Paul Chacko

Be not afraid of life. Believe that life is worth living, and your belief will help create the fact. - William James

@EJSMD @drjohnm verify open payments openpaymentsdata.cms.gov/search if there is funding >$5000, i see COI written all over. if a physician believes a product is good, advocate without having someone to pay you for advertisement.

@drjohnm If the goal is to advance as a distinguished clinician, shouldn’t be a problem. If the plan is to be an innovator, few pathways divorced from industry in a technical field like EP. Industry partnership can be done right. Embrace the good.

I wish career advancement and mastery of clinical skills did not require having industry #coi <- that’s the post

@hrs_journal @MGhannamMD someone explain why there is more thromboembolic events in WATCHMAN grp. how many had gaps will be a good question.

Clinical Outcomes of Patients Referred for Left Atrial Appendage Exclusion Who Did and Did Not Undergo the Procedure @MGhannamMD heartrhythmjournal.com/article/S1547-…

The MOC Monopoly Wins Another Round practicingphysician.org/the-moc-monopo… Nevertheless, it up to us as physicians to advocate with local credentialing committee to accept alternate agencies.. we as physician can make a difference.

@doctorwes @Drdevignair as in most technologies rushing to market, the motto is “get to the market, ask questions later”.. same as in residual leak in WATCHMAN.. until version 2.0 came out. I hope those who are involved in trials ask the right questions for the sake of patients and not industry.

@Drdevignair Had a similar left atrium post-MAZE. No EGMs in nearly all the atrium. And let’s just say: LOTS of smoke. Methinks we need to be careful with PFA.

Newest Ensite software - helps plan your lesion set with #PFA catheter visualization! Works for lesion sets with PV and beyond PV such as posterior wall isolation. #ICE for contact assessment and mapping for lesion overlap - continuing the #ZeroFluro journey with #PFA continues. @AbbottCardio @bostonsci @StBernards #ArrhythmiaResearchGroup #epeeps @Medinbox

@AveragingBogey But then again, ICE can also miss depending on the U/S slice.. Use all tools to get the results. I had cases where I had t ablate beyond what I drew. Relying on all info is the key. ICE/Map and Contact force and ablate all way till falling into IVC. CARTO helps show the U/S slice

@AveragingBogey My approach to flutter: 1. Draw the ICE line (CARTO only) which helps anticipate pouch and EV. 2. Post abln, check BiD block. If neg, then pace and see earlier site (as u did). In most cases, there is something we may have missed like a crypt/pouch. 3. high - low actv with CSp

Challenging CTI line, no block in spite of substantial effort. Pacing proxCS (star) gives this activation map from LAO caudal view. Red early,purple late. Where to target next? Answer ultimately in replies

@Ed_Gerst why would it surprise us.. if we can preserve esophageal issues but avoiding collateral damage, then epicardial ganglion likely be spared as it is not deep enough injury and also apoptosis related mechanism for pfa

PFA leads to less autonomic denervation than either Cryo or RF. Maybe patients with bradycardia/pauses should still undergo RFA? DOI:10.1016/j.jacep.2024.05.005. #JACCCEP

@DrBradleyKnight no access yet..

IF you now have access to PFA (FARAPULSE or PulseSelect) in your EP lab, for what % of first-time AF ablations do you use PFA?

@drjohnm @EJSMD the only reason for that is that $$$ have been paid by industry for that sole purpose. now the physician is obliged to do just that. Amazed that some physicians have amassed millions for this purpose.. sharing knowledge is one thing but now it’s all advertisement

@EJSMD The paper goes over that nicely. There I think consent might be a little less problematic b/c a peer reviewed case is a lot different from a cake picture w shiny-happy reps and an industry logo.

Good to give the issue of patient privacy attention. The writers l, I think, give too much value to consent for social media sharing. The dr-pt relationship is asymmetric, so a pt will likely feel pressure to allow sharing when asked by their doc. Good discussion in the paper on case reports and meeting presentations

@narrowQRS BSC has a bigger volume of battery compared to others.. that will account for this.

How much do your patients value ICD battery longevity? Sooner gen change anyone? 🤔

@DFCapodanno most cases there is payment from industry for this..

Increasingly, social media features photos of interventional cardiology groups proudly showcasing a procedure performed for the first time in a specific hospital. These photos celebrate the results of hard team work and show rightfully proud faces, often including not only doctors but also nurses, fellows, and anyone else present that day. The photo often also shows the bulky packaging of the device used, capturing the event and displaying the brand. I do not want to express a judgment of absolution or blame, but I wonder what my followers think. Is it a rightful celebration of hard work, or free advertising for the device industry? Poll.

@LogarithmicDis @doctorwes @ABIMcert don’t disagree with u.. just giving a perspective of what’s going on. @doctorwes has been a voice for change..

@drpchacko @doctorwes @ABIMcert We’re entering a circular argument. My point is that whining online publicly as an MD is unbecoming and a bit tone deaf to patients (whose costs of care are much greater) and hospital staff, who also share prof certs they must upkeep. You want to whine, be my guest.

Sucks that I have to use my vacation time to rectify my prematurely cancelled Cardiac EP cert. I don’t appreciate being bullied by @ABIMcert to pay more fees before I can do MOC things to restore my cert status. Here’s the letter I sent them after paying my fees last night.

@LogarithmicDis @doctorwes @ABIMcert everyone is human.. frustration builds up. its like having a bank account and a card and suddenly the bank says, u need to pay a surcharge fee every time u want to access ur account. everyone here has paid their dues but ABIM keeps making new changes which halts a physician.

@drpchacko @doctorwes @ABIMcert Change is needed. All I’m saying is effect the necessary change through leadership qualities and be a part of the solution. This constant whining online isn’t becoming a physician.

@LogarithmicDis @doctorwes @ABIMcert have the courage to stand up and change from within hospital credential committee. ABIM has no control on this but physician themselves. there is no excuse to inertia within physicians to change how medical credential committee behaves.

@doctorwes @ABIMcert If I knew my cardiac EP doc spent his time whining on social media about paying nominal fees to maintain his or her certification, I’d pick a different doctor. Ditto sentiment for the staff putting in long hours working alongside him or her.

@syamkumarmd @Hapa_EP @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP why would pac repeatedly induce and also able to terminate tachy.. more fitting with reentry

@Hapa_EP @drpchacko @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP True. these features make me think this could be a PV tach than flutter?

Strange biatrial figure-of-8 flutter going through a leak in the old right WACA and jumping epicardially from RSPV to posterior RA via an intercaval bundle connection. Where would you burn first ❤️‍🔥? #EPeeps @jacabreracardio @DrFerminGarcia @drluissaenz @DrRoderickTung @GkhanAksan

@Hapa_EP @syamkumarmd @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP deconstructing this: if u think the mechanism is reentry, the site u burned had to be part.. but then ur circumferential lesion should have worked..but ur q is is there a rspv-ra tract.. i am trying to see the circuit that includes rspv despite waca unless ur waca is not intact

@syamkumarmd @drpchacko @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP 10 mA and 2 msec. We only tried at that output. Since flutter was able to be induced until those last 2 burns within the vein and we had no exit afterwards, I wonder if the circuit both entered and exited from that same general spot?

@Hapa_EP @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @syamkumarmd @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP prior to entrance block, any evidence of exit block?. also was the rspv signal FF/svc?.. just curious to know..

@drpchacko @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @syamkumarmd @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP After we got entrance block, we paced all around the inside of the vein with no capture of the atrium.

@Hapa_EP @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @syamkumarmd @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP did u have exit block when performing perivenous pacing?.

@drpchacko @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @syamkumarmd @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP What was interesting though was the complete lack of inducibility only after we finally achieved RSPV isolation. I cannot explain it from the way the map looks, but somehow the vein was involved in the circuit.

@Hapa_EP @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @syamkumarmd @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP i see the RSPV is passively activated. the activation seems to breakout from septum and the. activates the LA and then slowly through leak to RSPV. the ease of inducibility and termination with PAC is more supportive of reentry, either microreentry or macro.

By popular demand, here's anterior view alongside the original. LAT, Voltage, and entrainment info up next! @javadm20 @CarinaHardy4 @EPWaveDoc @drluissaenz @sumitvermaep @syamkumarmd @finnakerstrom @DFahadAlmehmadi @fvassallomd @AsfDanon @Mohamed81307853 @cclang @SchakrabartiEP