Hi, everybody. Welcome here from HRX in Atlanta, 2024. I have with me here Anish Amin, one of the premier up-and-coming EPs in the U.S., and maybe globally soon, I don't know. But Anish have been one of the drivers when he was at Ohio State, and now he's the head of EP at Riverside, Ohio Health Riverside. I have him here today to discuss this new exciting innovation in ablation of AFib. Some of you heard about this already, maybe, the vector medical, a new concept of looking at triggers and sites of initiation of AFib. And there's no better way to understand this technology and where we are today than talking to somebody who has been using it extensively and for a while now. So welcome, my friend. And tell me more. Tell me more about vector medical and the concept you're working on. How is this being applied today in your practice? Well, thank you so much, Dr. Maroosh. Thank you to Vector for organizing this event here at HRX. The solution that Vector is proposing is actually using a 12-lead ECG to help us understand the etiology drivers behind common arrhythmias. So before the broadcast, we were talking about the primary intent, which was for PVC and VT site of origin. Most of us would say we can readily assess a 12-lead ECG and regionalize where VT or PVC is originating. Certainly I think in the atrium, as you have described over the last two decades, understanding the origin and the driver of atrial fib is... That shows a real-time version here. Exactly. Understanding the origin drivers of atrial fib, complex atrial arrhythmias can be more difficult. The way Vector works essentially is using previously simulated ECGs and previously described models of scar and conduction velocities in both the atrium and ventricles. It will recognize a patient's ECG and try to forward, derive where an ectopic focus may be. What's exciting about this, as you know, we have a lot of models that came to life over time helping us to ablate persistent a-fib or even persistent a-fib rotors and so on. What's unique about this, what I like, the simplicity. All you need is 12-lead ECG. Tell me how did it help you improve your ablation outcomes in your lab? You nailed it. Simplicity is what this is all about. There are certainly solutions that have been shown to be effective but require invasive mapping, long procedure times. What we want to try to do is we want to try to improve access for our patients for interventional therapy but we want to have it be the right access. We all see patients who have persistent a-fib, redo, redo patients. The strategy for ablation is difficult to identify. We're able to use a 12-lead ECG completed in the lab, maybe in a non-invasive room within the lab and understand whether there are areas of interest. Maybe it's a posterior wall, maybe it's a right-sided area of interest that we can target. Maybe there isn't a clear focus that we can go after. It helps us risk stratify patients, gives us some ability to plan what the intervention is going to be and overall improve the efficiency when the patient is actually on the table and we're completing the intervention. For you, for example, you and me have been doing this for a while. You just told me that you graduated in 2015 from one of the major institutions in the country, Ohio State University. We've been struggling all along for the last 24 years, I can tell you my experiences since we started this in Cleveland, with persistent a-fib patients, trying to find the real solutions, especially this patient population, let alone paroxysmal a-fib. How do you see this connecting? Obviously what I see here, is it throttles, is it drivers, is it triggers? How do you see the value of this improving ablation success in this specific patient population? Well, again, I think it's all about risk stratification. We're in a new age of ablation. In fact, I think many of us now are not only impressed with the efficiency of PFA solutions, but we're probably starting to think about what can we do to insert some discipline in what we're doing. Where previously we may do wide areas of ablation, I think most of us want to ablate the right areas and not just do PBI, posterior wall, SVC, every anatomic area that we can think of, but we want to try to focus the ablation. It's solutions like Vector, I think, that will help us create a strategy out of the box, try to limit the total amount of ablation, and deliver ultimately the best result for the patient. Can you explain to me how the VMAP integrate step-by-step for me, for people listening to us? Because I started with simplicity. Can you walk me through it? Sure. Patient come to lab, he's having an ablation, or she's having an ablation, how you go from there? A typical workflow for us, and I'll describe an AF patient. Patient has to be in atrial fib, of course, because the algorithm is trying to identify the driver of an arrhythmia, so a patient in sinus rhythm is going to demonstrate that their sinus node is working appropriately. With a patient in atrial fibrillation, we incorporate a 12-lead ECG from the recording system. We transfer that to the Vector medical desktop. It takes roughly about a minute for the algorithm to then generate a hypothesis as to where the driver of atrial fibrillation may exist. We can then complete our contact mapping, however you wish to delineate that, and then deliver the ablation. During the procedure, you can also reacquire ECGs and have the Vector algorithm reinterpret where new drivers may be. If it's a de novo persistent case, you may complete an initial evaluation with Vector, complete the PVI, then ask the software to reassess, now that you've got a PVI completed, if there are any additional drivers, and then go target those lesions, so on and so forth. Usually, how many drivers do you find, roughly? Well, I think depending on the type of case and the substrate, of course, there can be one or two non-pulmonary vein drivers that we've anecdotally seen in folks who have very complex disease, post-MAYS, etc. Sometimes it's three or four. And they're, I think, very consistent with work that has been previously done over the last several years, and that you're aware well of, and so is our audience, that we would anticipate two to three non-pulmonary drivers in most of these models, and we've seen similar results through Vector. And have you seen this in relationship to your voltage maps? Is there any connection? Have you seen it there? It's not routine that you do voltage maps in these patients? Well, no, no, no. I mean, as I said, the way that we've incorporated it, we've worked with some of the contact-based persistent mapping algorithms, and there is close correlation between what Vector will identify as an area of interest and what some of these other solutions will identify as areas of interest with contact mapping, whether it's basket mapping or point-by-point mapping. So what I see here, I'm so happy to talk to somebody who's been doing this for a while. We've been talking about with all this myopathy mapping or scanning or imaging, we're talking about personalization, individualization of treatment. This is the perfect fit, right? Because you have an access to the patient in the clinic. You have the same access to the patient in the lab. You can triage, you can treat with this, and it seems like from the data you're generating, it's helping you more and more to individualize the treatment. The thing you said initially, some patients do this, some patients do that, and you stopped short of saying this is for everybody, but I can choose a patient who will just profit from this, and I can treat them in the lab. This is a perfect way for personalization of treatment as I see it. Correct me if I'm wrong, or maybe elaborate on that a little bit. No, you're absolutely right. I mean, I think we want to democratize AFib care, but that doesn't mean we want to deliver the same care for every patient. So solutions like this are intended to improve access for patients, and as I said, the right kind of access. So are we doing the therapies that they're actually going to benefit from, whether it's a PVI, whether it's an additional ablation target. Knowing what our plan is going to be before we actually intervene, I think ultimately is going to help our patients. Yes, I see it. And again, I go back to where I started with the tools that we have. They're getting more and more complex, and I have to say some of them, especially with now simple ablation technologies like PFA, but we cannot neglect the fact that not every patient needs the same treatment. Every patient needs different treatment. We learned this from other trials as well, specifically when we start talking about outside the veins ablation. And I see here you can decide that when you're in a clinic with your patient before even you go to the lab, and follow the same map all along to your lab and integrate it into your ablation platform. When do you see, how do you see this integrated into every platform in the ablation business? Do you see this as part of a mapping system? Do you see this as part of an ablation system? You're having it now part of your flow, but do you see it part of integrating into one of the systems? Yeah, I mean, ultimately, our goal would be that we would love to triage patients in a clinic setting, help describe and share the treatment plan with them before they actually come to the lab. You start with saying it's an AI-driven algorithm. When you say AI-driven algorithm, that means the more you do, the smarter it's getting and more opportunities. And I encourage everybody to start collecting the 12-lead. It's really simple, 12-lead collection. It's the level of simplicity these guys get to, it's impressive. And I hope to see this implemented everywhere in every clinic at least until they start taking it with you to the lab and then start triaging our patient. Exciting times ahead. I hope next year we sit here, you and me, and tell me about the bigger scale of this, how it becomes part of your every single ablation procedure, and especially in a clinic, triaging your patients and finding the right one. So there's two platforms you're building here. Thank you. Thank you everybody for being with us today in HRX Atlanta.

atrial fibrillation

AI-driven algorithms

Vector Medical

ECG technology

personalized treatment