Natale - persistent AF ablation video

Direct from the master. It is technically heavy but this will be a good reference for those asking about how he thinks and how he does it..

[stdavidshealthcast.com]

The video below from Peter Weiss of Utah Intermountain on stereotaxis magnetically navigated paroxysmal AF

[www.youtube.com]

Cryo balloon ablation of paroxysmal AF from Javier Sanchez of TCAI (great comments from Doug Packer of Mayo)

[stdavidshealthcast.com]

Pierre Jais presentation on latest thinking regarding ablation of persistent AF in Bordeaux (with some obligatory slides re St Jude mapping tools as sponsors). It's the first video on the list.

[www.innovationsincrm.com]

PS. decided to gather these in one place for future reference



Edited 7 time(s). Last edit at 08/05/2015 07:59PM by researcher.

Thanks researcher, the St Davds video of Dr Natale doing a long standing persistent AFIB ablation (the most challenging kind) was done I believe at EP Live 2014 three day event hosted at St Davids every other year to train EP fellows from all over the world with real time procedures to view from the large St Davids' amphitheater education room there that has a whole wall covered with huge LED screens all connected to all 5 cutting edge equipped EP Labs there at St Davids.

There is also satellite hook up to some remote centers as well and all with a top tier team of EPs performing a different given procedure with the Docs relaying, as Dr Natale is in this video the step by step process, to all the attendants in the amphitheater room and as you can tell Dr Natale is fielding questions from the audience which is being chaired in this particular presentation by Dr Francis Marchlinski who is head of the renowned University of Penn EP AFIB/VT program and Fellowship teaching program.

I had the good fortune to attend this conference and found it very interesting and insightful... In fact, our own Smackman got his persistent ablation on screen just like this and I was sitting right in front of Dr Marchlinski with his same brownish/grey suit on during the presentation with the cameraman one eisle next to me during that same event.

Shannon



Edited 1 time(s). Last edit at 08/03/2015 06:08AM by Shannon.

Shannon, I was wondering if you were sitting in on these. Lots of questions and feedback from other top experts too like Packer, Mansour, Tomassoni, etc in addition to fellows in the audience and a couple assisting the procedures. I added a cryo balloon video to the first post.



Edited 1 time(s). Last edit at 08/03/2015 02:26PM by researcher.

Shannon, in your guesstimate, what % of Natale's ablations are narrated (for remote or local learners)? I'm hoping the answer is close to 1%, because... one of the central attractions of a Natale ablation for me (aside from his skill level) is the fact that (unlike an EP who is associated with a teaching hospital), there is no distraction of him answering questions.

I'd much prefer to have him 100% focused on (my) ablation, rather than be distracted answering questions.

We've now got two data points on this, the (above) video (where's he's answering q's during a live ablation), and the Fellowship posting (which implies he wants to do more answering q's during live ablations - since that's how most teaching is done at the Fellowship level).

Will Dr. Natale be offended if one were to request an ablation with no distractions of this sort?

And since it was stated earlier that one of the reasons Natale travels to the different facilities (SF, San Diego) was so he could teach more people his technique, does that imply that Austin is the best place to go, if one wants to go to a facility where the chances of him multi-tasking (teaching others while he ablates you) is minimized?

Thanks,
-Ted



Edited 1 time(s). Last edit at 08/03/2015 05:08PM by apache.

Yes Researcher, most of the big guns were there including a number of EU EPs like Claudio Tondo and a few of the Dutch and German leaders in their area, plus Francis Marchlinski and David Callans from U Penn, Moussa M. from Havard/Mass Gen, Kalyanam Shivkumar from UCLA. Gerry Tomassoni and all of Natale's groups including Connor Barrett from St Luke's in New York and Vivek Reddy's group was there and plenty others including the Mayo leaders as you noted and Univ of Michigan group etc.

Half of the second day was all on VT ablation with truly the top best guys in the world in that area, including Natale doing live and recorded cases.

Many of the well known operators were asking Dr Natale questions too. And a number of them also were down in one of the EP labs doing procedures too for us all to watch and learn from.

And Apache, I personally would not have the slightest hesitation to being part of a narrated procedure as long as Dr Natale was the one manning the catheters the entire ablation.. From all that I have learned and experienced with Dr N over the years, he is without any doubt at all clearly a physician who can walk and chew gum at the same time without missing a beat.

In fact, I know pretty well the very gentleman being ablated in this very video as I helped arrange him being there on relatively short notice with the proviso that his case could be recorded. Yes, it does take a bit longer at maybe a total of 15 to 20 minutes longer max due to the pauses for questions and deliberation, but if anything, one could argue that these pauses buys a few more moments for reflection too along the way in the process and it certainly doesn't seem to hurt his production.

Dr Natale is in frequent communication with his ablation team during every ablation in any event, asking for them to infuse more heparin or isuprel and the head tech manning the Carto-3D mapping system to set a specific parameter at any given moment as he flows along like a smooth winding river running down hill as Ive nots a few times in watching him carefully over an entire ablation.

For example, this gentleman had a case of persistent AFIB that was quite challenging, but that had initially been mis-reported as a long standing persistent case and as noted by Dr N at the start of the procedure and he remains in pure unbroken NSR with not one bit of arrhythmia recorded now at well over a year and a half in what was the first LINQ installation done right after his ablation there in Austin in Feb 2014, and in spite of just the kind of ablation you would almost say was a given for needing one or possibly two touch ups if I was to guess from the outset. So its very hard to say he was at any disadvantage at all under the circumstances. The whole crew was on their toes and making sure to cross every 'T' and dot every 'i' with such a prestigious audience in attendance and Dr Natale converted him to NSR in around 45 something minutes where ehe has been ever since.

In any event, the odds of you even being asked to partake in such a teaching experience are very remote Apache .... and you would have full say so to approve or disapprove in advance. Dr N would never just spring that on someone without their permission for privacy reasons at the least.

From my knowledge, he does perhaps three to four such fully filmed and narrated procedures out of his average now that he has slowed down slightly with his expanded conference and research schedule, or 450 to 500 ablations a year tops while at his peak he was doing just over 550 ablations a year.

However, that doesn't mean he is anything but focused on the ablation at hand or putting any such patients at added risk, because he is top distracted to do his job at a top level.

You'd have to watch him perform a few times to digest how this all works.

Shannon



Edited 1 time(s). Last edit at 08/03/2015 11:23PM by Shannon.

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Perhaps two to three out of 450 to 500 ablations a year are, as you say narrated, but that doesn't mean he is anything but focused on the ablation at hand.

Good to know. I presume that also applies to him answering questions to EP's who are in the EP lab with him during-procedure, being trained on a less formal basis...?

It's been well established (ref: all the multi-tasking studies) that no matter how good one is, if they are performing a non-trivial task and their train of though is interrupted (eg, by an IM message, or a tap on the shoulder question from a colleague), their performance suffers from the distraction. Most people can recall instances when they were in some intellectually challenging task (let's say, doing their federal income tax return, on a non-trivial case), and were interrupted by someone, only to later realize they'd forgotten to do something (eg, check for eligibility for a particular rare deduction) that they had intended to do before submitting the completed tax return. In Natale's case, the minor things he may forget during the interruption may not rise to the level of being clinically evident, because everything else he does is so skillfully done. Nonetheless, I don't want him mentoring anyone or answering anyone's questions during my ablation. And I am more than happy to pay extra... for that level of dedicated focus.

Quote

he is clearly a physician who can walk and chew gum at the same time without missing a beat.

If the task at hand were as inconsequential of either of those acts (walking, or chewing gum), then I would not be concerned. When someone has a heated instrument inside one's heart, where minor deviations can cause performations or char (or steam bubbles) leading to intracranial embolism, it's a whole other ballgame.



Edited 1 time(s). Last edit at 08/03/2015 11:08PM by apache.

All you have to do is tell Dr Natale, you don't wish to be part of a formal training ablation for any other EPs. he understands and there is NEVER any one else taping him of the shoulder or whispering in his ear while he is in the midst of doing ablation lesions inside the heart. He runs a very tight ship during the actual procedure and everyone in
the actual
EP lab room itself is a highly trained professional in his crew... You can let him know that you don't want to be a guinea pig, which he would never subject you, or anyone else, to without your expressed consistent beforehand and then leave all your worries behind after than infusion of Propofol, which will definitely insure there are no more worries. I've watched him closely from the EP lab equipment room through these he glass window about 4 feet away from the head of the table where the patients head is while he performs a full procedure and his focus and one pointedness is quite something to behold.

Again as I noted in my recount of my close friend 'Tony's' persistent AFIB ablation at CPMC in June 2014 while I sat next a very nice and intelligent BioSense Webster Carto 3D tech who was working in concert with Dr Natale in running the software at his every beck and call during the process she remarked that after all these years of working with him
as well as many other EPs along the full Western U.S. region, that it remained still such a treat to be apart of any ablations by Dr Natale because of his consummate mastery of the catheter ablation.

She was also the first one of the rest of us in the group in that room to break into a cheer of celebration when Dr N converted my friend to NSR in about 43 or so minutes and who had a very large 53mm diameter LA and a 24/7 persistent case of unknown duration but of at least several years running.

And she was just recounting her experience and impression that is the same one that I have heard echoed by large number of colleagues and other EPs who have worked with him over the years... At a certain point you can help but begin to realize why he has earned the reputation that he has.

Shannon

Added Jais presentation video regarding mapping and ablation of persistent AF to first post here. Covers the latest thinking in Bordeaux. Great Q&A interaction at the end with Marchlinski and Pappone.