Chapters Transcript Video Seventh Annual Clinical Advances in Heart Failure and Arrhythmias: Case Presentations and Panel Discussion - Part 2 Drs. Gibson, Olson and Rogers review real-life cases from their practice and answer questions from course participants (session 2 of 2). Back to Symposium Page » Yeah, they're going to gather your questions and then send them directly to you in the chat, so check your chat. So I got a question about that Xarelto study where they looked at triple therapy versus double therapy. And the question was, if you remember those slides, um, vitamin the warfarin with triple therapy was the worst. And then you had triple therapy with reduced those rifle racks van on double therapy with Rival Rocks, Band and Plavix. And so both of those to the triple therapy with reduced rose rival rocks. A ban on the double therapy was compared to buy McKay, and there was statistically significant differences between those two, personally asking, Was there a difference between the triple therapy with Rival Rocks Brand and the Reduced the Survivor rival rock band double therapy? And I don't know. I'm trying to get an answer that question. I The study may have not been powered to detect significant difference, and there was a small difference. Um, let me just leave my slide real quick. There was a small difference in that. The double therapy had a slight reduced incidence of bleeding, so we're talking about bleeding risk here both of the triple therapy with rival rocks Band therapy Driver Rocks Band were significantly reduced in comparison to triple therapy, you know, standard triple therapy. But there's a small difference. 18 points victory over 16.8 triple therapy with right Roxanne double therapy. I don't know. The study was large enough to detect a statistically significant difference there. So So perhaps if you follow those patients for longer, I think the important slide is the next one you want to know if you have any difference in stroke rates are stent thrombosis McArdle Death and the devil therapy numerically had the highest number of ischemic events. 6.5 triple therapy with warfarin had the next lowest number of ischemic events. Six point. Oh, and the triple therapy of rival racks. Van had the lowest rate of ischemic events at 5.6. There was no difference again between either the two rival racks Ben therapies in the triple therapy um, eso. But again, it didn't directly compare the two compared, all that study was power to detect it compared to a war friend. So let me just get back to my other slides. So anybody I hope that answers that question. I'll try to find the answer to that, but I'm guessing that the study wasn't large enough to detect. It wasn't planning to detect the difference. She knows, too. Um, second question for me is an 80 year old patient. Then stayed Long war for a history of multiple DDT s. He also has a history of a fib in the past, but EKGs and normal Sinus rhythm now and wants to convert eloquence. Given the advanced age, would eloquence load those for TV? Pro DVT prophylaxis 2.5 mg twice daily Be okay or should patient beyond 5 mg to cover the 8 ft as well. So in general, you wanna worry about a fit and has a tendency that want to come back over time. Unless there was truly reversible event that was associated with the trump election, I would I would expect that if it to come back. We tried to do this in an older trial where we looked at patients that we thought were in Sinus rhythm, and we took away their blood thinner after about three months on, basically, over time, what happened is that those patients had atrial myopathy that continue to put a rest for stroke and a fib or have recurrent episodes of fit. And they canceled that study early. So, um, in general, that study would would we've all taken that study to mean that we shouldn't be using rhythm control or the you know, the presence or absence of a fib, particularly on the single Ikea GTO. Make decisions about stroke protection with a fit. If so again, if you have a reversal episode, maybe okay, to go on DVT prophylaxis what you might want to do. That patient is checked them with, um, extended monitor patch like monitor you can wear for a longer period of time. We're implantable cardiac rhythm monitor that Dr Rogers and Dr Olsen put in a lot of something called the a Link Monitor is the one that's made by Medtronic, and that would be a more reliable way to really confident we exclude a fit and perhaps go with different Xarelto. A couple more quick question John unique answer smears. But it says my dad the question, but three is. My dad was diagnosed with a fib. He falls a lot other than blood thinners. What is the best medication prescription to prevent bleeding and treat a fib. Unfortunately, you know the blood thinners in the in patient that's at risk for fall is going to be an issue. That's what my grandfather passed away. So that was near the fell hit, his head on the counter, tiptop going down and died of a brain bleed. Falls were a big deal in older patients and so obviously don't wanna over treat patients for falls. But what I like to see in my practice is if the person has a reason for ongoing fall arrested if they have orthopedic issues or neuropathy Ortho static type of attention. I really respect that fall risk. And that's why I start thinking about lifting appendage closure. Unfortunately, aspirin is not enough. Rhythm control is not enough. You really have to think about blood thinner and some preventive strategy for falls like physical therapy or Tai Chee and some over people. They want to actively pursue the fall risk or consider a non pharmacologic therapy like appendage closure. And then which, in the my last question is which method of rhythm control do you recommend for cancer patients entering the drugs relation. Uh, given they have at least one year survival, would you recommend for referral for left actual appendage inclusion in these patients? That's a very individualized decision making process. And a lot of it depends on the type of cancer. So so and again, I look to that question that you made a statement you made is that what is the survival of the cancer? The survival of cancer is good. E Usually we'll start with rhythm control with a drug cartel birth them, make sure that they feel better enough in a normal, normal rhythm, that it's worthwhile going after if we can. And we might think about rate control those patients. But again, I usually at least go with the drug first to try to ensure that they do feel better enough to make it worthwhile. Suicide is for them, and then then all bets are on the table. You know, the patient has a good survival. I would dio would go ablation or drug whatever they prefer. Whatever works, um, in somebody who prognosis is not so good. It's all about symptom control, right? You want them to have a good quality of life of the time they have left and usually will be thinking more about rate controlling that population that use a with just a drug or in a more aggressive situation, this would be some somebody with a longer survival. But, you know, really significantly impaired by agent tribulation. You might consider every node revelation pacemaker, but in general, that would be raped. Rhythm rate control of the drug. Um, you tackle your questions. I think you got him in the chair. Yeah, sure. So I just have two quick questions here. Question number one was What percentage? Roughly of all devices do you think Micro could replace? And do you think we should still be in planning conventional pacemakers in patients who would be well served by micro? So just looking at the statistics with the second generation the V D. E. D. Device. Now we have a device that can do pacing and just vai pacing in the right ventricle and also VVD pacing for heart block. Technically, you can and plan we could replace up to 50% more than 50% of pacemaker and plantations with leaderless devices. I think the two main issues that I need to be touched upon. Based on that decision, number one obviously is cost. These devices are much more expensive than conventional transience pacemakers for now, especially considering there's only one FDA approved device. You don't really have the benefit of competition yet, or we don't have the benefit of competition. And I should say so. I think that, you know, certainly I try to keep health care costs down. And you know those patients that have the highest risk of complications those with highest risks of infection or bleeding complications or pocket erosion pocket complications, dialysis patients. Those are the ones that I really pushed for the lead list devices. But I love to put them in all the people. And I think in general people are much more satisfied with the device. Um, the other issue, obviously, is device lifecycle management, as I talked about. You know, I don't think that the greatest devices right now for a very, very young patient, because, you know, you need to think about their whole life, and after a year, we don't know if we're really gonna be able to get these things out. Maybe down the line we'll have some way of removing the devices after encapsulation occurs. But right now we don't have that. So I have some some hesitation in very young patients. Second question WAAS how can you remove or reposition the lead? This device with the times and the RV being heavily Trebek elated. Is there a risk of perforation? So it turns out so the times when you shoot the device out of the delivery catheter, the times, uh, penetrate the tissue and they take their curved shape toe hold the device in place. But, uh, the times themselves actually are pretty malleable. So if you pull on the device, the times will fold back very, very easily, and they don't typically rip any tissue or cause any damage. The risk of preparation is really about, uh, the original insertion avoiding the free wall so that the times don't penetrate the right ventricular free wall. I believe that, you know, perforations and effusions are largely to full. They're kind of in two categories. One is time perforation in a very slowly, especially in an anti coagulated patient. Usually, those effusions are either expectedly managed, just watched or maybe a drain the rial big ones that required surgical intervention based on, uh, evaluation of the trials is that they were actually larger tears not even due to the device, but to the delivery catheter itself. A cup of the delivery catheter tearing the right ventricle. And by avoiding that, getting that device to avoid the ventricular free wall is the best way to avoid those bigger perforations. John, you go ahead with your questions. Now those with yeah, I I agree. Just with what you're saying. The guy those times were made out of night in all, which is very flexible, softer type of material. They're not super hard and stiff. And I guess I must have a really good job discussing the top because I don't have any questions. There's one more question that came in. And the question is, Is there any strong evidence or your opinion on continuing anti coagulation in a patient population of Chad's best for greater than two history of maze procedure and surgical L a clip? Um, my opinion would be that you could extrapolate from the pendant closure data on day. Probably treat that similar. Thio Perky titties, appendage closure. So, in my clinical practice, I do like to ensure that the appendages adequately closed with some version of an image ing trial or imaging study. And then I generally will take them off for Atlantic coagulation. They're gathering evidence now, so the surgical clip is interesting. It got approved as a safe procedure, but they didn't do the large trials. Those large trials are ongoing. I haven't seen results of them yet, but at some point the surgical literature will will be out showing the stroke right after surgical click placement. I expect that to be pretty similar to what we see in Dependent Closure Arena. So there will be a formal answer to that question soon. Um, particular patients of high bleeding risk patient. Then I generally will will stop anti coagulation surgeons replaced equipment that amaze. So I just wanna make one comment on that. You know, I think the Onley hesitation I have with stopping anti coagulation and that type of patient, or is, um, you know, when someone who's had mitral stenosis or some type of a valvular atrial fibrillation and has extremely dilated left atrium Now we say that most of the blood clots that cause embolism and a fib are coming from the left atrial appendage. But I do think that especially in people who have very advanced atrial, atrial myopathy is there atrium. Maybe there. But it's not really squeezing that much. Um, I think I have some hesitation in stopping anti coagulation. Those clipped patients, just like Doug would have hesitation and putting a watchman or left atrial appendage closure in someone with really advanced Chad's vast score. Yeah, no, this is definitely a different animal. So you have to be a concern about patients that had a maze operation is an add on to a micro valve replacement or repair, so that that's a very good point. And then, yeah, you're right. Most of the boy thoughts come from the appendage, depending on which study read. Those numbers are a little bit different. Modern eco studies. It's the height 90 percent range that come from the appendage. But definitely we're seeing that in some of the watchman data is being teased out on. We're thinking I'm actually part of a paper now, recently showing in patients of the pending closure, perhaps have just know it's a very specific patient population where half does no act may be beneficial way don't have data to support that. But I agree. That would be very careful. In that patient population, they have a valid surgery. So we have. Let's see, we have about about five minutes left. Do we want to try to do a case quickly? Sure. We're taking more questions. You guys have questions? Feed them in. Sure. Let me just breathe through this case really quickly. Um, an arrhythmia management case. So this is a navy four year old hypertension. Some co morbidity. These persistent a fib. Um, uh, on rate control strategy initially build Utopia law, but has had some multiple coming in the hospital. Multiple admissions for a fib with RVR and the setting of the heart failure exacerbation. One thing that we've learned over the last couple years through ablation trials is that these heart failure patients tend to do much better with rhythm control strategy. So often we'll try. We'll really attempt that if we can to improve their heart failure status. Uh, this patient was switched from rhythm to a rhythm control strategy, started on soda wall, 80 mg twice a day and prevented, presented for outpatient cardioversion. Um mhm restored thio out of a fib. cardio voted out of a fitted with a small shock. E f is a little on the low side in the in the forties, but not a severe systolic heart failure. So this is the trump ahead There. This is version E K. G. That obviously prompted a quick phone call from the cardio verging doctor I'm taking a look at at the c k. G. And we kind of decided, you know, you're sitting in the outpatient, uh, the cardioversion lab and yet to decide what to do with this patient. Um, you know what? Your thoughts Doug and John, what would you do in this in this case right here? I was just thinking, this is a good example of, ah, cancer patient, right? That is having trouble with nature from election. The question came in earlier, you know? What do you think? The best strategy for somebody with cancer. Here's somebody. What was the prognosis from her? Cancer obviously has metastatic cancer, but she still feels badly enough that they did. You want to give her a good quality of life at the time she has left? Yeah. I mean, I don't think ablation was really in the cards here. We don't wanna be that aggressive, but certainly a trial rhythm control to prevent these heart failure. Exacerbations This was an older, uh, an older case. Way didn't leave this pacing technology as well. So, um well, it wasn't quite as mainstream, but the thing that I wanted to emphasize here is if you look at the cardioversion of patients on solo, all of a sudden we have, ah, looking at the Q t interval here. And, uh, one thing, obviously, is the highest risk of or a high risk is bradycardia associate with QT prolongation. And I'd like to emphasize, in this particular case, where do you draw the QT interval? Sometimes I think assessing what the Q T interval is can be pretty challenging, especially when the baseline is not particularly clear. Eso Typically, we like to do it and lead to, because the on and off set of the T wave tends to be a little bit more discreet. However, lead one V five v six. Ah, historically, when the QT interval was initially described, it wasn't lied to. And that's why we've tended to use that one. Um, don't typically use the you wave, even though you wave can be part of re polarization. So in this particular example here, the Q T interval was at 622. Obviously want to correct that because of the bradycardia on the Q T. C actually gets labeled as 494 milliseconds, which really, that is an okay. Q t C interval for administration of solo. However, looking at this, there's a couple red flags for me or things that make me very concerned. First of all, bradycardia. Once you start getting extremes of heart rate either fast or slow, the Q T C interval tends to be with low heart rates over shortened. Because the Q T C is divided by the square root of the R R interval and in this particular case that even though the QT interval 622 milliseconds, the Q T c gets truncated significantly because of that, that factor I do think very low heart rates. We tend to lose. So, um, if I call it accuracy but reliability as a measure of tor sods risk once you start getting really low heart rate. So anybody that I think it's cardioverter did and is on soda wall. Um, I think with a very low heart, right like this, I'd be very, very reluctant toe let go without some monitoring. Obviously, we're not gonna really let this patient go home with the heart rate of 38 Aziz. Well, so I guess the questions in the case are what do we do? We continue Soto all admit for close monitoring. Do we stop soda wall and admit stop Slowed wall on discharge or discharge home on soda? Lol, obviously, I don't think discharging home on solid walls a great option. In fact, I don't think stopping the soda lol on discharging. Is that great of a decision either? I think we would need to monitoring in the in this patient. I certainly don't think, you know, without a pacemaker in place, I wouldn't leave her at a heart rate of 38 beats per minute is Well, what do you think about loading that person? Outpatient outpatient? Load it. Waas Yeah, it waas originally in. And that's another reason you know a fib with RVR in fast heart rates, the Q t c interval um, can be a very challenging, especially in irregular rhythms like a fib can be very challenging to get an accurate Q T C measurement. Yeah, I don't know what her body weight is, but low body weight, female, a little bit of renal insufficiency. That might be one where you would make a judgment call to admit that patient for so long. But I don't, Uh, tough question. We have it on every case, right? I mean, you don't like in patients? Don't want, obviously be admitted. Especially this one has had a number of admissions lately. I want to try to avoid people coming in the hospital. Yeah, a lot about patients, total loading, for sure. And I, you know, generally try to respect those risk factors. But as you started my doctors and maybe five or six of them, it's hard to remember all that stuff all the time. Yeah, the judgment call, Especially when the black box says you should be admitting these people. So this is another e k g in the pack. You, um this is another major red flag for me. As you can see here, we have normal Sinus beats at a very low rate. But now we're starting to get by Gemany coming right off of the T wave, right? And this should be a major red flag for the development. Of course, odds risk, Because what exactly is happening? I'm gonna go to some basic electrophysiology here, bringing way back to your action potential here. Um, cardiac cells they normally dipole are in the re resting state. They deep polarized when they're activated, and then there's a time delay and then they re polarized back down. Now, any medication that prolongs the Q t extends this period of re polarization to the dotted line here. However, when that occurs, it's not homogeneous, meaning some heart cells change significantly while other cardiac cells or not. So what ends up happening is you get this dispersion dispersion of re polarization. Some cells air de polarized, some are re polarizing, and there's a Grady in between them. That's why the T ways in these states, not only are they prolonged, but they're very wide and broad. And that's what was so concerning about the initial electrocardiogram. On top of that, when you get this dispersion, what can happen is sometimes thes thes heart cells that air re polarizing instead of going back to the resting state, they can actually deep polarized again. And this little light blue line here is a subclinical, uh, deep polarization called in after the polarization. But if it's sufficient enough, it can actually cause another heartbeat. And if that perpetuates on and on, that is, uh, ventricular tachycardia or Taurus odds. So this patient was brought into the hospital and on celebratory. This happened, um, on the floor at this point. So the question is, what do we do at this point? What do you got? What would you do? Doug was a couple of hours increase the heart rate. Exactly. So, uh, theme of this case is, you know, bradycardia severe bradycardia is a real risk for tor sods in the setting of beauty prolongation. So we have to increase the heart rate two ways of really doing that. Isil paternal or trans Venus pacemaker. The problem with, uh, ice support Paranal is that if you're wrong, we're assuming that this is not a ski mia related. She does have a lot of ischemia risk factors. Um, I support tearing. All infusion will obviously make that worse. So in this particular case, we ended up putting a trans Venus pacemaker in temporary. Also because she was so great a Kartika as well. From a symptom standpoint, what plans to change that to a regular pacemaker if need be? Um, but I pretend I might have worked as well. I don't think an angiogram, certainly an urgent i c. D. You would not be the indication for that. And IBM Yoda Rone really in the setting of ah ah, drug toxicity like this would be the medication of choice, but typically is not your first line therapy. Magnesium supplementation may be helpful as well. I've also also been taught lighter King may be helpful if you go back to your action. Potential diagram. I don't know if you've experienced this or not. I had the opportunity give it, but that Phase zero deep polarization that's all. Sodium channel mediated and white of Kansas sodium channel blocker. So what your essence do is you decrease that peak from going this high, And so by decreasing the people going as high, it comes back to baseline quicker you. It's around that way to decrease the Repola, the amount of time it spends in re polarization. But that would be that the other drug I might think about, in addition to what else you mentioned. So obviously, therapy decreased the tea interval by pacing faster. Avoid bradycardia, stopping the offending agent. Also, you always want to consider evaluating and being thorough for your investigation. Um, could consider doing an angiogram or some type of I wouldn't say a stress test would be appropriate at this point. But certainly some type of coronary evaluation may be indicated. If that has, you know, a significant risk factors Defibrillator indicated. No. If we reverse the cause and fix the heart rate, particularly the offending agent, I don't think of defibrillators indicated. And what about the A fib? Certainly, I think at this point we've. Our experiment with rhythm control probably was not the best option. The was a little bit on the low side in the forties range. We didn't want to exacerbate that. There is some, um, you know, there's definitely some debate as to a patient with an ejection fraction the forties. If we are going to paste them all the time, should we be doing that with re synchronization therapy versus just a standard pacemaker? Obviously we use the standard pacemaker. A leaderless pacemaker may be a great device for this person because of their co morbidity. Is the metastatic breast cancer avoiding things underneath the clavicle Infection risk? However recent leave, this device is not going to give us re synchronization therapy or having the option for that. So we have to weigh one versus the other. So ultimately, we decided to do a navy note ablation in the Bible. Particular pacemaker, a zoo, A definitive rhythm control strategy. She did have heart failure, exacerbations. That's largely related RVR. But we felt that re synchronization therapy would leave that way. Just gotta know. We do have another 10 minutes ago, I only schedule. I thought we were concluding at 12. 15. But, John, do you have a You have a case? Load it up. Well, right? Yeah. It should be on there. Patients. You great. So this is a patient taking care of over the last number of years. So it was a 46 year old man with non ischemic cardiomyopathy. His left ventricular ejection fraction was 28% You know, class three at times, Class four, chronic systolic, congestive heart failure, and a left bundle branch block. He's pushing £400. He's a big guy. Um, he had really not much improvement with the guideline directed medical therapy as much as he could tolerate with carvedilol. And, um, interest. Toe originally was on Ace's inhibitor. Switched to entrust toe when it became available, So he had a c r t implantation. And, um, let's see or look at Hiss. Um, there we look at his chest X ray. And this is the lead the CRT device that was implanted. He has a CRT defibrillator. There are three leads. There is a lead to its kind of shadowed out down here, but to the right atrium, a dual coil I c d. Lead going to the right ventricular apex. And you can see the LV lead coming out into the coronary scientists branch coming out lateral to the mid lateral wall here and you can see the Quadra polar lead. Uh, here. So he did fairly well with that, his his he experienced symptom improvement decreasing or increasing Heart failure class um, becoming better toe 12 to New York Heart Association class 1 to 2. So from asymptomatic to not that symptomatic compared to what it was before, So he would be somebody we call Responder. He did well approximately two years later with no event in there. In the meantime, he actually developed recurrent shortness of breath, was back to class three symptoms and came in front evaluation. And you can see on the left picture that you're looking at. His atrial lead is still intact. Has ventricular lead is still intact. But now his Quadra polar cardiac vein lead was no longer out here in the heart it had pulled back. And so here is the four electrodes 1234 So in the upper spc going into his other Venus structures that lead to pull back. Interestingly enough, the other leads had not pulled back. So if you it's interesting, if you know, why would that happen? So like I said, he's a very big man and doesn't do a lot physically. But does do some, you know, like the usual type of normal activities of human being would do with their arms. But with despite the other leads not moving, this lead pulled back now, could there could The suitor that ties it down to the pectoral muscle over what we call suit your sleeve. Could that suits your broke? Well, I usually tied down with three suitors, so that's not likely. Could that had loosened up over time, tying down? If, for whatever reason, if one of the suitors might have broken or was it not tied down tight enough? Usually, Um, usually, if it's something physical manipulation that he had done, we would see the other leads pull Bacchus well, So for whatever reason, his LV lead pulled back. And here's a zoom in of the lead. You can see the four electrodes. Here's the tip Electrode 23 and four right here. So he was no longer obviously receiving CRT therapy. Why he worsened. As it turns out, he was reluctant to go through another surgery. His symptoms worsened to the point where he decided to go through ah, lead revision and the chest X ray as his symptoms worsened and he did not want to go through the surgery. We now see that over even more time. His LV lead not only is no longer in the vein here or back here, but it has completely wound up into his pocket. So as we zoom in you can see Here is 123 and the fourth electrodes right there. So this lead not only pulled back, it pulled back all the way into the pocket. Now, sometimes we can see this when we have what we call it twiddle er which is, or somebody twiddling, which actually happens. Fortunately, not that often, but where a patient will manipulate their device, Pacemaker or defibrillator actually turning it around and around now, after people hell, if they're fairly large or there is very soft elastic tissue, People can do that without causing much pain for themselves, but it obviously can pull the leads out of the heart. This is not consistent with twiddling, because what we see is the leads wrapping around one another all twisted up together, and it would have affected more than just this one lead. So we don't see that if that's a question you might have had in your mind. But for whatever reason, his lead pulled entirely back into the pocket. Now, if you look remember that video I showed you of the active fixation lead you when that that lead was out in the vein and we were looking with a camera out into the vein. You can see the heart movement because let's remember, this vein is on the surface of the heart, the outside surface of the heart and Picardy Lee. It's that movement. Could that have caused this lead to work its way back and then work its way out of the coronary Sinus? And that could have been one of the reasons for dislodge mint. But probably the issue was either the vein was big and the lead, even though it has those curves to help it stay, that's not enough. Or there was something mechanically up here that the way his device was sewn down, I did it. So I know I think I did it right, because the other leads didn't move, and that's how we normal. I normally do things. They didn't do anything differently. But for whatever reason, that lead pull back. And so how do I know that when I was done correctly the first time, how do I know that leads not going to do the same exact thing so it could? And then every time we open that pocket, this person is at risk for infection and his nickels and told you when there is an infection, no amount of antibiotics cures it. Everything has to be removed. So we not only don't help him, we don't protect him anymore either. And so our options are to consider in the past have been to consider an epic cardio lead where cardiothoracic surgery does. Athor economy spreads the ribs, exposes the EPA cardinal surface of the lateral ventricle and puts the lead directly on the outside of the heart screwing that lead into the heart muscle. Um, the other option is now we have this active fixation quad same Quadra polar type lead with an active fixation mechanism on DSO. That's the option we chose to go forward. In doing so, the active fixed lead was placed and actively fixated to the vein wall. Now what's interesting about this guy is I mentioned very large man, and it's mostly out of post. He's that's muscle, and he's a big man, but almost £400. Well, Anesthesiologist delivered him back to the recovery room, and the nurses were watching him, and he was laying there, breathing on his own, and all signs were that he was waking up, but he clearly wasn't awake from his anesthesia and he jumped out of bed, was walking around the recovery room Barenaked, but hanging out through his gang of all the other patients but didn't realize where he was or what he was doing. And nurses were trying to help him. He was swatting them away like they were flies. And I got called into the recovery room and I looked and I the first thing I thought was I hope that nurses, okay, that's lying on the ground. The second thing I thought was down that lead is not going to stay No way. Even after we placed this new active fixation lead, we ended up. I ended up having to get a chair put behind this person and sort of sitting him down, which actually took out my back for a few weeks to. But eso enough people were like concern. We had to help this man. He didn't know what he was doing, and within about 20 minutes, just laying there, he woke up going, Hey, that was great things I don't feel a thing is there's like a path of destruction around the recovery room from him, but a few minutes later. He had no recollection of this event. So I thought for sure I don't care what type of fixation mechanism, the way his arms were swinging around, flailing around. I thought there was no way that that lead would stay in place. And so this is the chest X ray we did in recovery room after that. And sure enough, you can see that I placed this new active fixation lead out into a vein slightly different. His other vein was over here. I thought maybe it was something about that vein. So I chose a slightly different vein again, going to the left lateral wall. You can see 1234 electrodes. But when I zoom in 123 fourth electrode, here's that active fixation helix that really tightened that lead down in that vein. So I believe that that's kind of what it endured in a few minutes after the procedure. I think is going to be a very hopeful sign and he's doing better. What's gonna of how this will stay for him? Long term? That's a pretty good stress test. Yeah, How recently was that? Uh, that was just, uh, six months ago or so seven months ago. And he's actually still doing well, so he hasn't passed a two year test like he did before, but I think it's gonna be fine. Did it Did the symptoms get better? Yes. Yeah, he improved back to where he was. New York Art Association. Class 1 to 2. Good. Good. All right. Uh, yeah. Anybody doesn't have any other questions. I think we'll wrap with that. Thank you, John. Thank you, Nick. Thank you. Everybody who put the conference on and I hope it was worth your while. Thanks, everybody. Have a good afternoon. Published February 5, 2021 Created by
