Got Rhythm? Ramesh Hariharan, MD, FHRS

Transcription

1 Got Rhythm? Ramesh Hariharan, MD, FHRS Professor of Cardiology UTHealth Medical School Medical Director of Cardiac Electrophysiology Memorial Hermann Heart & Vascular Institute-TMC

2 Logical conclusions! Conflicting medical studies: The French eat a lot of fat and also suffer fewer heart attacks than the British or Americans. The Italians drink excessive amounts of red wine and also suffer fewer heart attacks than the British or Americans. The Germans drink a lot of beer and eat lots of sausages and suffer fewer heart attacks than the British or Americans. CONCLUSION: Eat and drink what you like. Speaking English is apparently what kills you!

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10 Sudden Cardiac Death Jason Collier, Center for the Hawks, died October 2005 in his sixth year in the NBA.

11 Sudden Death Thomas Herrion 23 years old lbs Offensive lineman Died shortly after the Niners touchdown drive Aug 2005

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13 The impact of Sudden Cardiac Death Percentage of patients surviving to return to NORMAL day-to-day activities is around 1% Outcome of SCD Causes of SCD Mortality Survival Other Ventricular Tachyarrhythmias

14 The heart in Hypertrophic Cardiomyopathy

15 CARDIAC RESYNCHRONIZATION THERAPY Pacemaker

16 Radiofrequency communication!

17 Wireless Efficiency at Home Alleviate patient compliance issues Pre-program automatic scheduled transmissions Automatic alert notification with physician-selected CareAlerts

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19 Defibrillator technology discussed on National primetime TV

20 ATP terminates VT

21 QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. Now playing at an ER near you: My ICD ed my EP doctor, and he asked me to come to the ER.

22 The S-ICD

23 Atrial fibrillation Warfarin Pradaxa Xarelto Eliquis Ablation Wireless Defibrillator Novel household terms

24 Faces of Atrial Fibrillation

25 Faces of Atrial Fibrillation

26 The Problem of AF gets Larger Number of AF patients likely increases 2.5-fold in 50 yrs 1,2 Reflects growing proportion of elderly individuals 3 Due to an ageing population Improved survival of patients with conditions which predispose AF (e.g. heart attack) Projected number of persons with AF 2 1. Go AS, et al., Prevalence of diagnosed AF in adults: national implications for rhythm mgt & stroke prev.: ATRIA Study. JAMA 2001;285: Miyasaka Y, et al., Secular trends in incidence of AF in Olmsted County, MN, , implications on projections for future prevalence. Circulation 2006;114: Briffa T, et al., Long term survival after evidence based treatment of acute MI and revascularisation: follow-up of population based Perth MONICA cohort, BMJ 2009;338:b36 Projected number of persons with AF in the US between No further increase in age-adjusted AF incidence (solid curve) A continued increase in incidence rate as evident (dotted curve)

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28 Stroke Over 15 million strokes worldwide 1 5 million fatal 5 million permanently disabled Europe averages approximately 650,000 deaths due to stroke each year 2 3 rd leading cause of death behind heart disease and cancer 1 1 st cause of serious long-term disability 1 Stroke social cost accounts approximately for the 3% of total health care expenditures 3 1. World Health Report Roger, et al, Heart Disease and Stroke Statistics 2011 Update: a Report From AHA. Circulation. 2011;123:e18-e Evers, et al, International comparison of stroke cost studies. Stroke. 2004;35:

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31 Risk Factors for Stroke and Thrombo-embolism Major risk factors Previous stroke, or TIA, or systemic embolism Age > 75 years Clinically relevant non-major risk factors Heart failure or moderate to severe LV systolic dysfunction (e.g. LV EF < 40%) Hypertension Diabetes mellitus Female sex Age years Vascular disease Camm, et al., ESC 2010 Guidelines for the management of Atrial Fibrillation; European Heart Journal doi: /eurheartj/ehq278

32 What do latest the guidelines say? Fundamentally: everyone with AF and one risk factor should be on anticoagulation therapy Recommendations for antithrombotic therapy should be based on the presence (or absence) of risk factors for stroke and thrombo-embolism Assessment of bleeding risk should be part of the patient assessment before starting anticoagulation Bleeding risk assessment: high risk : some caution and regular review of the patient is needed following the initiation of antithrombotic therapy, whether with VKA or aspirin. Camm, et al., ESC 2010 Guidelines for the management of Atrial Fibrillation; European Heart Journal doi: /eurheartj/ehq278

33 Rat poison? Cows dying after dehorning Bulls dying after castration Canadian veterinary concerns Karl Link, Univ of Wisconsin Wiconsin Alumnus Research Foundation ARIN

34 Country Distribution of Mean Time in Therapeutic Range in the RE-LY Trial 5791 Patients on warfarin Major variations between countries Europe: about 3 out of 10 patients out of therapeutic range Sweden: 23% out of range Taiwan: 56% Wallentin, et al., Efficacy and safety of Dabigatran compared with Warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial; The Lancet, 2010: 376;

35 Advances in Anticoagulant Therapy 10-12% mortality reduction 21% reduction in stroke/systemic embolism 31% reduction in major bleeding episodes Coumadin-greater use of home monitoring Target INR in trials 55-64% of the time. Dabigatran PRADAXA 150/110/75 mg BID RELY trial Rivaroxaban-XARELTO 20/15/10 mg QD ROCKET AF Apixiban-ELIQUIS 5mg PO BID ARISTOTLE Edoxaban-LIXIANA 60/30 mg QD ENGAGE AF-TIMI48 Betrixiban When compared with Warfarin

36 Approach to Intracardiac tracings

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42 Conversion of atrial flutter to NSR during RF ablation

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50 Left atrial appendage by TEE prior to occlusion

51 The WATCHMAN product is a device for percutaneous closure of the left atrial appendage WATCHMAN is a self-expanding nitinol frame with fixation anchors and a permeable fabric cover It is designed to be permanently implanted at or slightly distal to the opening of the LAA to trap potential emboli before they exit the LAA WATCHMAN LAA Closure Device Images on file at Boston Scientific Corporation Five sizes of device (21, 24, 27, 30 and 33 mm) allow for precise fit within ostium It is implanted via a transseptal approach by use of a catheterbased delivery system The delivery catheter is capable of recapturing the device if necessary Received CE mark in 2005

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