CNA Conference - Brian Tilton - CNA mapping: pearls and pitfalls

And what we're gonna do now is hear a little discussion from Brian Tilton. Brian is not an official part of our agenda today. There is no CME available with his lecture because he works for industry. And uh therefore, this is really just going to be a fireside chat. With Brian. Brian is my mapper as an industry rep, and he is phenomenal. Um, and if you don't have a Brian and you're trying to do CNA, you're gonna have a heck of a difficult time, so you need to find one. And he has a lot of good advice and for anybody doing this or any technicians now, uh, we wanna hear what he has to say on CNA mapping, pearls, and pitfalls. My name is Brian Tilton. Uh, I'm gonna be talking about the, uh, mapper's perspective of CNA. Kind of the pit pitfalls and perils. Uh, I wanna thank Doctor Clark and Doctors Patone. Uh, for inviting me to this meeting. So without any further ado, So, uh, one of my disclosures, I am actually, uh, an employee of Abbott. So I just kinda wanna give each of you, uh, my disclosures here. I am by no means providing any sort of uh guidance by Abbott. Uh, all of my guidance here is through uh personal case coverage with Doctor Clark uh and some of my work uh with Doctor Patan. Um, understanding CNA, uh, kind of the idea, what we did is when we started. To talk about wanting to do these, uh, we reviewed several publications, several articles and techniques, uh, to figure out where and how, uh, we came to, uh, where we uh are within this procedure at Akron Children's. Uh, we wanted to familiarize ourselves, uh, with other etiologies of syncope, the structural components, the anomalies, as well as the other mechanisms. Uh, so here you can see there's a few articles, uh, the top physicians that, that we kind of, uh, reviewed all their publications and came up with what we came up with. So steps for CNA, uh, you know, our big thing is make sure you do your homework, uh, understand and try to identify if there's any other root causes, uh, uh, for the patient's syncope. Uh, we want to understand the anatomic locations of interest, uh, go through our signal analysis, identify the high frequency locations, uh, versus the low frequency locations, and then we correlate those with electroanatomical mapping. Um, and then we want to also discuss the endpoints, so the pharmacological, the physiological, as well as the, uh, vagal stimulation. So, these are gonna be the things that I'm gonna review, uh, anatomically. This is kind of a nice map uh for us based upon a collaboration of the GP locations from the list of physicians as you can see here on this slide. Um, each of the, uh, ganglion plexi insertion points into the heart, the GP locations in the heart as well as the P point. Um, familiarize yourselves with these locations, uh, each of the GP's effects, uh, on the sinus node, the AV node. Um, again, this is, uh, uh, a start point for you to identify and, uh, to map your high frequency, high frequency signals as they correlate to these GPs. So in reviewing the signals, uh, what we found to be very helpful in identifying, uh, electrograms in the high frequency zones is to, uh, add a different fast filter, uh, 200 to 500 in our high frequency analysis and not necessarily looking at these signals in a traditional 30 to 500 analysis. Uh, as you can see in this slide here, uh, in our high frequency, uh, those signals pop right out at you. Um, makes a huge difference. Uh, next slide here. Uh, this talks about everyone's seen the kind of classic, uh, Doctor Picon, uh, vagus stimulation illustration and how they use fluoroscopy. Uh, we've kind of identified additional methods, uh, to, to access the vagus. Uh, as you can see here is a picture of echo. Uh, we use echo guidance through the neck. Um, it, it kind of eliminates the guessing as to whether or not we're in appropriate vagal contact. Um, I'm here. We have Uh, the addition of Our mapping, uh, we don't use fluoroscopy. You know, fluoroscopy is pretty good for understanding superior inferior view. Uh, Navix helps us to provide our superior and inferior view. And then again, uh, the additional uh utilization of ultrasound of the neck, it, it provides us true visualization, anterior, posterior, and if we have a catheter in actual contact with the vagus uh for that stimulation. So what our map is showing us here, uh, the true 3D geometries, there are some limitations, uh, I'll kind of talk about that a little bit. Um. Next slide. Uh, our expectation with the, uh, extra cardiac vagal stimulation. Here's an illustration of uh uh the importance of good vagus contact. When we stimulate the vagus with 50 hertz and you may, may not be in complete contact with, with the vagus nerve itself, you do get some slowing, uh, but then when you get into better contact, uh, we get true sinus nodal pause of the noodle. Uh, here's another example of a nodal pause, uh, with good contact. And again, I can't stress enough, uh, adding echo to your mix, uh, in which Doctor Manu will talk or have talked about, uh, provides in, in our, uh, understanding of where we are. Uh, so, mapping, uh, settings and like I said, this is kind of the mapper's perspective here. Uh, there's a lot of technical setup in this slide. I'm happy to kind of discuss, review with, with any mappers or any physicians. Uh, I'll have my contact information at the end. Um, bottom line, a lot of our settings to start are very tight, uh, meaning we really want to be able to get. A, uh, a good look at, at true conduction through both the right and left atrium, uh, to have a nice accurate dense map. Um, we utilize the auto map features, and give us the ability to adjust those on the fly. Uh, we adjust the score and the cycle length. Um, Obviously, many of you may notice when you, you're mapping around the insult to the, the atrial tissue kind of changes some of your scores. Uh, we can go as low as 60, 70% in our scores and sometimes remove the cycle length, um, but that's very rare. We, we try to maintain our settings. Uh, so that we can again. Get a full continuity of electrical conduction of the heart from right atrium left, left atrium. This is, this is to reduce the error of data collection. Uh, and again, to introduce any sort of high frequency signals that may be artifactual in an area where typically be low frequency signals. Um, we like to also make sure we have atrial electrograms, uh, comparing our apples to apples and oranges to oranges. Uh, we will put in an esophageal, uh, electrode to give us the, uh, atrial electrograms and a nice stable reference. Um, we tend to map the right atrium first identifying the sinus nodal endocardial location. As you can see, uh, I'm not sure if you can see my arrow here if I included a laser. Yeah, sorry, uh, but the black circle, uh, is our earliest sinus nodal, uh, breakout point within the endocardium. Um, we're able to sort out our good points and bad points and then create a yellow brick road. You can kind of see some yellow outlines here, uh, near our, our lesion sets where we identify our high frequency signals. Um, it's important for us to understand the anatomy, the area of the sinus node. Make sure you, uh, understand the sinus nodal artery location, frantic stimul locations, uh, in which we have marked out in the blue. Um, and all of your very important, uh, anatomical locations for him and his coronary sinuses and etc. So then, uh, during uh the setup for the transeptal procedure, I am cleaning up these maps. Uh, again, I, I talked about how this is kind of a collaboration between myself, the mapper, and Doctor Clark, the, uh, ablationist. Um, so, some of our auto settings, we, we like to use these auto settings, uh, to analyze, uh, impedance declines, uh, 10 ohm, 20 ohm impedance decline. We usually ablate uh 35 watts with 10 g of pressure, and we want to watch, watch these declines of impedance. I want to make us, both Doctor Clark and I accountable for the dots that we're placing and not necessarily just placing uh dots for no reason at all. Uh, this is just kind of a little bit of a, a product plug to some extent, uh, but we do find that the grid is able to provide us directional data, uh, whether you're utilizing, uh, Omnipool or just the fractionation software, and it also gives us the ability, uh, to see when the grid is in contact with the tissue and pushing. Uh, you see that, that flexing or pressing of the grid when you're in good contact. Uh, that cross-directional data is very important in the analysis of, uh, the high frequency versus low frequency signals. Um, you know, if you had a linear catheter, you're not, not necessarily going to be able to see the, the delineation between the low frequency and high frequency. Us, uh, being predominant pediatric, we will use, uh, 5 or 6 French 222 Decapo catheter, uh, to map these out. So, uh, just kind of nitty gritty here, uh, we're gonna review the continuity. Again, as I talked about the continuity, the electrical flow from right atrium, left atrium, identifying the sinus node, which was marked out, uh, it was a black circle. Uh, we marked the frantic nerve stimulation areas. Uh, one thing I, I failed to mention back in the, uh, vagus stimulation. Make sure you're doing your vagus stimulation with patients are paralyzed when you're assessing the phrenic nerve, the patient is not paralyzed. So again, we want to identify structures we want to stay away from, we want to identify structures where we want to ablate which correlate with the known GP zones. Um, so, this map here, we have a sparkle map with the continuity of electrical activity, uh, an overlay of our, uh, fractionation map which our scale here is anything greater than 10, uh, is white, so those white islands are greater than 3 deflections, and then I, uh, provide an additional additional fractionation threshold of 5 depolarizations, uh, which you can't necessarily see in this slide too well. The next slide you'll see. Uh, which, which helps me to, uh, kind of work my way down, uh, on the, on the basis of the density of the, the map points. Uh, next slide. So, this next slide will kind of go through the, the reviewing of true high frequency signals versus artifactual, uh, as well as me as the map or deleting uh the low frequency signals in which the computer marked as high frequency. So you can see the sparkle map here, uh, the black outline is uh on the removed right atrial geometry. Uh, you can see the white dots are deflections of greater than 5. The white islands are deflections of greater than 3. You can see the high frequency electrograms here, which are true high frequency electrograms. I switch between the fractionation and the activation timing because the fractionation will put up little yellow tick marks and sometimes it's hard to see the EGMs. So you see me kind of gaining up, gaining down the electrograms and selecting the electrograms outside of the known GP zones in which the computer marked them as high frequency, and I'm deleting or sorting those out. Now this can be a bit of a nightmare if you have OCD. You would want to delete these things out. But in a matter of time, a lot of times we do not delete those out. We know those to be computer erroneous. So you see me marking out here with my yellow brick road, the area of interest for the GP zone that we need to target. Um, and then we proceed on, on to the next. So once we're sorted out and we identify the zones where we need to ablate, this is pretty typical of what we see when we ablate. Uh, we come on, uh, within the first lesion. The first lesions we usually do outside of the right superior pulmonary vein septally. Um, you see the baseline cycle length was 840 milliseconds, and, and you tend to see, uh, the changes up to 630 milliseconds in the rate. Uh, here's a map of our final P point locations. Again, as I said, we're outside of the right sphere pulmonary vein septally. Uh, we will trace this all the way down to our transeptal location. This will basically eliminate all those P point GP uh locations. Another thing to point out again from an OCD standpoint, we, we did not feel the necessity to make nice pretty pictures. I wanted to show some realistic pictures here and the fact that the computer has some limitations, and we don't really care about these points on the anterior LA wall because they're not necessarily correlated with the GP zones. Uh, so now here's a nice cleaned up, um, timing map, uh, in correlation with fractionation. Uh, the fractionation is representing, uh, greater than 5 deflections. So you see your white dots in this left lateral view, uh, in the typical P point zone. Um. The lesions are added to, uh, so, so we provided the P point lesions on the left side, we added the lesions on the right side. Um, and identified the additional fractionation zones, uh, that were also identified down here from the coronary sinus, uh, back to Eustachian Ridge. End point Uh, so this is just an example of what we would see as an endpoint with extracardiacc vagal stimulation. Uh, you can see there was a small amount of slowing, but comparatively to the beginning of the case where the patient had sinus arrest, uh, we would consider this a successful endpoint. Uh, effects endpoint, we tend to see the Winky box cycle length change within about 10 to 15%. Um, so in this particular example, we had a 12% change. Additionally, we'll see a heart rate change, uh, pre and post procedure. This particular patient, we had a 15% change. Typically, that's about 10 to 15%. Um, pharmacologically, uh, what we will do is we'll give atropine of 0.04 mg per kilogram to a maximum of 2 mg. At the end of the case, so you can see that this particular patient's cycle length was starting around 720 and then two minutes post, uh, there was no change pharmacologically. So, uh, in conclusion here, uh, just again, the, the mapper's perspective, uh, you know, you need to do your homework. You need to make sure what tools work best specifically for your patients, the size of your patients, as I mentioned, sometimes we don't always use the grid. The grid is optimally what we would like to use, um, but, but we can't always do that. Um, adopt your techniques. You should make sure you're adopting techniques not only on the basis of what you as the physician or you as the mapper, uh, do. I think, uh, that's something that Doctor Clark and I have, have really worked out well, um, uh, to, to do what's best for our patients. Uh, you know, the doctor-driving catheter and the mapper, uh, also need to, to collaborate, but they need to communicate. Uh, so, Anytime I feel that there's ever not enough dense mapping points, I'll ask for more points in a particular area, uh, from the doctor, uh, and, and likewise, he'll do the same with me. Um, you know, I also mentioned about the, the world leaders. Uh, when we decided to, to do this, it, it took us about a year to make the decision not only from, from reading the, the materials, reading the publications, but we reached out to a few of these guys and, and actually did some site visits. These, these guys are very open to communication and, and wanting to discuss, uh, and, and do teleconferences, uh. And so on. So, my big thing is, uh, don't, don't just be taking your drive off of Twitter, you know, make sure you, you go above and beyond. Um, you know, the futures, we don't really have much experience right now with omnipolar technology. Uh, some of the other signal processor companies that are out there, I, I would like to see, uh, what additional things they could provide. Um, you know, make sure you know, uh, the completion processes, whether it's a pharma pharmacological standpoint, uh, vagal stimulation standpoint, where we feel the vagal stimulation process is kind of the gold standard. It gives clear dramatic effects pre and post, uh, as far as the heart rate changes, Winky pox cycling changes and, and so on. Um, you know, I, I think people should really also be thinking about, uh, vagal-mediated atrial fibrillation. There's a lot of you that are out there doing, uh, just atrial fibrillation, um, and seeing if maybe there's a need to incorporate, uh, some of your GP ablation, uh, in there as well. And finally, uh, we like to keep it off the, uh, KISS principle, you know, keep it simple, Simon, uh. Uh, as far as the procedures go. Um, so again, here's my information. If anybody has any additional questions, want to read it, reach out to me, uh, Uh, feel free. Thank you. Thank you, Brian. You know, when I, when I first went down to visit Doctor Pashan, I went by myself, and uh, you know that, that first trip convinced me that this was the way to go, but it also made it clear to me that this is not a one-man production. Um, that there are definitely people who have to give you the information to allow the person holding the catheter to do the procedure. And so I twisted Brian's arm. As the best mapper I know in Northeast Ohio to, to come learn this, and I'm very thankful, very appreciative that he did. Um. We have One question, and Brian, this may not be a question for you or me, from Juan Carlos Jurado. How to prevent injury in sinus nodal artery. And uh so I think I'm gonna lean on Doctor Pashan for that one. Yes, uh, the, this, uh, aspect is extremely important and is a good thing for members because, uh, one possibility of to, to have lesions of sinus node artery is to do, uh, when you do, uh, a continuous lesion from the, the, the area one that is located in, in higher position in the superior than a cave. And if you do ablation uh uh continuously until the interator septum, the right interator septum, it is, uh, in this moment, it's possible, it's more probable if you, you have, and you, you will need to be closer to have a, a lesion of the sinus nodeal artery. So, OK, it's necessary that the physician pay attention of this and it's very important, the mapper to call attention of the physician. In order to avoid this kind of uh application. Uh, obviously, there are several anatomical uh uh uh variations from one patient, from one patient to the other, but it, it, it, this, uh, this approach is very important to avoid this kind of lesions. Do you feel, uh, you know, in those particular anatomic locations that you want to be wary of, right? So the area of the sinus nodal artery, like there are triggers to be looking for. Uh, for example, would you start to see a heart rate deceleration, deceleration. Yes, yes, yes, it, it is a, a bad sign. To have the reduction of uh half rate. It's a, it's a, it's a dead and we have to take care about it. So another comment from Nestor Lopez Cabanas. We like to highlight the probable area of sinus node artery in the fan map to avoid sinus nodal artery injury. Yes, I think it would be very interesting to, to, to have in all cases and uh tomography. Of the sinus node artery. I think it would be very interesting, but mainly in patients with a small patients that is easy to, to, to, to prone to have this kind of lesion. So, and I, because it's very difficult to, uh, to suppose the position of the artery of the sinus node, but obviously, we use the as much as possible, the tomography in order to see the position of the artery.