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13 Jan Session 2_Recording_1

[SPEAKER 1]: This group was the same, so when we do not see non PV3, pulmonary vein were
isolated in the areas that our patients see a dissociation were isolated, the outcome were the
same were the non PV3 were seen and ablated. So that’s something that’s very important, and
this is our strategy. Now, in the group of patients were none PV3 get by, not detected, the
presence of PV isolation. What we saw is the rate of pulmonary vein reconnection over time
dropped, and probably the most significant dropped corresponding with the effect of contact
force. I think the contact force, is going to be an effort in the coming year, to make our priority
more avoidance of non PV3 trigger, because we are going to do a better job when isolating the
pulmonary vein and we are going to have to deal with this type of scenario.

This is a typical example, assuring, this is cryo, with defective pulmonary vein isolation
that are triggered from the coronary sinus. I want to remind you this this I show you yesterday,
even paroxysmal, overtime, you are going to see patients coming back ten, seven, ten, fifteen
years after, with defective pulmonary vein isolation, where they now have developed over time
non pulmonary vein trigger. And the most common location in our experience are in the
appendages of the coronary sinus. So clearly attention to trigger is important, take a few more
minutes to make this point, which is about the prevalence.

The prevalence in the latter should vary, extends in the… the difference is the definition,
so, in this paper from the pen group, the prevalence is the same across the board, obviously this
makes no sense, because that we know that on the long standing we’ve more non PV3 that are
responsible for failure after you isolate the pulmonary vein. The definition of this paper was “too
conceited, inductional or sustained arrhythmia under I2 or isolated outcome”. In our experience,
usually all the non-paroxysmal, every non PV3 appear, but our definition is PAC the taquencies
and we have a number of 10 e-, but if they are consistent we take less in the absence of
pulmonary vein reconnection. So, the definition is pre-TR, and I show you a… this population. If
you know our PC, our detrimental can be to patient follow up.

I guess it will have time to go to cases so I’m going to… there’s a few examples of
patients. I think the only one that I want to, maybe, show you, is this. Because we still, despite
the report in this, in 2004, we still see a lot this expression, this expression is the many, many
pulsed ablation. And the, despite they continue to… arrhythmia, you know. So, this is a, I’ll show
you, this is the one that I’ll show you. This is the underlying situation so, despite the many, many,
previous procedures, the… all the ignored persistent left superior vena cava. When you have this
anatomy, if you don’t target this anatomy, you will never be successful. You can cap and bond
the liftation right and left. This area is responsible, you need to address it, and the best way to
address it is by cutting the circled map in catheter in the structure, then doing isolation, as we
do for a pulmonary vein, and this is the number of lesions that you might require to do that.
Those are the white dots, so it’s not trivial, but this is what you need to do, otherwise, you know,
this machines are going to come in back with some tachycardia, some form of organised
arrhythmia, and the best way to do that is not to ablate with the ablation catheter, you have the
lasso, in this structure; use the lasso as you are guiding the catheter.

So, we’ll stop here saying that in patients’ recent recordings, after multiple fail PVR, it’s
prior to the reconnection, non PV3 were responsible for a feedback recession the majority, and
placing the trigger results to a superior position outcome. The present of permanent PV isolation
in non-PV3, in no evidence of non-PV3 were on I2 or isopropyl on in PV for isolation of the left
atrial appendage, CS, provide an aid to an enhanced survival, and we have observed extended
cryo in the rate of PV reconnection over the years, mostly in conjunction with the event of a
counter force. Thank you very much.

[SPEAKER 2]: Thanks you very much, Doctor XXX. Thanks for talking now, for the occasion and
coming, riding by the 102. [05’ 00’’]

[SPEAKER 3]: Thank you Dr. XXX that’s a great presentation. My question for you is when is
enough, enough. And there might not be an answer for the question, because I think there’s no
place were the need to individualize becomes more apparent than the need for repetitive
procedures. But if you have thoughts about what triggers your response, you know, that’s
actually really time to stop, if they often ignore it.

[SPEAKER 1]: You know, I, as you’ve seen and we all almost have all those patients that came to
us after four, five, six procedures. And I said, mentioned, many or some of them were post-
maze. I think I look at that mostly based on what was done before. So if they do pulmonary vein
and just linear lesion, usually we’ve seen that a few are willing to target the appendage, yes,
with many of this patients we achieved good results. I always tell the patient they can take 2
procedures, in our experience, even in the best ends, in two procedure is about 40% for those
just for the appendage and CS. It’s mostly driven by the symptoms, you know. If your patient
comes with recurrence about I’m fine. It’s the same way when I see somebody for the first time,
and every known symptoms, you know, what benefit are you trying to get? What are you trying
to get out of this? But if they come back and their life, their quality of life is affected, I think if
you feel you can do something, because of the experience or, I mean, that with those patients.
I don’t have a limit, even in the event of post-mazed, usually the findings are the same.

I show yesterday the team, after closing the appendage, epicardial, it is always a poach,
which you are found to be up too much xxx, also the CS, many of the surgeon on team G mean
cough, that it’s a bit strong after he has done a good job in trying to target the CS. But it’s not
easy, most of the surgeons don’t do anything, that’s a very common source of recurrence in
post-maze procedures of, sometimes focal tachycardia so, I think if you feel comfortable, I don’t
set a threshold as long as they feel that they can do something. If they have a good procedure,
or if there are no symptoms then, I mean, you have to take a look at the patient, individually. If
their life is affected, I don’t think there is a limit as long as you feel comfortable.

[SPEAKER 4]: Okay, alright. Can you clarify, in terms of your protocol for looking for this non
common made triggers of inducing them, in terms of …, what is the dose of isoproterenol you
use and then, are there all patients are they all off antiarrhythmic drugs or off beta blockers,
they are on beta blockers, they are on antiarrhythmic drugs? Can you clarify what’s your
current…?

[SPEAKER 1]: Yes, those are very important questions. They are all off antiarrhythmic drugs and
beta blockers before. If they are in a miodrag (¿?¿?), we try to get them off the miodrag on three
to four months, we usually try that using tikosyn, which is the best, the best alternative to a
miodrag. So, we try to avoid any subtle interference that, from…, seeing as much as we can, and
the protocol is very important. So when other difference from the pen group is that the pen
group ties traits, and you end up staying at I2 for 5 minus, that’s not enough, we go straight to
30 minus for at least ten-fifteen minutes; and then in some patients we go to 30 minus if we
don’t see a good read response. So, that’s, all the things we mentioned are really important, a
critical factor in increasing the chance of death. But, I don’t want people here to think that
isoprene is the one other percent triggering strategy. Because it’s not, the effect I showed you
out of many descriptions, we have no evidence on non PV3 catheters, and those cases where
the pulmonary veins are isolated, we now have enough data to support those traits to… the
appendage and the CS, and usually we have good results with that.

[SPEAKER 5]: Yesterday’s live cases showed that… how difficult it was to isolate the left atrial
appendage, you can get RF, the reconnection peculiarly was happened. So the question is, let’s
say you do isolate the left atrium appendage, and then, either imped in going or you get some
focus on the con there, and then later on they repeat procedures. You have any data on what is
the reconnection rate?

[SPEAKER 1]: So as we’ve mentioned before out of ten patients, 40% chances of two procedures,
for appendage and CS elong, 40%, yeah.

[SPEAKER 6]: So, 40% the area of PV isolation case in current as the repeat procedure? [10’ 00’’]

[SPEAKER 1]: So 40% of the time we need a second procedure to achieve a permanent isolation
in the appendage and the coronary sinus. Even with high power, you know, the sort of strategy
that we put together, that doesn’t mean a failure. This is our total measure

[SPEAKER 6]: Okay.

[SPEAKER 7]: A question, yeah, a question. If the isolation of left atrial appendage has proved to
be important in some patients, why not make a large left wide connection?

[SPEAKER 1]: Yeah this integrates. You cannot isolate, I mentioned that yesterday, you cannot,
it’s very difficult to isolate the appendage by making large or linear vision around it. You really
need to stay at the ostium. I have people calling me, so you know, we deliver when I enter the
lesion around and we cannot isolate, you need to straight the lasso, remark the ostium, stay at
the ostium. If you go outside neutral tissue, especially in men, it’s extremely difficult. You can
abolish all the electrograms, you go inside the appendage to not isolate it, so the best strategy
is to move the side mark mapping at the ostium, and going at the ostium through the appendage
otherwise it can be even more challenging.

[SPEAKER 8]: Okay, thank you very much. Okay, we now have no more time that ends up the
session. Okay, now I move into another very interesting topic. Dr. Robert D. Patrouala, from the
Silicon Valley cardiologists xx xx xxxx x, how to improve the speed and the physicians’ side of
operations while creating safety and effectiveness.

[SPEAKER 9]: Good morning, NAME SURNAME, thank you for this opportunity to speak today.
So the topic of the talk that I’ll be giving today is improving the speed and efficiency of F ablation
while maintaining safety and effectiveness. However, I’d say that this are not mutually exclusive
concepts, I think there are many choices that we can make with this procedure, that not only
improve the efficiency of what we do but also improve their safety and effectiveness.

I think that we all agree that all procedures expose to hazards both patients and
physicians. On the patients’ side, long times over general anaesthesia, long left atrial access hard
burnt the left atrium, can increase the complication rate. On the physicians’ side, others don’t
have to look fat to find a colleague that had an occupational hazard at some point related to
long procedures either back with the PV type issues or related.

So a pack of six hundred physiologists from California we’ve done, upwards, over five thousands
AFIB ablations on the last decade plus, a trial issue with our experiences around the value
proposition, that we can actually make things faster and in turn, make them safer and more
effective. This are my disclosures, so, we’ve learnt over the last decade or so that there’s three
important moments leading to a safe, efficient, effective procedure.

The first two procedural work xx, and technical moments, were covered during my talk,
but the third is actually equally important, and that’s running ancillary support. EP and AF
ablation is a team sport, and in order to have a very efficient aid and get to this cases quickly we
need all these pieces on mind. So we need cardiac anaesthesiologist when engaged, available
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