Jeremy, thank you for that fantastic talk, and it's a nice concept that the lead is, if you only need atrial pacing, you can get into that space and not then do the second puncture into the venous atrium. One comment I wanted to share and then I'll let Dr. Law take over for the conclusion and any questions. Dennis Kim just put in the chat that he has, their group has gone away from using Brock and Burr needles and are using an electrified CTO guide wire and how easy it is to cross. So for those interested, you can review that. There is a fair bit of published literature on electrifying CTO guide wires. And for my case, I just want to, one thing I forgot to mention is this patient, the one I described is now six years out. He has been maintained on Coumadin, obviously. So far, fortunately, he did not develop progressive tricuspid regurgitation or any significant tricuspid regurgitation, and also he has not had a stroke, fortunately. So that's been reassuring. So Dr. Law, do you want to maybe close the session and then we'll answer any questions that are there? I know we're a little bit over time, but we can go from there. I think, so those are great talks, and as always, I learned from my colleagues. I think that as I was watching this, I think we all realized the Fontana is challenging and not every Fontana is the same. So the key thing is knowing the anatomy and then knowing the risk going into where we're going to approach it from. I think there's a nice, Joe brought up a nice point about the going to the liver, a great idea until the leads break, and then you really haven't helped yourself. Planning accordingly, and it sounds like the bag of tricks is always helpful. I never have to worry about my interventionist having a bag of extra things on there. I walk in, they're in their table, they're always full of extra sheets and catheters and wires, so I don't have to worry about that, and the post-procedure monitoring. And then I think Joe brought up a great point about when these leads have to come out, how are we going to get them out of there? So just doing it is not the, is the last step. You know, we walk out of the lab and pat ourselves on the back, then we've got to make sure they don't have any complications, and at some point in time, they'll get infected or there'll be some other problem and we'll have to take these leads back out again. And I think the last point that's probably maybe the most important is that EP doctors and cath doctors can get along. You know, it's like Democrats and Republicans, you know, who would have thought we can get in the same room and, you know, share ideas and benefit patient care. So I thought that, but overall, I thought it was a great talk, and I appreciate everyone putting the time and effort into this. So and with that, I'll address any questions. I don't see anything in the chat, and I think Abay already... In the end, there is one question in the chat for Dr. Giovanni. How did you get the snare down across the fenestration you created? Does the snare, do you use the needle to go through the snare? I think he can clarify that. So essentially you do a straightforward access of the left subclavian vein in the usual way, only a tiny incision. And you go down the innominate and the SVC, and you place the snare in the SVC. So you leave it in the SVC, you don't cross the fenestration. And then once you put the, whatever you're going to use, a transeptal needle or an RF, so long as it goes, if you're going through the jugular, then you need to make sure that before you do the puncture with a broken bra, for instance, you're actually going through the snare. So you just close the snare temporarily, just to make sure that you're not through the side of it, you're actually through the lumen. So the only thing that you need to make sure is that the transeptal needle, if you use the technique that I'm using, is going through the snare. If you're going with a CTO wire, electrified or an RF, then you don't need that. You don't need the snare. It's only because when we started, and I still use it, is to go through the right pulmonary artery into my atrial mass with a broken bra needle. However, the CTO, I'm not sure the person who pointed out the electrification of the CTO, what kind of tip load CTO wire does he use? Do you have that? So I think Dennis is going to actually maybe able to... Hey, Dennis, are you able to speak or do you want to answer that question? The load tip on your CTO wire? Yeah. Typically, I mean, you can use a wide variety of wires. Can you hear me? Yep. We can. Typically, you can use a wide variety of wires. We typically use the Estato XS wire, but really anything that has a non-jacketed tip is useful. The Estato is fairly stiff, so it goes in a straight line. I've used a BMW wire before. One thing you have to realize is that a lot of these coronary wires are jacketed all the way out to the back end, and if so, you have to scrape off the insulation off the back end of the wire, which you basically attach to a bovie blade just using a hemostat. Yeah. Yeah. That's... Yeah. Okay. There's another question from Dennis Kim. I think he probably answered it. I just want to give a shout out to Dennis. He was a fellow a couple years behind me, and he always looked up to me, and it's just an honor to work with him now too. He thought I was the greatest. Hey, with the group here, do we have a sense of how many people have had... Have we had some stroke complications? People that have the larger series, what's been your thoughts on that? So, no. I see some heads say no, but I mean, that is encouraging. That would go along with that all sync trial in the adult population where they put the leads in on the left side, and if you keep the INR at a good range, for whatever reason, we seem to be doing okay, but as I would agree with Joe, stroke is not usually a good thing. We did have one here at UCLA, so that's why we've actually modified our approach, and it occurred with the therapeutic INR, so. And then that was what... So, that's why you have a cardiologist when you can, if you can do that approach, I think it's a good point. Yeah. I mean, these patients are relatively young, and their Hasblad score is usually quite low, so we can probably afford to keep the INR high, especially in the first few weeks until the leads get kind of either adjusted, covered, or whatever. Any other, I guess, maybe there's also a question and answer session. I don't think those, the remainder of questions from Dennis are worth sharing with the group. They don't add to the science. Abhay, can I ask a question? Abhay, can I ask a question? Absolutely. Yeah. I think just, I think Dr. Mohr might remember this question was probably put up in the BCCA as well. Is there any experience in the panel about using of epicardial wires by a transvenous route? So, the electrophysiologists in the room are probably going to be the ones... No, the epicardial leads we use most frequently are the Medtronic steroid leading, the button and they have to be sewn on. So, there's a lot of work that's been done on leads that are being put in epicardially with minimally invasive approach, but the challenge is, if the surgeons can't do it with direct exposure, I think trying to do it with a puncture and, you know, thoroscopically is going to be really challenging. But the other ones have to be sewn on with a, you know, suture, so it's been done as far as I know. I don't know, Jeremy, have you known anything that does that? No, I've not seen that. I do wonder about, you know, with the newer technologies with these leadless pacemakers that are going to probably include atrial leadless pacemakers in the future, there's going to be a lot more options here. We're going to be able to potentially put in less material into the heart and get the same kinds of outcomes. So, I think it's going to change the field quite a bit, potentially. One of the problems with the current leadless pacemakers are they, most of them are ventricular pacing. There are some where they sense the mechanical activation of the atrium and then they pace the ventricles so you can get that AV synchrony, but their upper tracking rates were 110. And so, you put that in a child, you're really not going to get a lot of chronotropic competence. The use of endocardial leads by the surgeons is an alternative, particularly for atrial implants to put a lead in an atrial appendage. It's not too difficult. They can do it with a beating heart and that is an option occasionally if you have no site where you can put an atrial lead. All right, well… Actually, one of the transplant around got saved by pacemakers, actually. I thought that was nice, actually. Go ahead, Bhai. No, I said if there are no more questions, I really want to thank all of the speakers for taking their time out of their busy schedule and actually using demonstrations and geographically to walk people through the steps that you take and things that you have to think about. So, I think that has educational value that cannot be put into a paper that we are reading. Thanks again for everyone and looking forward to more webinars.

cardiac pacing procedures

atrial pacing

venous atrium access

electrified CTO guide wire

post-procedure monitoring