Good afternoon. Thank you very much. I appreciate it. It's an honor to be part of this team. My job here is to talk about post-procedural care. That was the section 10 of the document. I will discuss these five topics here. Access, anticoagulation and disposition, incidence and management of complications, hemodynamic deterioration and pro-arrhythmias, follow-up post-catheter ablation on VT, and assessing the outcomes. The first recommendation was for venous access in most assists. It was class 1 manual compression and class 2A temporary piercing string and figure of 8 suture techniques. That was 2A, although the recommendation was based on non-randomized data. For arterial access, for achieving the hemostasis using manual compression or vascular closure device is recommended. For epicardial ablation, all recommendations were based on expert opinion or non-randomized studies. It was class 1 indication for leaving the pericardial drain when any complication or bleeding was occurring during epicardial VT ablation. There was a 2A recommendation for installation interpericardial corticosteroids to reduce pericardial chest pain after epicardial ablation, and 2A to remove all pericardial excess sheaths at the end of the procedure if there is no bleeding or tamponade during procedure. Atrial fibrillation post-epicardial ablation was also discussed in the document, which is expected in up to 20% of the procedure. AF is more common in patients with pericarditis, but the writing committee did not recommend amyloidron to prevent atrial fibrillation in the pericardial ablation settings. For the anticoagulation, the recommendation was based especially in the extents of the endocardial ablation. For less than 3 centimeters, it was recommended as 2A recommendation and platelet agent for a limited period. And for more than 3 centimeters, more extensive endocardial VT ablation, treatment with oral anticoagulation was recommended. There was a recommendation among the writing committee in their practice in extensive VT ablation more than 3 centimeters. 9% of the writing committee prescribed anticoagulation for 4 to 6 weeks, 35% antiplatelets, and 65% oral anticoagulation. Complications are not a rare occurrence after cataract ablation of VT. It's higher in patients with structural heart disease. About 8 to 10% of complications are reported, and vascular damage and pericardial complications are the most common complications. It's interesting to note that the complication rates are higher when procedures start after 2 p.m., so it's better to schedule your procedure in the morning. In the document, there is a table that includes the incidence, mechanism, and prevention of most of the major complications. I will discuss here just a few. Early and in-hospital mortality, it's expected up to 3% of the procedure. Mostly, it's caused by VT recurrence, heart failure, and complications of ablation. To prevent that, optimize clinical status before ablation is recommended. For late mortality, 3 to 35% in 12 to 39 months of follow-up in these studies, mostly because of VT recurrence and heart failure progression. Some predictors of early mortality are fluid and electronic disturbance, chronic anal failure, peripheral vascular disease, lower ejection fraction, ischemic cardiomyopathy, presence of multiple slow VTs, and centers with small and medium volume of procedures. An important complication is cardiogenic shock and hemodynamic decompensation, which may occur in up to 11% of VT ablations. This complication is related to higher in-hospital mortality, procedure failure, and higher long-term recurrence. Some predictors of cardiogenic shock are older age, diabetes, ischemic cardiomyopathy, New York Heart Association 3 and 4, lower ejection fraction, long procedures, and general anesthesia. How to prevent that? Close monitor of fluid balance and diuresis, hemodynamics, and the hemodynamic status. Avoid VT induction in sicker patients. It's preferable to perform ablation without VT induction. And the use of percutaneous LV assist devices is recommended in some specific cases. Another complication is neurologic, cerebral embolism and hemorrhaging. It's reported in up to 2.7% of the procedures. How to avoid that? Optimal anticoagulation and adequate control of energy delivery. It's highlighted in the document that it's important to establish a protocol to treat this complication, especially involving the hospital stroke team. Pericardial complication is also important. It's very common, especially in greater, when doing a cardio ablation. It's important to have arterial lining VT ablations in structural heart disease. The use of IC. It's important for quick detection when we have a tamponation. And pre-recording of cardiac silhouette is also useful. And installation of steroids in the pericardial space to prevent pericarditis. Vascular injury is the most common complication. It's expected in up to 8.6% of the cases. It's higher in some, it's higher in patients, there's some patients that have a higher risk, especially in high BMI patients. And in these patients, ultrasound-guided puncture should be used or is useful. Hemodynamic deterioration pro-arrhythmia is another complication. It's important to perform an echocardiogram if there is a suspicion of cardiac tamponade. But however, other possibilities of this complication is worsening heart failure during extensive ablation in viable myocardial and VT episodes. And extensive ablation in normal ventricle needs close monitor of left ventricle function. For the follow-up after VT ablation, there was a two-way indication for non-invasive program to stimulation. It can be useful for ICD program after ablation, evaluation of risk of VT recurrence, decision on antirrhythmic drug, and decision for repeated ablation. This is one of the studies that was served as base for this recommendation. In these studies, there were 132 patients who underwent non-invasive program stimulation about three days after ablation. 44% had no VT inducible, 37% no clinical VT inducible, and 18% had clinical VT inducible. Based on the results of the non-invasive program stimulation, one-year VT-free survival in 87% that had no VT inducible, 67% when no clinical VT was inducible, and less than 30% when clinical VT was inducible. It's important to note that the inducible clinical VT was an independent predictor of VT recurrence. These results also impacted the mortality at one-year follow-up. When no clinical VT inducible, mortality was 3% compared to greater than 20% when any clinical VT was inducible. So for non-invasive program stimulation, maybe useful in decision to keep on antirrhythmic drug, balance the risk of recurrence versus toxicity of antirrhythmic drugs. Also for programming parameters of ICD, like increasing the, including ATP or prolong arrhythmia detection, and decision to use remote monitor for arrhythmia detection in patients with higher risk of recurrence. And that is my last slide, assessing the outcomes. We look, of course, especially for recurrent sustained VT. Most of these studies have reported Kaplan-Meier curve, but it's also important to remember that VT ablation can reduce the burden of VT and impact the quality of life, prevent the VT storm, and convert ICD shock to ATPase in VT termination, and also to reduction of medications. Thank you very much.

post-procedural care

catheter ablation

ventricular tachycardia

complications

hemodynamic deterioration