So, to start with, thank you very much, Abel, for inviting me and for the SCAI team to help us with the organizing of the webinar and to support us throughout. So the talk is related to the same subject but there are obviously different variations that we can apply the technique to. Obviously, there have been major advances in both devices and leads and as you can see on the left, you know, we started with this kind of first implantable type of pacemaker which was an induction coil and, you know, we are proud in Birmingham because it was actually, you know, designed and actually made in Birmingham. The company that made it used to make light bulbs for cars, so they had some electrical knowledge but they had no heart knowledge at all, so it was one of the surgeons and one of the technicians who helped them out. But nowadays, you know, on the right-hand side we can see how far we have advanced using leadless pacemakers. In the past, we had several patients with Kawashima and you can appreciate that it's not easy or possible to actually get AIDS with access in that situation, so we elected to go for transvenous pacing and remarkably, it was very easy to do. We accessed the hepatic veins with ultrasound and it was very easy to then place sheets and pacemaker wires. The only problem that we did encounter, and you can see in the bottom right, a fractured wire. And what we probably did not appreciate is that there is a huge amount of movement and constant movement with respiration between the liver and the lead. And obviously, the lead gets attached to the liver and it's being pulled up and down. Now, these leads can move sideways, like they go through the tricuspid valve, but they are not meant to be pulled up and down. So, we had quite a few that fractured. Remarkably, again, it was easy to extract them and replace them, but we decided to try and avoid that after that experience. So, accessing the atrial masses has been described by Chetan and others. There are different indications. We started by doing it for fenestration, and that's the only situation where I would put a stent. I wouldn't put a stent for other reasons, but you can use access to carry out an ablation, and we have had several with focal and reentry tachycardia involving the atria for permanent transvenous pacing. But obviously, there's no reason why it can't be used for other procedures like left atrial appendage occlusion, AV valve, repair or replacement, or paravagular leaks. So, the commonest technique that is currently used is the TC-PCR, though, you know, there are doubts as to how much beneficial that is over the lateral tunnel, but it should have better hemodynamics, according to the Marcelletti and DeLaval studies that they did years ago, and they should have fewer arrhythmias because it's all plastic. However, you know, access to the atrial mass can be difficult if you don't have a fenestration in the conduit, but if you have a fenestration, it's easy enough to close it, but before you close it, think twice because you might want to use it. So, if you have patients with left pulmonary artery stenosis in the context of a Fontan or similar, it's not usually possible to just get a good result with ballooning, so you will put a stent. However, it's very, very, very important when you put a stent not to put one which is unnecessarily long. In other words, it should not get close to the SVC-RPA junction. The same applies to the surgeons because if you have stenosis and you've decided not to stent it, but to ask the surgeon to do an angioplasty, some of the surgeons will just use an extension of the plastic conduit to repair the proximal LPA, but it is very difficult even from the top to puncture the PTFE. So, in that situation, you would mention it to the surgeon, and if they can use something like bovine pericardium, that would be for us a lot easier. So, in the absence of fenestration, you can either puncture the conduit. Not easy because it's tough plastic. There's no fossa to latch onto. It's very difficult to orientate your needle, and it's not without complications. You can do a retrograde approach to the AV valve. For instance, if you're doing an ablation, you can use a percutaneous parasternal approach, and the late John Murphy described a technique about this, and you can also sometimes go below the conduit. In other words, there's sometimes a gap between the IVC and the beginning of the conduit where you can actually access the atrial mass, but that just depends really on the surgery. So, in a lateral fontane, you know, if you have, say, a dual pacemaker, but only the atrial lead has failed, then you can leave the ventricular leads, put an atrial lead in the lateral tunnel, and then truck it down to the abdomen to keep the same pocket and the same ventricular lead. Obviously, if you're doing this, you need to get an 85 centimeter lead, because it needs to be long enough. You can use a standard lead, but then use an extension, but I try to avoid using extensions at all costs, and 85 centimeters is usually more than sufficient, and it's not usually a problem to get a good position of the lead and a good threshold. In some patients who have had a fontane and previous pulmonary artery band, there are some operators that leave the pulmonary artery band in place. It's usually quite tight, and you can use quite tight, and you can use that as access to enter into the ventricle. So, this is a patient who did have a pulmonary artery band, which was not removed at the time of the fontane, so there was a little bit of flow from the ventricle to the PA, and you can see you could put a lead in the lateral tunnel, but also then a ventricular lead through the pulmonary artery and into the ventricle, and that seemed to work well. So, use any ports that you might have available. This is a patient who did have a fenestration, and she needed pacing for sinus node dysfunction, so we only need a natural lead here. It's very easy to cross the fenestration from above using a steerable sheath, as was mentioned earlier, but in this case, we use the Select Secure sheath from Medtronic, which has the advantage, obviously, not being just steerable, but it's also splittable, so it can put a Select Secure lead into the atrium. I think Ian at the beginning mentioned atrial pacing and phrenic nerve stimulation. It's very, very important to avoid putting the lead in the left atrial appendage because, you know, at least 90% of the time, you're going to get stimulation of the phrenic. Always check it out, and if there is any stimulation, go elsewhere, and if you have a Select Secure sheath, you can go wherever you want to. The Gore-Tex tube can be perforated, but it is difficult, as you can see, and, you know, sometimes even with these rather tough transceptor bronchoproneidols, they do tend to buckle because the pressure has to be so much. Look at the top as well. In the center, there is a stent, and I think that's a little bit too far to the right side to the right side of the patient. I would have used a shorter sheath, a shorter stent, and try to place it a little bit away just in case we need to have access. The anatomy has been described already. Technique, we usually use GA, biplane, and the usual technical details that have already been described. Most of the time, we use the bronchoproneidol. However, these are quite long. The pediatric version is no longer made. It used to be just over 60 centimeters, so we now have to make do with the adult, which is over 80 centimeters, and that's not easy to handle when you're going from the right endurner jugular. However, there is a radiology one which is used for creating transhepatic shunts and portal hypertension, and that's called the Roche-Ushida needle. It's only 40 centimeters, so it's much easier to manage. However, it's 10 French, and it's very brutal. The Brockenbra is a much nicer needle to use. I still use the Brockenbra most of the time, and as you can see in the middle section, you know, simultaneous injections in the SVC showing the pulmonary arteries and the atrial mass. There is a gap there. However, we've never ever had any bleeding, and I think part of the reason for that is these patients would have had numerous surgeries, and therefore, there would be quite a lot of adhesions there. You can see that in the middle slide there. So, in order to have access for pacing, what we tend to use is go from the right internal jugular. However, we do want to have a pocket either in the right or left infraclavicular, or if you're doing like a hybrid, in other words, someone who already has a good functioning ventricular lead, and you want to just put one lead, then you can go into the abdomen. So, the way we do it is we go through the subclavian vein, usually the left, place a snare, as you can see, in the SVC, then make sure that as you go with the needle in the SVC that it is through the snare. Once you've done your puncture and placed a wire into the ventricle, it can easily be floated into the aorta. I usually use a double-ended wire, so I put the curved end into the aorta. If I can't push it down, then I would use a snare from the femoral artery just to guide it down, and I would have the tip around three or four centimeters above the snare. And once you've got hold of that wire, in other words, you've taken out the transseptal needle, you can then snare the soft end of the wire and pull it out into the left subclavian vein and exteriorize it. So, now we have access from the infraclavicular region to the atrial mass, and then you can do what you want. You can put one lead or two leads depending on what you need to do. So, you want to put two leads, you have a wire already, you put a sheath through there, and it needs to be a big enough sheath to take two wires, and then you can put two wires, take the sheath out, and then put two sheaths separately. And they need to be splittable sheaths, so generally I would tend to use two select secure sheaths if I want to do dual chamber pacing. So, you know, once you've got your wire, as you can see, in the bottom right, pulled out and exteriorized, you're pretty much home and dry. And it's easy enough to place the leads, particularly if you select secure, you can place them wherever you want to. The roof of the atrium is a very, very good one, the ventricle you can sort of pick and choose, but avoid the left atrial appendage, because, as I said, phrenic stimulation is very, very common. So, if you are doing a hybrid, in other words, you've got someone with an abdominal pacemaker implantation, one of the leads is working and you're just replacing one, to tunnel from the infraclavicular region to the abdomen is a long, long, long way, particularly in adults. But there is this little kit, which is a little device, which is a little device that you can use to do that. And it's a little device that but there is this little kit, which is made by a company called Codman as an American company. And this is a kit that is used by the neurosurgeons to create VP shunts. And it's really extremely good. So, essentially, you introduce it from the abdominal pocket, you track it subcutaneously, right up to the infraclavicular exit. And it is, I believe, believe you me, it is really very, very, very easy. You can actually feel it over the skin, so that you know exactly where you're going. And then once you're through, you just simply feed the leads through, having secured it, obviously, by stitching it to the pectoralis, and you're then home and dry, because the lead comes into the abdominal pocket. But this is a good thing to have on the shelf. As I said, it's made by a company called Codman. And it's used as a tunneler for VP shunts by neurosurgeons. So potential complications, risk of perforation and tamponade, this is theoretical, we haven't had any, thromboembolic is real. But as Chetan said, we anticoagulate all our patients and make sure that especially in the first few weeks, you're better, you better have them on the higher end. In other words, 3.54 for the first six weeks to make sure that you don't get clots, because that's the highest time when you get clots. SVC stenosis and thrombosis, it happens with pacing. We haven't seen it in the situation, but inevitably, if we do enough, with time, it will happen. But we can always remove the leads, stent, and then repace. Always make sure that you keep access all the time. Obviously, you can fail to cross. So far, we haven't had that problem. And should a pacing lead need removal, it should be possible. But again, clotting issues are definitely real. So it's something which needs to be on the consent. Whether one should use carotid artery protection in that situation, I really don't know. I don't have that much experience. But the more I think about it, because stroke is the worst thing ever, a stroke is worse than a heart attack at any time. So it may not be a bad idea because there's a lot of experience with coronary artery work now to actually protect the carotids from having any clots. That's something to think about. So in conclusion, the RPA2I3Mx adds to other techniques and the TCPC physiology. And it can be used for many purposes, including pacing. It's feasible and usually successful. Crossing can be tough either because of calcium, PTFE tube extension, which the surgeons can do, or if the stent is a little bit too medial. So in that situation, think about using the stiff end of a coronary wire to try and help you. And obviously, anticoagulation is essential for life. Thank you.

pacemaker implantation

leadless pacemakers

transvenous pacing

accessing atrial masses

anticoagulation