Antegrade approach – how to start? Views of a minimalist and a maximalist poi...Euro CTO Club
Room: Salon Schinkel
Antegrade approach – how to start? Views of a minimalist and a maximalist point of view combattants
David M. Leistner, Germany vs. Alexander Ghanem, Germany
The Experts “Live” Workshop 2017
Saturday, September 16th, 2017
There are two basic IVUS catheter designs: mechanical/rotational and solid state. The mechanical catheters (OptiCross IVUS catheter, Boston Scientific, Santa Clara, California; Revolution IVUS catheter, Volcano, Rancho Cordova, California; ViewIT IVUS catheter, Terumo, Tokyo, Japan; and Kodama HD IVUS catheter, ACIST Medical Systems, Eden Prairie, Minnesota) consist of a single transducer element located at the tip of a flexible drive cable housed in a protective sheath and operated by an external motor drive unit. The drive cable rotates the transducer around the circumference (1800rpm) and the transducer sends and receives the ultrasound signals at 1° increment to form the cross-sectional image. The imaging catheters operate at a central frequency of 40 MHz or 60 MHz and are 5F or 6F compatible [Figure 1]A. In the solid-state catheter design (Eagle Eye Catheter, Volcano), no rotating components are present. There are 64 transducer elements mounted circumferentially around the tip of the catheter. The transducer elements are sequentially activated with different time delays to produce an ultrasound beam that sweeps around the vessel circumference. The catheter works at a central frequency of 20 MHz and is 5F compatible
Antegrade approach – how to start? Views of a minimalist and a maximalist poi...Euro CTO Club
Room: Salon Schinkel
Antegrade approach – how to start? Views of a minimalist and a maximalist point of view combattants
David M. Leistner, Germany vs. Alexander Ghanem, Germany
The Experts “Live” Workshop 2017
Saturday, September 16th, 2017
There are two basic IVUS catheter designs: mechanical/rotational and solid state. The mechanical catheters (OptiCross IVUS catheter, Boston Scientific, Santa Clara, California; Revolution IVUS catheter, Volcano, Rancho Cordova, California; ViewIT IVUS catheter, Terumo, Tokyo, Japan; and Kodama HD IVUS catheter, ACIST Medical Systems, Eden Prairie, Minnesota) consist of a single transducer element located at the tip of a flexible drive cable housed in a protective sheath and operated by an external motor drive unit. The drive cable rotates the transducer around the circumference (1800rpm) and the transducer sends and receives the ultrasound signals at 1° increment to form the cross-sectional image. The imaging catheters operate at a central frequency of 40 MHz or 60 MHz and are 5F or 6F compatible [Figure 1]A. In the solid-state catheter design (Eagle Eye Catheter, Volcano), no rotating components are present. There are 64 transducer elements mounted circumferentially around the tip of the catheter. The transducer elements are sequentially activated with different time delays to produce an ultrasound beam that sweeps around the vessel circumference. The catheter works at a central frequency of 20 MHz and is 5F compatible
Electrical mapping of the heart is a medical procedure that is use to diagnose Arrhythmias in patients. This is done by using sensitive catheter to map the electrical activity in the chambers of the heart.
To begin an electrical mapping procedure, a thin tube called a catheter sheath is inserted into a small incision in the arm or upper thigh. This process is usually visualized using x-rays and a special dye that helps reveal the arteries (called angiography). This catheter is carefully guided through the blood vessels until it is inside the heart.
The title of the talk is emblematic of the binary way that we have approached structural heart disease where cardiac surgery or an interventional procedure might be required – this thinking is now transitioning to an entirely different paradigm which is that of the “Heart Team”.
Remarkable advances over the last decade have led to a plethora of interventional options for both coronary and structural heart disease. In the coronary realm, as complex and high risk PCI options continue to evolve, the role for surgery in multi-vessel disease, diabetes and LV dysfunction has become well established. Hybrid revascularization options also evolve and are the subject of ongoing investigation. In structural heart disease, as TAVR application expands to a low risk subset, ongoing investigations will answer questions regarding durability of TAVR as compared to the historical surgical gold standard. Mitral valve repair remains the gold standard for degenerative MR and the Mitraclip has become a well-established option for a high-risk subset. Ongoing studies will answer the role of Mitraclip in functional MR and excitingly multicenter studies are investigating a role for transcatheter mitral valve replacement for mitral valve disease. The role of surgery in tricuspid valve disease, a large and underserved subset remains controversial and transcatheter devices remain investigational at this point. The reality is that decision-making is complex and central to the entire debate is the heart team concept, whereby surgeons and interventionalists sit at the same table as part of the same team to determine the best approach for any given patient. As evidence continues to evolve, lines between cardiac surgery and interventional cardiology continue to blur, with combined expertise from both sides going forward required to best serve our patients in a truly heart team approach.
Intracoronary Imaging – when to use, how to use and how to interpret the imagesEuro CTO Club
Intracoronary Imaging – when to use, how to use and how to
interpret the images
Javier Escaned, Spain
The Experts “Live” Workshop 2017
Saturday, September 16th, 2017
Invasive coronary physiology to select patients for coronary revascularisation has become established in contemporary guidelines for the management of stable coronary artery disease. Compared to revascularisation based on angiography alone, the use of coronary physiology has been shown to improve clinical outcomes and cost efficiency. However, recent data from randomised controlled trials have cast doubt upon
the value of ischaemia testing to select patients for revascularisation. Importantly, 20-40% of patients have
persistence or recurrence of angina after angiographically successful percutaneous coronary intervention
(PCI). This state-of-the-art review is focused on the transitioning role of invasive coronary physiology from
its use as a dichotomous test for ischaemia with fixed cut-points, towards its utility for real-time guidance of PCI to optimise physiological results. We summarise the contemporary evidence base for ischaemia testing
in stable coronary artery disease, examine emerging indices which allow advanced physiological guidance
of PCI, and discuss the rationale and evidence base for post-PCI physiological assessments to assess the success of revascularisation.
Electrical mapping of the heart is a medical procedure that is use to diagnose Arrhythmias in patients. This is done by using sensitive catheter to map the electrical activity in the chambers of the heart.
To begin an electrical mapping procedure, a thin tube called a catheter sheath is inserted into a small incision in the arm or upper thigh. This process is usually visualized using x-rays and a special dye that helps reveal the arteries (called angiography). This catheter is carefully guided through the blood vessels until it is inside the heart.
The title of the talk is emblematic of the binary way that we have approached structural heart disease where cardiac surgery or an interventional procedure might be required – this thinking is now transitioning to an entirely different paradigm which is that of the “Heart Team”.
Remarkable advances over the last decade have led to a plethora of interventional options for both coronary and structural heart disease. In the coronary realm, as complex and high risk PCI options continue to evolve, the role for surgery in multi-vessel disease, diabetes and LV dysfunction has become well established. Hybrid revascularization options also evolve and are the subject of ongoing investigation. In structural heart disease, as TAVR application expands to a low risk subset, ongoing investigations will answer questions regarding durability of TAVR as compared to the historical surgical gold standard. Mitral valve repair remains the gold standard for degenerative MR and the Mitraclip has become a well-established option for a high-risk subset. Ongoing studies will answer the role of Mitraclip in functional MR and excitingly multicenter studies are investigating a role for transcatheter mitral valve replacement for mitral valve disease. The role of surgery in tricuspid valve disease, a large and underserved subset remains controversial and transcatheter devices remain investigational at this point. The reality is that decision-making is complex and central to the entire debate is the heart team concept, whereby surgeons and interventionalists sit at the same table as part of the same team to determine the best approach for any given patient. As evidence continues to evolve, lines between cardiac surgery and interventional cardiology continue to blur, with combined expertise from both sides going forward required to best serve our patients in a truly heart team approach.
Intracoronary Imaging – when to use, how to use and how to interpret the imagesEuro CTO Club
Intracoronary Imaging – when to use, how to use and how to
interpret the images
Javier Escaned, Spain
The Experts “Live” Workshop 2017
Saturday, September 16th, 2017
Invasive coronary physiology to select patients for coronary revascularisation has become established in contemporary guidelines for the management of stable coronary artery disease. Compared to revascularisation based on angiography alone, the use of coronary physiology has been shown to improve clinical outcomes and cost efficiency. However, recent data from randomised controlled trials have cast doubt upon
the value of ischaemia testing to select patients for revascularisation. Importantly, 20-40% of patients have
persistence or recurrence of angina after angiographically successful percutaneous coronary intervention
(PCI). This state-of-the-art review is focused on the transitioning role of invasive coronary physiology from
its use as a dichotomous test for ischaemia with fixed cut-points, towards its utility for real-time guidance of PCI to optimise physiological results. We summarise the contemporary evidence base for ischaemia testing
in stable coronary artery disease, examine emerging indices which allow advanced physiological guidance
of PCI, and discuss the rationale and evidence base for post-PCI physiological assessments to assess the success of revascularisation.
Idiopathic VT refers to VT occurring in structurally normal hearts in the absence of myocardial scarring. Classification of monomorphic idiopathic VT includes outflow tract VT, fascicular VT, papillary muscle VT,annular VT, and miscellaneous (VT from the body of the RV and crux of
the heart). It is commonly seen in young patients and usually has a benign course. The 12-lead lectrocardiogram is critical in distinguishing the specific form and locations of idiopathic VT. Treatment options include medical therapy specific to the underlying mechanism of VT or catheter
ablation.
Today, in addition to measurement of left ventricular ejection fraction, the simple 12-lead surface ECG remains the only evidence-based means of identifying patients who may obtain the substantial benefits of CRT
EVOLUTION IN CARDIAC RESYNCHRONIZATION THERAPY
Moving towards Leadless pacing mainly in cases with difficult coronary sinus anatomy, where placing the LV lead is difficult.
Transradial coil embolization of coronary artery fistulas (CAF) and left internal mammary artery (LIMA) side branches from radial approach. A case series - Zoltan Ruzsa
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
How to Give Better Lectures: Some Tips for Doctors
2007 venezia, congresso mondiale, ablazione delle tachicardie ventricolari
1. Stefano Nardi MD, PhD
““SANTA MARIA” GENERAL HOSPITAL - TERNISANTA MARIA” GENERAL HOSPITAL - TERNI
THORACIC SURGERY ANDTHORACIC SURGERY AND
CARDIOVASCULAR DEPARTEMENT ARRHYTHMIA ELECTROPHYSIOLOGCARDIOVASCULAR DEPARTEMENT ARRHYTHMIA ELECTROPHYSIOLOG
CENTER AND CARDIAC PACING UNITCENTER AND CARDIAC PACING UNIT
Venice Arrhythmias ‘07Venice Arrhythmias ‘07
Mapping and Ablation ofMapping and Ablation of
late post-ischemiclate post-ischemic
sustained Ventricularsustained Ventricular
Tachycardias, guided byTachycardias, guided by
EnSite System.EnSite System.
3. Methodology
• Identification of protected isthmuses of
conducting tissue related to slow conduction zone
• electrically (entrainment with concealed fusion)
• anatomically (computer-assisted,3D-mapping)
RF lesion bridges between constraining barriers
Interventional Therapy
Post-ischemic sustained VTsPost-ischemic sustained VTs
4. How can we approach ?How can we approach ?
MappingMapping
• Point by pointPoint by point
• EPEP
criteriacriteria
TrackingTracking
• XrayXray
• CARTOCARTO
• LocaLisaLocaLisa
• NavXNavX
• RPMRPM
• ICEICE
AblationAblation
• ConventionalConventional
• 8 mm tip8 mm tip
• Irrigated tipIrrigated tip
• InvestigationalInvestigational
(balloon, cryo...)(balloon, cryo...)- Framework for ablationFramework for ablation
- Mapping guidanceMapping guidance
- Anatomic localizationAnatomic localization
- Tagging of ablation sites- Tagging of ablation sites
- DetermineDetermine
catheter contactcatheter contact
- ImprovedImproved
efficiency ofefficiency of
power deliverypower delivery
Post-ischemic sustained VTsPost-ischemic sustained VTs
5. EP drawbacks
• High complex SUBSTRATE
• Non-uniform distribution of MYOCARDIAL SCAR
• Imprecise fluoro guidance in ISCHEMIC BORDER ZONE
• Imprecise creation of contiguous lesions
Post-ischemic sustained VTsPost-ischemic sustained VTs
6. Clinical Carachteristic
Nr pts : 24 (48%)
Age: 63,79 ± 7,84 yrs
Sex (M/F): 16/8
LVEF: 30,41 % ± 4,48
Nº ep/mo: 1,92 ± 0,79
NYHA II-III class
Post Ischemic sustained VTsPost Ischemic sustained VTs
76 pts with ICD implant
SVTs despite 2/3 AADs
50/76 pts eligible
From 04/04 to 10/06
7. - CREATE a virtual geometry of LV chamber
- IDENTIFY the target zone of each SVT
(low-voltage zone, diastolic potentials, scar)
- DESCRIBING the EA and EP characteristics of the
substrate
- EVALUATE the efficacy of RF lesions at the
identified critical isthmus
- DEMONSTRATE with post-RF EP study the non-
inducibility of SVTs.
operative end pointsoperative end points
Post-ischemic sustained VTsPost-ischemic sustained VTs
10. RFCA consisted in a series of contiguous CTR RF guided by EA
activation map and EP criteria of atrial potentials
Post Ischemic sustained VTsPost Ischemic sustained VTs
11.
12. • Procedure (min): 148±26 144±24 151± 29
Global SR VT
• Fluoroscopy (min): 59±17 58±16 66±19
• Mapping (min): 35±8 33±9 38±4
• Pulses of RF: 34±16 28±17 41±19
Post Ischemic sustained VTsPost Ischemic sustained VTs
Results
13. Procedure (min): 148±26
Fluoroscopy (min): 59±17
Mapping (min):
35±8 Nr. Pulses
of RF: 37±16
24/27 SVTs operative mechanism (88%)
Acute EfficacyAcute Efficacy
24/27 SVTs (85%)24/27 SVTs (85%)
InefficacyInefficacy
4/27 SVTs (15%)4/27 SVTs (15%)
Post Ischemic sustained VTsPost Ischemic sustained VTs
Results
After mean FU of 13,4±6,7 18/20 pts free SVTs
16. Post Surgical AT MechanismsPost Surgical AT Mechanisms
• Complex anatomical model
• Multiplicity of simultaneously ongoing
wavefronts
• Short CL (<225ms)
• Variation of AT
• Haemodynamic instability
InefficacyInefficacy
4/27 SVTs4/27 SVTs
(15%)(15%)
18. Conclusions (1)Conclusions (1)
• Conventional EP mapping
it’s not always appropriate
strategies for SVTs
ablation because it
provides very limited
understanding of these
complex arrhythmias which
are highly variable from
one pt to the other.
• The main drawback of a pure
EP approach is that the
identification of all putative
“endpoint” could be extremely
difficult to achieve.
19. Post-ischemic sustained VTsPost-ischemic sustained VTs
• The implemented use of
virtual geometry and a
combined approach of EP
with EA criteria is able
to allow us a realistic
3D reconstruction of LV
• An individually tailored
approach is needed
• A combined approach may
be useful in the treatment
of pts where RFCA is
primarily both EP and EA
based.
20. What is success?
• Complete freedom of VF, off drug RX?
• No symptoms, but drug Rx required?
• Dramatic decrease in symptoms, but AADs
still required?
• QoL
• How do we detect asymptomatic episodes?
• Anticoagulation ………………...?
QUESTIONSQUESTIONS
23. - Related to the slow conduction
regions located in the MI region
or at the border zone
Post-ischemic sustained VTsPost-ischemic sustained VTs
- Macro-reentry is the most
frequent mechanism
- Larger is the area of tissue
infarted larger is the
probability of potential
reentrant circuits
How does it work?
Editor's Notes
(SLIDE 1) The continuous development of more efficacy and effective applicable percutaneous strategies for treating or, in some ambitious instances, curing with catheter ablation (CA) the human atrial fibrillation (AF) has followed a complex path over the last past ten years, throughout different technique have been proposed and applied. Actually, more than 5,200 patients each year undergo CA of AF, and this number continuing to grow-up over the time.
(SLIDE 5) At this purpose nowadays, novel and different technologies for mapping, tracking and ablation are available for approaching AF and in this view the technologic progress continuous to evolving over the time.
(SLIDE 6) Currently, there are two mains and very different ablation strategies, all of them with the aiming primary purpose to eliminate the arrhythmogenic activity around the PVs ostia. (1) The first, named cirumferential left atrial ablation (CLAA) with the primary objective to create of an “encircling” line around at the LA antrum with or without the addition of further LA linear lesions, according with the outcome of the initial procedure and with the underlying atrial substrate. (2) Another and always more prevalent strategy that have emerged, aiming at segmental ostial catheter ablation (SOCA), with primary “end-point” of eliminate the focal triggers of AF, with disconnect all PVs from the adjacent LA tissue using a circular mapping steerable catheter placed under fluoroscopic guidance at the putative LA-PV antrum.
Selection of the appropriate pacing mode to fit the patient’s electrical and haemodynamic status is usually not difficult. Striving to provide both AV synchrony and rate modulation, whenever possible, assists in the decision-making process. Mode selection dicisions related to electrical considerations take into account three principle issues. These are atrial rhythm status, status of AV conduction, and the presence of chronotropic competence. A mode selection flow chart is shown above.
This recording was taken during the patient’s EP study.
(SLIDE 33)
Selection of the appropriate pacing mode to fit the patient’s electrical and haemodynamic status is usually not difficult. Striving to provide both AV synchrony and rate modulation, whenever possible, assists in the decision-making process. Mode selection dicisions related to electrical considerations take into account three principle issues. These are atrial rhythm status, status of AV conduction, and the presence of chronotropic competence. A mode selection flow chart is shown above.
(SLIDE 35)
(SLIDE 6) Currently, there are two mains and very different ablation strategies, all of them with the aiming primary purpose to eliminate the arrhythmogenic activity around the PVs ostia. (1) The first, named cirumferential left atrial ablation (CLAA) with the primary objective to create of an “encircling” line around at the LA antrum with or without the addition of further LA linear lesions, according with the outcome of the initial procedure and with the underlying atrial substrate. (2) Another and always more prevalent strategy that have emerged, aiming at segmental ostial catheter ablation (SOCA), with primary “end-point” of eliminate the focal triggers of AF, with disconnect all PVs from the adjacent LA tissue using a circular mapping steerable catheter placed under fluoroscopic guidance at the putative LA-PV antrum.
Selection of the appropriate pacing mode to fit the patient’s electrical and haemodynamic status is usually not difficult. Striving to provide both AV synchrony and rate modulation, whenever possible, assists in the decision-making process. Mode selection dicisions related to electrical considerations take into account three principle issues. These are atrial rhythm status, status of AV conduction, and the presence of chronotropic competence. A mode selection flow chart is shown above.
Selection of the appropriate pacing mode to fit the patient’s electrical and haemodynamic status is usually not difficult. Striving to provide both AV synchrony and rate modulation, whenever possible, assists in the decision-making process. Mode selection dicisions related to electrical considerations take into account three principle issues. These are atrial rhythm status, status of AV conduction, and the presence of chronotropic competence. A mode selection flow chart is shown above.