Dr Andrew Hogarth (Specialist Registrar EP and Devices, The Yorkshire Heart Centre, Leeds General Infirmary), Dr Dominic Hares (Specialist Registrar Paediatric Cardiology EP, The Yorkshire Heart Centre, Leeds General Infirmary)
October 3rd – 6th 2010 saw over 1,500 delegates descend upon the Birmingham Metropole Hilton Hotel for this year’s Heart Rhythm Congress (HRC). This report examines some of the highlights of this ever more popular meeting.
The opening day marked the start of three sessions dedicated to the Heart Rhythm UK (HRUK) certificate of accreditation course, providing a valuable resource for physiologists, arrhythmia nurses and physicians preparing to undertake this increasingly recognised exam. HRUK continue to work hard to establish a coordinated training programme, which was evident throughout the meeting with a broad range of relevant sessions directed at trainees. In such a quickly evolving and technically demanding speciality, a unified and coordinated training programme is crucial. It was reassuring to witness the time and effort being put into achieving this.
Educational sessions for the more advanced practitioner were readily available throughout the meeting. Those of particular value provided debate and insight into how colleagues have developed their practice, including tips and tricks on how they overcome common problems. In such a rapidly advancing field, it is challenging for individuals to keep abreast of evolving techniques. Some of the advanced electrophysiology on offer provided food for thought as well as reassurance that others have both similar problems as well as successes. Such sessions were all well attended, with characteristically enthusiastic crowds and often completed with a session of unknown EP traces which taxed the grey matter and allowed the application of previously presented techniques to solve clinical scenarios. Later in the meeting a review of ST elevation, Long QT syndrome and Brugada syndrome left many delegates convinced that they had missed at least one on a daily basis for most of their careers, just highlighting the difficulties in diagnosing and management of these challenging problems.
From a trainee’s view-point, one of the most useful events was the Cases and Traces section, with difficulties in diagnosis being discussed by colleagues from around the UK in a light-hearted “show and tell” confessional. The incisive questioning of some of the more technically minded delegates was in contrast to the “just look at that” intrigue of the majority, but the style enabled all involved to feel that they had finished the session having learnt valuable lessons.
The first day of the conference was once again dedicated to Patient’s Day, with meetings arranged by the Atrial Fibrillation Association (AFA), Syncope Trust And Reflex anoxic Seizures (STARS) as well as the Patient’s Day Exhibition. Once again a notable feature was the positive relationship evident between clinicians in primary, secondary and tertiary care as well as physiologists and nurse specialists; this seemed a facet which was appreciated by the patient groups represented. A light-hearted quiz pitting a team of specialists from secondary and tertiary care against one from primary care provided further entertaining evidence for this. The general practitioners demonstrated not only their specialist interest in cardiology arrhythmia management but also their supremacy in the field of general cardiology trivia and quiz technique!
Atrial Fibrillation (AF), particularly the interventional treatment of AF, was predictably high profile. There was ample opportunity for the experts to discuss the efficacy and evolving techniques of catheter ablation therapy for atrial fibrillation. Increasing experience and continual developments in technology have resulted in quicker and effective interventional options. This evolution has already reduced procedure times whilst still maintaining efficacy. These advances are of great interest given the massive burden of atrial fibrillation on the NHS (approximately 1% of total budget) and the potential benefits of offering a potentially curative, or at least markedly alleviating, procedure to so many people. However, the recent Government White Paper, Equity and excellence: Liberating the NHS, has focussed the minds of clinicians, managers and politicians alike as the cost effectiveness of AF ablation is called into question. This was an area of intense debate. Whilst the role of catheter ablation of AF in paroxysmal AF is valid and well established, the cost effectiveness of ablation of permanent AF is potentially more questionable. The technology and enthusiasm for utilising complex techniques has arguably got ahead of the evidence base. In these financially demanding times the profession must demonstrate outcome evidence to justify the use of expensive, time consuming and technically demanding catheter ablation strategies.
With this in mind, a timely debate about this hot topic (Any Questions on AF? Ask the experts) was stylishly chaired by Mr Jonathan Dimbleby. Although the questions were flying thick and fast from the audience, control was never in question with Mr Dimbleby in the chair. This interactive question and answer session was packed, with even more delegates squeezing into the room as Mr Dimbleby chaired a lively debate between Dr Todd and Professor Camm in which the (rather extreme) motion of left atrial ablation becoming the first-line treatment for most patients with atrial fibrillation was soundly defeated -much to the dismay of those looking for consultant appointments in the near future! Mr Dimbleby, characteristically flawless and professional throughout, could not hide his surprise at the paradox which emerged following a straw poll of the audience; this confirmed that the vast majority would opt for a catheter ablation if they themselves had problems with paroxysmal AF, yet this was considered a rationed treatment requiring measured evaluation when applied to patients. The increasingly expensive options for AF management, both pharmaceutical and interventional, allied to its increasing prevalence in an aging population, means this important debate will run for some time.
Nevertheless, AF remains a major cause of stroke, morbidity and mortality and despite major advances in both medicines and interventions to reduce symptoms and to reduce the risk of stroke, the lack of awareness of AF within the population delays the implementation of these advances. The AF Symposia and NHS improvement session once again examined some of the developments in both understanding the challenges and inducing change in practice. This provided a valuable forum for clinicians and allied professionals from primary, secondary and tertiary care to discuss relevant issues, with many sessions specifically directed toward the challenges of arrhythmia management in primary care. This was particularly evident in the interesting debate surrounding screening for atrial fibrillation, how and where best to do it and the subsequent cost benefit issues.
Much time was dedicated to the central issue of anticoagulation for thrombo-embolic prophylaxis and stroke risk reduction in atrial fibrillation. The message was loud and clear; warfarin prescribing needs to increase in at risk groups, particularly in the primary care setting. Strategies were outlined as to how this may be achieved, including altering the Quality Outcomes Framework to be more specific with regard to the mode of thromboembolic prophylaxis. The identification of those individuals at risk of stroke and therefore justifying full anticoagulation was thus the topic of much discussion. The expert consensus seemed to be that all but those in the very lowest group of stroke risk should be considered to need warfarin, and refining the threshold calculated by currently used risk scores (e.g. CHADS-2: 1 point each for C=cardiac failure, H=hypertension, A=age over 75, D=diabetes, S=previous stroke 2 points) will be necessary to achieve this aim. The paradigm shift would be for a clinician to now question: “Why shouldn’t this patient be on oral anticoagulation therapy”?
The CHA2DS2 VASc scoring system might better answer this question leaving less room for grey-area indecision. It scores 2 points for age over 75 (the first A) one point for age over 65 (second A) and allows consideration to be given to (V) vascular disease (including coronary) as well as female gender (S-ex c- category). A score of 2 or more means stroke risk justifies the risk of warfarin.
With this in mind, it was refreshing to see the data on bleeding risk presented in a balanced manner, specifically with regard to the elderly population, in whom the risk is often over estimated. It was clear that there is a big problem with under utilisation of effective thrombo-embolic prophylaxis, with an estimated 46% of at risk AF patients not on warfarin, potentially resulting in 1250 preventable strokes per year.
It waits to be seen whether the next few years will see an improvement in this situation, perhaps catalysed by the emergence of effective and potentially safer alternatives to warfarin. With regard to dabigatran, news on when this may become widely available was not forthcoming. Cost implications, impending changes to commissioning arrangements and recently announced changes to the processes involved in approving new drugs are likely to be major factors.
The evidence for the application of left atrial appendage (LAA) occlusion devices was the focus of some attention. As much as 90% of the thrombus leading to thrombo-emboli and stroke is believed to originate in the LAA, this has led to the development of percutaneous therapies for occluding the LAA, which ideally allow the patient to stop oral anticoagulant therapy. Essentially, the device is placed distal to the ostium of the LAA to occlude flow thus preventing the migration of thrombus from the appendage. Whilst it is clearly early days, increasing registry data seems to confirm that these devices can be implanted relatively safely (major complications in the region of 2- 5 % reducing with increasing operator experience) with supporting randomised controlled data suggesting that stroke risk reduction is non-inferior to warfarin. Routine use is some way off, with few UK centres currently having an active programme, but enthusiasm is growing and the EP profession is naturally keen to take the lead. UK experience was generously shared in the form of video presentations demonstrating the technique for delivery of both the Watchman device and Amplatzer Cardiac Plug; with Dr Murgatroyd even allowing his first ever procedure to be broadcast to the audience. Importantly, these device alternatives to oral anti coagulation offer promise for those patients with high bleeding risks who are threatened by the high risk of stroke associated with AF; developments in the application of such devices are likely to accelerate as evidence, availability and experience evolve.
Bringing all these issues together, this year’s meeting coincided with the publication of the European Society of Cardiology guidance for the management of AF. Many of the experts presented data critical to the formation of this guidance which provides an excellent resource when weighing up the evidence base for options in managing AF. It can be found at http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/atrial-fibrillation.aspx or in the European Heart Journal, 2010, Volume 31 (19) pages 2369-2429.
State of the art indications and management of devices once again featured prominently. There was much discussion about the indications for complex devices, and how current practice and NICE guidance are often at odds. In general, we do not implant enough devices, including basic bradycardia devices. As inevitably the population of people with devices grows so too will the need for lead and device extraction. Evolving techniques with tips and tricks for percutaneous removal were discussed in detail alongside surgical options, with revealing insights from Dr Charles Byrd (Fort Lauderdale, Florida), a world leader and pioneer of lead extraction.
In order to help reduce the morbidity that is inevitably associated with implanted leads, a subcutaneous implantable cardiac defibrillator system has been pioneered, with implant experience increasing throughout the UK over the last 12 months. Early registry data seem to suggest that this is a reliable, safe and effective alternative to traditional systems which depend on implanting intravenous leads with all the potential problems which they might cause. The subcutaneous device also offers an alternative cosmetic result (device is in the mid-axillary line with minimal scarring visible on the chest itself) which may be more acceptable for certain groups of patients.
MRI conditional pacemaker systems are now routinely commercially available, and maintained a high profile at the impressive industry exhibition. Until recently the presence of a pacemaker would have meant all other imaging modalities would had to have been exhausted, with MRI only being utilised as the absolute last resort. New leads and devices have been shown to be safe in an MRI scanner, with no damage to the function of the device or lead. However certain implant, device follow-up and scan criteria protocol must be followed and the manufacturers describe the system as MRI ‘conditional’ as oppose to MRI ‘safe’. With some minor specialist modifications of scanning technique it is therefore possible to MRI any part of the body, including the heart. The aging population with devices will no doubt be increasingly likely to require MRI imaging in the future, and this is an interesting field of development. Implantable Cardiac Defibrillators (ICDs) due to their nature have more potential to develop electromagnetic problems, and the consequences of damage to sensing and function are potentially more serious, so for the time being ICDs remain an absolute contraindication to MRI. However, research is growing utilising specialised techniques of MRI scanning, and this, allied to the potential of MR compatible leads, may mean that MRI is even an option for certain patients with ICDs within the next few years. This field is being closely monitored with registry data.
A session entitled ‘Star Wars’ was clearly based in a galaxy far, far away from some of the delegate’s centres, in a land where magnets and robots have taken control of the catheters. The steer-ability of the magnetic catheters was shown to lend itself readily to the treatment of complex congenital patients, where achieving catheter stability for ablation in an abnormal heart can prove even more difficult than the correct diagnosis of the arrhythmia itself. The robotic ablation for atrial fibrillation was shown to allow the consultant to relax and control the case from outside the laboratory itself, a technique which could replace the currently available but technologically inferior option for radiation dose reduction- the registrar!
The opportunity to see some of the industry’s finest and shiniest new toys and gadgets was certainly welcome, with new mapping systems for electrophysiologists and updated devices for implanters. After hearing so much about technological advances there was the welcome opportunity to get “hands-on” with some, particularly with the supportive industry colleagues keen to facilitate the learning.
The congress provided an opportunity for specialists to consider various techniques for treating other more complex and challenging arrhythmias. Case study presentations provided an interesting and informative forum for debate. One particular highlight was the evolving field of catheter ablation for ventricular tachycardia (VT). This is an increasingly necessary intervention, particularly as the population of individuals with life saving defibrillation devices continues to grow, and experience across the UK continues to develop at a rapid rate. This prompted a round table expert discussion to stimulate a consensus statement from HRUK regarding the implications, infrastructure, training issues and the delivery of VT ablation across the UK.
It seems that the face of electrophysiological intervention is evolving at a rapid rate, providing cause for optimism that challenging, intrusive and sometimes life threatening arrhythmias can be effectively treated.
The field of paediatric and adult congenital cardiac electrophysiology was well represented. Of particular note were the updates on inherited cardiac disease and sudden cardiac death in the young. This emotive field was covered by some of the UK’s leading experts with real world practical discussions about cardiac genetics, how to deal with screening and family issues, and how to approach the sudden unexplained death of a young person. One of the stand-out sessions involved a multi-disciplinary approach to communicating risk to teenagers, based around a fictional diagnosis of Broad STU syndrome (which Dr Graham Stuart promises to publish on in the summer of 2012). The session brought together perspectives from clinicians, ethicists, lawyers, counsellors and parents, with lively debate both from the invited faculty members and the audience, and some important points for improving practice in this very difficult area.
Further presentation covered a tool-kit of useful “how-to” talks, including the setting up of a clinic to look after patients with inherited cardiac conditions (and the pitfalls of having patients booked into the “sudden death clinic”!), the insertion of “leadless” subcutaneous implantable defibrillators (which seem promise particular advantages for the paediatric patient – see above), the management of the transition to adult care of a patient with a complex device, the treatment of atrial fibrillation in childhood and the training of future paediatric electrophysiologists.
There was a good deal of attention on the issue of syncope. Models to help set up and run a cost effective syncope service were particularly topical. Recently published work from Eastbourne has helped establish the role of implantable loop recording devices, capable of continually transmitting diagnostic information for analysis, in improving the cost effectiveness, quality and rapidity of diagnosis of patients with unexplained syncope. Interestingly these devices were often implanted by trained and enthusiastic emergency department physicians to facilitate early discharge. Also of note, some of the world’s leading experts on autonomic dysfunction were represented, providing useful insight into the multi-system involvement of such difficult to manage pervasive clinical problems as inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS).
EP trainees were represented in large numbers and once again had their own session, with one highlight being the practical tips from a recently appointed consultant on how to tackle applying for and securing that perfect consultant job. There was a flourishing contribution from delegates including moderated and displayed posters as well as oral abstracts, the majority of which held real world value and stimulated some heated debate. Details of all this year’s abstracts will be published in Europace October 2010: Volume 12; Supplement 2.
The winners of the young investigators awards were:
Dr FZ Khan (Clinical)
A Systematic Assessment of the Optimal Left Ventricular Pacing Site during Cardiac Resynchronization Therapy: An Initial Derivation of a Novel Non Invasive Method and Subsequent Validation with a Randomized Controlled Trial
Dr KE Brack (Basic Science)
The increase in nitric oxide and antifibrillatory effect of postganglionic vagal fibres is preserved during VIP inhibition and does not involve the endothelium
HRC 2010 provided a welcome opportunity to catch up with colleagues throughout the UK, both from clinical and industry settings. The annual Gala Dinner provided a focal point, with the annual awards ceremony following an impressive and engaging address from Jonathan Dimbleby. The annual Arrhythmia Alliance Excellence in Practice Awards 2010, which aim to recognise outstanding achievements and contributions to arrhythmia management services, were as follows.
1/ Charles Lobban Volunteer Award for Outstanding Contribution To Arrhythmia Services 2010
Winner – Matthew Fay
2/ Award for Outstanding Medical Contribution to Cardiac Rhythm Management Services 2010
Winner – Janet McComb
3/ Allied Professional Award for Outstanding Contribution to Arrhythmia Management 2010
Winner – Jenny Tagney
4/ Team of the Year Award 2010
Winner – BCUHB Arrhythmia Team
5/ Lifetime Achievement Award
Winnner – Dr Richard G Charles.
HRC 2010 was once again entertaining and educational, with a well balanced programme of cutting edge developments, relevant education and real world clinical management. Next year’s congress promises more of the same and can be sincerely recommended to all health care professionals involved in the management of patients with cardiac rhythm disorders.
Heart Rhythm Congress 2011, 2nd-5th October Birmingham, U.K.
Published on: November 3, 2010
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