Jay Mathews MD, MS, FACC, FSCAI

@aribindi @TunaUstunkaya @drjohnm This is a video of a patient with prior Atriclip I saw today.

@aribindi @TunaUstunkaya @drjohnm I am not familiar with data looking at risk stratification by AF type, but would make sense. Perhaps why LAAC for postop AF may be beneficial, but more advanced types of AF benefit of LAAC may be more equivocal. I'm just a plumber... what do I know. 😂

> 600,000 left atrial appendage devices have been placed NOT NONINFERIOR 👇🏻 Trial is large, nonindustry funded and done in experienced centers in Germany Endpoint had both efficacy and safety components and still did not make non-inferiority I tried to tell you all

@aribindi @TunaUstunkaya @drjohnm In patients with significant electromech dysfunction from longstanding AF, that may not always be the case. Pts getting cardiac surgery with drive-by LAAC are a different population with their transient AF. If you have a huge akinetic LA and do clip, there's prob still risk.

@JayMathewsMD @TunaUstunkaya @drjohnm Last I checked, evidence suggested 90% of embolic strokes happen in LAA- exclude that with no intra-vascular foreign body to cause thrombus... you may make the benefit of anticoag a lot lower.

@TunaUstunkaya @aribindi @drjohnm A lot of thrombus in AF occurs outside the LAA.

@aribindi @drjohnm Oh yeah. No doubt that surgical LAAC is a helpful procedure however until ATLAAC results we cant really say stopping AC is safe - anectodally or not

@AmputationSuck @karananandpara @JChurches @SIRRFS @SriniTummala @_backtable @FadiSaab17 Hard to do without someone else holding the probe or unless you have the Asahi EVUS robot @AIU_Medical

@karananandpara @JChurches @SIRRFS @SriniTummala @JayMathewsMD @_backtable @FadiSaab17 et al made this a thing over a decade ago. Highly technical skill, but when executed…it’s efficient and effective 👊🏾👍🏾

“Patient wants to attempt endo first”. What’s your approach?

@JChurches @AmputationSuck @SIRRFS @SriniTummala @_backtable I agree. I tend to stay small. Even sheathless if just sending a wire. But if you want to do the case from the foot and the pedal artery is healthy... vaya con dios!

@JayMathewsMD @AmputationSuck @SIRRFS @SriniTummala @_backtable Rarely have the need to go larger than 5 Fr unless I’m deploying a supera at the SFA origin TBH. I’ll usually stick to the cook pedal access kit or a 4 Fr. A buddy of mine usually defaults to the 5 F which is overkill IMO

@JChurches @AmputationSuck @SIRRFS @SriniTummala @_backtable You'd probably need at least a 5/6 Slender if coming from the foot. 6/7 if you want to debulk potentially depending on the device.

@AmputationSuck @JayMathewsMD @SIRRFS @SriniTummala @_backtable Slender 5?

@JChurches @SIRRFS @SriniTummala @AmputationSuck @_backtable I'd still try from above and abandon the high reentry. You can propagate the flap even if you laser. Sometimes balloon short of the origin so you can do a CART. You'll clean up the flap with the SFA stent.

@JayMathewsMD @SIRRFS @SriniTummala @AmputationSuck @_backtable Retro wire jumped out exactly at the femoral bifurcation for a few millimeters (> 5). Would you laser through the flap or attempt something else?

@DrSiyabMD @DavidLBrownMD @AmputationSuck @BudoffMd @khurramn1 @RonBlankstein @rblument1 Whole separate conversation. But still trying to get more data funded.

@JayMathewsMD @DavidLBrownMD @AmputationSuck @BudoffMd @khurramn1 @RonBlankstein @rblument1 funny thing is people practice like it's already at least IIa. discrepancy between guidelines and real world practice

The 2026 ACC/AHA Dyslipidemia Guidelines now officially promote coronary artery calcium as a Level 1 class of recommendation - not once, but 6 times. The final step in the 36 year journey since Agatston published the first paper in 1990. @khurramn1 @RonBlankstein @rblument1

@DrSiyabMD @DavidLBrownMD @AmputationSuck @BudoffMd @khurramn1 @RonBlankstein @rblument1 Hell- I'd be happy with IIa, but we can't justify that.

@JayMathewsMD @DavidLBrownMD @AmputationSuck @BudoffMd @khurramn1 @RonBlankstein @rblument1 we need to make aspiration thrombectomy in STEMI a level 1 rec. if they can do it for CAC why can't we do it as well? (sarcasm obvs)

@DavidLBrownMD @AmputationSuck @BudoffMd @khurramn1 @RonBlankstein @rblument1 I sense a #BigCalcium conspiracy.

@JayMathewsMD @AmputationSuck @BudoffMd @khurramn1 @RonBlankstein @rblument1 Trump science- if you say something is true often enough, it becomes true

@DavidLBrownMD @AmputationSuck @BudoffMd @khurramn1 @RonBlankstein @rblument1 How does that get a Level 1 rec?

@BudoffMd @khurramn1 @RonBlankstein @rblument1 The power of zero (randomized trials)

@kmadass I've always wondered why people always talk about "going for the jugular" as if something really bad will happen. Hold some light pressure. Clot it off. No big deal. I'd be more concerned about lacerating the carotid.

Wish people wouldn't use terms they don't understand for impact "...is the Jugular Vein of the worlds lifeblood of energy" 🤦🏽‍♂️

@CMichaelGibson Identify causes of depression and normalize talking about it openly without judgement or punitive consequences. I went through a traumatic divorce and discovered many others with similar experiences/feelings, yet no one wants to talk about it openly. No reason to go it alone.

How can we lower the physician suicide rate?

@DrMarthaGulati @AmputationSuck @CMichaelGibson Agree... but still send pizza.

@CMichaelGibson Stop sending pizza to doctors in the name of wellness. Stop making wellness modules for physicians Stop MOC or repeat exams Change value assessment to quality of care over RVUs Ensure everyone gets 6 weeks of vacation and days off for weekend call

@Drakhil_cardio @DrRajeshG1 @iamritu @ESC_Journals @ACCinTouch @MDedgeCardio @UCSDCardFellows @uclaCVfellows @SinaiCards @UAMS_Cardio @CardiolUpdate I trained in the era of fluoro puncture, but with the advent of TEE and ICE- really have low risk of complications with transseptal crossing. Never do it without imaging, but do recognize that there is added cost that can be challenging in some countries.

#Sharing for learning What went wrong during septal puncture? How can it be avoided? We do not routinely use TEE. Should it help? Do you routinely use TEE or rely on fluoroscopic landmarks for transseptal puncture?

@TWilsonMD @realarainmd @farkomd @_backtable @DrRajeshG1 @KPujdak @cardiojaydoc02 @SripalBangalore @IR_Doctor You will have to coil several branches before a long covered stent and risk a lot of dead gut. I think send back out for another surgical opinion. Tough case!

@realarainmd @farkomd @_backtable @JayMathewsMD @DrRajeshG1 @KPujdak @cardiojaydoc02 @SripalBangalore @IR_Doctor Hard to see an option without risking an ischemic bowel for me. Agree w above.

@farkomd @_backtable @JayMathewsMD @DrRajeshG1 @KPujdak @realarainmd @cardiojaydoc02 @SripalBangalore @IR_Doctor 70M, h/o SMA aneurysm w surg repair x2 (2010/18) at tertiary care center. Back w ASx enlarging SMA aneurysm. Next step? Pt has not done well w/ Surgery. Endo option?

@DonGarbettMD @oelma__ Toilet books.

@oelma__ There was memorizing shampoo bottle ingredients, counting tiles, seeing patterns in the pine wood grain wall paneling, turning the toilet paper the other way, imagining your favorite song, setting long term goals, having eureka moments..

Before cell phones, what did people do on the toilet?

@ChengaziMD @TheRealDoctorOs @DrJayMohan @t_intheleadcoat @AustinBourgeois @kmadass @roblookstein @PERTConsortium @drochohan @DonGarbettMD @linemonkeymd @vikasaggarwalmd @Jonathan_PaulMD If you have forward facing IVUS you could see clot/residual clot burden. Would need to couple with CT overlay which Akura is working in with NavIQ. I already do these cases with 20-30 mL contrast. Each pulm angio is 5 ml (50/50 saline contrast mix) and puffing is 1-2 mL.

@JayMathewsMD @TheRealDoctorOs @DrJayMohan @t_intheleadcoat @AustinBourgeois @kmadass @roblookstein @PERTConsortium @drochohan @DonGarbettMD @linemonkeymd @vikasaggarwalmd @Jonathan_PaulMD I imagine a future where these cases are done with essentially no contrast…

In the spirit of chronic clot (@DrJayMohan) - just pulled out the largest chronic PE I’ve encountered. Tough situation w/ peds patient, malignancy and prolonged hospitalization with delayed diagnosis. PA angle also very difficult to deal with. Well compensated but symptomatic with chest pressure improving immediately. AC wasn’t going to touch this, guarded prognosis overall but I’d argue better out than in Controversial? What are your thoughts?