Elad Anter
@EladAnter
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Director, Arrhythmia Institute, Shamir Medical Center. Professor, Tel Aviv U. Trying to make meaningful contributions in cardiac electrophysiology.
Tel Aviv, Israel
Joined April 2020
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6 years ago on this day we lost Mark Josephson. Mark’s life and career were extraordinarily. A giant and one of the founders of clinical electrophysiology, his numerous contributions remain as relevant today as they have been originally, and his book remains the bible of EP.
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How to deliver RFA in the ventricle? moderate power for longer duration is preferable over higher power for shorter duration- larger lesions with less risk for steam-pops. Good remainder. Curtesy of
@yavin_h
@EPeeps
@ClevelandClinic
@TallRoundsTM
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Today the 11th of January 2022 marks the 5-year anniversary of the death of Mark Josephson. His greater than life personality, brilliance, curiosity, humor, and friendship are so missed.
@EPeeps
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Persistent AF case with Affera: PVI+Mitral Line+PWI+CTI with transpired therapy time of 30 min. Multiple cases, durable lines, consistent results. High-Res mapping and PFA/RFA from the same lattice catheter at a switch of a button. Exciting times to be in EP and Cleveland Clinic
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Another PerAF case with Affera PFA: PVI+PWI+MAL: 1st to last lesion <30min with total procedure time <1Hr including mapping and 20min waiting period (no reconnections). We may soon be ready to re-evaluate ablation strategies to treat different types of AF w/ rapid and durable Tx.
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The lateral boundaries of the VT isthmus are functional. 65M with large AMI and recurrent VTs. 4 VT morphologies using 3 isthmus sites. Note that boundaries forming the common channel of one VT are conductive in a different VT: a functional phenomenon
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First Case of Brugada syndrome ablation @ Shamir Medical Center. A 36-year-old man after SCD and ICD shocks. Technique, endpoints, and tips. Proud of our hospital and team.
@EPeeps
@BarkaganMichael
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PFA may be superior to RFA for VT ablation as it eliminates myocardium separated from the catheter by collagen/fat. Our new paper also unlocked a major limitation of RFA in scar, showing lower max intra-myocardial temperature compared with healthy tissue.
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Interesting case of a previously failed PVC ablation (attempted from left+right). Today, early pre-potential and near-field EGM just above the pulmonic valve but no EGM during sinus rhythm. Terminated immediately.
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Ablation Index for ventricular ablation: An an in-vivo beating healthy ventricle, lesion dimension plateaus at ~700. More
@hrs
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Should we re-map after ablation to confirm channels elimination? IMI-related VT isthmus corresponded to site of slowest conduction during substrate mapping. Term with <1sec RFA. Remapping confirmed elimination of endo slow conductiing channels. Amazing
@CleClinicMD
EP team
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The direction of LV activation influences the location and magnitude of activation slowing (and locations of LP). The area of maximal slowing corresponds to the site where the wavefront first interacts with the infarct (~≤0.5mV). IMI, CABG, Parallel mapping (RV+LV pacing).
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1. Is this a localized-reentry or macro-reenty?
2. What would be your ablation approach?
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Sonny Jackman receives the HRS Teaching Award. So well deserved to such an incredible individual I’m proud to call a friend.
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Incessant triggered VT in healed LAD infarction. Not all scar-related VTs are reentrant! Yet, late activation during SR corresponded to easiest EGM during VT. Termination with 1s RF.
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AMI, Pentaray and Coherent mapping (as described in ). Partially intramural circuit as beautifully illustrated by
@DrRoderickTung
. Termination with endocardial RF W/NHS as described by
@True_EP
. A community effort.
@ClevelandClinic
@BiosenseWebster
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EGMs during sinus do not predict VT isthmus sites. Note the normal EGM at isthmus site during sinus, delay with pacing, and unidirectional block before VT initiation. Functional substrate -≥ limited specificity in sinus. WE need to automate DEEP mapping.
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How clinically important are Direction-Aware Mapping algorithms? The directional dependency of bipolar voltage amplitude is greatest with stationary catheter but minimal when the catheter is allowed to rove and collect EGMs at multiple angles (Figure).
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First case with INTELLANAV MIFI OI Direct-Sense. Impressions:
1) Good correlation between contact indication, ICE and changes in EGMs.
2) First pass isolation.
3) Zero fluoroscopy easily obtainable with this technology
4) accuracy of impedance for contact in scar- don't know
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"Impact of HP-SD on Long-Term Lesion Durability" published this week in JACC EP. Learn the rationale, benefits and potential limitations of use! congrats to
@yavin_h
@narrowQRS
@JACCJournals
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82M IMI, S/P CABG, VT storm, failed 2X endo ablations elsewhere, flew to the Cleveland Clinic. Mapping the epi via the GCV identified a distal isthmus site; ablation resulted in termination. High flow irrigation was helpful to dilate the GCV and deliver adequate energy.
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The best way to avoid these bi-atrial ATs is to stay away of anterior ML. In treating MAF, creating a durable lateral MI is key (with or w/o VOM alcohol abl
Type II biatrial atypical flutter after anteroseptal mitral line!! The clue: no full tachy CL could be mapped either in RA or LA.
@Arritmias_HRC
@cris_lozano
#EPeeps
#carto3
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What is more important: mapping density (≥data point) or mapping resolution (≤electrode size and spacing)? This study provides an answer: In heterogenous scar, reducing the number of points by 90% from 20K to 2K had no effect on scar distribution (Orion catheter).
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In 2018 we coined the term HP-SD ablation and described its biophysical properties (). However, what is the long-term lesion durability in AF ablation? Results will be presented at HRS 365 and simultaneously at JACC EP.
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Friday afternoon VT case: 78M with healed AMI. Example of intra-mural isthmus. Note the quasi- simultaneous endocardial exit. Terminated at epi-to-endo exit. (note the lower blind loop) Our excellent fellow
@EoinDonnellan1
@CCFcards
@TallRoundsTM
@BSCCardiology
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Lasso PFA with Carto for PVI. Excellent lesion durability, supra-therapeutic PFA dose (10X) is safer than 3X RFA dose for esophagus and phrenic. Excellent effort by
@yavin_h
. First-in-Human study is underway.
@ClevelandClinic
@BiosenseWebster
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NICM with septal VT (S/P 2 failed ablations). Simultaneous RV and LV mapping with 2 X HD-GRIDs plus venous septal perforator using 2F EP Star catheter (via Terumo Glidecath) as described by
@DrFerminGarcia
can be highly revealing.
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PFA may not be safe around coronary arteries, causing reversible and fixed stenosis. Much more to learn. Excellent work out of
@MayoClinic
@EPeeps
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PFA is the future of AF ablation. However, its biophysics is much more complex compared to RFA: non-linear (and less predictable) dose-response, the angle between the electrical field and the tissue (fiber direction) impacts lesion size. Lots more to study & learn
A novel circular PFA ablation catheter for PVI: durable lesions without esophageal or phrenic nerve injury.
#AHAJournals
#Epeeps
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It is fascinating how little differences in 12-lead VT ECG QRS configurations can produce reentrant circuits of opposite directions. Likely small circuit and similar exit site
@EPeeps
@CleClinicMD
@MikeRaiman
@AbbottCardio
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VOM dependent LA flutter. EP star 2F catheter in VOM (PPI+5ms); endocardial MA (+65ms). Terminated during alcohol injection! Next slide shows the maps. Amazing
@ClevelandClinic
team
@tavrkapadia
and Amar Krishnaswamy
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Another Surgical VT ablation with
@ClevelandClinic
exceptionally telented heart surgeons
@AaronWeissMD
@EdSolteszMD
. The
@ClevelandClinic
patient-centered multi-team effort and expertise are unparalleled and humbling. Together with Mo Kanj,
@djcantillonmd
,
@mbelshazly
,
@omwazni
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Final preparations for sharing a recorded case of PVI, MAL PWI and CTI using Affera W/ PFA+RFA at
#EPLliveAustin
A bonus, eye-opening capabilities for VT ablation
#ablatevt
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VOM alcohol ablation in a pt with Watchman. Great opportunity to appreciate anatomical relationships.
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Macro or Micro Reentry in a patient with IMI: How can you tell? Clue 1: how would you determine the excitable gap? Clue 2: Josephson chapter no. 11. More to follow...
Mapping is helpful, but physiology should not be forgotten
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A difference in baseline impedance of 10-20 ohms is the difference between durable and not durable PVI, successful or unsuccessful PVC/VT ablation. Know the fundamentals, tips and tricks, and teach them to your lab staff. Another reference:
How to avoid AF recurrences after ablation?
Do you always check pt basal impedance ?
30W 10gr w/different basal impedance.
Dramatic change in lesion dimension is related to basal impedance as Current decreases steeply.
@LAHRSonline1
meeting.
doi: 10.1161/CIRCEP.118.006690.
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ARVC: Multiple VT morphologies anchored at the base- lat RV. Fixed slowing zone (review Sinus vs VT); mapped VTs shared a similar (and partially endocardial isthmus). Term at anchor with non-indicibility. Propagation in next slide.
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Is Ablation Index useful for guiding therapy in the ventricle? For a pre-specified AI, RFA at 30W makes larger lesions than 40W and RFA w/ CF of 25g makes smaller lesions than 15g. Read our new publication
@JACCJournals
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This is how 10:30PM has been looking like in our animal lab for the past few weeks. I’m so proud of our fellows and the excitement they create. Innovative work that helps patients worth it!
@yavin_h
@ClevelandClinic
@LarsSvenssonMD
@omwazni
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#togetherVT
Pieree Jais presents the powerful utility of image integration in structural VTs using inHeart. A 10- year journey that has really matured. Congrats!
@MiguelVldrbno
@C_Meyer_MD
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I usually do not use this platform for anything but professional, but today this is much more important than EP.
I was compelled to reply to outrageous statements made at the
#UN
today against
#Israel
by the representatives of Iran, Syria and the Palestinian Authority.
We will not give in to terror.
#Israel_under_attack
#HamasTerrorists
#IsraelPalestineWar
286
1K
3K
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New high-resolution mapping array and algorithm for rapid differentiation between slow conduction, conduction block, or wavefront collision. Congrats to
@yavin_h
.
@ClevelandClinic
@CirculationEP
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Reentrant RV Pap Muscle VT! Endocardial exit producing a pseudo-focal pattern. However, diastolic pathway recorded along the pap muscle. I wonder how often we miss it unless using ICE as intra-cavitary objects are excluded from the shell unless using sound
@EPeeps
@BubarZachEP
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Electrophysiology is beautiful: Entrainment from VT Isthmus (upper panel) and termination with single beat stimulation (lower panel).
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Block during SR ≠ block during VT and vise versa
Mechanisms of block during SR/rapid stimulation are different. Nice case today!
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Pulse-field ablation in the ventricle: In contrast to biophysics of RFA, lesion repetition of PFA has incremental effect on lesion dimensions, likely via a mechanism of permeability preconditioning. Congrats to
@yavin_h
@CirculationEP
@ClevelandClinic
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EPLive Austin 2022: A great live LV summit PVC case w/ Streotaxis by Dr. Burkhardt.
@Zo_EP2
@Dr_Santangeli
@drluissaenz
@natale_md
@LuigiDiBiaseMD
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HRS teaser:
Does ablation index (AI) predict lesion depth in the ventricle? Does a similar AI value achieved with 30W or 40W result in same lesion size? How does AI perform in scarred ventricle? Answers on Friday at 15:30 by Israel Zilberman.
@EPeeps
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The 5th Annual Signals Summit, September 17-18, 2021. Please register and join this unique meeting led by >20 international leading scientists and clinicians discussing mechanisms, engineering solutions, and innovation
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New tool to discern complex patterns of conduction.
Real-time propagation vectors enhance the ability of activation maps to differentiate between complex patterns of propagation
@eladanter
#AHAJournals
#Epeeps
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Found this treasure book in a hallway outside an office being remodeled. So many scientific meetings since 1984 and nearly daily virtual webinars- but the fundamental information in this book still encompasses most of what we know in EP in 2021.
@EPeeps
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Interesting case: Young woman with Para-hisian AT (RA preceding NCC by ~5ms and LA by ~10ms). Seems focal right? However increasing resetting response curve with termination suggestive of reentry. Thoughts?
@Ed_Gerst
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First VT case I have had of a pt w/ Filamin C (FLNC) gene mutation. 40M otherwise healthy with two SCD episodes (PVC-induced VF). Focal LGE in the infero-lat epi. PVCs of similar morphology. Any experience?
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Very low endocardial bipolar voltage and lack or capture are not indicative of transmural scar even in thin atria! Unipolar voltage can be helpful.
Atrial unipolar voltage has greater sensitivity compared with bipolar voltage to detect viable intramural and epicardial myocardium in the presence of endocardial scar
@yavinh
@arwayounis2
@BarkaganMichael
@eladanter
#AHAJournalshttps
://doi.org/10.1161/CIRCEP.122.011321
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Signal Summit 2021 comes to a completion. Content will be available at Thank you to all faculty and audience. See you next year!
@EPeeps
@BSCCardiology
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A brilliant Review Article by
@MiguelVldrbno
on anisotropic conduction and physiology of wavefront propagation.
A must read to anyone interested in ELECTROPHYSIOLOGY
@EPeeps
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Interested to understand fundamentals of conduction and block, activation/repolarization, how to differentiate arrhythmogenic from non-arrhythmogenic tissue? Join open discussions with basic scientists and engineers to better define our next steps for innovation.
@ClevelandClinic
Founder
@EladAnter
along with over 20 scientists & EP leaders share their insights at this year’s 5th Annual Signals Summit: The Forgotten Art of Electrophysiology on September 17-18. Learn more and register today:
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The International Multi-Center PHYSIO-VT Study: Long-Term Clinical Outcome Comparing Ablation Guided by Sinus Rhythm or Multi-Site Pacing. Simultaneously published at
#HRS365
and
@CirculationEP
Narrated presentation at
#HRS2020Science
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2nd slide: Endocardial block (left) with far-field endo re-annotated based on opposing EP star catheter in VOM shows the complete circuit/.
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The beauty of substrate mapping with Extra-stimulation. Out of a large scar and delay, one site with significant decrement corresponding to isthmus/exit. All by CCL amazing EP fellows.
@aportasanchez
@ClevelandClinic
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Signal Summit ON DEMEND is now available. Access the full video library of the Summit.
@EPeeps
@FredSacher_EP
@HoneyBadgerEP
@nmsdegroot
@NTrayanova
@ClevelandClinic
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Esophageal temperature changes are similar between HP-SD and MP-MD RFA strategies. If using HP-SD, the shorter application duration should not prompt shorter intervals between applications.
@yavin_h
@CirculationEP
@EPeeps
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Together VT in Prague. In a Substrate Mapping Strategy Techniques session,
@aportasanchez
elegantly presents the utility of functional mapping.
@EPeeps
@BiosenseWebster
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Physiology had surrendered to technology rather than physiology guiding technology. The possible implications for education of younger generations are worrisome, particularly because education is funded by industry. We ought to guide the industry and teach our fellows.
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Nice example of paired VTs with reversal of unidirectional block. VT-1 terminated in proximal isthmus with a non-propagated pacing beat (red arrow) and this site became exit of VT-2 (activation map in second slide). Excellent EP fellow
@KojiHiguchiCCF
and mapper
@BubarZachEP
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The International Multi-Center PHYSIO-VT Study has been published simultaneously at
#HRS365
and
@CirculationEP
. VT Physiology and mapping cannot be overly simplified! . Narrated presentation at
#HRS2020Science
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Great First-In-Human experience with Affera’s new ‘single-shot' PFA catheter. More at HRS: “Single-Shot Lattice Tip Catheter for Pulmonary Vein Isolation with Pulsed Field Ablation” on Friday 2:50-3:00PM
Affera, Inc. Announces Successful First-In-Human Use Of SpherePVI Circumferential Pulmonary Vein Isolation Device ...
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35M; LBBB that normalized with catheter bump of the distal LBB with retrograde activation(subsequent slide). Normal CMR, PET, LVEF 50%.
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@rdschaller
Biophysics of RFA in scar are different. Fat acts as heat capacitor: effect can reach 10mm; and collagen as insulator: effect <2mm. Work by
@BarkaganMichael
at published in
@JACCJournals
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Alberto, it was such a pleasure to spend a day with you in the lab! I learned a lot. When passionate EPs get together it’s 🔥
It was an unforgettable moment to meet one the best EP in the world in Tel Aviv, Israel.
@EladAnter
. Above of all a humble and kind person. His passion for EP spreads out to all his team.
It was a gift to scrub with him to keep learning deep knowledge in EP.
Just amazing !!!
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Be careful interpreting activation maps without physiology. This was a macro-reentry as explained in the figure. The plethora of "micro-reentry" with high-res mapping should be taken cautiously. Also wondering about ablation implication for AF "rotors".
@EJSMD
@mike_lean
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Cleveland clinic at HRS 2021- multiple presentations by a world-class group with diverse expertise including mapping, ablation, digital health, leadless pacing, lead extraction, LAAO, genetics, metabolomic. Amazing team and institution!
@omwazni
@khaldountarakji
@djcantillonmd
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Reentry requires spatial heterogeneity in both activation and recovery (a largely neglected component). Can repolarization maps increase the specificity of mapping VT (and AF)? Jakub Sroubek presents how to measure ARI
#HRS2020Science
via
@YouTube
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The Lattice may be a game changer for VT. Titratable energy up to a max volume of X8 compared to 3.5mm at both unipolar or bipolar configuration (may not be needed).
#ablatevt
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We are learning that biophysics of PFA are different from RFA but promising also for VT ablation. We will continue to study its usefulness and limitations. Congrats to
@yavin_h
@AfferaEP
@ClevelandClinic
@omwazni
for pushing the envelope of innovation.
@LarsSvenssonMD
*New Research Article* - Pulsed-Field Ablation in Ventricular Myocardium Using a Focal Catheter
@eladanter
#AHAJournals
#Epeeps
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A great comprehensive review on the topic. A must read for any EP.
My latest State-of-the-Art Review about Purkinje VT/VF is now online.
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This is how scientific meetings should start..with inspiring recital of Bach and Mozart.
#EPeeps
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Vivek Murthy is one of the most kind and special people I have ever met. This is an extraordinarily profound and empathetic book everyone should read. Loved it!
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Why patients develop VT only years after infarction? Nerves sprouting is a more dominant factor than expansion of fibrosis (Yoram Rudy, Ruben Coronel and Bruce Smail)
@shivkumarmd
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Impact of HP-SD ablation on long-term lesion durability: Benefits are partially related to catheter stability (reduced range of catheter motion during application). Is it safer for the esophagus? probably not.
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PFA has larger effect in scar tissue. Really promising for VT ablation.
@CirculationEP
@yavin_h
PFA creates deeper lesions compared to RFA in scar.
@yavinh
@arwayounis2
@eladanter
#AHAJournals
#Epeeps
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Prague Rhythm 2023 - Thank you for the invitation and opportunity to perform a live VT ablation case. A bonus visit with friends to the statue of Purkinje in prague
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A great case today with termination of CW MAF during VOM 🍸injection. Great team work at SMC in Israel
@BarkaganMichael
@Saar_Minha
@MiguelVldrbno
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@DrJCheungEP
All AF should be screened for OSA. Prospective data published this month in JACC EP
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Great
@ClevelandClinic
collaberative effort to treat this patient with NICM and septal VTs. Normal RV+LV EAMs. High-quality CMR W/ LGE in a patient with BiV ICD by
@DebbieKwonMD
and Impella 5.5L by
@EdSolteszMD
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It is incredible that in a 2-3mm thick tissue, dense scar on one side hides a vibrant electrical activity on the other. Whether PFA has a greater effect in scar compared with RFA like in VT () is yet to be determined. Uni Voltage is helpful 👇
Atrial unipolar voltage has greater sensitivity compared with bipolar voltage to detect viable intramural and epicardial myocardium in the presence of endocardial scar
@yavinh
@arwayounis2
@BarkaganMichael
@eladanter
#AHAJournalshttps
://doi.org/10.1161/CIRCEP.122.011321
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ISCAT Paris 2022: Pierre Jais presents on new strategies for VT ablation
@FredSacher_EP
@DrRoderickTung
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There are very few things in life that are absolutes (I.e. be kind, loving, honest). HP-SD RFA is not one of them. Learn where it beneficial, where it is not do much and where it is dangerous.
#EPeeps
now online in
@JACCJournals
, JACCEP August issue.
@EladAnter
and team 👏👏
Here’s a teaser from the excellent editorial of Felix Bourier and
@Phiso_de
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What differentiates arrhythmogenic from non-arrhythmogenic scar? Using the needle catheter to precisely mark the VT isthmus for histological correlation. Work by
@yavin_h
at the
@ClevelandClinic
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