we know that pacing the left bundle, even though we don't have randomized data, probably is the way to go. But what happens when you're not successful in getting the conduction system? And many times that happens. You don't really get the feeling that you're pacing the left bundle, but you're doing just left ventricular septal pacing. So we just wrote this paper. This paper is going to be published probably in one or two weeks in JAG, also JAG-EP. And we compared these three groups. So you're going to have... I just realized that you have different slides than mine. So I just realized... no, go back please. So we compared two different groups. The first group is left bundle branch area pacing. The second group is by ventricular. And the third group is left ventricular septal pacing. So you can see that left bundle is so much better than by ventricular pacing and left ventricular septal pacing, but there's no difference between by ventricular and left ventricular septal pacing. Why this is important is because you have to make a decision when you're doing the case, you know, if you don't capture the left bundle but you are in the left ventricular septal pacing position, are you going to take it or you're going to start another case with CS leads? So this data suggests that probably it's good enough for now. And important is like, of course, left bundle branch area pacing is going to be faster than biventricular, and the flow of time is going to be also for left bundle and left ventricular septal pacing is going to be faster than biventricular, but all the echocardiographic EKG parameters are not going to be different between biventricular pacing and left ventricular septal pacing. So this is an important concept, okay? So we all know that women do better with biventricular pacing than left bundle branch area pacing. No, that men do worse than women with biventricular pacing. Why? Because men have worse AV conduction. So most men have longer PR intervals and when you're doing biventricular pacing, I mean it's two, three-hour case, then you finish and you try to get interventricular synchrony. So you spend ten, five minutes getting the perfect LV, RV interval, but not too many people try to do AV synchrony. And that's why many, many patients, male patients, they didn't benefit from CRTD. Nowadays we know that if you try to fuse the intrinsic conduction with the biventricular pacing, these patients are going to have shorter QRS and better improvement in left ventricular ejection fractions. And this is how you have women here. If you do AV synchrony nothing happens. But men, instead of doing just interventricular synchrony, if you do fusion between the intrinsic conduction and the biventricular pacing, these patients are going to do the same as women. And that's why we decided to do a sub-analysis of our registry. So we compare men versus women, left bundle versus biventricular pacing, and we found that if you see here, there's no difference between left bundle male and female. Why? Because, I mean, you're bypassing the AV node essentially. But there's a major difference between left bundle branch area pacing male and biventricular pacing male. So male population are going to benefit from left bundle branch block significantly. This is a meta-analysis that we also submitted to Jack last week. And we have like 9 or 10 studies comparing mortality, heart failure, hospitalizations. And once you put 3,000 patients together, then you have the power to show all-cause mortality reduction. It's a small 3% absolute difference. But again, in heart failure, if you can prove that you can decrease all-cause mortality by 3%, it's great. All these medications for heart failure, they have decreased 1.5%, 2%. So it's good. More recently, we have this study, they're trying to do left bundle branch area pacing in patients with mild reduced ejection fraction. You can see they compare left ventricular branch pacing versus medical therapy. You can see the patients on left bundle pacing, they didn't have any events at 36 months versus 60% of the events on the control group. This is a slide of the SYNCHRONY trial. We've spent like 18 months designing this trial and trying to get funding from Biotronic to run. This is going to be probably one of the largest randomized control trials comparing left bundle branch area pacing and biventricular pacing. We're going to be comparing as a primary outcome the composite of all-cause mortality and heart failure hospitalization and safety. And also we're going to see echocardiographic parameters, EKG parameters, quality of life and NEHA. My main concern, it's not my concern, it's heart failure attendance concern, it's like now that we started doing left bundle branch area pacing, they're complaining that they're seeing a lot of tricuspid regurgitation. And this paper showed that the moment that you have a left bundle branch area pacing you have 32% of tricuspid worsening. But I mean that has always been the case when you put an ICD lead when you do biventricular pacing. So now again as we speak we're collecting data. Our control group is going to be a group of sub-QICDs, no leads in the right ventricle. Because even when you put a sub-QICD in a patient with heart failure, you're going to have deterioration of the heart failure and these patients are going to have more TR. So that's going to be our control group. We're going to do another group biventricular pacing with two leads, the ICD lead, with one lead, the ICD lead and the left bundle branch area pacing with the ICD lead and the pacing lead. The ideal distance, you can always try to measure this on echoing for chamber view, the ideal distance that you can use to put the left ventricular area pacing lead safe that you're not going to pierce the septal leaflet of the tricuspid valve is in some papers 16 millimeters, in other papers 20 millimeters. And with that one I finish. Thank you so much. Thank you very much, Jorge Romero, excellent talk. The next speaker is Dr. Fernando Vidal, welcome, thank you very much Dr. Fernando Vidal. He is a cardiologist, he is an electrophysiologist at the Metropolitan Hospital of Santiago in the Dominican Republic and it is a pleasure to have him here with us, thank you very much. Hello, good afternoon, thank you very much to the organizing committee, to DELARS, to the person of Ulises who is not here but I wanted to leave it reflected. Thank you very much to SOMEC also for this invitation, I feel very honored and I will try in the next few minutes to give you a vision, yes, to give you our vision of some countries on the stimulation of the conduction system as an option for therapy of resynchronization if we should or should not think differently. We have, ah, perfect, well, I will try to answer this question starting by telling you the first case that we had in 2018 of a 70-year-old patient with a history of hypertension, diabetes, ischemic cardiopathy, he had had an auricular tachycardia that had been interpreted as a VT due to the wide QRS, we saw it, reviewing the episode, we saw that the QRS was the same morphology and based on what is below, which was his ventricular dysfunction, we started beta-blockers as part of the optimal treatment, right, at that time, and we also started an antiarrhythmic. The patient begins to develop dizziness, dyspnea, in the halter we began to see advanced conduction , his echocardiogram at that time had a fraction of rejection 31% with very increased volumes and the diameter also increased in the left ventricle, this was the electrocardiogram of the initial patient, everyone will say, uh, because it was the worst of our enemies, right? The cardiac failure with right branch blockage, enlarged, that was the width of the QRS, 190 milliseconds, so we have a patient, in short, ischemic, fraction of reduction reduced, with a prediction of a stimulation that will probably exceed 40%, this was the same as indicating a resynchrodyte, but here begins our Latin American reality, it is not covered by insurance and after almost a year of fighting, of letters and well, trying, the patient begins to worsen, presents pre-syncope, and well, I had fully immersed myself in what was physiologic stimulation therapy with HIS, at that time, HIS bundle pacing, there have been several training sessions and I said, well, let's see, let's offer him what his medical insurance covers, which was a bicameral step-marker, putting the electrode in HIS. This was a sign similar to the one we obtained, and so was the electrode, which everyone has already seen, right? Those who have had the opportunity to check a patient with HIS stimulation. Of course, the QRS was corrected, that right branch blockage, as we all know, narrowing considerably, and strikingly, at that moment I was surprised because I said, well, everything that I have been told in these courses, in these training sessions, it is like this, already at 30 days, 31 days of follow-up, the patient was with a very significant clinical improvement, the echocardiogram had also significantly increased the ejection fraction, the volumes had decreased, the diameters slightly, at 8 months, although he did not increase much more the ejection fraction, which in the end, all this coincides with what the literature marks in these patients with the right branch blockage, it continued to lower the volumes and it continued in a good functional class. So, in our country, as I think many others, when one comments with leaders of the region, resynchronization therapy is not covered, it costs between 15 and 18 thousand dollars. The tools for physiological stimulation are not covered either, but the difference is great because really the shirt and the electrode are around 800, 900 dollars, so that is important that we take it into consideration. So, to the question, should we think differently, the Latin Americans, about physiological stimulation? Well, I think part of the answer is that we are part of the development of these guides that were recently presented, where physiological stimulation is included in all techniques, that can be debatable, if biventricular stimulation is physiological, that is still being discussed, but in the guide it was included, the stimulation of the conduction system as such, with the stimulation of HISS or left bundle area pacing. We all know that the stimulation of HISS, I will not go into details, it can be selective, not selective, with or without correction of the left branch blockage, basal, obtaining such incredible electrocardiograms until recently, for us, if 10 years ago, 7 years ago, they told us that we were going to have an electrocardiogram of a patient with marcapasso, we did not believe those characteristics, well, we can get that, but we also know that we have the problem that we have had, all of us who started with that technique, of the elevated thresholds, as happened in this patient, that at 4 years old we had to change the device. That shortens the life of the device, as we say, increases the possibility of early replacement, the electrodes revisions were greater than expected, and the European guide, and also the American guide, recommends that if the patient is dependent on stimulation, we leave a backup electrode, then we are going to have another electrode. Then the stimulation of the left branch arises, I will not go into details, because my colleagues have done it, they will do it throughout the course of this Congress, but we see that the area is a little further forward, down, and those are the criteria that this last guide recommends. What happens when, and today I heard Roderick Tong talking about that this morning, yesterday also, when we see all this, and well, that discourages anyone because several colleagues who want to do the technique feel overwhelmed when they see that amount of criteria. It is very important that we be very clear, those of us who are working on this and those who want to encourage this to go forward, that we have to choose two or three criteria of this to make the implant successful and not try to dedicate ourselves to meeting each and every one of those criteria. This slide, which has been shown by everyone, clearly tells us that we have an easier area, more accessible, more extensive to implant our electrode, and that we have better thresholds and sensing, no matter where, at what level we place it. I had the pleasure of seeing Dr. Guijaraman's presentation, representing his collaborative group at HRS, showing these almost 1,800 patients, as Dr. Jorge mentioned, and that they were patients with class 1 indication for resynchronization therapy. The first thing that came to mind was this. It was a relief for us, a feeling of light on the road, because really, seeing the results that Jorge has already shown, both the primary endpoint and the secondary endpoints, even without being a randomized study, it gives us a lot of strength to make the decision to do what was actually coming. costs and insurance coverage, well, it closes the equation and we are always left, in case we don't Let's have the success of the patient's response, try one of these techniques, either Lot-CRT or Hot-CRT, as they will detail below. But I want to stop here, because there is something very important, beyond trying, and we electrophysiologists try a lot, but we are not Much of the prevention, and we have evidence, we are a machine for producing heart failure Also now, and we know, we have clear evidence from these two studies, from these two larger records, but when we look at the recent ARS guidance, all the evidence that they Some, up to more than 30%, have some type of stimulation-induced heart disease, But well, we know that at least, probably two out of every 10 patients that we put in a device in the Apex, we're going to have ventricular diffusion, we're going to have pacing-induced cardiomyopathy, this is a lot. Of course, fortunately they respond to the therapy resynchronization, but this means more risk for the patient, more risk of infections and more expenses, more costs, which is precisely what we cannot afford. And here I just want to emphasize that simple things like QRS width, beyond whether you have a left bundle branch block, in this very nice study that Dr. Cho presented in 2019, if we have The wider the QRS, the greater the probability, that is, these are simple things to measure, not complex things, because we are talking about trying to simplify the technique, they said, Several have already said this. So, in addition we have this evidence that we can simplify the technique In this very elegant study by Dr. Zhang, where in this nine-partition model, He corroborates with a three-dimensional mapping the best sites where there was capture. In this study They do not use a polygraph, they do not use a polygraph to measure electrograms and the result that They have it very good with this simplified access, placing the electrode, they say between four, five, seven and eight in that region and all the points are in that same place. So if we have the above and we have evidence of this, I say, why not try to offer everyone something simple? Countries where we can have neither one nor the other, where the guide does not yet support that we ask for a physiological stimulation system, why are we not going to perform the stylet as it is advocated at the presentation of the European guide last year at the European Congress? They did it They justify it by saying that it is to reduce perforations at the apex. I have my doubts, I think it's because they want to achieve a little more physiological stimulation. Why can't we try to measure the QRS and try to get electrocardiograms like this one from a patient Our young woman who had no resources but had a third-degree B block and we know that she was going to stimulate all the time? We are starting a record, therefore, of something that I have not seen that exists because really after Protect PACE everyone went backwards, nobody wanted to get involved with anything other than advanced techniques, with expensive tools and we want Collect patients who have more than 40% of expected stimulation, perform the stylet, use the 9-part model to try to go to the target area easier, use the two fluoroscopic views, use the right anterior oblique, 30 degrees, to try to achieve that goal and put it there. Measure the QRS trying to get a QRS less than 140, Those 2 positive leads are the peak stimulus, now I'm going to change it after what Dr. Jorge said, I'm going to change it to 100 probably, I think it's correct to be able to change it like this, it's easier. Echocardiogram and then in a randomized manner we're going to do images on the patients to try to see if the electrodes are where we say and how much They are also deep. We will follow up, of course, as appropriate. So, to answer the initial question, I do not think that in Latin America we should think different, but many times we must act differently because of our resources. In many countries with this resource constraint, probably due to new evidence that Juan Carlos, Jorge present with their well-designed studies and the evidence of, although whether it is non-randomized studies, evidence from many patients, it is probably our first choice. And we certainly need to think ahead, trying to avoid heart disease induced by stimulation, probably preforming the stylets, measuring the QRS, using the views, asking the industry to provide us with electrodes with longer screwings. I learned that There are companies that are working on this. The problem is that approvals take a long time now. time. They are working on conventional electrodes with longer active screwing. It is probably an answer for these patients. And finally, to gather the evidence from our population to create or guides or suggestions or recommendations based on our realities. Thank you very much. Doctor Fernando, thank you very much. Excellent presentation. And to finish, well, very well, We are doing stimulation of the conduction system. The idea is that we want that everything goes well for us, but what have we learned from the possible complications? And for this we have Dr. Juan Carlos Díaz, a great speaker who has extensive experience in left bundle branch pacing. He is a cardiologist, electrophysiologist and works in the city of Medellin. And he's going to talk to us about what we've learned from the complications of the system of conduction, of the stimulation of the conduction system. Doctor Juan Carlos, thank you. Well, Thank you very much. The first thing is my conflicts of interest. My main conflict of interest is that I am a speaker and producer for Medtronic for this technology specifically. The others don't matter. for this talk. But the main conflict of interest is that I deeply believe in this technology. And as you have realized with what Jorge has told you, our entire group has turned towards the use of left bundle branch stimulation. And this, I think, many will agree with. asking why so much stimulation of the conduction system and a whole session of stimulation of the conduction system. We are already talking about it and all We want to take the photo on Twitter and we all want to take the photo capturing the left branch or capturing the GIS. And we believe that there are two scenarios where it can be very useful. One is in cardiac resynchronization therapy and another is in those patients in whom we want mitigate the possibility of developing left ventricular function impairment induced by stimulation. Now we have already talked about that we have stimulation of the conduction system through of GIS stimulation and we have stimulation through the area of the left branch or the VAP in English, which can be stimulation of the branch as such, whether it is a fascicle or the trunk, or it could be stimulation of the left septum, which Jorge already showed you the results of, which can also be quite good. And although they are very safe techniques, very easy to perform, as there may be acute complications during the procedure or complications during the long-term follow-up and that's what we're going to focus on. Now, to talk about this, Well, we have to talk about something new, but I also want to talk about something old, because if I only talk about the complications of the stimulation of the conduction system, which They are already doing it right now in the auditorium they are going to say, son, mother, I am screwing you, I am not I must continue doing this because I am doing a brutality, because I am going to show them the complications of what we are doing. And those who are not doing it will say, thank goodness I am not I've stuck to that, because I'm sure you'll see all that bit of complications. So let's get started with what we have been doing for more than 30 years, which is conventional stimulation through bioventricular stimulation. We usually say, no, my patients are doing great, all of them They respond, all are not hospitalized, none have complications and the truth is that that is not true. It turns out that when I add up all the complications, a good percentage of patients are going to complicate things. The most common and the simplest one that we all overlook is the stimulation of the phrenic nerve. In almost 40% of patients and in one in five patients this stimulation is so important of the phrenic that prevents the use of that left ventricular cable or the proper functioning of that cable and then when we use quadripolar cables we end up using the vector of the tip that is at the foot of the apex and that we know is associated with greater morbidity and more mortality. What for? To avoid stimulation of the phrenic. We can have dislocation of the cables, we can having thresholds rising, we can have loss of catch and it is because we leave many things to random. I am placing a wire inside a vein, a structure that is larger than the cable and that will form a thrombus. If my thrombus forms towards the epicardium nothing happens, but if My thrombus and my fibrin plaque form between the cable and the cardiac surface. I will have an isolating mechanism that will increase the threshold and make me lose it more easily. capture. So it's not so easy to just talk about no, that suits them very well. Also There are complications. When we talk about right ventricular stimulation, the doctor already showed them about the possibility of developing pacing-induced heart disease, but I also have perforation of the ventricle, I can have dislocation of those cables and I can have failure tricuspida, which Jorge already spoke to you a little about, because now that we are talking about the left bundle branch everyone is saying no, no, you can produce tricuspid insufficiency, but any cable can produce tricuspid insufficiency. So since we know that the old also has problems and that has problems in the fault, then we begin to talk about the problems of the new, which is the stimulation of the conduction system. You have already seen this slide and when We use stimulation of the conduction system specifically through the GIS, because you are going Let's see that the thresholds are going to increase, in fact the battery consumption is so high that after five years one in ten patients will require a change of device. Now remember that with The battery technology we have today, battery decay is very initially predictable, but there will come a point where it will decline rapidly and we have information In five years, we have no further information, but in addition to that there is an 11% chance that the patient requires readjustment of that cable because it was dislocated and that possibility of dislocation is going to be closely related to the position that the GIS cable is assuming in relation to the valve tricuspid. If the tricuspid valve is hitting all the time there is a greater chance of dislocation, if it is not hitting you because it is on the atrial side where there is less possibility of capture the left branch, as it will have less chance of tricuspid insufficiency and dislocation. That is, everything is going to have complications, but the main problem of GIS, apart from this tricuspid insufficiency and that it could improve, is that it is technically difficult. So This is technically so complex that this is the Hot CRT that was released to Head of Print a few years ago. couple of weeks. They tried to randomize 50 patients to GIS stimulation and the arrow below tells them is showing that four patients were actually taken to GIS stimulation. That is, that GIS is technically so complex that even in highly experienced groups, which are committed to enter to do GIS stimulation, they say nothing, we go through the left branch in 39 of the 50 cases. That is to say, this is not easy, it requires a very large learning curve and on top of that it requires a longer fluoroscopy time. And that's where the new one comes in. And you know everything is new, sweeps well and is the stimulation of the left branch which is simply entering a cable, penetrate the seventh interventricular and reach the left subendocardium to stimulate the branch distal to the blockage site that I already have. Obviously that has complications. I can have a dissection of the seventh, I may have a coronary artery injury, I may have a perforation septal, that is, the cable continues long. There is a study, more or less it is being discussed in the 3%, 3 to 4%. There is a study that says 14% septal stimulation and one says, well, no, Please stop him, don't go so fast. There are others who say, look, there may be deterioration of the tricuspid insufficiency and what we have with any cable, loss of capture by macroscopic dislocation or loss of capture of the left bundle branch. That is, it continues to capture left myocardium, but not left bundle branch capture. However, many of these Complications can be avoided with a fairly simple technique. For example, a good part of Septal dissections occur when we inject contrast against the septum. And So, although for me personally, we're going to see if we can make this run here, they're going to give tells how the contrast is going to go up there through the veins. Although that makes very pretty photos and images for Twitter and post the contrast injection, personally I don't like it I see no use in injecting contrast through the septum, because we already know that we are perpendicular to him simply with the movement of the catheter and apart from this nice image we are not going to do absolutely nothing. That is to say, the dissection of the septum often occurs by the injection of the contrast. Remember that this is an extremely thick medium and if I inject with force, I'm going to cause tissue trauma. If they're going to inject contrast because they want the image for Twitter, then what they need to do is pull the shirt back a little and gently inject until that a cloud of contrast forms between the tissue and your catheter and there they can increase the injection speed. With respect to tricuspid insufficiency, coronary lesions, well, there We have, this is from an article that Jorge and I worked on and that we are going to publish right now. in the Electrophysiology Rhythm Reviews, on how precisely to avoid these complications. If We can see the plane of the tricuspid, which you see there in the video and it looks very easy, it is not inject contrast, 10 centimeters of contrast is enough. If I manage to advance beyond 1.6 thousand centimeters, I can avoid the risk and significantly reduce the risk tricuspid insufficiency. If I manage to avoid being more than 3 centimeters away from the tricuspid, I will avoid the coronary septal vessels. That is, I will decrease with only that distance at which I find tricuspid insufficiency and injury to the septal vessels. That is, two complications in a single technique and it is quite simple to perform. As for the dislocation of cables, there are several ways to avoid it. One is to be safe that I'm drilling well, that I have a good amount of cable advanced inside the septum and There you will realize that one can see the fulcrum, the place where I am having that support. of the cable over the septum. That tells you, look, it's well advanced there. Sheaths are used, cables, sorry, they should be retractable. Remember that we only have one at the moment which is, Elix, that is Medtronic. All the other companies are working with retractable stylet. They always tell you, look, take out the Elix, give it over torque. Can they take it away from me? a little bit of reverb? Thanks. Give it over torque and after giving it over torque, look at the torque. What happens when you over-torque a cable and then release that over-torque? The Elix is collected. So, for me that is a mistake that many of the experts who are Speaking of left branch stimulation, they are committing and it has already happened to me. How do I realize that It's a simple mistake because I've already screwed up. It's very easy to realize that you're screwing up. because it captured the branch. The moment I release the over torque, the Elix does, returns the Elix and I lost the branch. Why? Because it went too far and we know what happens with Biotronic and we know that Ingevity has problems with retraction of that over torque. So, my recommendation is that If you are going to use retractable Elix cables, do not over torque it. You just have it there and you leave it at that point and the cable will be able to drill. And the way of drilling is also important. If I press too hard against the fabric of the cable, remember that when I go to When talking about friction between two surfaces, there are two important components. One is the coefficient of friction, I think nobody here knows what the coefficient of friction of the tip of the cable is against the endocardium. So, we are not going to talk about that one. But another is the normal force, which is how much is pushing that wire against that endocardium. So if you push too hard, there's going to be too much friction and suddenly that cable is not going to penetrate as well. It's going to start producing twisting of that right subendocardium and it will not penetrate that cable. They can also simply keep drilling, as is the screwdriver effect there, or they can start drilling and stay in the same position and they will make a tunnel without security and the cable will be dislodgeable. So, the technique and the strength in which they are doing it is also going to have something important. And in Septal perforation, if I am very happy drilling, then I can reach the other side and You can tell because you push the cable and it reaches the mitral valve. So you say, well, yes, I drilled it. Usually nothing happens, there are no cases of serious complications with this, but it is better avoid it and there are several ways to avoid it and the simplest is to be aware of the heartbeats branch capture. As soon as you see a capture beat, stop, evaluate the changes in impedance and the changes in morphology and suddenly there is the possibility of doing Continuous stimulation is very, very useful. And finally, for the patient to get better, we have had discussions, for example, there are people who say, no, it's that the width of the QRS doesn't matter and it turns out that QRS width matters. It is our biggest predictor in the room of whether we are achieving resynchronize or not and patients who achieve QRS shortening have better outcomes in the medium and long term. That is, the width of the QRS matters and Jorge just showed you how the Proper programming of the device can modify the results. And the same happens in left bundle branch. Look at the tracing above, it's a QRS at almost 200 milliseconds. When we do stimulation of the left branch only in unipolar, we will achieve capture and a pattern of incomplete right bundle branch block, but if I achieve fusion, and I assure you that it is of the same patient, I'm not making this up, I'm not trying to deceive, they are from the same patient. If I I fuse and I want you to assess how long the VA is in this patient. Look at the VA from where the P wave starts up to where the spike is in unipolar. If I achieve fusion, I will achieve that my right bundle branch captures my right ventricle and my total ventricular activation time is going to decrease and I will achieve better synchronicity. And if I remove that spike and show you only the QRS, someone could say it is a QRS that has something strange but I cannot identify it, But no one will be able to tell me that a patient with heart failure whose initial QRS was almost 200 milliseconds. So, programming in the AV is very important and there are times we have to put AVs as short as 50 milliseconds, because remember that since I stimulate the system of conduction until ventricular scanning begins, several milliseconds will pass, up to 35 milliseconds. And on top of that I have to add the time it takes from the node sinus to the tip of the cable in the atrial appendage and during that time it is advancing through the atrium and reaching the AV node. That is, I will have to compensate for that and I may require AVs very short. And the same with bipolar stimulation, the one below is only unipolar stimulation and Look, if I do bipolar stimulation and again I assure you that it is from the same patient, I'm not fooling you, look at the QRS that can be achieved if I manage to capture the right endocardium. same time or if I manage to get it to drive retrogradely along that branch. I think the risks outweigh the benefits, we definitely don't think so, because that relationship is favoring very well to the stimulation of the left branch by randomized studies we know that it improves the FEBI, from observational studies we know that they improve clinical outcomes, there seems to be a Reduction of the risk of pacing-induced heart disease and non-pacing complications is higher or could even be lower. We believe that over time we will have less infection rate, because remember that when you spend more than 30 minutes of time implant, increases the risk of infection and all procedure times always give consistently shorter, except in the studies of Dr. Villa de Ramán who gave them more high for left branch and flow time as well. So in conclusion, although there are associated complications that we cannot ignore, the stimulation of the conduction system is going to be probably the technique of choice in the future, almost all of us are going to stimulation of the left bundle branch and many of these complications can be avoided with very simple techniques that we can all apply. Thank you very much. More information www.alimmenta.com

Latin American Society of Cardiac Rhythm

Colombian College of Electrophysiology

physiological stimulation

heart failure management

cardiac resynchronization therapy

left bundle branch pacing

randomized controlled trials

His bundle pacing

conduction system stimulation