Catégorie
📚
ÉducationTranscription
00:00:00 (upbeat music)
00:00:02 (upbeat music)
00:00:05 (upbeat music)
00:00:07 (upbeat music)
00:00:10 (upbeat music)
00:00:12 (upbeat music)
00:00:20 (upbeat music)
00:00:27 (upbeat music)
00:00:35 (upbeat music)
00:00:38 (upbeat music)
00:00:51 (upbeat music)
00:01:00 (upbeat music)
00:01:02 (upbeat music)
00:01:24 (upbeat music)
00:01:27 (upbeat music)
00:01:30 (upbeat music)
00:01:39 (upbeat music)
00:01:55 (upbeat music)
00:01:57 (upbeat music)
00:02:11 (upbeat music)
00:02:18 (upbeat music)
00:02:21 (upbeat music)
00:02:40 (upbeat music)
00:02:43 (upbeat music)
00:02:57 (upbeat music)
00:02:59 (upbeat music)
00:03:02 (upbeat music)
00:03:14 (upbeat music)
00:03:27 (upbeat music)
00:03:30 (upbeat music)
00:03:48 (upbeat music)
00:03:51 (upbeat music)
00:04:09 (upbeat music)
00:04:12 (upbeat music)
00:04:30 (upbeat music)
00:04:33 (upbeat music)
00:04:46 (upbeat music)
00:04:49 (upbeat music)
00:04:51 (upbeat music)
00:05:04 (upbeat music)
00:05:18 (upbeat music)
00:05:21 (upbeat music)
00:05:34 (upbeat music)
00:05:37 (upbeat music)
00:05:51 (upbeat music)
00:05:53 (upbeat music)
00:06:07 (upbeat music)
00:06:09 (upbeat music)
00:06:12 (upbeat music)
00:06:36 (upbeat music)
00:06:38 (upbeat music)
00:06:54 (upbeat music)
00:06:57 (upbeat music)
00:07:00 (upbeat music)
00:07:09 (upbeat music)
00:07:24 (upbeat music)
00:07:27 (upbeat music)
00:07:30 (upbeat music)
00:07:43 (upbeat music)
00:07:55 (upbeat music)
00:07:58 (upbeat music)
00:08:24 (upbeat music)
00:08:27 (upbeat music)
00:08:44 (upbeat music)
00:08:46 (upbeat music)
00:08:58 (upbeat music)
00:09:01 (upbeat music)
00:09:14 (upbeat music)
00:09:17 (upbeat music)
00:09:42 (upbeat music)
00:09:45 (upbeat music)
00:10:00 (upbeat music)
00:10:02 (upbeat music)
00:10:15 (upbeat music)
00:10:18 (upbeat music)
00:10:35 (upbeat music)
00:10:37 (upbeat music)
00:10:49 (upbeat music)
00:10:52 (upbeat music)
00:11:05 (upbeat music)
00:11:08 (upbeat music)
00:11:21 (upbeat music)
00:11:23 (upbeat music)
00:11:36 (upbeat music)
00:11:39 (upbeat music)
00:11:51 (upbeat music)
00:11:53 (upbeat music)
00:12:06 (upbeat music)
00:12:09 (upbeat music)
00:12:35 (upbeat music)
00:12:38 (upbeat music)
00:12:55 (upbeat music)
00:12:57 (upbeat music)
00:13:11 (upbeat music)
00:13:14 (upbeat music)
00:13:39 (upbeat music)
00:13:42 (upbeat music)
00:13:56 (upbeat music)
00:13:59 (upbeat music)
00:14:15 (upbeat music)
00:14:17 (upbeat music)
00:14:43 (upbeat music)
00:14:45 (upbeat music)
00:15:01 (upbeat music)
00:15:04 (upbeat music)
00:15:29 (upbeat music)
00:15:32 (upbeat music)
00:15:46 (upbeat music)
00:15:48 (upbeat music)
00:16:15 (upbeat music)
00:16:17 (upbeat music)
00:16:33 (upbeat music)
00:16:36 (upbeat music)
00:16:51 (upbeat music)
00:16:54 (upbeat music)
00:17:07 (upbeat music)
00:17:09 (upbeat music)
00:17:22 (upbeat music)
00:17:25 (upbeat music)
00:17:37 (upbeat music)
00:17:39 (upbeat music)
00:18:06 (upbeat music)
00:18:08 (upbeat music)
00:18:24 (upbeat music)
00:18:27 (upbeat music)
00:18:42 (upbeat music)
00:18:44 (upbeat music)
00:19:10 (upbeat music)
00:19:12 (upbeat music)
00:19:25 (upbeat music)
00:19:28 (upbeat music)
00:19:44 (upbeat music)
00:19:47 (upbeat music)
00:20:00 (upbeat music)
00:20:02 (upbeat music)
00:20:15 (upbeat music)
00:20:18 (upbeat music)
00:20:43 (upbeat music)
00:20:46 (upbeat music)
00:21:02 (upbeat music)
00:21:04 (upbeat music)
00:21:16 (upbeat music)
00:21:19 (upbeat music)
00:21:35 (upbeat music)
00:21:37 (upbeat music)
00:22:02 (upbeat music)
00:22:04 (upbeat music)
00:22:20 (upbeat music)
00:22:23 (upbeat music)
00:22:36 (upbeat music)
00:22:39 (upbeat music)
00:23:04 (upbeat music)
00:23:07 (upbeat music)
00:23:25 (upbeat music)
00:23:27 (upbeat music)
00:23:53 (upbeat music)
00:23:55 (upbeat music)
00:24:11 (upbeat music)
00:24:14 (upbeat music)
00:24:39 (upbeat music)
00:24:42 (upbeat music)
00:24:58 (upbeat music)
00:25:00 (upbeat music)
00:25:15 (upbeat music)
00:25:18 (upbeat music)
00:25:27 (upbeat music)
00:25:45 (upbeat music)
00:25:48 (upbeat music)
00:26:13 (upbeat music)
00:26:16 (upbeat music)
00:26:32 (upbeat music)
00:26:34 (upbeat music)
00:26:46 (upbeat music)
00:26:49 (upbeat music)
00:27:15 (upbeat music)
00:27:18 (upbeat music)
00:27:32 (upbeat music)
00:27:34 (upbeat music)
00:27:43 (upbeat music)
00:27:53 (upbeat music)
00:27:56 (upbeat music)
00:28:02 - Good evening, everybody.
00:28:05 My name is Ariane Zoltan.
00:28:07 I'm an electrophysiologist from the University Hospital
00:28:10 in Cologne, Germany.
00:28:12 And today we're gonna talk about lean LIA
00:28:15 and device selection, what makes an efficient procedure.
00:28:18 And obviously I will have a very nice panel with me today.
00:28:21 Professor Dupont from France,
00:28:23 Dr. Amado Pérez de Vrado from Spain
00:28:26 and Dr. Francesco Meucci from Italy.
00:28:28 And obviously it's a very fast forward
00:28:31 and pretty straight procedure in the vast majority of cases.
00:28:34 However, I think LIA occlusion can also be tricky
00:28:38 and I'm very lucky that I have this excellent panel
00:28:40 with me tonight that will give you some expert opinion
00:28:43 on tips and tricks in patient selection,
00:28:45 their tips and tricks for access,
00:28:47 for imaging during the procedure
00:28:49 and which device selected which patient.
00:28:52 And not to steal any more time from the speakers,
00:28:54 without further ado, I'd like to introduce the first speaker
00:28:57 it's Professor Dupont from France.
00:28:59 And he will talk about device selection
00:29:02 starts with transeptal puncture.
00:29:04 Please Gregory.
00:29:05 - Thank you, Ariane.
00:29:08 Thank you.
00:29:09 Hello everybody.
00:29:10 So my name is Gregory Dupont.
00:29:13 I work in Bichat Hospital in Paris.
00:29:18 And of course I am an LIA occlusion operator.
00:29:21 I think it's very important to understand
00:29:25 when you perform a LIA occlusion that the first step,
00:29:28 which is a transeptal puncture is a really a crucial step
00:29:31 to be able to perform a safe, fast and efficient procedure.
00:29:36 So I'm sure that most of you perform a T guided
00:29:47 transeptal puncture.
00:29:49 And it's important to understand that the site
00:29:54 of the transeptal puncture, sorry.
00:29:57 - Sorry, can you go on your presentation mode?
00:29:59 We don't see your slides.
00:30:00 - I don't see my slides, sorry.
00:30:02 We have to switch.
00:30:05 Is it okay now?
00:30:09 - You need to switch to the presenter mode.
00:30:13 - Yeah, this is what I just did.
00:30:15 - Okay.
00:30:16 - Can you see?
00:30:19 - It's still not in the presenter mode.
00:30:23 Maybe the tech support can help us.
00:30:25 - I did.
00:30:33 Okay, so.
00:30:45 - There.
00:30:46 - Maybe I can ask the other presenters
00:31:09 while we're trying to fix the problem.
00:31:12 So you guys always, obviously you're all very experienced
00:31:15 interventional cardiologists.
00:31:17 So you always use imaging before the procedure
00:31:21 or do you have patients where you do not do that
00:31:24 before without giving away everything?
00:31:27 Maybe we can already discuss a little bit about it.
00:31:40 - Okay, okay.
00:31:41 Okay, so I stopped the screen sharing.
00:31:47 Okay, next slide.
00:31:50 - Okay, we are good to go, I guess.
00:31:52 - So sorry, I apologize for this beginning.
00:31:57 Next slide, please.
00:31:58 Next slide.
00:32:00 So, okay, so it's very important to understand
00:32:05 that when you perform a transeptal puncture,
00:32:10 the site of the puncture will depend on the procedure
00:32:14 you will want to achieve.
00:32:15 If you want to do a mitral clip,
00:32:18 you will do a puncture which is superior and posterior.
00:32:23 And at the opposite, when you want to perform
00:32:28 an LA occlusion, which is the thing
00:32:30 we want to understand today,
00:32:33 you will have most of the time to do a puncture
00:32:35 which is inferior and posterior.
00:32:39 So that being said, next slide,
00:32:42 one might wonder what does that mean?
00:32:44 Superior, inferior, anterior, posterior.
00:32:47 And it's very important to use the right words
00:32:50 because you will need to speak the same language
00:32:54 than your echographer.
00:32:55 So what does mean inferior?
00:32:58 Inferior means toward the inferior vena cava.
00:33:01 So if you want to do a puncture which is inferior,
00:33:05 you will do a puncture from this direction.
00:33:09 I don't know if you can see my pointer.
00:33:11 And if you want to puncture posterior,
00:33:16 that means posterior means at the opposite of the aorta.
00:33:20 So anterior means towards the aorta
00:33:23 and posterior at the opposite of the aorta.
00:33:25 There is a third dimension which is used for a mitral clip
00:33:30 which is low and high.
00:33:31 So here we want to do inferior.
00:33:34 So towards the inferior vena cava
00:33:36 and posterior at the opposite of the aorta.
00:33:39 So that is true for the majority of DLA occlusion.
00:33:44 Next.
00:33:46 Next slide, please.
00:33:49 But it's not true for all the procedure.
00:33:54 And for some patients,
00:33:57 you will need to optimize your transeptal puncture.
00:34:01 Next slide.
00:34:04 So for this, I really like to use CT scan.
00:34:09 And actually we perform a CT scan
00:34:12 for the screening of each of our patients.
00:34:15 And we reconstruct, as you can see on the right panel,
00:34:20 we can reconstruct the LAA and also the fossa
00:34:25 that you can see here.
00:34:27 And for these patients,
00:34:29 you can see that if you do a puncture inferior
00:34:32 and posterior, you will be pretty well aligned with the LAA
00:34:37 and you will be able to easily go into the LAA
00:34:42 even without using a pituitary catheter.
00:34:47 So next slide.
00:34:49 But there are some patients
00:34:53 that have anatomical particularity.
00:34:57 For example, this patient has an implantation of this LAA
00:35:01 which is quite inferior and very anterior.
00:35:05 You can see that it's very far from the pulmonary vein.
00:35:10 And for these patients,
00:35:13 you will probably need to do a very specific puncture.
00:35:17 Next slide.
00:35:18 So here, if you use the CT scan,
00:35:23 you can move to a virtual LAO.
00:35:26 This is the left part of my screen.
00:35:29 And here, it's a pity that you cannot see my pointer
00:35:33 because it's more difficult to understand,
00:35:36 but here you can see that you will need to do a puncture
00:35:40 which is very inferior on the left part
00:35:44 to be well aligned with the LAA.
00:35:47 And on the right part,
00:35:50 you move to a virtual aerial projection.
00:35:53 And you can see that if you do a puncture that is posterior,
00:35:58 you won't be aligned with the LAA
00:36:01 and you will be almost at the horizontal of the LAA.
00:36:07 So for these patients,
00:36:11 I will need to puncture much more anterior.
00:36:15 Next slide.
00:36:16 So basically, we use this CT scan for each of our patients
00:36:22 and this allows us to have a very specific transformation
00:36:28 of transseptal puncture
00:36:29 and to avoid to redo transseptal puncture
00:36:32 and to, in most of the cases, be well aligned with the LAA.
00:36:37 So there are also some specific situation.
00:36:41 Here, you can see a natural septum aneurysm,
00:36:44 which is a specificity that can make
00:36:48 the transseptal puncture difficult.
00:36:50 Next slide.
00:36:51 Here, another actual septum aneurysm,
00:36:57 also called a floppy septum.
00:37:00 This can cause several problems.
00:37:01 Next slide.
00:37:02 The first thing is that when you push a lot on the septum,
00:37:08 here you think that you're right in the middle
00:37:12 of the fossa, but by pushing, next,
00:37:16 you push, next.
00:37:19 Next slide.
00:37:25 When you cross, you can see that sometimes
00:37:28 you have some surprises and that here you end up
00:37:32 at the inferior parts.
00:37:33 So to avoid that, we use, next slide, the radiofrequency.
00:37:38 So at the beginning of our experience
00:37:45 with the radiofrequency, we used an electric cutter
00:37:48 that we placed on a standard needle.
00:37:53 This is a broken bone needle.
00:37:55 Next slide.
00:37:56 And you can see what it does.
00:38:00 So here we apply the radiofrequency,
00:38:03 and you can see that there are some fog in the atrium.
00:38:08 And you can see, previous slide, sorry.
00:38:11 You can see that the septum is gently crossed by the needle.
00:38:16 There is another advantage, is that if you push a lot
00:38:23 on these patients, you might reach the free wall of DLAA,
00:38:28 and you might end up with a pericardial effusion.
00:38:33 Next slide.
00:38:34 So this was the beginning of our experience.
00:38:36 And then there was this dedicated device,
00:38:41 radiofrequency wire-based platform.
00:38:45 And you can see that it's an interesting tool
00:38:48 because the tip is very soft,
00:38:52 and it gives you a very short burst of radiofrequency.
00:38:56 You can see that you have much less cavitation
00:39:01 in the left atrium than before.
00:39:04 And it has been described that this helps you
00:39:08 reduce the risk of thrombosis.
00:39:11 So much less traumatic.
00:39:13 It's not only useful in the floppy septum,
00:39:18 but also in other situation, like here.
00:39:21 If you have a floppy septum,
00:39:23 if you have a, sorry, a thick septum,
00:39:25 some septum are very resistant,
00:39:28 and you could need to push a lot to be able to cross.
00:39:33 And also in post-causotomy septum,
00:39:35 again, you have in this situation, very thick septum.
00:39:38 And sometimes we also see like here,
00:39:40 represented here, some calcified septum.
00:39:44 So here, radiofrequency is almost mandatory
00:39:47 to be able to cross this type of septum.
00:39:51 Next slide.
00:39:52 So that being said,
00:39:55 the last improvement we have made with transceptal puncture
00:39:59 is improving our workflow.
00:40:02 Next slide.
00:40:03 So here is represented the standard workflow
00:40:07 you would use for a transceptal puncture with a needle.
00:40:11 So you do a venous puncture, you advance a 032 wire,
00:40:16 you advance a sheath on the wire,
00:40:19 you remove the wire, you introduce the needle,
00:40:22 you do the transceptal with the needle,
00:40:25 then you remove the needle after advancing the catheter,
00:40:28 and you introduce a stiff-gain wire
00:40:33 into the pulmonary vein.
00:40:35 So this is the standard workflow.
00:40:38 Next slide.
00:40:39 And there is a new tool, which is called the VersaCross,
00:40:43 that we use for almost all of our cases,
00:40:49 for the LA occlusion.
00:40:51 This is the VersaCross.
00:40:52 So you can see that it is made of first catheter,
00:40:57 which can be easily reshaped.
00:41:01 So based on the curve you would like to give,
00:41:04 you place, you make a curve on this catheter.
00:41:09 Usually you do it this on the needle,
00:41:14 but here it's on the catheter,
00:41:15 and it's very easy to do this curves.
00:41:20 And you can see on the right part that there are two wires.
00:41:25 The first one is a pigtail-shaped wire.
00:41:28 This is the one we use, and there is also a G-tip wire.
00:41:33 Next slide.
00:41:34 So the thing is that the wire is connected to a generator,
00:41:42 and this generator will apply radio frequency
00:41:47 when you will need it.
00:41:48 Next slide.
00:41:49 So this is the way I use it.
00:41:52 I first start with a puncture,
00:41:56 then I do a closure device,
00:42:00 and I simply advance the wire in the closure device
00:42:04 to the superior vena cava.
00:42:07 You can see that it's, it's very gently
00:42:11 because of the pigtail tip,
00:42:15 it doesn't go into collaterals,
00:42:17 it doesn't go into the right appendage.
00:42:22 Next slide.
00:42:24 Then you advance the catheter that you appreciate.
00:42:30 You remove the wire,
00:42:33 but you keep the wire at the tip of the catheter,
00:42:37 and then you will start the maneuver
00:42:39 for the transeptal.
00:42:40 Next slide.
00:42:41 So the nice thing is that if you're not in a good position,
00:42:45 you can simply re-advance the wire.
00:42:48 You don't have to remove the needle
00:42:50 to re-advance the wire.
00:42:53 You have everything in place.
00:42:55 Next slide.
00:42:56 So here we have advanced again in the superior vena cava.
00:43:00 We remove the wire.
00:43:01 We have a good tenting here.
00:43:04 And once you are here, next slide,
00:43:08 you simply advance the wire a millimeter outside
00:43:13 the catheter and then apply the radio frequency.
00:43:16 And you're very smoothly in the left atrium.
00:43:21 So next slide, you can see,
00:43:22 you can see this on echo.
00:43:26 So the tenting on the left part,
00:43:29 and then the wire cross with the radio frequency.
00:43:32 So it's very atromatic
00:43:36 and we believe this is,
00:43:41 this can allow you to achieve a safe puncture.
00:43:46 Next slide.
00:43:47 So once you have done that,
00:43:49 simply advance the catheter to predilate the symptom.
00:43:54 Then you remove the catheter.
00:43:57 Next.
00:43:57 And finally, next slide.
00:44:05 You can advance the Watchman catheter on this wire.
00:44:10 So, next slide.
00:44:15 So with this device,
00:44:17 you can see that you are able to eliminate a few steps
00:44:22 and this can allow you to really improve the workflow
00:44:26 and to go faster with your traceptor puncture.
00:44:31 Next slide.
00:44:34 So this has been described and published recently.
00:44:39 You can see that using this workflow
00:44:45 compared to a needle-based device
00:44:49 can allow you to save on the average
00:44:53 one and a half minutes of fluoroscopy time.
00:44:56 You can also see that it allows to reduce fluoroscopy dose.
00:45:01 And at the end,
00:45:04 it can reduce the time of the whole procedure.
00:45:08 So these are the few things I would like to,
00:45:13 I wanted to share with you about traceptor puncture.
00:45:17 So to summarize,
00:45:19 I believe that a very precise traceptor puncture
00:45:24 is key to achieve an efficient and safe
00:45:27 LA oculin procedure.
00:45:30 For this, we have improved traceptor puncture
00:45:35 with planning the puncture with CT scan
00:45:38 and also to improve the traceptor puncture itself
00:45:43 by using radiofrequency and wire-based device.
00:45:48 Thank you.
00:45:49 - Yeah, Gregory, I think that was a very nice
00:45:53 and very comprehensive overview
00:45:54 and especially the use of the VASA process.
00:45:56 I think you nicely have shown how to use it
00:45:58 and how it facilitates your procedure
00:46:00 and you even spare some steps in between.
00:46:02 And there are luckily a few questions in the slide.
00:46:05 And at this point in time,
00:46:06 I want to engage the audience
00:46:08 and please send us questions via the chat and sliders
00:46:12 so we can answer the speakers directly.
00:46:15 So there was one question in the beginning of your talk
00:46:18 from Dr. Arceeves.
00:46:19 Can one simulate your traceptor puncture
00:46:22 using CT scans to see the best puncture locations
00:46:25 or is there some kind of a simulation mode
00:46:29 for your CT scans?
00:46:29 Can you do that?
00:46:30 - You can do that with several softwares, of course.
00:46:36 I would like to say that I don't like so much
00:46:41 the simulation.
00:46:42 I don't think it adds a lot to simulate the catheter.
00:46:48 And the thing I use is that,
00:46:53 you know, the shape of the catheter we use
00:46:57 allows you to go superior and anterior
00:46:59 and you need to have the fossa,
00:47:04 which is aligned quite vertically with the appendage.
00:47:09 If it's horizontal, it doesn't work
00:47:15 because when you do a counter-clockwise rotation
00:47:19 with your catheter, it goes anterior and it goes superior.
00:47:23 So if you want to go anterior without going superior,
00:47:27 it's not possible.
00:47:28 So if you have an appendage which is anterior
00:47:33 and not superior, it's not possible
00:47:36 with the standard catheter.
00:47:38 So I use this alignment and I don't feel
00:47:43 this is really useful to do this simulation.
00:47:48 - Completely agree.
00:47:50 I think for a beginner, it's a good tool to get some idea
00:47:52 where to puncture, how the fossil wallets might look like
00:47:54 and what's the relationship to the vicinity
00:47:57 of other structures, but I completely agree.
00:47:59 I wouldn't rely on it completely.
00:48:01 So there are two more questions.
00:48:02 Maybe we can have short answers on this.
00:48:04 Concerning the aneurysm of the septum,
00:48:09 in which anatomies would you expect to see benefits
00:48:11 of RF puncture as opposed to a mechanical puncture?
00:48:16 In terms of, I guess mechanical puncture here means
00:48:19 if you just apply a little bit more push
00:48:20 to get through the septum.
00:48:22 - You can always push if you push a lot.
00:48:26 So the problem is that with the aneurysm,
00:48:32 you can see that if you really push a lot,
00:48:34 you will reach the opposite wall of the atrium
00:48:38 and then you can damage the atrium and-
00:48:43 - Do you have like a cutoff where you would say,
00:48:46 let's say an extension of the aneurysm
00:48:49 more than one centimeter would lead to RF or?
00:48:52 - Actually we use it in every case.
00:48:55 The problem is that once you are started with the needle,
00:48:57 you end with the needle.
00:48:58 You don't remove the needle
00:49:00 and then place another device.
00:49:04 So at the beginning, when we used to use the electric cutter
00:49:09 we started to push a little bit
00:49:13 and when it doesn't cross with pushing a little bit,
00:49:16 we used to apply radio frequency.
00:49:18 Now that we have specific devices,
00:49:21 we believe that it's very difficult to anticipate
00:49:26 for which patients you will need radio frequency.
00:49:29 Of course, if you have a very thick septum
00:49:31 or if you have a large aneurysm,
00:49:35 you will be sure that you will need it.
00:49:37 But sometimes you have some surprises.
00:49:39 Sometimes you push a lot and it doesn't cross.
00:49:41 So very difficult to anticipate.
00:49:44 For this reason, we use radio frequency
00:49:46 in all of our patients.
00:49:47 Of course, you need to have the device
00:49:51 reimbursed by your hospital.
00:49:52 We use it because we can use it.
00:49:57 - I think that's a very, very important topic.
00:50:00 So one question was how often do you use it?
00:50:02 You already answered that one,
00:50:03 that you use it in every case, the versatile wire.
00:50:05 Is that right?
00:50:06 - Yes, yes, yes.
00:50:08 - And the last question, yeah, go ahead.
00:50:11 - Again, we are lucky enough to have it reimbursed.
00:50:15 So we use it for every case,
00:50:17 but I can understand that you could need
00:50:20 to select for a few patients.
00:50:22 - And for the sake of time,
00:50:24 maybe the last question, short answer,
00:50:26 just for the handling of the rest of the process,
00:50:28 the question, because of the pigtail morphology of the wire,
00:50:31 is there a necessity to put the wire in the pulmonary vein
00:50:34 when you want to exchange the sheath?
00:50:36 I think we can answer that quite quickly.
00:50:38 - No, no, the wire is very supportive.
00:50:41 I was very surprised because it looks like a very thin wire,
00:50:46 but it gives you really a strong support.
00:50:49 And I know that there are some operators
00:50:51 that also use it for MitraClip,
00:50:54 which is very surprising because you need to push a lot.
00:50:56 You have a very bulky device,
00:50:58 but some operator use it routinely for MitraClip.
00:51:02 And actually, if you use this wire,
00:51:06 you just need to keep it in the middle of the atrium.
00:51:10 - Yeah, fully agreed.
00:51:11 I can tell you from the EP perspective
00:51:13 and patients who have pre-group procedures,
00:51:15 but the septum sometimes might be a little bit stiff
00:51:17 due to previous procedures.
00:51:19 We also use the wire, easily process the septum
00:51:22 as opposed to a transseptal needle, so that's quite nice.
00:51:25 So once again, Gregory, thank you very much
00:51:27 for this excellent talk, excellent discussion.
00:51:29 I think for the sake of time, we will move on to Spain.
00:51:32 Let's go a little bit further down
00:51:34 to Dr. Armando Perez de Brado,
00:51:35 and he will give us some insights
00:51:37 on what does the data suggest with LIA device selection.
00:51:41 Dr. Perez de Brado, please, the floor is yours.
00:51:44 - Hello, can you see my slides?
00:51:46 - Yes, excellent.
00:51:49 - Okay, thank you.
00:51:50 Thank you to Boston Scientific
00:51:52 and also doing CatLab for the technical support
00:51:54 and all the participants in this very interesting,
00:51:58 I think, I guess, very interesting book on LIA closure.
00:52:02 My topic will be what data we have
00:52:06 that can help us to select a device for doing LIA closure.
00:52:12 And the question is, are all the devices almost equal?
00:52:16 Or this is a question like Coke versus Pepsi
00:52:21 or Rolling Stones versus the Beatles.
00:52:23 I mean, what can help you to select the best device
00:52:26 for your patient?
00:52:28 So we can look for help in four different ways.
00:52:33 Looking for the data published on efficacy of the devices,
00:52:37 if there is anything,
00:52:39 but also on the behavior of the devices in the real world.
00:52:43 Looking for some problems that could be more relevant
00:52:47 once we are expanding the indication of LIA closure
00:52:52 that could be device leaks, the presence of device leaks,
00:52:56 and also device-related thrombosis.
00:52:58 And finally, how can you manage all this information
00:53:01 and join to do the procedural optimization
00:53:04 and finally, or previously,
00:53:06 do a precise device selection for your patient?
00:53:11 So let's go for the first question.
00:53:14 Is there any meaning
00:53:15 or what does a pre-device leaks mean
00:53:18 for the device selection?
00:53:20 The first point is to talk about the mechanisms of leak
00:53:24 and the relevance, final relevance of these leaks.
00:53:27 There are different mechanism of leaks of the device
00:53:29 once you implant in the LIA.
00:53:32 It could be a niche or side leak,
00:53:34 or maybe it can be leaks that are termed fabric leak,
00:53:39 intra-device leaks.
00:53:40 Probably it does not mean the same,
00:53:42 but you have different mechanism
00:53:44 and you should have taken into account these differences.
00:53:49 Anyway, the relevance of the leaks is well-known,
00:53:52 especially big leaks over five millimeters.
00:53:54 It's a cutoff point, probably not well-tested,
00:53:59 but the bigger the leak,
00:54:00 the bigger the chances of having a big thrombus
00:54:04 that can be clinically relevant.
00:54:07 Anyway, even small leaks can have some clinical relevance
00:54:11 and the incidence of ischemic events is higher
00:54:15 when you have a leak in your LIA closure procedure.
00:54:20 We really don't know the real incidence
00:54:23 of peri-device leak.
00:54:24 The most common point in which the imaging
00:54:28 after LIA procedure is done is about one half a month.
00:54:32 And you can see in this slide that there is a wide
00:54:36 variability in terms of the incidence of peri-device leaks,
00:54:40 depending on the way, on the imaging method,
00:54:43 but also on the time.
00:54:46 But anyway, at one and a half months,
00:54:51 there are striking differences in the incidence of leak.
00:54:55 Anyway, I would like to stress that the WatchMount Flex
00:55:00 device has shown consistent low rates of peri-device leaks.
00:55:06 So it can help in the selection of your device,
00:55:09 this data, this published data.
00:55:12 I have said that leak detection and measurement
00:55:15 is really not easy.
00:55:16 If you use TE to do imaging follow-up of these patients,
00:55:21 probably only one third of the patients show relevant leaks.
00:55:25 But if you use CT, probably you are looking
00:55:27 or you are obtaining a 61% of incidence of leaks.
00:55:31 Small leaks, medium leaks, and also big leaks.
00:55:35 Probably CT is more sensitive and shows more wide,
00:55:40 more higher dimensions of the gap as can be seen
00:55:47 in this comparative analysis of the two methods
00:55:51 of the detecting leaks.
00:55:52 Second point, device-related thrombosis.
00:55:54 This is a real nightmare because it is common
00:55:59 that you close the LEA in patients
00:56:01 that could not tolerate oral anticoagulants.
00:56:04 So come back to oral anticoagulants
00:56:06 is not a good idea in general.
00:56:09 Which is the relevance and predictors
00:56:10 of device-related thrombosis?
00:56:12 This is a very nice collaborative study
00:56:14 in which we have participated.
00:56:16 Many of the centers in the world
00:56:18 have participated in this study.
00:56:20 The timing of device-related thrombosis
00:56:23 is mainly two thirds appearing in the first six months,
00:56:27 but there are one third of cases detected after this.
00:56:31 And the main point is that you can see
00:56:35 in the middle of this slide, the outcomes are not good.
00:56:39 I mean, device-related thrombosis is clearly related
00:56:43 to a major adverse cardiac and embolic events.
00:56:48 There are some predictors of the appearance
00:56:52 of the device-related thrombosis,
00:56:54 but it depends on the device and also on sometimes
00:56:58 and not modifiable factors like patient-dependent factors
00:57:03 that can influence on the device-related thrombosis
00:57:08 appearance.
00:57:09 Also, the definition is not clear.
00:57:11 I mean, probably again, CT is very sensitive
00:57:15 in detecting this phenomenon of hypoattenuation images.
00:57:20 So we should discern difference between thrombosis
00:57:27 and images like let's say healing or endothelialization.
00:57:33 And it's not easy sometimes to ascertain
00:57:37 if the image is thrombosis or not.
00:57:40 I strongly recommend the reading of this review
00:57:45 but this is really interesting in this point.
00:57:49 The incidence, the real-world incidence
00:57:52 of device-related thrombosis is also highly variable.
00:57:57 The meta-analysis published some years ago
00:58:01 found a 3.8 incidence of device-related thrombosis
00:58:06 up to one year or even a longer follow-up.
00:58:09 But in the last data we have from a randomized
00:58:13 clinical trial, that is the ADALA study
00:58:16 by Freysen and collaborators presented at the EuroPCR
00:58:20 this year, the real incidence in these patients
00:58:23 comparing the APT with low-dose oral anticoagulation,
00:58:28 the real incidence was almost 9%.
00:58:32 Probably between these points, we can find the real figure,
00:58:36 the real incidence of devices-related thrombosis.
00:58:39 The other point, and I think we are going to discuss this
00:58:42 is what is the best way of getting rid
00:58:45 of preventing the appearance of device-related thrombosis.
00:58:50 Finally, we should compare all the data efficacy
00:58:54 that there are also these small problems,
00:58:57 leak and also device-related thrombosis
00:58:59 between different devices in face-to-face comparisons.
00:59:03 There are a few data and we are going to review briefly
00:59:07 the data presented, the AMULET-IVE study
00:59:10 is a randomized clinical trial mandated by the FDA
00:59:13 to compare AMULET with WATCHMAN 2.5.
00:59:17 And I should explain this because this is not the data
00:59:20 that we are going to obtain with WATCHMANFLEX,
00:59:22 but with WATCHMAN 2.5 and AMULET,
00:59:25 the procedural results and the clinical results
00:59:29 were pretty the same.
00:59:31 No differences, no significant differences.
00:59:34 And I should explain that one and a half year follow-up,
00:59:38 very effective treatments with any of these both devices.
00:59:42 So the small differences that could analyze
00:59:47 probably are really small differences
00:59:50 and the final relevance of these differences
00:59:53 is really arguable.
00:59:54 This is another randomized clinical trial, smaller,
00:59:58 eight centers in Switzerland and in Italy,
01:00:03 randomizing AMULET device versus WATCHMAN.
01:00:08 In this case, the majority of the patients
01:00:10 were treated with WATCHMANFLEX,
01:00:13 sorry, three quarters of patients.
01:00:15 And the primary endpoint was not clinical results
01:00:19 because it's not power up.
01:00:21 It's the patency of the LAA at one month and a half,
01:00:26 whatever it means the patency of the LAA.
01:00:29 No differences between these two devices
01:00:33 and the clinical outcome seems to be even better
01:00:36 with WATCHMAN, but as I have said,
01:00:38 no power to detect clinical differences in this study,
01:00:43 but the patency of the LAA seem the same with both
01:00:48 and really low because the patency of the LAA
01:00:53 was really high, almost 70% in both cases.
01:00:57 So I don't know, we don't know what it means,
01:01:00 but the results seems the same.
01:01:04 Talking about leaks, there is some,
01:01:07 I think it's more important to make publicity
01:01:11 and not clinically differences,
01:01:13 but it seems that in the IDE study,
01:01:17 there is some advantage for AMULET
01:01:21 over WATCHMAN 2.5 in terms of residual leaks at 45 days
01:01:26 with TE, but the difference is mainly driven
01:01:30 by intermediate leaks that maybe are not very relevant
01:01:34 in terms of clinical events.
01:01:35 And in fact, there is no clinical differences
01:01:39 in this study.
01:01:40 Also in the Swiss Opera study,
01:01:42 the results are pretty the same in the patency of the LAA.
01:01:47 Probably there are more intra-device leaks
01:01:51 in the AMULET case and more side gap leaks with WATCHMAN,
01:01:56 but the final result is that the patency of the LAA
01:02:01 is pretty the same between these two devices.
01:02:05 Another study, a smaller study, not randomized.
01:02:08 This is a prospective registry trying to compare
01:02:12 the results of the AMULET with WATCHMAN Flex,
01:02:15 only WATCHMAN Flex.
01:02:17 They did in the Aarhus University in Denmark,
01:02:21 two months imaging follow-up with CT,
01:02:25 looking for the results of these both devices
01:02:28 in the series, and it's completely different
01:02:31 from what we have seen in the Swiss Opera
01:02:34 because the rate of occlusion of the LAA is really high,
01:02:39 over 65% in the cases with WATCHMAN,
01:02:44 and significantly lower with AMULET.
01:02:48 So this is a real, these are real conflicting results
01:02:53 as compared with the Swiss Opera.
01:02:54 And a relevant point for me is that it does not depend
01:02:58 on the morphology of the LAA.
01:03:00 WATCHMAN Flex is consistently effective,
01:03:04 closing the appendage, not having patent your appendage,
01:03:08 and with AMULET, some cases appear to be different
01:03:11 depending on the morphology of the LAA.
01:03:16 In terms of figures, 31% of patients with AMULET
01:03:21 have totally closed, completely closed the LAA
01:03:26 versus 72% with WATCHMAN Flex,
01:03:28 and the device-related thrombosis were really low,
01:03:31 lower than we have reviewed in the previous studies.
01:03:35 So I, to get all this data in one single,
01:03:38 although this is not only randomized clinical trial,
01:03:41 but also only observational studies,
01:03:44 the rate of periprocedural complications
01:03:47 and peridevice leaks favor in both cases to WATCHMAN Flex
01:03:52 as compared with the AMULET
01:03:55 in this meta-analysis published recently.
01:03:58 So the last point of my topic of my presentation
01:04:03 is talk about procedural optimization,
01:04:05 and we are going to focus in the selection of the device,
01:04:09 the pre-selection of the device.
01:04:10 If you have more experience using WATCHMAN 2.5
01:04:15 or WATCHMAN Flex, are you going to have better results
01:04:19 that the groups or operators
01:04:22 that does not have this experience?
01:04:25 The answer is no.
01:04:27 Probably the only difference with WATCHMAN Flex,
01:04:29 if you are a heavy user
01:04:30 and you have done more than 10 cases with WATCHMAN Flex,
01:04:34 probably you are going to do,
01:04:36 you have to success at your first attempt
01:04:39 to place the device, and it's real normal.
01:04:43 I mean, it's not a surprise
01:04:47 that if you have more experience,
01:04:48 you can get a good selection of the device
01:04:51 and close the LEA.
01:04:52 So experience does not have a significant influence
01:04:56 in the results with WATCHMAN Flex.
01:04:58 So finally, there are some cases
01:05:01 in which you have select different devices
01:05:04 that you have expected.
01:05:05 I should confess that I am a heavy user
01:05:09 of WATCHMAN Flex, so this is my bias.
01:05:12 But sometimes I think,
01:05:14 okay, I maybe cannot close this kind of big anatomies
01:05:18 or hammerhead LEAs, or even this bizarre,
01:05:23 I say bizarre, anatomies that I like this elephant trunk
01:05:28 that even you can move the trunk and shift up
01:05:30 when you go with your pigtail inside the LEA.
01:05:35 I think there are three cases
01:05:36 in which you should think in different devices.
01:05:39 The first one is the whale tail
01:05:41 or the hammerhead morphology.
01:05:43 Two proximal big opposite lobes,
01:05:46 and that could be like in this center image
01:05:49 that can be now, this is an image from the,
01:05:52 some years ago, only WATCHMAN 2.5,
01:05:55 and it's not easy to go in one of these two lobes,
01:05:58 although some authors like Alcooliare Collaborators
01:06:01 have selected to get WATCHMAN Flex
01:06:04 to be implanted separately in the two lobes.
01:06:09 Some years ago, the only chance we have
01:06:11 was using a lumbar device with a small umbrella
01:06:16 to fit in one lobe and a big disc to close finally the LEA.
01:06:21 The second point, and this is common for different devices,
01:06:26 is the giant LEA, over 35 millimeters of lumbar zone.
01:06:30 And this is a 40 millimeters,
01:06:32 more than 40 millimeters lumbar zone,
01:06:35 great LEA that also show mitral regurgitation.
01:06:39 The point is that there are no WATCHMAN,
01:06:42 there are no AMOLED device that can fit in this anatomy.
01:06:46 So we selected and especially made a tailor-made
01:06:50 46 millimeter disc device of lumbar.
01:06:53 And even with this tailor-made device,
01:06:59 we cannot close completely the LEA.
01:07:02 And this was pretty shown in the follow-up CT,
01:07:07 showing a big gap because there is probably not enough disc
01:07:13 or not depth enough in the LEA.
01:07:17 So sometimes you should look for other devices
01:07:20 than you usually use.
01:07:22 And the third and last morphology
01:07:25 is the steep-angle anterior cheeking wing,
01:07:28 in which probably WATCHMAN or even WATCHMAN Classic
01:07:32 is not an option.
01:07:33 I think WATCHMAN Flex also is not an option here
01:07:36 in this anatomy.
01:07:38 And some authors have opted for doing the sandwich technique
01:07:42 with the AMOLED device.
01:07:43 So giving a part, I mean,
01:07:46 if you're taking into account this strange anatomies
01:07:49 but that can be appear,
01:07:50 I should say as a summary of my presentation
01:07:53 is that having the data demonstrated
01:07:56 that there are no big differences between devices.
01:08:00 And you can opt for your best option.
01:08:04 In my case, I should say that 95% of cases
01:08:07 can be effectively based on the data
01:08:10 and on the results of the day-to-day
01:08:13 and the daily basis,
01:08:14 treated with WATCHMAN Flex.
01:08:16 Thank you so much.
01:08:17 - Dear Dr. Borjaska-Tardos,
01:08:20 congratulations to a very on-point presentation
01:08:22 for a very important topic.
01:08:24 And I can tell you from the slider
01:08:25 that there are a few questions
01:08:27 and I tried to discern them between
01:08:29 leakage related questions and DRT related questions.
01:08:33 And one of the first questions is,
01:08:34 and I know that from our clinical routine as well,
01:08:37 what do you think is the best way to identify leakage?
01:08:40 Is it CT or is it TOE?
01:08:43 Because we see that in TOE,
01:08:45 sometimes we see leakages that we don't see in CT
01:08:47 and vice versa.
01:08:48 So what's the best way to do that?
01:08:49 And if you detect them,
01:08:51 especially the smaller ones
01:08:52 between three and five millimeters
01:08:54 of a covered two questions,
01:08:55 what do you do in those patients?
01:08:57 - Yeah, I guess we are doing CT follow-up
01:09:00 because we have a very good availability of the CT.
01:09:04 And I have to say that there is more leaks
01:09:07 than the previous years we do the TOE follow-up.
01:09:12 I'm confident in this.
01:09:13 And the point is you have to be aware
01:09:16 that one to five millimeters leaks
01:09:18 are really not an issue.
01:09:20 I think that except in those cases
01:09:24 that have presented a stroke or TIA
01:09:28 on oral anticoagulation,
01:09:31 and you want to do a better treatment of the LA,
01:09:33 you can be more aggressive.
01:09:35 But in other cases, I leave them alone.
01:09:39 The only point is what to do.
01:09:41 Keep on doing the platelet treatment,
01:09:44 go and try an oral anticoagulation.
01:09:48 I mean, it depends on the size.
01:09:52 If you have a big leak,
01:09:55 we have close five, seven, six, seven cases of leaks
01:09:59 with ABP2 devices.
01:10:03 And the results are really good.
01:10:05 Although some of them could be really challenging to close.
01:10:10 But if you have less than five millimeters leak,
01:10:14 I leave it alone.
01:10:16 And probably if the patient can tolerate,
01:10:19 I keep on anticoagulants.
01:10:22 And do another CT six months after.
01:10:24 The results of the CT usually is the same.
01:10:28 You are not going to change.
01:10:29 And you should have to decide
01:10:30 if you keep the patient on oral anticoagulation
01:10:33 or only aspirin and see what happens.
01:10:35 - Very good.
01:10:37 Now switching to DRT to deviatorate,
01:10:39 it's run by a few questions on that topic.
01:10:41 And one question is,
01:10:43 is there a robust protocol or criteria,
01:10:45 or do you have a criteria or protocol in your center
01:10:48 to define DRT on CT?
01:10:51 - No.
01:10:52 No, the point they are trying to do,
01:10:54 we are doing our homework in this point.
01:10:57 So we are trying to guess if, you know,
01:11:00 measuring the Hounsfield units,
01:11:03 comparing to other tissues,
01:11:05 comparing to the venous phase of the CT scan,
01:11:09 trying to guess the real incidence of the DRT,
01:11:13 the device-related thrombosis,
01:11:15 in our experience is less than 10%.
01:11:18 Every series has less than 10%.
01:11:21 I should say that it's around five, six, 7%.
01:11:24 So every case is different,
01:11:27 but there are no images,
01:11:29 there are no conflicting images.
01:11:30 I haven't seen small flattened
01:11:33 that could suggest this is healing device.
01:11:37 Probably you have something about this.
01:11:39 Although, especially with WatchmanFlex,
01:11:43 CT can see some flattened surfaces,
01:11:45 see flattened weighting.
01:11:47 And it could imply that is endothelial disease.
01:11:50 Not sure about this,
01:11:52 but I think we are still learning
01:11:54 on the DRT diagnostics.
01:11:59 - Agreeing, completely agree.
01:12:01 So there's one very interesting question.
01:12:03 Is undersizing of the non-passive fire occluder
01:12:06 a potential risk factor for DRT,
01:12:09 due to the higher possibility to create a Kildesac
01:12:12 if you leave, I mean, if you implant it really deeply in?
01:12:16 - Yeah.
01:12:16 - I would say it depends on your indication,
01:12:19 but yeah, I think there is a clear answer.
01:12:21 - Could be.
01:12:22 - Yeah.
01:12:23 And there's maybe the last two questions,
01:12:26 we can summarize them.
01:12:28 So in patients where you detect the DRT,
01:12:31 what's your follow-up in those patients?
01:12:32 How often do you see them?
01:12:34 And what's your anticoagulant regime?
01:12:36 Do you, there's one question,
01:12:38 if you continue to give half dose,
01:12:40 no wax in those patients,
01:12:42 or would you continue to give DAPT for a longer time?
01:12:45 What's your procedure?
01:12:46 - Yeah, I think we have some data
01:12:48 from the Italian groups and also from the Adala study,
01:12:51 not only for preventing DRT, but also for treating DRT.
01:12:56 And I think that the results with half dose of XAVAN,
01:12:59 I mean, not for a prevention of strokes or embolism,
01:13:02 but only for preventing or treating DRT.
01:13:06 There are some data suggest that that is a good idea.
01:13:11 I mean, if the patient can tolerate full anticoagulation,
01:13:14 I think full anticoagulation is a good idea.
01:13:16 But if the patient cannot tolerate
01:13:18 full anticoagulation and indication is bleeding
01:13:20 or higher risk of bleeding,
01:13:23 I think 2.5, twice a week XAVAN is a good idea.
01:13:28 And probably, and we usually do,
01:13:30 depending on the size of DRT,
01:13:32 we do one, two months follow-up, CT follow-up,
01:13:37 or go up to three months and see what happens.
01:13:40 Usually all the cases we have had with the DRT
01:13:45 resolves after three months,
01:13:46 or at the worst, six months with the low dose NOAC.
01:13:51 - So aside from DRT, what's your protocol
01:13:55 and your center for the dapt after implantation?
01:13:58 Is it three months, four months, six months?
01:14:01 - We usually are doing the APT for three months
01:14:04 or until the patient bleeds.
01:14:05 That is common.
01:14:06 I mean, we usually do the APT and instruct the clinicians
01:14:12 to see if the patient begins to bleed,
01:14:16 just stop one of the antiplatelet, usually clopidogrel,
01:14:20 and keep on only aspirin.
01:14:22 Some patients are discharged only on aspirin,
01:14:26 bleeding, actively bleeding patient,
01:14:29 and a few cases of no DAPT at all.
01:14:33 You don't want to look what happens with these patients.
01:14:35 I mean, but we do, we usually do the three months CT,
01:14:40 and we haven't had a problem so far, cross fingers.
01:14:44 - Excellent, brilliant discussion.
01:14:47 Thank you so much once again.
01:14:48 And for the sake of time, I think we have to move on
01:14:50 and we're gonna jump over the Mediterranean Sea to Italy.
01:14:54 And it's my distinct pleasure to announce
01:14:56 Dr. Francesco Meucci, who will give us a lecture
01:14:59 about implant tricks to add device selection.
01:15:02 I think it's a very important topic
01:15:04 and we are really looking forward
01:15:05 to hear your talk on this.
01:15:07 (silence)
01:15:09 You're still muted.
01:15:14 - Thank you for the kind introduction
01:15:18 and for the invitation.
01:15:19 It's a pleasure to be here and I'm gonna share my slides.
01:15:24 So this is,
01:15:25 oh, I hope you can see my screen now.
01:15:31 If you see it, I go ahead.
01:15:37 Is that okay?
01:15:38 Can you see it?
01:15:41 - Yes, please, please move on.
01:15:43 - So my presentation will be basically on this topic,
01:15:47 the fusion imaging with the echo and the fluoroscopy together.
01:15:52 You can see in this slide,
01:15:55 the main argument is the superimposition
01:15:59 of the 2D images on the fluoroscopy.
01:16:02 This is the great advancement you can have
01:16:06 when you use a combination of these two techniques,
01:16:09 fluoroscopy and echo.
01:16:11 And the other thing you can have in your screen
01:16:16 together with the 2D superimposition are these nice points.
01:16:21 You can choose and pick them on the echo
01:16:23 and find them on the fluoroscopy.
01:16:25 And you will see in a moment when this could be useful.
01:16:29 So in this presentation, I will share with you some images
01:16:35 that I collected in my experience,
01:16:37 just to let you know what this technology
01:16:41 can add to your practice.
01:16:44 These are all points that we common do
01:16:47 when we close the appendages, nothing particular,
01:16:50 but you will see they can be augmented
01:16:55 in the comprehension and the velocity of doing
01:17:00 by the superimposition.
01:17:03 This is the transeptal puncture.
01:17:04 You can see it in the bicarbal view,
01:17:07 and you can see that in fluoroscopy,
01:17:08 you see very well together the sheet and the fossa.
01:17:13 You're not able to see the sheet already here in the echo,
01:17:18 but you see it in the fluoroscopy.
01:17:20 So you see them together and you see very well
01:17:22 the same thing once you do it.
01:17:25 And this is very well seen if you use it,
01:17:29 the green, sorry, the yellow coloration
01:17:33 on the fluoroscopy.
01:17:34 And if you stop here with your hands in this position,
01:17:38 then you rotate the arch in LAO,
01:17:42 and the previous one was LAO, so LAO this time,
01:17:46 and you ask your epicardiographer to change the projection
01:17:49 and see the appendage.
01:17:51 You see if you are in the right direction
01:17:55 towards the appendage.
01:17:56 So you can adjust the angulation of the puncture,
01:17:59 not only the height of the puncture,
01:18:01 in terms of a good trajectory towards the appendage.
01:18:06 And this is something that you can have only
01:18:08 if you have the navigator in place.
01:18:11 And the third point that you can have
01:18:13 when you do the procedure,
01:18:16 you can pick before the point that you want to puncture
01:18:21 in the fossa, let's say inferior and posterior.
01:18:25 And then as you can see in this example,
01:18:28 you go down in the common maneuver in the fossa,
01:18:33 and you try to land exactly where the green point is,
01:18:37 and then go ahead and puncture.
01:18:40 So these are points of the transeptal maneuver
01:18:43 that are made easier and quicker
01:18:46 if you have in place the navigator system.
01:18:50 Going ahead inside the procedure,
01:18:52 another point that is commonly done
01:18:55 with the, while we close the appendage,
01:19:00 is the movement of the sheet,
01:19:04 the malins sheet inside the left atrium.
01:19:07 As you can see in this example,
01:19:09 we are in the left atrium with the malins.
01:19:11 We want to go in the left upper pulmonary vein.
01:19:15 And if you see the appendage, if you see the marshal,
01:19:18 and if you see the septum with this nice point,
01:19:20 you can go back and rotate the sheet
01:19:24 without the fear of losing the left atrium
01:19:27 and without moving too much in the left atrium.
01:19:29 You can see it again.
01:19:31 We pull it back the sheet and rotate it towards the marshal,
01:19:36 put the wire out and gain the pulmonary vein.
01:19:41 And again, going ahead,
01:19:43 another maneuver that we commonly do
01:19:44 when we close the appendages is this one,
01:19:47 is to go back from once you have in place,
01:19:51 let's see here, the watchman sheet.
01:19:55 If we are in the left upper pulmonary vein,
01:19:59 we have to go down and land in the appendage.
01:20:02 So basically we go back and try to rotate.
01:20:05 And this is how we see it without the navigator system.
01:20:09 If I let you see the same maneuver
01:20:11 with the navigator in place,
01:20:12 you can appreciate that the maneuver of going back
01:20:16 and to choose the right direction towards the appendage
01:20:20 is made easier and more understandable and more precise
01:20:25 looking at the markers and looking at the appendage here.
01:20:29 Sorry.
01:20:31 Going ahead inside the procedure,
01:20:33 another nice point that you can have
01:20:36 using the navigator is this one.
01:20:38 If you want to do for some reason,
01:20:40 let's say a light approach to the appendage.
01:20:43 So entering the appendage with the ball
01:20:46 already done in the left atrium.
01:20:49 Let's say, because you have a thrombus distally
01:20:52 in the appendage or something like that,
01:20:54 you can do it with a navigator system in place.
01:20:56 You can see that we did the ball here.
01:21:00 You cannot see with the echo alone, the sheet.
01:21:03 Now you see the ball, but the sheet you cannot see.
01:21:05 So you can regulate your movements
01:21:08 to go not too deep in the appendage,
01:21:11 just because you see it.
01:21:13 You see the appendage, you see the bone,
01:21:15 that is you can move it.
01:21:16 You can move towards the appendage
01:21:18 in a safe and quick maneuver.
01:21:21 And going ahead, this is a still frame,
01:21:26 just to let you understand how the fusion imaging
01:21:29 can give you a precise idea of the measure axis
01:21:34 of the appendage together with the measure axis of the sheet.
01:21:38 So you understand in a second without thinking too much,
01:21:42 you see what you have to do with your release sheet
01:21:46 to go in the axis of the appendage.
01:21:48 And basically, this maneuver is very often
01:21:51 to rotate counterclockwise, but you understand why
01:21:56 and how much if you see the two axis together on the screen.
01:21:59 And this is a tricky appendage
01:22:04 because not long time ago with the Watchman Flex,
01:22:08 you can see the angio, the distal release of the ball.
01:22:13 And then you will see in a second,
01:22:16 the key imaging here and the superimposition.
01:22:22 And the release was done, but you will see in a second
01:22:25 that the device was opened with a triangular shape,
01:22:30 kind of funny shape here distal in this lobe
01:22:36 that was compressed in the most proximal part,
01:22:39 but was like this, was a triangle.
01:22:43 You will see here, with this drawing.
01:22:47 So this is just to share with you an image
01:22:50 that you can find when you use this device.
01:22:54 And this has to be taken in mind
01:22:56 because this is not a device
01:22:58 that could be released like that,
01:23:00 because the hooks are not very well engaged
01:23:03 in the appendage, you can have embolization.
01:23:06 And this is another case I did in the past,
01:23:09 not nothing to do with the navigator,
01:23:11 but just to share with you some nice examples.
01:23:16 You see that this triangular shape is importantly,
01:23:19 this is not the device that you can release as it is.
01:23:22 So what we did in the previous case,
01:23:24 we tried to change our position in this appendage.
01:23:28 And this is where Navigator became useful again,
01:23:32 because we captured this device
01:23:35 and we wanted to go here in this part.
01:23:37 I think you can see my mouse.
01:23:40 In this part of the appendage,
01:23:41 you will see in a moment that after having
01:23:44 captured the device,
01:23:46 if you see this part of the appendage,
01:23:48 you see the marshal,
01:23:49 then you can move your release sheet
01:23:54 in a very precise way towards this part of the appendage.
01:23:59 And I'm trying to do an implant
01:24:02 that was definitely more proximal than the previous one.
01:24:06 And you would see in a second that this direction
01:24:10 of implant was the good one with a nice deformation
01:24:14 of the device and the absence of an evident leak.
01:24:18 You see here, this nice fusion imaging
01:24:21 of the implanted device.
01:24:23 And this is the same case in the preoperative,
01:24:27 the final angiographic result, echo and angio.
01:24:32 But going ahead with the Navigator,
01:24:35 just the last example,
01:24:36 we did one case a few days ago.
01:24:39 This was not intended in use of the Navigator,
01:24:42 but as you can read here,
01:24:44 this was a patient with a liver transplant station
01:24:48 with a severe renal failure.
01:24:49 And we aimed to do a contrast-less LAO occlusion.
01:24:54 So you can see here,
01:24:56 we had some problem in reaching the right atrium
01:24:59 from the inferior vena cava for some reasons,
01:25:02 maybe because of the previous liver transplant.
01:25:05 So one fellow was not able to reach the right atrium.
01:25:10 Then the second one also did some maneuvers
01:25:13 and we lost some minutes trying to reach this appendage.
01:25:18 Sorry, this right atrium.
01:25:20 While you see here,
01:25:22 our colleague with the echo
01:25:24 was looking at the appendage by itself.
01:25:27 So we were trying to reach the right atrium
01:25:29 without success.
01:25:31 This was the last attempt done
01:25:34 with the multi-purpose catheter
01:25:39 trying to reach the right atrium in various way.
01:25:42 But at the end, we were not able.
01:25:44 What we did was just to ask to our colleague,
01:25:47 "Hey, please look at the bicaval view."
01:25:51 And once we saw where the inferior vena cava was,
01:25:55 was here, it was just one second maneuver.
01:26:00 You will see here in a moment.
01:26:01 And you see better in the next slide.
01:26:05 This is not very well seen,
01:26:07 but you can individuate the borders
01:26:12 of the inferior vena cava.
01:26:14 And what we did was just to point there
01:26:17 with the multi-purpose catheter
01:26:19 and then enter in the right atrium
01:26:21 and go in the superior vena cava in 20 seconds.
01:26:25 So this was not planned,
01:26:27 but once you have in place the navigator,
01:26:30 maybe you use it for some indication
01:26:34 that were not planned.
01:26:35 You see very well how we reached the superior vena cava.
01:26:38 So these are examples of various type
01:26:41 of the conclusion of the appendage.
01:26:44 That normally I use the navigator in these steps.
01:26:49 We published our experience
01:26:53 in the European Journal of Cardiovascular Imaging.
01:26:55 This step-by-step presentation,
01:26:57 you can find in our publication
01:26:59 with the nice images you have seen.
01:27:02 We published also some experiences
01:27:04 of a fully contrast-less echo navigator
01:27:07 guided the left atrial appendage occlusion.
01:27:10 For instance, in patients with severe chronic disease.
01:27:14 And we did an experience that is not yet published,
01:27:17 but we are going to submit with our last,
01:27:21 let's say 20 cases done with the navigator.
01:27:24 And they were matched with the previous 20.
01:27:28 The morphology of the appendages were quite similar.
01:27:31 And the main difference in the procedure
01:27:34 was not the procedural time of photo time,
01:27:36 but what the contrast medium we use it,
01:27:39 that was around half of the quantity
01:27:44 that we normally use,
01:27:45 where the user to administer to our patients.
01:27:50 So this difference is quite important.
01:27:54 Maybe this data is to be confirmed in bigger experiences,
01:27:59 but it's something that can interest you
01:28:01 if you are going to use this technology.
01:28:05 Thank you very much for the attention.
01:28:07 I'm here to answer for questions.
01:28:10 - Dr. Meucci, congratulations.
01:28:13 And thank you very much for a very excellent presentation.
01:28:16 Maybe one or two questions.
01:28:18 What would you say, I mean,
01:28:20 for people who are not used to use the echo navigator,
01:28:22 what would you say is the learning curve?
01:28:24 How many cases do you have to perform
01:28:26 to get acquainted with the technology
01:28:29 and to train your eye to, you know,
01:28:32 merge the echo views that you have
01:28:34 with the horoscopy views?
01:28:36 - Well, that's interesting because there is a learning curve
01:28:40 with the echo navigator system,
01:28:42 but this is not so steep.
01:28:44 The learning curve is for all the team.
01:28:47 You have seen the picture of my team
01:28:48 because this is a teamwork
01:28:50 because you have to work with the technicians
01:28:53 and the echocardiographer
01:28:54 that are committed to the navigator system.
01:28:56 Because if one people looks at one thing
01:28:59 and the other looks elsewhere, this doesn't work.
01:29:03 But if everybody has in mind what was the final goal,
01:29:07 then it works.
01:29:09 So you need some time to coordinate the orchestra,
01:29:13 but once the orchestra is playing together,
01:29:16 it works quite easily.
01:29:17 About the learning curve,
01:29:19 the other point is that once you have it in your catalog
01:29:23 and you have young fellows, young people
01:29:25 that have to, let's say,
01:29:27 to learn how to puncture the septum where the fossa is
01:29:31 and how much you have to go down and posterior and so on.
01:29:36 If they see on one screen together the images,
01:29:39 the difference for them is enormous.
01:29:42 I have seen with my eyes.
01:29:44 - Yeah, I mean, we learned a lot today
01:29:47 about different anatomies and obstacles
01:29:49 that we can encounter while the implantation procedure.
01:29:52 Do you think it's helpful in every case
01:29:54 or do you think there are special anatomies
01:29:56 like a dual lobe or let's say a very floppy septum
01:30:01 or something like that
01:30:02 where this technology might be very helpful
01:30:04 would you be happy to use it in every procedure?
01:30:06 - As I said, once you have it, you use it.
01:30:10 But if I have to say there are situations
01:30:13 where you are in the left atrium
01:30:15 and you manage to reach, let's say,
01:30:17 the appendage or the pulmonary vein
01:30:20 and you struggle and you lose time
01:30:22 and you don't see very well
01:30:23 and you ask the vapor cardiographer,
01:30:25 these are the situations where navigator comes very useful.
01:30:29 - Maybe a provocative question
01:30:32 because you have nicely shown
01:30:34 that you significantly reduce the amount of contrast medium
01:30:37 that you use coming from the EP perspective
01:30:41 and zero poroscopy is very, very important nowadays.
01:30:46 Do you see a future for that?
01:30:47 I know there are some Chinese centers
01:30:49 already doing this performances and zero poroscopy,
01:30:52 but do you see a chance for the echo navigator
01:30:55 to really reduce the poroscopy in those patients?
01:30:58 - Okay, very nice questions.
01:31:00 I think this is a point that in the future
01:31:02 will be very important, will be stressed by research.
01:31:07 But to be honest, if you don't have fluoroscopy,
01:31:10 you cannot merge anything.
01:31:12 So you use basically only echo.
01:31:15 So the question becomes,
01:31:18 can we do it only with the echo guidance?
01:31:22 And this maybe is more possible
01:31:27 if we follow your example.
01:31:30 I mean, the example of EP guys
01:31:32 where you are more than us
01:31:36 use it to work with the reconstruction of a CT scan
01:31:41 and then fluoroscopy.
01:31:43 Do you agree?
01:31:45 - Yeah, completely.
01:31:46 And I can tell you it's also a generation thing.
01:31:50 The younger ones were more used
01:31:52 with the D dimensional reconstructions
01:31:54 and topics and technical support like this
01:31:57 are more relying on these technologies
01:31:59 as opposed to, let's say my generation
01:32:02 who might've learned it more on the fluoroscopy basis
01:32:04 and rely a little bit more on fluoroscopy.
01:32:06 However, I think the trend is going to zero fluoroscopy
01:32:09 or to really reduce fluoroscopy,
01:32:11 which is I think of importance, not only for our patients,
01:32:13 but for us as well as physicians
01:32:16 to reduce our daily risk of radiation.
01:32:19 So I think these tools are very, very helpful
01:32:21 to help us to perform less radiation.
01:32:25 There are maybe two last questions from the slide.
01:32:29 And I think maybe it's a question for the whole panel.
01:32:32 All of you have shown different anatomy
01:32:34 than those giant LIAs.
01:32:36 Are there any alternative devices to close those LIA,
01:32:41 these giant LIAs?
01:32:43 That's a question from the audience.
01:32:44 - Yeah, yeah.
01:32:45 I have this point because I'm not authorized
01:32:49 to show the new iteration, the new device,
01:32:53 the future development of WatchmanFlex.
01:32:56 WatchmanFlex is going to make some improvements.
01:32:59 One of them is the 40 millimeters size.
01:33:03 So it can help in this giant LIA anatomies.
01:33:07 Also, and I think it's a pretty nice point,
01:33:10 try to fight against device-related thrombosis.
01:33:13 The coverage of the device
01:33:15 is going to other fluoropolymer.
01:33:17 That is a well-known substance
01:33:20 for interventional cardiologists
01:33:22 because our favorite coronary stents
01:33:26 and that's the have this polymer.
01:33:28 So the new, the future generation of WatchmanFlex,
01:33:33 WatchmanFlex Pro is going to have a 40 millimeter size
01:33:37 and also a more antithrombotic coverage, okay?
01:33:41 And there are some published data in recent journals.
01:33:48 - If I can add just a quick comment.
01:33:52 When we have very big appendages,
01:33:55 as in the example we have seen before,
01:34:01 we are attracted by the lob and disc devices
01:34:05 because they are bigger,
01:34:05 but we have to pay attention of the dimension of the disc
01:34:10 that could be dangerous and impinging,
01:34:13 especially for the mitral.
01:34:15 I have had a bad experience in one patient
01:34:17 who had a mitral prosthesis
01:34:19 and the device fitted well in a very big appendage,
01:34:22 but we had interference of the disc of this device
01:34:26 with the mitral valve, so we had to remove it.
01:34:30 - Yeah, I can completely agree with that point.
01:34:33 I think the disc is not always very helpful
01:34:36 and sometimes the less disc devices
01:34:38 are also very helpful to close those giant LIS as well.
01:34:41 You just have to put it in a little bit more deeper.
01:34:44 - Yes.
01:34:47 Are there any more questions from the panel?
01:34:50 I don't have any more questions from the audience.
01:34:52 Do you guys want to add something
01:34:53 that we haven't discussed yet?
01:34:55 If this is not the case,
01:34:57 then it's my distinct pleasure to, first of all,
01:35:00 summarize quickly what we have learned today.
01:35:02 I think Professor de Coy has nicely shown us
01:35:05 that the first step of transeptal puncture,
01:35:07 which might be easy, can be tricky as well.
01:35:09 And I think he has shown us a lot of tools
01:35:12 that we can use to facilitate this first very important step
01:35:15 because I think this is a very important step
01:35:17 because it lays the groundstone for your whole procedure.
01:35:20 If the transeptal puncture goes wrong,
01:35:22 then it can make the whole procedure quite difficult for you
01:35:24 and quite painful, to be honest.
01:35:26 So I think that's very important.
01:35:27 The VASA cross, I think, is a very elegant tool
01:35:30 to overcome a lot of obstacles.
01:35:32 I think Dr. de Prado,
01:35:33 Peres de Bral has nicely shown the importance
01:35:35 and we can tell from Slido,
01:35:37 there were a lot of questions on device-related thrombi
01:35:40 and leakage and the importance of both topics
01:35:42 and how to handle it.
01:35:43 And I think we will have in the foreseeable future
01:35:46 other tools also from this company
01:35:48 that might solve some of the problems that we see,
01:35:51 especially with inter-device leakages.
01:35:54 So this could be very helpful in the foreseeable future.
01:35:57 And last but not least, Dr. Miyuchi
01:35:59 has nicely shown us additional tools like the Echo Navigator
01:36:02 not only facilitating our procedure,
01:36:04 but really letting us learn to learn more about the anatomy
01:36:08 and to make the procedure hopefully not only safer,
01:36:11 but also safer for us in terms of contrast medium reduction,
01:36:14 in terms of fluoroscopy reduction,
01:36:17 and especially for, let's say, tricky anatomies,
01:36:20 this addition of Echo Navigation can be very helpful
01:36:24 to overcome obstacles that might hamper our procedure.
01:36:27 So having said that,
01:36:29 I want to thank Boston Scientific
01:36:31 for organizing this LIA Club.
01:36:33 I think it's a very helpful and very important webinar
01:36:38 which tackles questions that we all face
01:36:40 on our daily routine, daily basis practice.
01:36:43 And I think our discussion was very truthful,
01:36:45 hopefully also for the audience.
01:36:47 And I want to thank the audience
01:36:49 because they were very interactive
01:36:50 in putting out questions
01:36:51 and making the whole thing much more easier for us,
01:36:54 especially for me,
01:36:55 because I hadn't come up with a lot of questions.
01:36:57 You guys did a tremendous job.
01:36:59 And last but not least, a great shout out to the speakers.
01:37:03 I think all the presentations were very on point,
01:37:05 very excellent, very informative.
01:37:07 So thank you all.
01:37:09 It was a very pleasure to host this evening with you guys.
01:37:12 And yeah, without further ado,
01:37:14 I wish you all a very nice and hopefully calm evening
01:37:17 and hope to see you all soon.
01:37:19 Bye-bye.
01:37:20 - Thank you.
01:37:21 (upbeat music)
01:37:24 (upbeat music)
01:37:26 (upbeat music)
01:37:29 (upbeat music)
01:37:31 (upbeat music)
01:37:34 (upbeat music)
01:37:36 (upbeat music)
01:37:39 (upbeat music)
01:37:42 (upbeat music)
01:37:44 (upbeat music)
01:37:47 (upbeat music)
01:37:49 (upbeat music)
01:37:52 (upbeat music)
01:37:54 (upbeat music)
01:37:57 (upbeat music)
01:38:00 (upbeat music)
01:38:02 (upbeat music)
01:38:05 (upbeat music)
01:38:07 (upbeat music)
01:38:10 (upbeat music)
01:38:13 (upbeat music)
01:38:15 (upbeat music)
01:38:18 (upbeat music)
01:38:20 (upbeat music)
01:38:23 (upbeat music)
01:38:25 (upbeat music)
01:38:28 (upbeat music)
01:38:31 (upbeat music)
01:38:33 (upbeat music)
01:38:36 (upbeat music)
01:38:38 (upbeat music)
01:38:41 (upbeat music)
01:38:44 (upbeat music)
01:38:46 (upbeat music)
01:38:49 (upbeat music)
01:38:51 (upbeat music)
01:38:54 (upbeat music)
01:38:56 (upbeat music)
01:38:59 (upbeat music)
01:39:02 (upbeat music)
01:39:04 (upbeat music)
01:39:07 (upbeat music)
01:39:09 (upbeat music)
01:39:12 (upbeat music)
01:39:14 (upbeat music)
01:39:17 (upbeat music)
01:39:20 (upbeat music)
01:39:22 (upbeat music)
01:39:25 (upbeat music)
01:39:27 (upbeat music)
01:39:30 (upbeat music)
01:39:33 (upbeat music)
01:39:35 (upbeat music)
01:39:38 (upbeat music)
01:39:40 (upbeat music)
01:39:43 (upbeat music)
01:39:45 (upbeat music)
01:39:48 (upbeat music)
01:39:51 (upbeat music)
01:39:53 (upbeat music)
01:39:56 (upbeat music)
01:39:58 (upbeat music)
01:40:01 (upbeat music)
01:40:03 (upbeat music)
01:40:06 (upbeat music)
01:40:09 (upbeat music)
01:40:11 (upbeat music)
01:40:14 (upbeat music)
01:40:16 (upbeat music)
01:40:19 (upbeat music)
01:40:22 (upbeat music)
01:40:24 (upbeat music)
01:40:27 (upbeat music)
01:40:29 (upbeat music)
01:40:32 (upbeat music)
01:40:34 (upbeat music)
01:40:37 (upbeat music)
01:40:40 (upbeat music)
01:40:42 (upbeat music)
01:40:45 (upbeat music)
01:40:47 (upbeat music)
01:40:50 (upbeat music)
01:40:53 (upbeat music)
01:40:55 (upbeat music)
01:40:58 (upbeat music)
01:41:00 (upbeat music)
01:41:03 (upbeat music)
01:41:05 (upbeat music)
01:41:08 (upbeat music)
01:41:11 (upbeat music)
01:41:13 (upbeat music)
01:41:16 (upbeat music)
01:41:18 (upbeat music)
01:41:21 (upbeat music)
01:41:23 (upbeat music)
01:41:26 (upbeat music)
01:41:29 (upbeat music)
01:41:31 (upbeat music)
01:41:34 (upbeat music)
01:41:36 (upbeat music)
01:41:39 (upbeat music)
01:41:42 (upbeat music)
01:41:44 (upbeat music)
01:41:47 (upbeat music)
01:41:49 (upbeat music)
01:41:52 (upbeat music)
01:41:54 (upbeat music)
01:41:57 (upbeat music)
01:42:00 (upbeat music)
01:42:02 (upbeat music)
01:42:05 (upbeat music)
01:42:07 (upbeat music)
01:42:10 (upbeat music)
01:42:12 (upbeat music)
01:42:15 (upbeat music)
01:42:18 (upbeat music)
01:42:20 (upbeat music)
01:42:23 (upbeat music)
01:42:25 (upbeat music)
01:42:28 (upbeat music)
01:42:31 (upbeat music)
01:42:33 (upbeat music)
01:42:36 (upbeat music)
01:42:38 (upbeat music)
01:42:41 (upbeat music)
01:42:43 (upbeat music)
01:42:46 (upbeat music)
01:42:49 (upbeat music)
01:42:51 (upbeat music)
01:42:54 (upbeat music)
01:42:56 (upbeat music)
01:42:59 (upbeat music)
01:43:02 (upbeat music)
01:43:04 (upbeat music)
01:43:07 (upbeat music)
01:43:09 (upbeat music)
01:43:12 (upbeat music)
01:43:14 (upbeat music)
01:43:17 (upbeat music)
01:43:20 (upbeat music)
01:43:22 (upbeat music)
01:43:25 (upbeat music)
01:43:27 (upbeat music)
01:43:30 (upbeat music)
01:43:32 (upbeat music)
01:43:35 (upbeat music)
01:43:38 (upbeat music)
01:43:40 (upbeat music)
01:43:43 (upbeat music)
01:43:45 (upbeat music)
01:43:48 (upbeat music)
01:43:51 (upbeat music)
01:43:53 (upbeat music)
01:43:56 (upbeat music)
01:43:58 (upbeat music)
01:44:01 (upbeat music)
01:44:03 (upbeat music)
01:44:06 (upbeat music)
01:44:09 (upbeat music)
01:44:11 (upbeat music)
01:44:14 (upbeat music)
01:44:16 (upbeat music)
01:44:19 (upbeat music)
01:44:21 (upbeat music)
01:44:24 (upbeat music)
01:44:27 (upbeat music)
01:44:29 (upbeat music)
01:44:32 (upbeat music)
01:44:34 (upbeat music)
01:44:37 (upbeat music)
01:44:40 (upbeat music)
01:44:42 (upbeat music)
01:44:45 [BLANK_AUDIO]