Eric Lim

@Carissa12399g @mike_lean @danealson @_shannonmillard @AMatthews0 @Hapa_EP @javadm20 @Yogesh_EP @forkknifecab_EP @pjsm83 @ALFIEEP1 @hikmetyorgun @da_silvr @AbbottCardio I think that layering peak frequency as part of an emphasis map is helpful in appreciating the three dimensional nature of the circuit. For myself, I find it helps to determine the optimal ablation strategy.

Some post-case learning with @danealson (Dr. Neal Bhatia) and @_shannonmillard: following an ischemic VT case, together we compared how the clinical VT circuit presented when mapped with the First Deflection algorithm versus EnSite™ OT Near Field.   What we found brings up an interesting question. Is it better to…. - Force the system to visualize the full circuit with First Deflection, or - Illustrate the potential midmyocardial bridges and touchdown points with OT NF? While there may not be a "correct" answer, we think there is value in appreciating both pieces of information. And if nothing else, it makes for a fun discussion with talented colleagues like Dr. Bhatia and Shannon.

@JRgar10 @murphy_lzy Hope you recovered from the jet lag Dr Rodriguez! and had a safe flight home. It was good of you to make the long flight to come.

It was a pleasure for me to give some talks in MAP, Kuala Lumpur (Malasia). Thank you @ericlim1975 @murphy_lzy 🙌🙌

@MRazminia That's very reassuring!

I performed cryoballoon ablation for a decade using the same technique. During redo procedures, I almost always had to perform a de novo transseptal puncture. I recently did a redo PFA ablation, which was three months after the initial procedure and there was no trace of the prior transseptal puncture. So, I don’t think that would be a concern.

“Thawing the ICE”: Fluoroless Concomitant Pulmonary Vein Isolation (PVI) and Left Atrial Appendage (LAA) Closure.

@MRazminia Thanks. I guess you probably place ICE through the same TSP as the Faradrive? Although I have done this also, I do have concerns aboutiatrogenic ASDs when placing both a 10Fr ICE plus the Faradrive (ID 13Fr) together through the same puncture. Is this a concern for you?

@ericlim1975 For Watchman procedures alone, I place the ICE catheter via the right femoral vein. For concomitant procedures, I position it via the left femoral vein.

@MRazminia Do you do this through a single transseptal puncture site? If so do you worry about the size of the hole needed to accommodate both a Faradrive and ICE catheter?

Here is a narrated video clip demonstrating the use of ICE during an ablation procedure for atrial fibrillation using PFA. Please make sure you turn up your volume. @mrazminia.bsky.social

@EduardoSaad3 @Drdevignair @MRazminia @LuigiDiBiaseMD @natale_md @BidmcCvi @BIDMCVFellows @LAHRSonline1 Very nice images. Do you place the ICE in LA through the same or separate transseptal puncture as the Faradrive?

Fluoroless PFA for Pers AF #Farapulse. ICE in LA allows great precision, full visualization and contact assessment. 3D Maps allow additional visualization and lesion tagging. Game changers! @Drdevignair @MRazminia @LuigiDiBiaseMD @natale_md @BidmcCvi @BIDMCVFellows @LAHRSonline1 @SobracO @CarinaHardy4 @joselmerino @DrFerminGarcia @drluissaenz @nlcabanillas @vivasfhrs @josoriomd

@Hapa_EP @EPWaveDoc @naijaQRS @javadm20 @CarinaHardy4 @ECG_Emily @jeffrey_vinocur @Ed_Gerst @dkenigsberg @B_Naz_MD @PennEPFellows This seems like a nice case for PFA with Farapulse. Pretty easy and safe to do the PVI plus take out the posterior wall with just a few additional lesions.

@EPWaveDoc @naijaQRS @javadm20 @CarinaHardy4 @ECG_Emily @jeffrey_vinocur @Ed_Gerst @dkenigsberg @B_Naz_MD @ericlim1975 @PennEPFellows If we're going to do a line, it better be rock solid 🦾. I've seen prior focal ablation cause reentry around the rosette 🏵️ later. I have also seen lines that were purposely unanchored on one side causing a new flutter. "Damned if you do, damned if you don't." 😅

In a denovo PVI case, how often do you see an atypical flutter like this one? 🎡 Where would you burn? ⚡ #EPeeps

@chris_monkhouse @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip I did use a Tyrx. Wondering what I’ll find at his follow up.

@ericlim1975 @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip Really interesting, I don’t think there is any qrs or ef too bad for crt! I’d have done conventional. Purely for evidence and unsure the risks of having 4 leads. Patient would want to feel better and live longer- this ECG is beautiful and gives hope for this. Did you use a tyrx?

1/ I wonder what #Epeeps would do for a 62yo male patient with NICMP, LBBB QRSd >200ms, LVIDd 71mm, LVEF12%? Conventional CRT, LBB-CRT, LOT-CRT, too advanced for CRT? For CRT, any vendor preferences? @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse

@James_Elliott01 @finnakerstrom @enes_elvin @riley_guntrip @chris_monkhouse I agree LOT-CRT has a lot of added baggage and I’ve tended to avoid them after going through a stretch of time trying them. At the end of this case, my regret is that I did not test adequately the LBB-CRT configuration and kept to that. Perhaps others can learn from my mistake.

@ericlim1975 @finnakerstrom @enes_elvin @riley_guntrip @chris_monkhouse Amazing case and illustrations. LOT-CRT never worth the extra hardware in my opinion when CRTD. As I mentioned yesterday. If LBP is good then stick with DF4 IS1 device. If not, then would go to conventional CRT. For me LOT is overkill but you've got great pacing from either! 👏

@curilakarol @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse Retrospectively, I would have tested impact of optimizing AV delay after getting the LBB lead in, since LBBP-CRT with RBB fusion gave such a nice result (without CS lead). But like others in this thread, I was convinced I needed a LOT-CRT. Turned out I was wrong - lesson learned.

@ericlim1975 @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse Nice case with a thoughful approach. Seen backwards, it looks like that going for BVP in first step would save you a fair amount of time. :) Don't you think?

@JoelSimonEP @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse Hi, yes there’s a ICD lead but it’s a DF1 lead. Defib part is connected to DF1 port for shocking but the LBB lead is connected to the pace-sense port. So pacing occurs via the LBB lead and the RV defib lead can shock but can’t pace. Allows connection to a standard DF1 CRTD PG.

@ericlim1975 @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse I'm confused. You don't have ICD lead connected?

6/ Actually, with CSP lead only+RBB fusion, we got a QRS almost as good. Previous morphology slightly nicer I think but is this worth the complexity of a LOT-CRT cf. LBB-CRT? (Would be a no from me). Overall, I thought this was an interesting case worth sharing with #Epeeps.

5/ This was the final optimised result with both LBB and CS lead pacing, and after adjusting VV plus the AV delay (which Biotronik allows via the autoAdapt %). It does look very good, with a QRS of around 110ms. But what if I had only used a CSP lead (or CS lead)?

@pjsm83 @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse Thanks! How would you decide when it is good enough to stop and when would you keep going to the next step? Any preference for lead and/or vendor for such cases?

@enes_elvin @finnakerstrom @James_Elliott01 @riley_guntrip @chris_monkhouse Haha. Thanks. I did the case last week and found the result … surprising. Just curious what majority #Epeeps are doing as I struggle now with deciding between options for these types of cases. I’ll post the result over the next day or two.

@ericlim1975 @finnakerstrom @James_Elliott01 @riley_guntrip @chris_monkhouse I have a feeling that you will end up with LOT CRT😊. But MRI would be helpful here. All the best!