Good afternoon, all. My name is Anish Amin. I'm one of the electrophysiologists at Ohio Health in Columbus, Ohio. I'm the assistant medical chief for electrophysiology, and I have the distinct pleasure of talking about solutions we're using to extend arrhythmia care beyond PVI back home. I wanted to thank Vector Medical for inviting me to deliver this presentation. Forgive me here as I try to advance this. There we go. Couple disclosures. All right. So what are we here talking about during our lunch break? Basically we're all here to try to leverage the vast amount of data that we have at our fingertips that are underutilizing in daily practice. The most concrete example of that is the 12-lead EKG, which we're all quite familiar with and have used for decades to try to understand arrhythmia etiology and help guide therapy, particularly in the lab. What Vector Medical and the VMAP does is it's trying to use a forward modeling algorithm to help us understand the origin of a whole host of arrhythmias. It was validated in a pivotal study, which was published in 2022, essentially looking at the primary outcome to delineate the underlying origin of PVCs and or VT. So 225 patients were evaluated. Half of those had a procedure that was completed for PVCs or VT. The solution was able to appropriately articulate the region of interest in 98.7% of those arrhythmias confirmed by the contact mapping done at the time of the procedure. The secondary endpoints, as delineated here, also reached a high level of success, and they were related to identifying the origin of other arrhythmias. So as I said, the first endpoint was ventricular arrhythmias. The second endpoints were, can you identify where atrial arrhythmias are originating from? And then the second, let's call it secondary endpoint B, was saying, can you be more focused than just the region? Can you actually dig into the subsection of the atrium or the ventricle? And again, a high level of fidelity. On average, VMAP was able to localize an arrhythmia within 1.5 centimeters of its ablated focus. And the mapping time, the VMAP time is what's incredibly relevant here, takes less than a minute with an overall spread that was between 30 seconds and a minute and a half. So a highly reliable, reproducible solution that we can complete within about a minute time frame. Okay. Why is this all important? Well, as I said, we have a tremendous amount of data at our fingertips that we're underutilizing. We've gotten incredibly efficient at therapies. So today, most of us now are using single shot PFA solutions to manage patients with atrial fib. We're seeing a vast number of patients being referred because of increased efficiencies, improved safety, and improved workflows to deliver those therapies. What we're forgetting is that as we do more interventions, and especially as we think about patients that are more complex than our PAF population, we're going to start to see recurrences. We're going to see recurrences initially because we have potentially reconnections of the initial ablation set, and I'm describing to you here the degree of reconnection that may occur with a simple PVI. Most of us recognize this as being between 30 and 40 percent of individuals who come back for redo will have at least one vein that's reconnected. But more importantly, we have to understand what are we going to do with the vast number of patients that are treated with today and tomorrow's PFA solutions who are coming back with more complex disease states. There are certainly going to be options to use intra-procedural mapping, contact mapping, and as we build science around that, we want to understand when those may be applicable. But we also want to help understand if there are solutions that are simpler, that can be used in a clinic setting, that can be used in a pre-procedure area that will help us triage patients and build a therapy plan for them before they actually get into the lab. So I wanted to share a couple of cases with you. This is a patient of mine who's referred to us following a maze procedure. They have persistent type atrial fibrillation. We allow the VMAP to take shape prior to us actually introducing catheters. We can see that we complete a right-sided heat map. And what I want to describe is we highlight the right atrial appendage, an area around the right atrial appendage. Similarly, when we use a intracardiac persistent AF algorithm, in this case the Occam algorithm that's available on the Arrhythmia system, we see areas of continuous activation that overlap with areas that were identified on the non-invasive mapping. This is the same patient now looking at the left atrial structures. And again, we see that our intracardiac continuous activation areas along the posterior wall coincide with what the VMAP is able to generate for us. And interestingly enough, this patient, as I said, who's had a maze done previously, has durable PVI, and the VMAP demonstrates, in fact, that they also have durable PVI. So before we actually complete a full chamber map, we already know that our ablation set is going to have to focus on something outside of the pulmonary veins. So I'll show you another example here, redo atrial fibrillation case. In this particular example, what we see is that VMAP is highlighting that there's continued conduction within the pulmonary veins. In this setting, we'll complete our contact map, and indeed, we demonstrate that there is continued conduction within the pulmonary veins. We're able to focus our application and our therapy towards those structures, and again, we're able to plan our procedure prior to actually completing an invasive map. Lastly, I'll share with you a case of sort of a nontraditional activation. So a patient, again, in a redo setting with persistent atrial fibrillation. The VMAP demonstrates activation along the floor. In this case, the patient has a successful intervention towards the floor and converts the sinus rhythm, in addition to which, if we go back and look at the right atrial structures that are involved, again, along the base of the right atrial appendage and just down the crista, we're able to successfully intervene on those sites as well, and one more time, demonstrate that what we see on the noninvasive mapping correlates with what we see as areas of interest on contact mapping using traditional solutions. And I should note that an abstract towards this end was presented at HRS last spring using 25 patients who had completed VMAP-guided ablation compared to patients who had not, demonstrating roughly about a 40 to 45% improvement in their six-month arrhythmia-free survival. So there's a lot to gain from noninvasive mapping, and certainly I think that as we look towards the future, increasing patient populations that we're asked to manage, we're going to have to come up with ways to, one, triage patients, two, to plan effective strategies for therapy, and three, build on the science that's been done so far to help us understand which and how many of these areas of interest on a noninvasive map really do need to be addressed. Our goal, of course, is that as the interventional solutions become more and more efficient, it's to help focus that efficiency in a way that isn't just ablating more, it's ablating the right things at the right time. Thank you.

arrhythmia care

VMAP

forward modeling algorithm

noninvasive mapping

electrophysiologist