Got Rhythm? Ramesh Hariharan, MD, FHRS

Professor of Cardiology UTHealth Medical School Medical Director of Cardiac Electrophysiology Memorial Hermann Heart & Vascular Institute-TMC

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!

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

Sudden Cardiac Death

Sudden Death Thomas Herrion

• 23 years old • 6’3” • 330 lbs • Offensive lineman • Died shortly after the

Niners touchdown drive Aug 2005

The impact of Sudden Cardiac Death

• Percentage of patients surviving to return to NORMAL day-to-day activities is around 1%

Outcome of SCD

Survival Mortality Ventricular

Tachyarrhythmias Other

Causes of SCD

The heart in Hypertrophic

Cardiomyopathy

Pacemaker

CARDIAC RESYNCHRONIZATION THERAPY

Radiofrequency communication !

Wireless Efficiency at Home

• Alleviate patient compliance issues

• Pre-program automatic scheduled transmissions

• Automatic alert notification with physician-selected CareAlerts

Defibrillator technology discussed on National prime-time TV

ATP terminates VT

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Now playing at an ER near you: “ My ICD emailed my EP doctor, and he asked me to come to the ER.”

The S-ICD

Novel household terms

• Atrial fibrillation • Warfarin • Pradaxa • Xarelto • Eliquis

• Ablation • Wireless Defibrillator

Faces of Atrial Fibrillation

Faces of Atrial Fibrillation

The Problem of AF gets Larger • Number of AF patients likely

increases 2.5-fold in 50 yrs1,2 • Reflects growing proportion of

elderly individuals3

– Due to an ageing population

– Improved survival of patients with conditions which predispose AF (e.g. heart attack)

1. Go AS, et al., Prevalence of diagnosed AF in adults: national implications for rhythm mgt & stroke prev.: ATRIA Study. JAMA 2001;285:2370-5

2. Miyasaka Y, et al., Secular trends in incidence of AF in Olmsted County, MN, 1980-2000, implications on projections for future prevalence. Circulation 2006;114:119-25

3. Briffa T, et al., Long term survival after evidence based treatment of acute MI and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005. BMJ 2009;338:b36

Projected number of persons with AF2

Projected number of persons with AF in the US between 2000 – 2050 No further increase in age-adjusted AF

incidence (solid curve) A continued increase in incidence rate as

evident 1980 - 2000 (dotted curve)

Stroke • Over 15 million strokes worldwide1

– 5 million fatal – 5 million permanently disabled

• Europe averages approximately 650,000 deaths due to stroke each year2

– 3rd leading cause of death behind heart disease and cancer1

– 1st cause of serious long-term disability1

• Stroke social cost accounts approximately for the 3% of total health care expenditures3

1. World Health Report 2004 2. Roger, et al, Heart Disease and Stroke Statistics − 2011 Update: a Report From AHA. Circulation. 2011;123:e18-e209 3. Evers, et al, International comparison of stroke cost studies. Stroke. 2004;35:1209-1215

Risk Factors for Stroke and Thrombo-embolism

‘Major’ risk factors ‘Clinically relevant non-major’ risk factors

Previous stroke, or TIA, or systemic embolism

Age > 75 years

Heart failure or moderate to severe LV systolic dysfunction (e.g. LV EF < 40%)

Hypertension Diabetes mellitus Female sex Age 65–74 years Vascular disease

Camm, et al., ESC 2010 Guidelines for the management of Atrial Fibrillation; European Heart Journal doi:10.1093/eurheartj/ehq278

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:10.1093/eurheartj/ehq278

Rat poison?

• Cows dying after dehorning • Bulls dying after castration • Canadian veterinary concerns • Karl Link, Univ of Wisconsin • Wiconsin Alumnus Research

Foundation ARIN

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; 975 - 983

Advances in Anticoagulant Therapy • 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

• 10-12% mortality reduction • 21% reduction in

stroke/systemic embolism • 31% reduction in major

bleeding episodes When compared with Warfarin

Approach to Intracardiac tracings

Conversion of atrial flutter to NSR during RF ablation

Left atrial appendage by TEE prior to occlusion

The WATCHMAN® product is a device for percutaneous closure of the left atrial appendage

• 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 catheter-based delivery system

• The delivery catheter is capable of recapturing the device if necessary

• Received CE mark in 2005

• 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