The next presentation is by Dr. Yong-Hoon Kim from Korea University Medical Center entitled New Technologies for AF Ablation, What's the Most Interesting New Trials, Dr. Kim. Thank you. Okay, thank you very much. I do not have the disclosure on this specific presentation. It's my great pleasure, and I'd like to thank the organizing committee. Okay, I'd like to share the new technologies for the AF ablation, what's the most interesting new trial. I'd like to start from this trial, the catheter ablation, the head-to-head comparison of sarcoscopic surgical ablation in the subject of long-standing, persistent CASA AF. As recently, the Heart Rhythm published this study. The surgical ablation is that they use the video assist, sarcoscopic, bipolar, ethyl cure, epical, the GP ablation, area appendix excluded, and also they confirm the posterior box isolated by the electrophysiological catheter here. Catheter ablation is the same in the conventional, in the PBI and mostly CTI. They focused more, I think, LA. As you can see here, the Kaplan-Meier curve, single posterior, surgical ablation is significantly better than the catheter ablation here. However, in the multiposterior, during the one-year follow-up, no different. And here, as you can see, the surgical ablation, the complication rate is higher than catheter ablation here. That's the message. And on other paper, this is the first long-term follow-up, seven years follow-up, sarcoscopic versus catheter ablation. Subject a little different, but here, randomized, as you can see, surgical ablation, sarcoscopic ablation is better for the atrial arrhythmia therapy, and composite of this event is same. So from this case, the previous failed and structural change, sarcoscopic ablation is better, and here, the PBI area appendix excision is in that little bit higher periposterior event as the previous CASA-AF trial as well. And I'd like to mention this, another interesting paper, PV reconnection gap using the high-density mapping. Okay? Here's the one example. If you use these high-density mapping, especially the Orion, you can see the very small gap which cannot be seen by the conventional catheter here. This is one example, RSPV. Orion has very discrete potential which cannot be seen by the conventional catheter. So their statistic, high-density mapping, gap recognition is much higher than conventional mapping, circular mapping catheter. I think this is gonna be the game-changer of the small gap detection. If you use the more sophisticated software, maybe you can see easily some gap in the gap dependent tachycardia as well. And also, HD grid also has this similar result, high discrete potential which cannot be seen either ablation catheter or conventional catheter, okay? So what we are seeing is not everything, okay? If you see here, you see a lot of the dogs grinding the laser on the phone. So we think the high-density mapping like the Orion and the HD grid and also these high-resolution mapping may change our PV and also increase the durable PV as well, I believe. And then I'd like to move the endoepicardia electrical dissociation. There's many paper about even atrial fibrillation. There is the endoepicardia electrical dissociation. Alessi Group already published direct proof endoepi, especially long-standing persistent AF. In our group, Hinan Park, we already published the hybrid percutaneous epi and ablation as well. Here is a recent paper, the Pirogovski and the endoepicardial ablation AF. This more than two prior attempt endoablation failed. They did the epicardial mapping. Endocardial mapping, low voltage area, posterior box. And then here, epicardially, posterior, and then SVC, IVC. There is some discrepancy, endoepi as well, okay? And another example, they mapped the epicardially. This, as you can see here, endocardial, same area, the same side, the corresponding side, which cannot be seen here. But here, epicardial clearly show the electrical potential here. In our institute also do the catheter position, rheotic catheter and epicardially. You see here, one example, catheter can show clearly by atrial tachycardia, like this. So without this, without this catheter, we cannot see the clear, complete reentry circuit. So one, just the epicardial catheter, the multi-electrode can maybe be helpful to identify the electrical circuit as well, okay? And then, and also we found in the entrainment, and that this, we target, terminate from the endocardial here, back one bundle, epicardial catheter, here is the corresponding here. This one example, and also we are now doing the prospective randomized for the redo, persistent AF, one-tone randomized, epi plus endo, endo only. So, and also epi group, we found the back one bundle, the lateral reach, which area is mostly very thick, and the epicardial structure dominant area is the pre-contamination site as well. In this paper, this group also had a very similar result without epicardial catheter. They confirmed by the block, but after epicardial ablation added, as you can see, more delayed. This is true, complete block in the back one bundle as well. So epicardial mapping provide new insight, and also epicardial ablation increase trans-murality ablation region as well. And the Chicago group, the Lauderdale Tongue, also this group, recently published, epicardial mapping, feasibility, endo mapping here, mostly scar, but epicardial, same site. There's discrepancy there. And also, as you can see, they used the Orion and the multipolar electrode. Endocardially, very silent, but epicardial, same site, had very fractionation potential. There are discrepancy. And also another example, endo, epi, at the box here, epicardially here, confirmed the trans-murality here. So, from this approach, high density epicardial mapping can provide non-uniform epi, endo, non-uniform region, and substrate the trans-murality of this direct evidence of the human LA. Lastly, I'd like to mention this, the Treanova and Johns Hopkins group optimal target, the Optima, called, this is the first in human clinical application computational modeling approach to guide the personalized way to treat cardiac disease. Our group, the Jamie and Shimi Hinan Park, also already published in virtual, in silico modeling in the Persistent AF, the guided ablation before. This one, the segmentation and the virtual ablation set up, where is the, which ablation is the most virtually effective, and then analyzed. We found, just compared to empiric ablation, this virtual ablation is similar result. This is, I think, very promising. So, return to Treanova and Boyle and the Karkin's group, the paper, initially they acquired MRI, LG, and then 3D reconstruction of fibrosis, and then personalized simulation, where is the rotor and the driver, and then ablation set up, and then sent to the Cato 3D mapping. This is very interesting study. They did the proof of a concept clinical feasibility study, 10 patient. These are 60% have previous failed ablation, the high, the comorbidity as well. The initially simulation, they transport these data to the Cato system, and they create in this region as well. This one example, the LG by HR mapping, computer simulation, define the reentry driver, and then set up the region set, and then exactly apply, and the same, the ablation on the 3D mapping. So, this is one example of this. And also, interestingly, they found these case, fibrosis, LA, the RA, almost equally distributed, which is very clinically relevant. And then set up their ablations, the region set as well. This is another example. This is very, and then also, the region is extended normal, the conduction variant, like the mitral annulus as well. Okay, those most common location, the driver is the posterior wall and the left side PV. This is, and also another example here, aft PBI, and they deliver the ablation here. This disorganized, it's organized, okay. So here, as I mentioned, the RA, the fibrosis is about 19%. And also, during the follow-up, here, this is the 58% they target RA, which is in long-standing process they have, and then RA is also very, I think, very important target, which is very clinically relevant as well. Clinical outcomes so far, very good, and ablation outcome during follow-up, only one patient recur, but the others maintain sinus rhythm. So this is the 3D bi-atrial optimal approach. In a personalized manner, re-entering driver-sustained property of fibrous substrate, fully integrated in the clinical flow via co-registration of the 3D mapping system. This is very interesting. But we need, for this clinical trial, adequate sample size and randomized comparison will need to be undertaken. So I'd like to conclude, Mr. Chairman and ladies and gentlemen, sarcoscopic ablation for long-standing process they have is superior in the single procedure at the cost of higher complication rate. High-density mapping allow greater precision in the identification of especially PV gap. AP and the mapping and ablation will be useful to understand mechanism and increase the region transmutality. Finally, virtual computer model targeting fibrotic structure, ablation for persistent, especially long-standing AF and refractory case, maybe new technology need to be clinically tested. Thank you very much for your attention. Thank you. Thank you, Dr. Kim. The paper's open for discussion. Thank you, Dr. Kim, for that nice overview. Thank you very much. I had a very simple question about your trial pursuing epicardial, endocardial mapping and ablation in persistent AFib patients requiring a redo procedure. Do you sometimes find it technically challenging to map epicardially when they've had a prior extensive endocardial atrial ablation? Right. So the epicardial, this redo is mostly the prior extensive endocardial ablation. But when we do the MRI in the most cases, the very heterogeneous and gap-dependent, a lot of fibrosis as well. And then, but in the percutaneous, the epicardial approach mostly the feasible, easy. And then the one catheter, the oblique sinus, transverse sinus, then that area mapping added great value to see the whole circuit. And also the, I think, fractionation potential as well. So we don't have experience on the very difficult to access or even patient has previous extensive ablation of endocardially. Thank you. Thank you, Dr. Kim.

AF ablation

sarcoscopic surgical ablation

catheter ablation

high-density mapping

persistent AF