HRS 2012 research highlights: A slideshow presentation
HRS 2012 research highlights:A slideshow presentation
HRS 2012 Research Highlights The Heart Rhythm Society (HRS) 2012 Scientific Sessions took place in Boston, MA from May 9 through May 12, 2012. Key presentations at the sessions included: Riata ICD lead safety: Attendance was off the charts at the headliner event RAAFT 2: RF catheter ablation with pulmonary vein isolation is more likely to suppress AF recurrences than standard drug therapy Founders Lectureship Award: HRS 2012 recipient Dr Michel Haϊssaguerre FIRM ablation: Patients who have undergone focal impulse and rotor modulation (FIRM) ablation in addition to standard pulmonary vein isolation (PVI) remain AF free more often than those treated with standard PVI PROTECT-AF: Watchman LAA closure device reduces the risk of ischemic stroke in patients with AF, entirely without anticoagulationPACES/HRS consensus statement on WPW: Consensus statement helps clarify which young people should undergo catheterablationPOSTERS: New research was highlighted at HRSs Poster TownMagnaSafe Registry: Findings show that MRI with pacers and ICDs are safe, with a few minor issuesSTARTER: "Sweet spot" for echo-guided CRT lead placement explored in trialDouglas P. Zipes Lectureship Award: This years recipient was Dr Dan RodenAF ablation: Reaching first-line statusAF summit: Tools and technologies for AF ablation
Riata ICD lead failure A highly promoted late-breaking trial, as well as several abstracts, attempted to define the nature and scope of the problem with the recalled Riata ICD leads Details: In December 2011, the Riata line of implantable defibrillator leads (St Jude Medical) was officially recalled because of a high risk of failure. The conductor wires can erode through their silicone insulation and "externalize," sometimes causing electrical abnormalities, lead malfunction, or possibly high-voltage shorts. At HRS 2012, the Riata failure rates and mechanisms took center stage, as groups lined up to report their experiences with the leads, abstract after abstract, as well as a highly promoted late-breaking trial."In my mind, cables that externalize, which people have called a cosmetic problem, are a lead failure. Its not how the leadwas designed to function," said Dr Laurence M Epstein (Brigham and Womens Hospital, Boston). "One of the concerns Ihave is that we dont fully understand the mechanism of why these leads are failing, and I think thats really important for usto understand moving ahead."See: Riata revelations: ICD lead failure rates, mechanisms take HRS center stage
RAAFT 2 Radiofrequency catheter ablation with pulmonary vein isolation is more likely to suppress AF recurrences than standard drug therapy Results: Radiofrequency (RF) catheter ablation with pulmonary vein isolation is not only safe as a first-line treatment for paroxysmal or persistent atrial fibrillation (AF), its more likely to suppress AF recurrences than is standard antiarrhythmic drug (AAD) therapy, suggests a randomized trial with a two-year follow-up, one of the longest for an AF-ablation trial. A single ablation procedure reduced the risk of AF recurrence by a significant 44% compared with AAD. Importantly, in the second Radiofrequency Ablation vs Antiarrhythmic Drugs as First-Line Therapy of Atrial Fibrillation (RAAFT 2) trial, which followed all patients with transtelephonic monitoring (TTM), RF ablations significant advantage over AAD was in reducing bouts of AF that were either symptomatic or asymptomatic."So to be able to claim victory with ablation, you really need to monitor these patients very judiciously," said RAAFT 2 co–principalinvestigator Dr Carlos Morillo (Hamilton Health Sciences-McMaster University, ON). Ablation also significantly cut the frequency ofsolely symptomatic AF, he said. "These findings support the indication of radiofrequency pulmonary vein isolation as first-line therapy inpatients with paroxysmal atrial fibrillation."See: RAAFT 2: Catheter ablation can be first line of defense against paroxysmal AF
Founders lectureship award HRS 2012 Recipient: Dr Michel Haϊssaguerre Results: The Founders lecture was delivered by Dr Michel Haϊssaguerre, from Hôpital Cardiologique du Haut-Lévèque, who discussed the past, present, and future of AF and catheter ablation. See: AF Summit: Current, Evolving and Futuristic Therapies for AF
FIRM ablation Patients who have undergone focal impulse and rotor modulation (FIRM) ablation in addition to standard pulmonary vein isolation (PVI) remain AF free more often than those treated with standard PVI Results: Dr Sanjiv Narayan (University of California, San Diego VA Medical Center) presented a technique called FIRM ablation. This technique involves placing commercially available multipole basket catheters into the atria. During AF, the signals are sent to an investigational computer system, which then displays optical images and movies of the activation. Distinct geographic "areas of interest" in either the right or left atrium can be seen in almost all cases of AF. Sometimes the rotors are located in areas typically targeted during pulmonary vein isolation (PVI), but in many cases they are not. Most remarkably, his prior work has shown that when these areas are ablated, AF terminates. Patients who have undergone focal impulse and rotor modulation (FIRM) ablation in addition to standard PVI remain AF free more often than those treated with standard PVI.Dr Narayan presented new data on the acute termination of AF with FIRM-guided ablation. In a cohort of patients with advanced AF,he showed that rotors or focal impulses could be seen in 98%. Ablation at these focal sites terminated, slowed, or converted AF toflutter in 88% of patients. Almost half converted to sinus rhythm. In one case, ablation for only one minute converted the patient tosinus rhythm.See: Turning the AF ablation world upside down—FIRM ablation
PROTECT-AF Watchman LAA closure device reduces the risk of ischemic stroke in patients with AF, entirely without anticoagulation Results: The Watchman left atrial appendage (LAA) closure device cuts the risk of ischemic stroke in patients with atrial fibrillation (AF), entirely without oral anticoagulation, suggests the observational ASA-Plavix (ASAP) Registry. These results add to what had been observed in the Watchmans main randomized trial, Embolic Protection in Patients with Atrial Fibrillation (PROTECT-AF), in which patients with the device took warfarin for at least the first six weeks. PROTECT-AF found the device noninferior to standard warfarin therapy for protection against stroke, cardiovascular death, or systemic embolism in patients with AF and a CHADS2 score >1. Patients getting the Watchman in ASAP, who took clopidogrel for six months and aspirin indefinitely but without ever going on warfarin, still showed only a 1.7% rate of ischemic stroke—compared with 2.2% in the PROTECT-AF Watchman group, 7.3% in historical controls with ASAP-comparable CHADS2 scores taking aspirin alone, and 5.0% in such controls taking aspirin plus clopidogrel.The findings, said Dr Vivek Y Reddy (Mount Sinai School of Medicine, New York, NY) when presenting the analysis, cast doubt on theneed for even temporary warfarin in patients implanted with the Watchman. Most strokes related to thrombus forming at the device wouldoccur in the first six months after Watchman implantation, Reddy speculated; so if anything, eliminating the early warfarin might raise thestroke risk, not lower it. Given the low stroke rate seen in the ASAP registry, Reddy said, "Its not clear how important that 45 days ofwarfarin is. In fact, its not clear that six months of [clopidogrel] helped at all."See: Without warfarin, Watchman still prevents strokes, says registry
PACES/HRS consensus statement on WPW Consensus statement helps clarify which young people should undergo catheter ablation Results: A "first-of-its-kind" consensus statement on the management of asymptomatic patients with Wolff-Parkinson-White (WPW) syndrome should help clarify which young people should undergo catheter ablation. The guidance is explicitly directed at physicians treating young patients with WPW and defines young people as between eight and 21. At the crux of the document is the question of just when physicians should intervene—and when they shouldnt—in young people found, on ECGs, to have the signature electrocardiographic WPW pattern. These are increasingly important questions, given increased emphasis on preparticipation screening for sports in young people. The expert consensus statement, a joint effort of the Pediatric and Congenital Electrophysiology Society (PACES) and the HRS, estimates that from one to three young people per 1000 likely have WPW, although many—around 65%— are asymptomatic."While it is a small chance that an asymptomatic young person could end up having a life-threatening heart event, the number is not zero,"said lead author on the statement, Dr Mitchell I Cohen (Phoenix Childrens Hospital, AZ). "Yet, catheter ablation for every child who hasever had a WPW pattern is also not the answer."See: Joint PACES/HRS expert consensus statement offers guidance in the treatment of asymptomatic young patients with WPWSee: New guidance for young people with Wolff-Parkinson-White (WPW) syndrome
Poster Town New research highlighted An overwhelming number of posters were presented at the Poster Town in the HRS 2012 Exhibit Hall. Poster sessions were available to attendees throughout the conference, as well as moderated poster sessions and interactive abstract poster sessions. Noteworthy topics included: Placing the ECG leads in the right place to avoid false diagnoses; PVC morphology and duration may predict the presence of cardiomyopathy; AF ablation may not yield good results for patients with sleep apnea and metabolic syndrome; LAA isolation is a good thing because patients showed a higher three-year success rate; and a single case of atrial-esophageal fistula presented following standard cryoballoon ablation. See: HRS 2012 poster highlights: ECGs, PVCs, OSA, Debates in AF ablation, and the dangers of cryoablation
MagnaSafe Registry Findings show that MRI with pacers and ICDs are safe, with a few minor issues Results: Interim findings from the MagnaSafe Registry show there were no important safety issues but some alterations in programming and transient impedance changes during nonthoracic magnetic resonance imaging (MRI) in patients with pacemakers and implantable cardioverter defibrillators (ICDs). No instances of imaging-associated death, device failure, generator or lead replacement, loss of capture, or electrical reset occurred with MRI, which was performed consistently at 1.5 T. Of less apparent significance, the battery-voltage changes seen in 12% of ICDs and device parameter changes seen in a tenth of pacemaker and a third of ICD patients."We cant say whether any of those changes were clinically significant in any way," said Dr Debra Doud (Scripps Clinic, La Jolla, CA).But whether or not there are advantages to such devices, "there still will be a large number of patients with non-MRI-conditional deviceswho need to undergo an MR scan for one reason or another. And certainly [going ahead with the scan] is much safer than leadextraction and putting in an MR-conditional device for patients who already have a device. The one population of [device] patients wehad to exclude was those with ICDs who were pacemaker-dependent," because devices from some manufacturers dont allow ICDfunctions to be disabled without turning off the pacing functions.See: MRI with pacers, ICDs: Safe, a few minor issues, says MagnaSafe registry
STARTER "Sweet spot" for echo-guided CRT lead placement explored in trial Results: Patients are more likely to respond to cardiac resynchronization therapy (CRT), clinically and in terms of reverse remodeling, if speckle-tracking echocardiography guides the placement of their pacing leads. For echo guidance in the trial, called Speckle Tracking Assisted Resynchronization Therapy for Electrode Region (STARTER), leads were positioned at or close to the myocardial site of latest mechanical activation for each patient individually. Those whose lead positions were tailored that way, compared with standardized positioning without echo guidance, benefited with significantly improved ventricular end-systolic volumes and survival without heart-failure hospitalization."A substantial proportion of patients, about one-third, do not respond to CRT therapy, and we dont know who those peopleare," said Dr Samir Saba (University of Pittsburgh, PA). "Now we are starting to understand better. Once we know where theleads should be appropriately placed, for that specific patient, we achieve better results."See: "Sweet spot" for echo-guided CRT lead placement explored in trial
Douglas P Zipes Lectureship Award: Dr Dan Roden Results: The lectureship award named for Douglas P Zipes recognizes an individual who has contributed to the advancement of cardiac electrophysiology in the area of basic science. This years award recipient was Dr Dan M. Roden (Vanderbilt University School of Medicine, Nashville, TN), who gave the lecture "Heart to heart: Treating arrhythmias using personalized medicine." The award was presented as part of the Basic/Translational Science Forum on Wednesday, May 9th, 2012 at 3pm. See: Heart Rhythm 2012 Program eBook p.27 Rodens research lauded by Heart Rhythm Society
AF ablation: Reaching first-line status Results: For the past few years, the evidence base supports the role of catheter ablation in AF patients who have done poorly with medicines. But has catheter ablation progressed enough to offer it as a first-line therapy? The North American expert task force guidelines call for trying an antiarrhythmic drug before ablation; the more lenient European guidelines allow us to offer catheter ablation as first-line therapy. Which is the best approach? An important multicenter study, RAAFT 2, supports the notion that AF ablation (pulmonary vein isolation [PVI])—as a first-line therapy—has made the transition to the front line. The RAAFT 2 trial demonstrated that low-risk symptomatic patients with AF (87% paroxysmal) treated with standard catheter-based PVI had less AF and fewer complications than did those treated with AF drugs. Adverse events occurred in 7.7% of patients who had ablation compared with 19.7% of those treated with medicine.Although preliminary, this study will have a significant impact. The results of RAAFT 2 add more information to an already-complex decision-making process. Until Dr Narayans FIRM ablation becomes mainstream, AF ablation remains a dauntingchallenge. Always important is the doctor-patient relationship, but never more so in cases when life-threatening therapies areused for non–life-threatening diseases.See: Has ablation reached first-line status?
AF Summit: Tools and technologies for AF ablation Results: "The AF summit: Tool and technologies for AF ablation" was a state-of-the-art update concerning the tools and technologies that are available for use in the field of AF ablation. Operators learned about which tools to use and how to use them to achieve maximum success. The topics included the importance of PV isolation and the limitations of current technologies in achieving permanent PV isolation; contact force in lesion creation and the available knowledge as to whether newly available force-sensing catheters improve outcomes; and the current and future role of remote navigation technologies in AF ablation. See: AF summit: Tools and technologies for AF ablation
For more information Complete HRS 2012 coverage on theheart.org HRS 2012 Scientific Sessions
Credits and disclosures Journalist: Steve Stiles, theheart.org Fremont, CA Disclosure: Steve Stiles has no relevant financial relationships to disclose. Blogger: Dr John Mandrola Louisville, KY Disclosure: John Mandrola has no relevant financial relationships to disclose. Editor: Shelley Wood Managing Editor, heartwire theheart.org Kelowna, BC Disclosure: Shelley Wood has disclosed no relevant financial relationships.Contributors:Steven RourkeManager, Editorial programming theheart.orgMontreal, QCDisclosure: Steven Rourke has disclosed no relevant financial relationships.Katherin VasilopoulosMontreal, QCDisclosure: Katherin Vasilopoulos has no relevant financial relationships to disclose.
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