 Thank you. Dr. Coulter Really appreciate that introduction. I I second dr. Hernandez's You know Congratulations on really organizing this. This is the second time I've spoken at this conference and It's not an easy thing to do. I'm sure so again. Thank you In the interest of time. I already cleared this pre cleared this with dr. Coulter I'm going to kind of make some adjustments to my talk. My talk was initially going to be two parts One part was going to be kind of focusing on a rhythm is an in in the female population and what's unique and what? Differences there are gender-based differences and a little bit a touch a little bit also on a rhythm is in pregnancy I'll give a shout out next Saturday. There's an arrhythmia symposium the Ali Missoumi arrhythmia symposium In the Houstonian so if you want to get more detailed information Especially about arrhythmias and pregnancy. I advise that you guys show up to that But what I will do is focus exactly on the topic that she asked us Dr. Coulter asked us to review which is what is new in atrial fibrillation and the answer obviously is typically a lot, but I'm going to just focus on three studies and these are going to be They're going to be I think clinically relevant studies that Have a has have had a large impact on our clinical practice and I think Their outcomes in some cases Are more nebulous and more subtle than what we expected in the beginning Although some in the EP community especially when it comes to the cabana trial, which I'll get to in a second We're predicting that there's going to be some problems in terms of You know using that data to guide our clinical decision-making. So the first study is crystal AF Crystal AF basically it's it's a study that is Asking the question and patients with cryptogenic stroke Who often? You know receive cardiac monitoring There's usually two ways to go about this one is you can have them wear a monitor an ambulatory monitor You can wear two weeks four weeks even six weeks Ambulatory monitors and the other group was an implantable loop recorder, which is I'll show you here in a second but you know 30% of the ischemic strokes are of an unknown mechanism so-called cryptogenic strokes and one of the most common Cardiac causes is atrial fibrillation the question is often a patient will come in and their first symptom of atrial fibrillation Is having a stroke? Of course at the time that they present we don't know this and this obviously again is going to have significant long term sequelae in terms of Oral anti-coagulation and management of these patients so that there's no recurrence So the question was is it better? What's the best modality to be able to detect the causative rhythm or the atrial fibrillation in one group? You have what we would call implantable loop recorders, which are basically exactly what those words say their tiny loop monitors two of the big companies make them they go subcutaneous and They have battery life that lasts typically up to three years and they're just continuously monitoring. They store if there's an arrhythmia The second group, which is the standard group is these ambulatory monitors and the ambulatory monitors these day arts are pretty easy to to use and the the study's purpose was to then compared the outcomes in terms of a diagnosis so These patients were typically 40 years of age or older cryptogenic stroke They had follow-up at one three six months and using a 12 lead EKG or 20 Four-hour EKG monitoring or Holter. They also receive TEs and of course the CTA and MRA So here's a loop recorder Plantable loop recorder it literally takes 30 seconds to put one in It's You know you make a little injection you inject lidocaine subcutaneously usually on the left fourth intercostal space and This you literally again pop it in subcutaneous and you get beautiful single lead EKG It is titanium. So MRIs are not an issue. There's no issues with you know Magnetic interference or things of that nature and most of my patients after three years They like to just keep it in because it's relatively you know inert You can also now nowadays have these ambulatory monitors and actually the most common ambulatory monitor Used in this study was not what we typically think about a five-lead Holter it was a zeal patch made by a company called iRhythm and It consists of a monitor that you stick on your on the surface of the chest It has a rubber covering so you can take a shower and things of that nature without difficulty There's two weeks of recording and in a newer iteration Actually, it will give you a trigger and not notify the physician if an arrhythmia occurs You don't have to wait and you know analyze it after after two weeks of implant The the patient wears it they drop it off in the mailbox after you know after two weeks We analyze the the recordings and and then we See if they've had an arrhythmia so the follow-up again as I said one six and twelve months and Every six months they're after and they recorded all the different types of symptoms associated with potential arrhythmias and I don't think it's you know, I don't think it's it's a surprise to anyone But I think it's important for us to see you know That implantable loot monitors detect these arrhythmias much more easily much more frequently and in fact The ambulatory monitors are somewhat useless for this purpose So I think the the current strategy is that when someone presents with a cryptogenic stroke It's absolutely critical. This should become these implantable loop recorder should become part of the clinical Streamline management And you can see here that again with controls subjects the percentage of AFib that was detected in these patients over time It goes up to about 10% here and here it's about five percent I'm sorry about 10% In conclusion implantable loop recorders were superior to standard monitoring the detection of atrial fibrillation at six months 12 months 36 months and moving forward AF is detected in Almost 10% and ultimately up to 30% of patients at six at 36 months So about a third of these patients do end up having atrial fibrillation is the cause which should not be a big surprise but to document it so effectively I think is impressive and Obviously, and this is a good piece of news that once AF is Detected it does change the way that these patients are managed as it ought to in terms of oral anticoagulants versus anti platelet agents So this is the big study that I think everyone has talked about this past year the cabana trial Doug Packer I'll tell you just how old and how long it took for this study to be To actually happen. I was Doug Packer's fellow still when he was starting this trial. So that was a while ago and The the study basically had very good intentions It was it was designed to look at the efficacy of atrial fibrillation ablation In patients who who had this who have this disease and it was I think perhaps a little over ambitious At the time atrial fibrillation ablation was still kind of feeling its way gaining its You know, it's a toehold in the clinical arena And so the decision was made to take patients and compare and randomize and to really three groups medical therapy and in not without rhythm control rhythm control with pharmacologic therapy and ablative therapy and Perhaps again overambitiously the primary endpoint was determined to be death disabling stroke serious bleeding or cardiac arrest You know for a disease like atrial fibrillation who that if you give oral anticoagulants and you you know treat the heart rate adequately is is really a symptom-driven problem Looking at the efficacy of ablation in these patients and looking at its effect on death or disabling stroke I think it's something that that's pretty ambitious and the data did support this ultimately after a Medium follow-up of about five years. There was a non significant 14% reduction with ablation as Assessed by intention to treat and this was the big thing if you got randomized to one of those groups It turns out that the chances of you dying or having cardiac arrest or having a major stroke or bleed Was really not that low or whether or not you had ablation And this is where all the controversy started this is with this trial because if you were if you didn't look at the patient on an intention to treat basis in other words as The patients came in over time a decision was made. Okay The medications are not working or we for whatever reason decide that we want to switch into the ablation arm then the numbers Really dramatically shift in favor of ablation and I think that we have to keep in mind that over the course of These five years of this study or overall about ten years of follow-up are really that the adolescent teenage prepubescent phase of Atrial fibrillation ablation and the technique and the technology as it starts maturing and as it starts maturing correspondingly more and more Physicians and patients elect to go with the treatment of ablation as they you know as as its safety increases And so what this study has been dogged by is the fact that there was such a high crossover between the groups and Intention to treat versus the therapy that they ultimately did receive So here's a Just kind of a Overview of those in terms of the incidence of atrial fibrillation This is not this is the intention to treat groups and of course ablation I don't think that there's any debate these days that ablation is more effective in rhythm control than medication be at rate control or anti-arrhythmics for rhythm control, so so that's that's fine and dandy and You can see also that the incidence of atrial fibrillation flutter and tachycardia over time Ablation has a higher percentage of patients who are free from atrial fibrillation This number is somewhat disappointing But I think again we have to remember that a lot of this data comes from the periods where Atrial fibrillation still had its acne and still had looked at its awkward stage and still was not really kind of at a more Presentable phase of its of its process and so the other point I think here is if you eliminate the atrial fibrillation patients here drug and ablation with atrial flutter and tachycardia were similar Yet again something that we know in clinical practice It's somewhat unusual that atrial flutter ablation is over 90 95 percent successful and Multiple studies since the beginning of the study of Cabana have shown randomized trials that as a first-line therapy ablation of typical atrial flutter is far vastly superior to To pharmacologic management and yet here you see that they really did not make a difference so and so Here you can see over time as the incidents of patients who with who do have atrial fibrillation With drug versus ablation and again no surprises the big debate with cabana was the fact that that primary endpoint intention to treat did not Did not was not positive and I think cabana is the ultimate Rorsch test You know if you're an EP who does ablations for a living you can look at it in the frame of what I just described to you If you are someone who believes the numbers If and the numbers don't lie and you have to go and be statistically rigorous. Yes, it was a failure So, you know You you you kind of long as you understand why this study Showed what it did and how that can be and the nuances involved in interpreting it then I think it's less And then the amaze trial is a trial that is just actually was completed and I'm putting a plug for dr. Rasek here who was the third leading second leading Contributor to the study nationwide and the amaze trial is a study that is looking at the use of the lariat Which was also invented by a alumni of THI Dr. Billy Cohn Which is a left atrial appendage occluder and the question was not whether or not this left atrial appendage occluder is Going to cause Decreased stroke, but whether or not it actually helps in the management of persistent permanent atrial fibrillation And and the rationale behind that is that more tissue Increases your susceptibility to a rhythm. Yeah, that's it's as simple as that bigger hearts are more susceptible to arithmias because there's more tissue to have these reentrant Rhythms and smaller tissues aren't so what we call atrial debulking electrical debulking using this lariat technology was studied and You know, I I think from what I've seen it looks promising But we won't know that for probably another 18 months or so. It's technically it's somewhat I think one of the more challenging Procedures you require drive pericardial tap things can happen But you know use a micro puncture needle and things of that nature and you decrease the incidence of of some of those Complications there was a very very very steep learning curve with this procedure But at the end of the day, we're going to find out whether or not Isolating because unlike the watchman, which is a plug in the opening or the mouth of the left atrial appendage The lariat actually mechanically cinches around the neck and you basically Strangulate not only the the left atrial appendage, but the tissue itself and over time it just Infarct and it sloughs off and you lose that tissue and follow up CT scans. It disappears so again, we will we will find out but this the study was 600 participants was just completed about three weeks ago, so we will know very soon and Thank you for this opportunity and hopefully help get things on time