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Md Form 1 For 1919 Demand Assistance

good morning good morning grab your food.grab the coffee we will begin as usual.Medical time about five minutes after.the hour so a couple of housekeeping.issues we get asked to do so.surveys you'll get a survey about this.and every round.please remember to do that it helps.maintain our CME accreditation ability.this will be videotaped and live.streamed on Facebook and and the like so.remember when we get to questions please.do use the mic so you will show up on.the audio we do want your feedback on.this course in every other course helps.with the ABIM MOC credits and if you.haven't already registered for that you.can certainly get that for this.conference and all the others and then.lastly don't forget about pumps of pipes.on December 3rd please join for that.alright so it's my pleasure to introduce.dr. Muhammad's Eric I've known though.for many years he is the director of the.echo lab and a non-invasive imaging at.NYU he's really very well-known.nationally international for structural.heart imaging a particular 3d echo and.3d echo guidance of a lot of structural.heart procedures really all of them.mitral clips.Elya watchman's taverns TM be ours and.in fact he was involved and led the.imaging for the first T and V are trans.septal tmb are done in the country I.think done in the world maybe 2016 so.Mohammed's got a fascinating ability to.infuse history into the topic and I've.seen him talk about I don't know public.25 different topics so he talks about.everything he talks about but it's.always a neat take on the history of the.topic as well so without further ado.please welcome dr. Sarah thank you so.much.I grew up in Sarajevo in Bosnia former.Yugoslavia and I remember as a child.reading about the baekje and all the.things that he did then to be here one.day and presented his institution is.just absolutely beyond imagination so.thank you very much for inviting me so.let me share some imaging in for.percutaneous and surgical occlusion of.left atrial appendage and so these will.be my disclosures for this presentation.and so let me just give you an overview.of the presentation so first I will.provide you with a little bit of atrial.fibrillation history as Steve said I.like a little bit of history then we'll.talk about early surgical experience in.closing left atrial appendage and why.that did or did not work and then BALCO.presentation will be at about.percutaneous left atrial appendage.closure and if there is some time I'll.show you the new advances in surgical.closure of the left atrial appendage so.let me just start with a little bit of.atrial fibrillation history and anybody.who I ever I did some research and the.first person who has ever mentioned.something that we might consider atrial.fibrillation is this gentleman Jean Pope.is the cynic he was a French physician.in the 18th century and he published.this book this is a treatise on the.structure of the heart it's action and.it's maladies huh doctor and if my.reading of the Roman script is here it's.a 1749 and I was lucky something you.know interesting but it was not just a.physician you know like if you read this.he says he's a physician consultant to.the king and that King was the Louis the.15th then it's a big guy it's really.like that luckily he died before the.French Revolution so his head was not.chopped off huh it was his son's head.Alou at the 16th so what did cynics say.so he's in this book and he says that he.postulated first rheumatic mitral.stenosis is severe was very common.disorder and he noticed that patients.with advanced traumatic mitral stenosis.had rebellious palpitations or delirium.cordis and he couldn't call it atrial.fibrillation because there was not the.term atrial fibrillation yes invented.and the first person actually to first.record what we call now atrial.fibrillation is William.Eindhoven himself he as you know he.invented EKGs and this is his paper I.mean he was Dutch but he published the.first paper in French and he said the.title of the article it's a telic.cardiogram I mean not only that he.invented EKG but he invented telemetry.and you'll see that this is the chap you.know that the one of the patient in his.original publication you see beautiful.hands in a saline solution and then she.left the head this nightcap I mean it's.just a patient hanging an EKG and.actually he did all of this he recorded.EKG and then transmitted him over a mile.to another place so it's truly amazing.not only kg but telemetry as well and.this is actually his first recording of.an EKG of see it from his 1906.publication he didn't know the term.atrial fibrillation he couldn't use it.because it was not invented yet instead.he used the latin term and equal in the.regular pulse you see this but anybody.what do you think what lead this is see.that it doesn't say what the lead of EKG.is recording that was also not.established yet but you see if you're in.a little bit of French who says the left.arm and left leg so that therefore that.will be a third lead number three so.it's still it's really it's an infancy.all of this doing so what in the.Eindhoven say essentially said he.recorded electrical recordings of an.atrial fibrillation but he didn't have.an absolutely no knowledge of a.substrate what that does I mean where.does that come from and interesting at.the same year two guys one of working at.University of Michigan actually they.observed in open chested dog dogs that.actually there is a muscular.fibrillation of the heart and I said.they're even call it auricular.fibrillation as it was the first time.anybody used that term but what did they.did they assisted they observed muscular.fibrillation but they didn't have EKG.recordings so essentially like you know.there are two different things and then.you say Oh sooner or later somebody's.going to connect those two observation.into one and that person is this British.guy Thomas Lewis and you see he what he.published and he says it is well-known.that the late stage macho stenosis bla.bla bla.the pulse is frequently continuous and.extremely irregular and then this is.then he says you know that essentially.he was the first is the irregular of.mitral stenosis is due to fever.relation of Oracle so essentially he was.really and then he later on three years.published the different paper and this.is his record a look at beautiful.handwriting on the top is a normal EKG.and the bottom is atrial fibrillation so.even in 1909 people could do very good.EKGs but now let's go back to the.present why the atrial fibrillation is.important and he said it's a leading.cause of cardio and bollocks stroke due.to thrombus formation in the left heart.we know that it took a couple of decades.to establish that and if the clearly is.the leading cause of cardio embolism and.not surprisingly American Society of.echo enticed us to write the guidelines.and cardiac source of ember line.including atrial fibrillation and just I.happen to be the chairman of those.guidelines but clearly the contribution.is for many people around the country.and the world particularly for this.session Richard Greene from Cleveland.Clinic contributed on atrial.fibrillation and these are the other.people involved so I recognize their.contribution so I'll start with the.simple case presentation that you have.seen a patient just like this so 67 year.old woman she has hypertension.she has paroxysmal atrial fibrillation.she is a Chad vast score of three.luckily you know there are web tools.that you can always find out at red.score exactly we can establish what her.annual risk is about five percent which.is typical for an average patient of.atrial fibrillation and interesting she.is an aspirin and she's refusing.anticoagulation so she was going for a.couple of years like that.and one day she presents to her primary.care doctor with the left flank pain and.hematuria she undergoes CT immediately.and shows the right renal in fact with.the really clearly suspicion of a.systemic embolus to the right kidney.so she's admitted to the hospital and.and route to her room she suddenly.develops left-sided weakness and clearly.there is a suspicion of a.thromboembolism to the brain and not.surprisingly her EKG shows atrial.fibrillation.so so we look at the brain MRI and in.our guidelines we emphasize the.importance of neurologic imaging and.this would be a typically something what.happens in a patient with atrial.fibrillation see she was in the hospital.for a long time for about three weeks.and actually see it in the first week of.her hospitalization she had the right.middle cerebral artery.occlusion due to thromboembolism and.it's a one territory one point of time.then three weeks later she has a.completely different stroke in a.completely different territory which is.left middle cerebral artery.three weeks later different territory.different time typical for embolic.stroke and then te not surprising huh.she has a very large thrombus in the.left atrium that doesn't matter what do.you look at it 2d or look at the 3d is.look very menacing well you look at the.velocity it's clearly emptying velocity.or a systolic function of the left.atrial appendage is very low and the.physician who did P even used.microbubble contrast to show that this.is the thrombus as if there was a.confusion but it's actually it's okay.you know it's hundred bucks were spent.so it's actually clearly showed that.this is a left atrial thrombus.allocation appendage thrombus so now.what would we see thus far we say that.it's a multiple that she had the.involvement of multiple organs kidney.and a brain.she's a multiple vascular territories.three different artery territories and.occurring in multiple times point time.points so this is clearly strongly.suggestive of Cardian Baalak stroke so.now that we have seen all of this we can.then ask question in this patient who is.refusing long-term anticoagulation could.have he prevented thromboembolism prior.to thrombus formation by closing that.left heel appendage or it can.reformulate that question and actually.say why would closing the left atrial.appendage be sufficient to diminish the.risk of thromboembolic stroke after all.atrial fibrillation is a systemic.disease I mean if all the entire heart.why one one particular part of the heart.would be efficient and that comes from.studies that this is the typically.quoted study from 1996 but there are.other studies that close location of a.thrombus is strongly dependent on the.type of atrial fibrillation as you know.and in non-viable atrial fibrillation.which is most of atrial fibrillation.that we see in this country virtually.all thrombi are located to the left.atrial appendage and in as opposed to.rheumatic mitral stenosis.is that up to one third of Klotz.actually in the body of the left atrium.or somewhere else in the heart and.therefore in on Valhalla atrial.fibrillation we can say that the left.atrium is the primary primary source of.thrombus formation and since left atrial.appendage is not well seen on.transthoracic imaging tea is the must.for visualizing left atrium appendage.and contrast in the valve lateral.fibrillation which typically involves.dramatic mitral valve disease particular.mitral stenosis a lot of clots are in.the body of the left atrial appendage.and therefore the devices that are.approved for the closure rotational.appendage are specifically approved only.for non valvular atrial fibrillation and.not for valvular atrial fibrillation so.there if we can stay what's the.rationale for left atrial appendage.closure in a sense we can say this is a.local therapy for in a sense local.disease although atrial fibrillation is.a systemic disease involving the entire.heart thromboembolism in nonverbal.atrial fibrillation tends to be.localized to the left atrial appendage.then this was known from very early on.it was like a surgeons have been trying.to close left atrial appendage for.decades and the first ever report that I.could find is actually back from 1948.and the journal that was published.general American Medical Association.surprising in the early years how many.surgical papers were in JAMA and this is.the actual paper resection of the left.atrial arrests left auricular appendix.and I you know as a prior to New York I.have to say he was from New York it was.done in New York I can't say that was.done an N by you unfortunately it was.actually at the hospital st. Clair as a.Catholic a school that was closed.several years ago but John Madden he did.it and what he did essentially he did.amputated left atrial appendage and it.was one of the acceptable surgical.techniques to remove the risk of.thromboembolism through left atrial.appendage by chopping off the left.atrium some say it's too radical so.instead you can do suturing of the left.atrial which also accepted technique so.so but what are the limitation of this.it's very nice to have that you can do.this at first I mean nobody will do it.as a surgery only it's usually an add-on.to other valve research or some other.cardiac surgery there is a clear risk of.damaging left sir.because left sir goes underneath the.left atrial appendage and more.importantly it was often incomplete left.atrial occlusion and there is limited.outcomes data and essentially this is at.our lab we were the first to point out.in a systematic fashion that there is a.truly limitation to closure of the left.atrial appendage by surgical means and.in this study from 2000 we showed that.it was actually one third of all.surgical closures of the left atrial.appendage were incomplete and especially.you can see this like this is 3d image.mitral valve this somebody mitral.bioprosthesis and said there is a series.of surgical left atrial appendage.closures looks everything fine you turn.around and then you see that there is.actually a thrombus hiding inside the.left atrial appendage but you say it's.okay it's closed so there is no access.to the systemic circulation and actually.see it often you see these mattress.search sutures along the left atrial.appendage.everything seems okay until you know you.look at also the simultaneous by plain.view again it's left atrial appendage is.closed there is a clot inside maybe it's.confined that's fine then again you look.at the 3d there is impressive thrombus.in the left atrial appendage but then.you turn on the color and you clearly.see that there is a residual.communication between the left atrium.and the left atrial appendage so now we.have a double whammy you have a.appendage that it's closed increases.chance of clot formation now it's not.fully closed so therefore that clot can.escape and essentially if you're not.convinced by color you can use.microbubble contrast and you can see.clearly that then contrast is entering.left atrial appendage establishing that.there is a still communication between.the left atrium and the left atrial.appendage so you can say okay maybe at.NYU we are biased against our surgeons.you know we are looking with them but.maybe there are other institutions so.there is actually see Allen Klein it's a.very esteemed investigator from a.Cleveland Clinic past president American.Society of echo what did a study show.and actually see that the surgical even.worse result of a surgical closure of.left atrial appendage that it's really.the greatest success in closing left.atrial appendage so but you can say okay.these are all data but we have advanced.and then essentially they did.something called extra clip and this is.the first paper about that it that they.didn't even call it a true clip but it.was not invented yet but if there is a.time at the end I will show you that.even that has challenges they may not.completely close the left atrial.appendage either but now let's go to the.main part of this talk and at the.percutaneous left atrial appendage.closure and so the recently gentleman.said echo asked my colleague and me to.write a review article and this was just.published a few months ago so it's.almost that I will be talking it comes.from this publication and is it.important actually you know J's the.general emergency echo every month.publishes ten most read articles what.are the list of 10 most articles in this.article that I just showed you is the.seventh most read article just last.month and the other the guidelines of.the thromboembolism of the heart is the.10th so we are happy that it's really.there is a interest for these topics so.let's look at the percutaneous left.atrial appendage closure what are the.procedural steps as you know there are.three steps that it's important for all.of us who do imaging to understand the.basic elements of the procedure as you.know this starts with the femoral venous.access tip then do a transept I'll.puncture and then some form of device.deployment and in the entire procedure.not only that we guide but the key.element to establish the size and the.shape of the left atrial appendage and.it's truly that's where the.multimodality imaging comes into play.and we try to leverage benefits of each.imaging modality depending on the.context that we are using and so these.are the three most commonly used devices.in the United States there are others.that if there is time I'll show you at.the end typically the most common and.most investigated is the watchman device.it is a two trials protect and prevail.that established the effectiveness of a.watchman closure of the left atrial.appendage and you led to amplify that is.in trial in the United States and then.there is epicardial closure with the.Lariat device which is not specifically.approved for left atrial appendage but.it's used in this context and it's also.it's important.there are people behind these and these.are helped run in group in Germany they.were the first people to implant.watchman device in a human Gruber was.also famous for he was the first to.establish a core valve in a human this.is called Amplatz he was an Austrian.born he is he is Austrian born American.radiologist his Amplatz and in German.something that belonged to Amplatz is an.Platzer so he has a series of devices.including amulet and here in Texas Billy.Cohn came up with the idea of a lariat.procedure specifically for left atrial.appendage.although the indication is not stated as.such so and this is so the watchman is.has the only indication this is 2015.essentially you have to have truly non.valvular atrial fibrillation you have to.have Chad where score that necessitate.anticoagulation but at the same time you.are not a candidate for long-term.anticoagulation and this you know we.have this a procedural step you start.start with the transept I'll puncture.then a delivery sheath as well as the.pigtail catheter they advanced into the.left atrial appendage and then angiogram.is done to assess the size and the shape.of the left atrial appendage and then.device is deployed in the left atrial.appendage once we are satisfied another.angiogram is done to assess for seal.together with the transistor for lack of.choreography monitoring throughout the.procedure and then you release the.device and then over time the device.will endothelial eyes and be part of the.structure so these are then and just the.elements of this imaging but what's the.role of the imager in this the entire.procedure and it's truly there for the.success of this procedure there has to.be a complementary in collaborative use.of both fluoroscopy and transesophageal.echocardiography with the sprinkling of.CT imaging and the roadmap for this.closed so we'll talk first of left.atrial appendage size and shape.determination Tran septal puncture and.then device moment a left atrial.appendage and let's see how each of the.imaging modalities can help us in each.of these.steps so let's start with the step one.left atrial size and shape determination.as well as demonstration of.contraindications if there exists for.the procedure and so this is for all.endocardial devices there is a.measurement data size it typically some.form of diameter entry diameter or the.orifice size as well as the depth but.it's a key to understand that there is a.difference between the anatomic orifice.of the left atrial appendage as opposed.to the orifice that it's a landing zone.where the device ends so essentially we.never closed the true anatomic orifice.of the left atrial appendage but some.orifice that is a distal to it and it's.a typically referred as the landing zone.diameter and essentially see that the.watchman device.the current generation or what should we.call it watchman classic essentially.it's a cube essentially that the.diameter and the height is the same and.therefore that appendage will have to.accommodate both the height and diameter.at the orifice and you know the it comes.in five sizes three millimeters apart.from 21 to 33 and just to give you a.sense of size essentially yours quarter.is not only twenty five tenths but it's.also its diameter is 25 millimeters and.so it's important you know because you.know that to be in America we had the.only country in the world that doesn't.use the metric system you know that and.there was a next to last you know who.was the next last country that adopted.metric system and abandoned Imperial.system.it was Liberia okay we had something to.do with Liberia don't you think huh.the capital of Liberia is Monrovia isn't.it so it's named after Monroe huh so but.it's an interesting ok so now when you.do watch one sizing so you essentially.you do measurements at four canonical.angles 0 45 90 135 so for angle is 45.degrees that all comes from our trials.protect and prevail and now it had.adopted to all imaging of the left.atrial appendage.so we then select left atrium it earth.at its largest then look up the table.and then select the device and again so.this is the size of the table you.measure the left atrial diameter.and then you look at the device the.diameter appropriate compression and you.hope that there is enough depth in the.left atrial appendage to accommodate the.device so simple easier and this is how.it's done.so it's a four canonical angles you.measure it so it's a you know 26 1919.and 18 millimeters looks nice huh and.then you say okay the largest diameter.is 26 okay so that device would be 30 or.33 millimeter it's nice I interesting.you know adjust you do this but the.problem is these are four independent.measurements that you cannot actually.establish that every of these you.measure this diameter at the same level.as a matter of fact if you pay attention.it's a specially there is no geometric.shape that would satisfy these.measurements because three measurements.are in nineteen one is 26 in session was.there is no dead diametric and that's.because we actually do not measure it at.the same level but then we can actually.use a 3d echo and truly measure the.diameter at the same level and.essentially have a two long axis and.then a therefore at the same level the.plane at orifice and you can say okay.now I have a short axis so I can measure.the size and the shape of the orifice.nice huh it's a beautiful we can do this.every day but there is a problem you.know that is this is the Philips.software and you see if you look at the.long axis there is no very angle.determination that doesn't say whether.this is zero 45 or you know how do you.determine so I was just wondering and.then one day I had extra time and then I.came up something that I called NYU.twirl and essentially this is what you.do so essentially you acquire with the.3d image but you have to acquire it at.zero degrees you're quiet zero degrees.3d data set and then watch essentially.what happens in the bottom what happens.to the green so the green a line is at 0.degrees and therefore the top is at 0.degree recommendation you rotate the.green to fortify that so now green and.the horizontal represent 45 then.essentially you have a 45 on the top huh.you move it to 90 degrees now you have a.top 90 degrees you move the green 235 so.top you have 135 so now this is a poor.man's establishment of the angles in the.3d so it's a neat if you need it I think.it sometimes helps so now you can say.okay but wait a second but you can have.a surface rent in the Guv 3d.left atrial appendage on fast why not.just to freeze the image and measure the.orifice huh and you can actually do that.but the problem is when we have an fast.view can't differentiate between the.anatomic orifice and the landing zone.orifice and so therefore you can that.they're they actually compressed so.that's why essentially we do multi-plane.reconstruction or 2d imaging of the left.atrial appendage and so now just to show.you all what it's needed and how.measurements there are a lot of some.contraindication and I have a little.website you know with the play on words.economy is completely non-commercial I.received no penny so I can just tell you.if you are free to use there is a lot of.calculations there and so I showed you.with all these devices that I showed you.and the cordial devices you measure the.size and the depth of the left atrial.appendage and all of them is the same.except for lariat in Larry it is.actually not important the size in that.as measured like that what we measure is.the width or the length of the left.atrial appendage which tends to be the.largest about a hundred and thirty-five.degree or so and that essentially that's.determined by the lariat diameter in the.older generation was 40 millimeters that.loop that has to go over the left atrial.appendage now it's 50 millimeters so.that the appendage has to have length no.more than the size of that loop and then.okay so now we have sent okay so we.really have a very good sense of by te.to measure the shapes to measure the.lateral size it's a gold standard for.thrombus formation but where we truly.have to say that we have a shortcoming.in te to determine the fine elements of.the anatomy including the precise shape.and indentation of the left atrial.appendage and we have to say that that's.a limitation and then essentially where.the CT often comes and as matter of fact.it was not a psycho choreographers who.described different shapes of the left.atrial appendage it's actually CT in.this paper 2012 many of you are familiar.with all funny names of a cauliflower.wince or cactus chicken wing it they.even mentioned that the least likelihood.AF associated stroke I don't know it was.a tiny is that but it's it's really.lucky very very innovative essentially.it's actually we didn't need and in our.paper then we tried we just published.that the review pay.we try to sort of correlate te imaging.of different shapes and it can actually.do it but the problem is really when you.do fluoroscopy unfortunately often we.are very surprised you would establish.the size and the depth of left atrial.appendage on a te but the fine Anatomy.like this in the REO Cordell view that.is small indentation often you can't see.on a te and often they actually can miss.aside lobes on a te compared to.fluoroscopy and a CT.so therefore okay so now we have.established the size and the shape of.left atrial appendage what's the next.step so the next step is to do transept.or puncture and how can imaging help.improve the safety of transept or.puncture and transept the puncture is.clearly not a new procedure has been.going on you know John Ross established.in 1959.look at this publication transept the.left heart catheterization a new method.of left atrial puncture 1959 and then.this is from his publication looked a.beautiful beautiful really illustration.and look at this then it's your zoomit.look look at the catheter next to the.for cell valise and crossing for valise.and truly of no imaging until 3d echo.could approach anything similar to what.he did in 1959 with this artist.rendering or the procedure so let's see.whether we can actually do this with the.3d and help us understand but so the key.for the success of the watchman.procedures you know is the transept of.puncture that it's done in a posterior.in the inferior aspect of the septum is.supposed to superior and a posterior.aspect for mitral procedures and let's.look at this this one or 3d te this is.the right perspective of the fossa.ovalis.UCS VCS and top IV seers and the bottom.yota Crowell is on the right so we're.looking through Leon the four so Valles.that the oval fossa okay so and then we.have to find first to locate where the.foramen ovale is huh because we don't.want to go through the foramen ovale huh.so let's see that this is that's what.the framing of alley is in the northeast.ah if this is geography that we know.England yeah so we don't want to be in.New England we want to be in Texas we're.gonna be in Southwest huh so this is.inferior and posterior aspect this is.truly the best way to do.for the success of left atrial appendage.and how can I convince you that this is.the posterior aspect is better well if.you look at the different aspect if you.look at the mitral valve on fastview and.it showed the atrial septum and you see.if you go posterior you'll go directly.into the left atrial appendage if you go.anterior actually go away from the left.atrial appendage so that's why the.posterior stick is extremely important.for the success of the left atrial.appendage and then in our institution we.do always two canonical views short.accesses the ORAC value level which.allows us to have enter of posterior.orientation on the septum and then we do.by cable view which allows the superior.inferior orientation of the septum and.then we say so you can do this.independently if you have a 2d image but.it's even better if you have a 3d.imaging with the simultaneous by plane.view which then allows you anterior and.posterior inferior and superior one.versus the other and then when there is.a tenting with the transept ah you can.say okay in the posterior aspect that's.appropriate but in the inference of.period two superior maybe you have to go.more inferior for a successful transept.or puncture but then also we use an fast.view and a 3d this is again the same.view and fast from the right atrial.appendage from the right atrial septum.and it's the SVC of the top IV cos than.the bottom and you see the catheter.transept of Kathryn of interventionalist.and valvular space they use the Mullins.catheter traditional Kathryn EP Docs.use am jealous Catherine but it's the.same idea that it actually can actually.see what observe on 3d as the catheter.slides from the park position in the SVC.and approaches at therefore so of Alice.and allows us to do that precisely and.that to do that you can see on a 3d you.can clearly show receptor this is from.the posterior aspect is as the tenting.of the integral septum and finally.puncture through the left atrial septum.so now that we have established that.transept I'll access we can continue.with the rest of the procedure and by.the way it almost like the entire.procedure can be guided by 3d echo and.then again it's a really collaborative.effort echocardiography and.fluoroscopy and then if you come to the.fluoroscopy and do these you actually.hear as an echo choreographer UD aro.cranial an REO Cordell if you're.fluoroscopy interventional eyes that.it's very familiar but as into as an.echocardiogram for this may not be.familiar and vice versa if you're.interventionalist you are very familiar.with these terms but you know may not.have knowledge of what chorus what T.which corresponds to that and so these.are the two favorite REO cranial and REO.cordon and fluoroscopy but let's see.what Eve used corresponds to that so REO.cranial corresponds roughly at a 45.degree angle of a te except you have to.mentally rotate this image to correspond.so essentially 45 degrees is equivalent.to re or cranial view and this is just.from our paper to show how you rotate it.and get up in the 45 degrees so then you.can ask for about 100 REO chordal view.what does it correspond to essentially.correspond to the 135 degrees again but.you mentally have to rotate the image.it's interesting you know like we have.these machines that cost tens of.thousands of the ultrasound machine but.we cannot rotate to the image in the Z.view to have have this it's an.interesting you know it's a simple fix.but somebody nobody wants to do it and.then this is essentially how you do it.and so now that we know we can actually.use also CT to actually informs us.because we own our T you really have a.good image of the heart but you don't.have necessarily imaging of the.surrounding structure so this is REO.cranial view and simulated by CT and.equivalent to 45 degrees and you see the.left atrial appendage left up a.pulmonary vein if you just rotate this.image clockwise by 90 degrees you will.get the 45 degree on a te and then this.is REO Cordell view and if you rotate.this image and flip it backwards you'll.get 135 degrees on te and then actually.I can show you like it like a 3d te and.essentially this is re or cranial on a.surface rendered CT this is left atrium.in REO short axis and REO Korolev it's.called the long axis of the left atrium.appendage and actually I can show you in.this image essentially as I rotate the.whole heart you can actually so this is.our Ukrainian.then you can go out of your chordal hmm.REO cranial and are you a chordal so.once you get the hang out it can really.start recognizing all the appearance on.the fluoroscopy and correspond that to.t.e imaging and now that we have done.all of the recognize now we can continue.Tran scepter function remember is.already done and here we said actually.we are advancing over the wire we are.advancing the delivery sheath and.actually see it's a delivered through.the intellectual septum and now it's in.the left atrium and in the next you know.that the length that the wire is parked.typically in the left half of pulmonary.vein and actually see about the size the.left upper pulmonary vein that's it's.exactly the ligament of Marshall or the.coumadin ridge and actually on a 3d you.can clearly see that the wire is above.at that and inside the left atrial.appendage in left left area of a.pulmonary vein while the left atrial.appendage is beyond it's a far field of.the of the image and actually can see it.there next to you where they advance the.catheter inside the left atrium which is.below the ligament of Marshall so.therefore in a 3 D can really establish.the safety why you don't have to go.switch to 2d to establish that the wise.and the left half of pulmonary vein or.that the catheter is in the left atrial.appendage as desired.so essentially allows really 3d imaging.but at the same time and this like.manufacturers actually have a 3d image.on the right hand side and have a 2d.images on the left hand side so have a.benefit of the both and now we will have.essentially established diagnosis to put.the devices you know that is the path.track position anchor size and Celia.might be very familiar with that.position should not be tilted device you.know on a tack test should be anchored.with its barbs should not pull out and.then there is a size and compression you.measure that the appropriate compression.15 to 30 percent depending on the device.and they put a color that it's a seal.and if everything's okay.then you'd deploy the device and.actually can watch it on to see 3d.essentially it's unscrewed and the whole.device hold the delivery sheath is.removed and now we have a left atrial.appendage closed with the watchman.device.you switch it simultaneous by planed.view.and actually you can see that the left.atrial appendage is closed canonical.view typically we like 45 and 135 views.it's really nicely closed and then it's.on a 3d again it's a released left.atrial appendage nicely sitting in the.left atrial appendage next to the mitral.valve and then you check it with color.and it's clearly completely sealed.there is no parent device although in.our trials that we have done the leak up.to five millimeters is considered.acceptable at the Nyquist limit of 35 so.now it's it I'll show you in the one all.of this I showed you nice deployment but.there are sometimes things may not go.well and essentially if you watch this.that will essentially you can see this.is when it's a nicely placed watchman.device said on A to D and then a 3d but.not always goes well you know sometimes.you can have sub mouths they have access.shoulder it's clearly a shoulder it's a.tilted device that's not acceptable and.you see there on a 3d luckily it's still.on the stick so you can reposition or.capture sometimes it you know develop a.power device leak again leak up to five.millimeters is acceptable and in a.long-term typically at 45 days rarely.you can see a clot on the device it's a.reported rate is about one want the few.percentage points in patient and then.especially if you look at the 3d CT you.can actually see this endothelial eyes.and essentially it's a nicely.endothelial eyes watchman device closing.the left atrial appendage and so now in.the last few minutes I'll show you other.occluders just a few images watchman.flex which is the second-generation.device I'll show you a little bit of.imaging of Amplatz amulet lariat.procedure wave crest and a triplet just.the rapid fire of a few images so that.we finish on time so this is a watchman.flex it's a second-generation watchman.device and actually can see it has a.different shape so standard classic.watchman device has a sort of a.strawberry shape this is more of a pear.shape and it's always the problem you.come up with the new device like with.the movie you know like there is a Toy.Story and then Toy Story 2 you know how.do you call the first Toy Story noir.directively call it Toy Story 1 so same.day this dislike a watchman one-hand.watchman 2 so this is a watchman two.Watchmen flex and it's really an.interesting and on a 3d it's looks like.a little cookie huh it has that like a.shortbread appearance and this is so.that what's the advantage of flex device.the fundamental problem with the first.generation of watchman device that's.actually a cube is that as tall as it's.wide and often that I have appendages.that have a wide orifice but they're.shallow and so for this advantage this.is actually this device tries to address.that and also it has you remember that I.showed you the thrombus formation it's a.typically at the site of the the screw.that screw on the device and so now this.is and/or what's called the threaded.insert so now this device is the recess.is the threaded insert and hopefully the.rate of a device associate rhombus might.be decreased it's in trial in the United.States so I can tell the answers whether.this is true or not.so Amplatz a amulet is essentially a.second-generation amplitude device it.cardiac clock was the original one and.the Amplatz a is a second and actually.can see it it's more complex device it.has a disk and a lobe disc closes the.left atrial appendage from the left.atrial side and lobe is inside the left.atrial appendage that both closes and.anchors the device in the left atrial.appendage and this is an fast view of a.3d on a 3d how that disk looks from the.left atrial size of an implanted device.and here it's a three minute 3d CT you.can actually see that this is recently.placed it's not doesn't appear fully.endothelial eyes yet over Amplatz device.applets ambulate closing the left atrial.appendage so just give you a sense and a.flavor of what it is so let's say that's.about the Lariat procedure i heard many.of you have done lariat procedure we.even wrote the original review article.and for some reason the I did a liked.picture and they put it even on the.front cover of the that issue of Jase.from an article and lariat and this is.essentially fluoroscopy at the heavenly.fluoroscopy it has a pericardial excess.with a series of wires that are magnet.tipped wire that creates a union between.the end of card.and epicardial or pericardial hardwire.and these magnets once they join then.you inflate the balloon on the.endocardial side and then I put the.cordials nail over the left atrial.appendage and you close it and.essentially this is how it looks this is.a prior to ligation at the unfairest.view of the left atrial appendage and.this is once you close it and we have.done many of this and it looked to us.and we call this bowtie sign essentially.if you look at the left atrial appendage.every time you close it it looks like a.bowtie and this is a sign of a good.lariat closure of the left atrial.appendage and then a few images of a.wave crest which is a newer device it's.also investigational and I'll show you.after 45 degrees it looks like I'm sorry.it looks like a little beehive let me.see if I have a mouse so it's it looks.like a little bee hive huh this is a.closing the left atrial appendage that's.a on a color it has a little bit of leak.and I look like a little it's like a.little turbine or that closes the left.atrial appendage it's not like a.watchman that it's a flush with with the.orifice of the left atrial appendage and.then if you will just recently publish.the case of the watchman device if you.need the details it's here and the.finally the etre clip and actually see.it in a long axis or this 1:35 and.actually at the heavily because it's.there is not much guidance because when.you do this procedure surgically the.heart is deflated it's a so it's really.with the image after the device but it's.actually a long axis and the closest but.actually if you pay attention here you.can actually see that left atrial.appendage is not fully closed that often.leaves this indentation and the left.atrial appendage is not often closed.with the atra clip and actually can see.it unfair you essentially not flush.surely with the surface of the left.atrium but there is a clearly a divot.that leaves by a actual clip stay and.essentially if you look at the 3d Mencia.3d CT and actually see a clip again.there is that indentation it's not flush.leaving a possibility of a clot.formation the part of it and.essentially if you do it let's render.ink and actually you'll end up with the.extra clip and essentially somebody who.has also two other surgeries and this.was done with the ORAC and the mitral.valve by prosthesis so I'll finish and.and thank you very much and I hope you.enjoy it and thank you very much that's.great think about a lot of interesting.stuff there is no thrombus and you're.deciding to take them off at a.coagulation but they have big atria and.a lot of spontaneous echo contrast are.these do we know anything about what is.the optimal management for those.patients so essentially I can so it's a.very interesting thank you very much for.your kind words and with respect to this.is all comes from protect and prevail.trial it essentially that is do you have.to be anticoagulated for the first six.weeks with warfarin according to the.trial and between six weeks or 45 days.in six months you should be on dual.antiplatelet therapy if there is no.contraindication and then after six.months its aspirin for life so the.question is with this medication is a.first whether the first six weeks should.you be on a no acts or anticoagulant.it's clearly it's the trials of warfarin.and then within six weeks and a six.months is essentially the in the trial.the continuation either the presence of.a large para device leak or.device-associated thrombus that a.necessitated continuation of.anticoagulation therapy for the rest is.really at the clinical judgment is a non.verbal H or fibrillation tends to have.clots in the left atrial appendage.rather than in in the body of the left.atrial appendage I'm a thank you for.coming really a very comprehensive state.of the art basically of atrial occlusion.the data on residual whole right five.millimeter five millimeters it's not.mom how strong is that data so first of.all I mean when we did those trials this.were all 2d imaging and it's a size of a.whole is just as five millimeter which.is the narrowest point but as you know.if you compare this to Tavor.you would never say okay this is a para.device paravalvular leakage is just a.five in one view because you should.actually look at the circumference so.five millimeter is a different from five.millimeters because if you look at the.3d or size device somebody can has truly.five millimeter just a point or somebody.can have a circumference of 20% of the.watchman device that it's affected by.something that it's in the narrow is is.so essentially the same thing with the.valve regurgitation isn't it like a sort.of a quando so essentially I would not.say that it's really we have good data.because of this definition what the para.device leak it never took into account.the circumference extent of of a leak.thank you for such a wonderful review of.a complex topic I'd like to just point.out that we have to be careful in.universally condemning surgical closure.because I'm not as a surgeon you know.there's there's a lot of different ways.of closing the appendage and the studies.that were done kind of took into account.all surgical closures or several.different ways of closing when you do a.suture ligation that that's a purse.string those often come open and I've.seen even the best surgeons years later.have open purse string closures we also.have to be careful that the one of the.pivotal studies that looked at surgical.closure was actually first authored by.somebody who has a very close.relationship with a chiclet so yeah we.have to be careful of the source of that.even though very prestigious in an.honest person yeah but I think we have.to be careful to say that 37 percent of.or however many percent of surgical.closures come open because they were.looking in these studies they were.looking at purse strings they were.looking at direct closures they were.looking at external closures and so it's.kind of like saying you.so many percentage of PCI's go bad and.you're looking at all ptc eius ab.salutely agree I mean absolutely I.didn't mean to say that it's really.surgical it's extremely placed.particularly if there is an add-on.procedure for existing it's often.combined with the maze procedure.it's absolutely but it does say that we.do they have much less outcomes data for.a surgical closure left atrial appendage.as opposed for instance of watchman.which is truly a randomized trial and.it's a clearly there is a surgical.element mom let me ask you so you you've.had a 30-year career mostly echo in.clearly the last many years you know 3d.echo and interventions and now an.appreciation for CT and you're showing.us Terra recon and three men Co so.comment on sort of the training training.for this field that we're in maybe woody.woody how do you train your fellows at.NYU and and what do you think is coming.for the training I really think that.multi modality imaging is the future.without doing multi medellín no matter.what kind of imaging you do you have to.have some familiarity with the.multimodality imaging and will make us I.can tell you I've done the echo cardigan.for many years once I learned the CT and.MRI particularly CT I think I became a.better echo choreographer and it truly.starts understanding and it really.should not be embarrassed any whether.you do CT and you start learning about.the echo or you do echo and they say you.should not be you can only strengthen.your knowledge of of a structure or.procedure by multimodality imaging and.it's truly familiarity even a basic.familiarity of all of this at a shoujo.fluoroscopy or te or CT and i think.that's the future and everybody i would.encourage and all the trainee to.undertake some of multi modality.training thanks I'm gonna ask a question.to our surgeon why don't we do more.often I mean many patients older.individuals who certainly are more prone.to atrial fibrillation at some point of.time an open-heart surgery why don't we.do clipping of the left atrial appendage.or excision I mean that should be I.would think a very simple procedure most.of the time you have te in there to help.you.I mean tell us why why not even some.patients who have atrial fibrillation.may not go for a maze procedure we don't.have enough data to show us that.clipping of all the appendages is.universally protective as you showed.there are some sometimes they come open.maybe we make things worse by creating a.small hole sometimes we could put the.circumflex artery at risk so it's not a.completely benign procedure there are.have been those who have advocated doing.prophylactic clipping on all patients or.on older patients or on patients at risk.for afib if you put a clip on a patient.who does not have a fib you run the risk.of not being reimbursed for that device.which is one aspect or of being of being.accused of doing something that isn't.isn't it hasn't yet been proven so.prophylactic clipping is probably not in.order right now I do every time I open.the left atrium to do a mitral valve.operation about 99% of the time I do.close the left atrial appendage from the.inside because those patients with.mitral valve disease with or without a.fib are at very high risk of afib.post-op so I think we are doing the.patient a service by closing the atrial.appendage in a way with a double running.suture line from the inside the heart.which i think is a very good way of.closing it but I we don't have a an.indication for prophylactic clipping of.the atrial appendage with the device and.we also don't have a as far as a maze.procedure goes the some have advocated.doing a prophylactic maze procedure in.patients at risk you don't have a fib.and the maze procedure really doesn't.work for post-operative afib it actually.can be pro a rhythmic genic in the first.couple of months as the scars are.developing so it has never been shown to.be a.prophylactic procedure for post-op afib.but it it is certainly indicated in.patients who have documented afib going.to the operating room as a concomitant.procedure yes thank you mommy that was a.really wonderful talk and a nice.historical perspective so two questions.for you one is how do you do you have.kind of a routine host imaging.evaluation process that you do is it.just CT is a tes or how do you approach.kind of a post procedure evaluation of.these patients you know six weeks you.know six months or whatever and then the.second questions slightly more practical.is it sounds like obviously you have a.very or the echocardiography has a.tremendous role in these procedures and.I don't think really they could be done.without the echocardiography I'm sure if.you're spending two three hours there in.the lab all these studies are piling up.how do you deal with the practical.aspects of all your time that's been.thoroughly in the cath lab so thank you.very much for your kind words about the.presentation so let me address the thing.to think essentially what you are.talking about the RV use and you know.how do you justify you know loci when I.talk to administration I told them last.night I mean I tell them mister do you.want to have emergency room yes we want.to have emergencies we won't have a.successful emergency room yes do you.want to spend 12 hours in emergency room.and three people show up and I said you.know will be paid by RV use of course.nobody you wouldn't have a emergency.room like that so the same thing do you.want to have a success of a structural.program I'm sorry do you have to pay for.that you know if there is a downstream.event I can't it just simply I would be.not in the right mind I spend you know.dufort hours in the morning and then we.build the you know for for transthoracic.occurs.I mean look and there'll be they'll be.nice you know but the fact that the.hospital make hundred thousand dollars.and that procedure that it's a different.story.I mean it's essentially we really have.to advocate for ourselves we have to.adrià mean if this is the service that.we provide and if it's really the DC's.expertise you know jumping between a.left atrial appendage and a.transcatheter mitral valve replacement.that's that's expertise.I mean it has to be valued by.institution and you know we try of.course I read everyday transthoracic.echoes and duties and all of that but.has to be the dedicated time for the.structural disease with respect to the.follow-up at presume here mostly the the.watchman is essentially what experienced.in the original trial it was really six.days six weeks six months and one year.currently with the commercial device we.typically do follow-up routine follow-up.forty-five days because that's the key.differentiator between the continuation.of anticoagulation and dwell and like.antiplatelet therapy the others is.depend you know the other is that the.investigational devices and in that.follow the protocol of each each of them.TR TR te for 45 days all watchman.devices doctor sir thank you for the.amazing talk just a quick question.regarding with the increased use of ice.in these procedures of watchman's what.do what is your opinion on the.complementary role of te if any on a tea.or iced tea.so essentially really the all watchman.device that we do is essentially by te.so the the left atrial appendage is not.as easily visualized by ice as the.transept ER so routinely our.electrophysiologists will do transept.with an ice ice is not a cheap catheter.i mean it's a couple of hundred bucks as.opposed to reusable te we have done one.closure with the ice in a patient who.had no esophagus and essentially you can.image but essentially you know just you.know there we have you have all get.received you know once i got a request.for transesophageal echocardiography.from an auto rolling ologist who did as.a fudge ectomy on the patient so you.know it's like the rats you know it's so.the problem is essentially really you.have the canonical use 0 45 90 135 so.remember an ice skater is is actually a.monoplane that goes back to what T was.30 years ago it's a monoplane with the.64 elements depending on the standard an.or there is more but it's still a.monoplane essentially not easy.and it's a far-field to do that there.are some people who have published in.Europe that they actually do the.transept oh and then you pass the ice.catheter into the left atrium and then.you image it from the left atrium it's a.possibility but it's I wouldn't say it's.a mainstream anywhere it's not just in.our institution but I don't think and I.reviewed the few months ago I review the.paper about this ice and it's clearly.forefront it's an interesting but it's.it's not there yet.a question from our electrophysiologist.well that was a beautiful talk and I'll.just say that was an amazing pictures.and and I completely agree with.everything you're saying we actually do.use ice and as well as at times T the.decision to use ice is mostly practical.as absolutely our preference would be to.have tea in every single patient it's.clearly better with ice the advantages.are purely that we control the ice and.so you don't have the need for yet.another person in the room someone.someone who's not getting our views.sitting in the room and yeah and and.also the the there are there are it is.true that if you're sitting with the ice.catheter in the right atrium you it's.useless you you generally have to put it.in the left atrium you can put it in the.coronary sinus or in the pulmonary.artery open what other people have tried.pulmonary as well yeah it's but the.views are very limited in the left.atrium essentially you have two views.one from the main body of left atrium.and one from the left superpower vein.I'm not exactly sure which views are.equivalent yeah now they're very similar.we we've created one view where you go.in the in the mitral valve and the left.ventricle and turn it upside down but.it's essentially the opposite of view.from left sort of aim it's pure.practicality that makes us do this it's.absolutely I mean actually now that it's.actually now that there is now for ice.Kathryn I really divide you know one of.the companies divided that actually at.the control unit that it actually.accommodates the cath lab standard table.and essentially that's so that you can.actually control not only that divide.but you can actually control whether.it's a cowl a spectral Doppler a choir.not acquired it's really nice rectangle.that but that's the future the more the.better.yeah yeah it's much since it is.monoplane it is very difficult to.visualize and therefore access.implantation success measurements.various things that you need to do yeah.so now we'll be involved in a trial of a.3d ice we are just starting this it's.already you know it's in the IRB process.it's going to be 3d eyes it's a 60 by 60.degree angle is not as good as a te I'll.let you know maybe next time we'll.invite you back to talk about that okay.all right we're at time so thank you.Mohammed really appreciate everything.[Applause].[Music].[Music].[Music].[Music].[Music].[Applause].[Music].you.[Music].

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