Charles Te

Electrophysiologist @OKHeartHospital @HeartRhythmOHH | @theArrhythmics ICD Support Group | Recreational Basketball Player

[Charles Te @CharlesTe]

You too can make ablate and pace (CSP) an elegant procedure, approx 1hr procedure time.

Make pocket.
Get access.
Place lead.
Ablate from pocket.
Add atrial lead. (If necessary)
Tie down lead(s).
Irrigate.
Attach device and tie down.
Close pocket.

h/t @SergioPinski

[Charles Te @CharlesTe]

@drjohnm @JAMA_current @NEJM At least have AI do a critical appraisal.

[Charles Te @CharlesTe]

@kendallbaker I’m interested too.

[Charles Te @CharlesTe]

Posterior wall ablation ≠ posterior wall isolation. And it’s easy to map.

We all have pretty post-ablation maps.

New rule: required, if you’re sharing one on X or LinkedIn, show the scale and settings.

[Ikram Haq, MD @IkramHaqMD]

🧵Should we use unipolar post wall mapping during AF ablation? Is endocardial silence in AF = posterior wall isolation?

Nice study in @CirculationEP by @Ed_Gerst et al. challenging both assumptions with human endo-epi mapping. Post wall = 3D substrate

https://t.co/79yhOWiGUG

[Charles Te @CharlesTe]

@MattSegar @drjohnm Both real. RE-LY: dyspepsia ~11% vs 6% warfarin, GI bleed ~50% higher. Apixaban is GI-cleanest.

But “dyspepsia on dabigatran” isn’t an indication for warfarin or LAAO.

It’s an indication for a PPI, food, a dose. conversation, or a different DOAC. We seem to skip those steps.

[Charles Te @CharlesTe]

Pradaxa is generic. Industry won't tell you, for obvious reasons.

Dabigatran 150 mg, 60 caps: $23.80 at Cost Plus.

We swap AF patients to warfarin over cost. We push LAAO without knowing it's better.

A $24/mo generic reframes both.

#AFib #Anticoagulation #EPeeps #LAAO

[Charles Te @CharlesTe]

@gautamsand @hrs_journal @rdschaller @Drdevignair @pvijayaraman1 @HRSonline Encouraging 3-mo ASCEND CSP data. But UltiSynq sits on the Riata-Durata-Optisure lineage. Given Hauser’s MAUDE finding that 93% of Durata failures were internal insulation breach, plus novel septal embedding, is 3 months enough to call this durable?
#EPeeps #CIED

[Charles Te @CharlesTe]

What does the left atrial appendage really do? What happens when it's gone? Does it matter how it was removed/occluded/closed?

Funday Activity, stick this prompt in your favorite AI and find out.

@drjohnm

https://t.co/KNRc1qSyKM

[Charles Te @CharlesTe]

@drjohnm Still confusing.

CONVERGE: ~68% vs ~50% freedom from persistent AF at 12mo, hybrid epi/endo vs endo alone.

Why beat catheter-only PWI? Maybe epi durability, LAA exclusion, or aggressive ablation of the posteroinferior LA and CS musculature, areas catheters reach poorly?

[Charles Te @CharlesTe]

@kidney_boy @MGKatz036 @franciscojlk I suspect that is true as well but there are so many confounders to really know for sure.

[Charles Te @CharlesTe]

@MGKatz036 @franciscojlk @kidney_boy This is great. I think a key concept to remember is that there is a difference between intravenous vs intraarterial (Cath/PCI) contrast use. Potentially significant.

I agree with the data for venous contrast use but we can’t apply all the same concepts for cath procedures.

[Charles Te @CharlesTe]

My first look at Medtronic’s new C320LBBS45 for LBBAP. Double-braided, 2 cm longer, redesigned septal curve. #EPeeps #LBBAP #ConductionSystemPacing

[Charles Te @CharlesTe]

@TheRealRo_Ro Sure. We’re over analyzing at this point.

[Charles Te @CharlesTe]

CHAMPION-AF is here. NEJM. 3000 patients. The biggest question in LAAC finally has RCT data.

Noninferiority: met. Bleeding reduction: real. Net clinical benefit: favorable.

Great abstract. But the devil is in the details.

[Charles Te @CharlesTe]

@TheRealRo_Ro ISTH major bleeding alone? Nonsignificant.
Both signals missed significance. But they don’t carry equal clinical weight. ~7 fewer CRNMBs per 100 patients vs. ~1 extra stroke per 100.

[Charles Te @CharlesTe]

@TheRealRo_Ro Fair. If the stroke signal (HR 1.46) matters despite not reaching significance, so does major bleeding (HR 0.78).

But the asymmetry: the safety win (HR 0.55) was driven by its softest component (CRNMB, HR 0.48). The efficacy composite was driven by its hardest (stroke, HR 1.46).

[Charles Te @CharlesTe]

@TheRealRo_Ro if you’re a patient sitting in your office, is a clinically relevant nonmajor bleed (a nosebleed that brought you to the clinic) the same weight on the scale as a stroke?

[Charles Te @CharlesTe]

This isn't anti-LAAC. The procedure works, the bleeding data are real. But if we're going to practice evidence-based medicine, we have to read past the abstract.

https://t.co/fboMJh81fZ

#CHAMPIONAF #LAAC #TrialDesign #Noninferiority #Cardiology #NEJM

[Charles Te @CharlesTe]

Then there's the stroke signal. 50 strokes in the device arm vs. 33 with NOACs. HR 1.46. It didn't reach statistical significance, but the trial was never powered to detect a stroke difference. Not significant is not the same as not real.