A P H R S N E W S L E T T E R

Contents02 Getting to Know APHRS Leader04 Webinar Summary: Biosense Webster06 SICD Future Perspectives and Sharing Experience from a Single Center in Thailand10 APHRS Virtual Congress 202012 Medtronic Ad: Every Patient. Everywhere.

SEPTEMBER 2020 | NO.50

Chief Editor: Anil Saxena

Deputy Editor: Kazuo Matsumoto

Managing Editors: Hsuan-Ming TsaoDavid HeavenPipin KojodjojoNwe NweSeiji TakatsukiJae-Min Shim

Jacky ChanYuanning XuArisara SuwannakulPhan Dinh PhongAparna Jaswal

02 GETTING TO KNOW APHRS LEADER

GETTING TO KNOW APHRS LEADER

Why did you choose to enter medicine and above all, prefer to specialize in Electrophysiology?

When I was a medical student, arrhythmia section was the most difficult and challenging to study, but ECG was so fun that I chose electrophysiology.

What do you regard as the most significant development in Electrophysiology in the recent past?

The arrhythmia field has been developing very fast and is still developing. There are many technical innovations, but I think the most significant thing is the technology that fuses cardiac imaging and electrogram.

Can you talk about an accomplishment that you’re particularly proud of?

I’m very proud to have a passionate EP team that will provide ongoing best patient care, cutting edge research and generous volunteer work. What’s more, I’m happy to have a system that will continue to carry on this mission by my junior colleagues.

Hui-Nam Pak

Professor of Medicine, Director of Heart & Vascular Intervention Center

Yonsei University Health System, Seoul, Republic of Korea

Name & Title:

Organization:

If you could have an alternative career, what would it be and why?

I want to be a Youtuber after retirement. That way I can communicate smoothly with my children.

Who has inspired you the most in your life and why?

I have three best mentors in my life. I learned how to study and practice arrhythmia procedures by Dr. Chun Hwang, and learned how to research and write papers by Dr. Peng-Sheng Chen. Moreover, professor Yong-Hoon Kim taught me how to live generously and survive fiercely in my life.

What are your hobbies and interests outside of medicine?

I have no hobby except ablation. However, interest in reading history books has recently increased remarkably.

03 GETTING TO KNOW APHRS LEADER

What is the funniest thing that has happened to you recently?

I took the wrong water bus in Venice just 40 min before my presentation at the Venice Arrhythmia conference. I could not get to the sea, so I enjoyed the restless sightseeing.

What is your best life advice, motto or favorite quote?

Study is to give others.The mentors taught me for free, so you should teach your junior fellows for free.

What advice would you give to your younger self?

Do your best in each small things. Then, pray and leave the rest that has not been accomplished yet.

What are your thoughts about some of the emerging technologies, and the way they will shape the future care of arrhythmia patients?

The convergence of artificial intelligence technology and current arrhythmia-related technology will be the hottest issue of the next generation. But we must make good use of new technology for humanity and not be dependent on it.

04 WEBINAR SUMMARY: BIOSENSE WEBSTER

Biosense Webster Live Asia Pacific Login link here:

Road to Expert - Accessory Pathways

WEBINAR SUMMARY: BIOSENSE WEBSTER

The first APHRS-endorsed, Biosense Webster sponsored “Road to Expert – Accessory Pathways” webinar was successfully held on Jun 13th.

It was a great honor for us to invite Dr. Warren (Sonny) Jackman (US), Dr. Matthew Swale (AU) and Dr. Kaijun Cui (CN) to share their great knowledge in diagnosis and treatment of Accessory Pathways with the most up to date techniques. We reached a total of 541 audiences globally online during this webcast. (see table below for details).

We received strong, consistent and positive feedback from our audience for this webinar. For those who missed the live webinar due to a busy schedule, please login via the “Biosense Webster Live Asia Pacific” platform to watch the webinar recording. This site will be a central location for you to get our upcoming webinar information and watch post webinar recording online.

05 WEBINAR SUMMARY: BIOSENSE WEBSTER

The second APHRS-endorsed, Biosense Webster sponsored “Mapping and Ablation of Accessory Pathways and AVNRT” webinar was successfully held from Jul 2nd-6th.

It was a great honor for us to invite Dr. Warren (Sonny) Jackman (US) back again to share his great knowledge in diagnosis, differential diagnosis and treatment of Accessory Pathways and AVNRT. We had a daily average of 833 audiences globally attending this webcast.

We have received many requests for the webinar recording. Kindly note this series is ‘live only’ and as such is not recorded. We plan to re-engage Dr Jackman in the future so please keep an eye out for our upcoming sessions.

Lastly, thank you to our Faculty and the APHRS for their great support! On behalf of Biosense Webster, we’ll continue our dedication of digital webinars to support the incremental education needs in Electrophysiology. Thank you.

06 SICD FUTURE PERSPECTIVES AND SHARING EXPERIENCE FROM A SINGLE CENTER IN THAILAND

Nitinan Chimparlee, MD., Kanin Jantraprapavech, MD., Asst Prof. Arisara Suwanagool, MD.Cardiology division, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR: FUTURE PERSPECTIVES AND SHARING EXPERIENCE

FROM A SINGLE CENTER IN THAILAND

Introduction

Implantable cardioverter-defibrillator (ICD) is an efficacious life-saving device introduced as a standard treatment for fatal ventricular arrhythmia (VA) since 1980. There were several trials demonstrated the benefits of ICD in the reduction of mortality in high-risk patients1. The first-generation ICD, weighing 250g, was used to be implanted in a subcutaneous abdominal pocket. Using two leads, a superior vena cava (SVC) electrode catheter inserted via a transvenous approach, the other was the apical electrode, which was inserted via pericardial approach2. As a result of the continuous development of technologies, ICDs are becoming more compact, and able to access via a transvenous approach to the right ventricle. Despite using a more simplified technique, complications still occurred, including complications related to implantation, lead malfunction, lead infection, and inappropriate shocks, leading to a requirement of either a transvenous or open-heart surgical approach for lead extraction. In transvenous implantable cardioverter-defibrillator (TV-ICD) lead technologies, the lead is considered the most fragile part of the ICD system. The problem of lead malfunction can increase over time as a result of mechanical stress accumulation3. The most common mechanisms are insulation break and conduction fracture due to subclavian crush or abrasion3, leading to oversensing and inappropriate shocks. Other complications caused by transvenous lead insertion were vascular obstruction, systemic infection, and cardiac perforation4,5. The infection rate may increase 2-7% in each pulse generator change6. Complications associated with transvenous lead extraction (TLE) also depend on implant duration, ventricular lead itself, especially in non-infected or younger patients7 even performed TLE in a high volume center, major adverse complications, including death, were reported8-10.

As a result of TV-ICD outcomes, non-endovascular defibrillator or subcutaneous ICD (S-ICD) appears to overcome these complications since the S-ICD lead positioning by fluoroscopy using the anatomical landmarks only. The heart and vasculature remain untouched (Figure 1), certainly this technique gives benefits in patients with difficult venous access and reduces the risk of vascular injury, tricuspid valve injury, pneumothorax, lead dislodgment, and pocket infection/erosion. The S-ICD will also reduce lead failure from the electrode’s flexing or motion during the cardiac cycle. However, each S-ICD implantation has its own associated risk for pocket-related issues such as pain, hematoma, pocket infection/ erosion, and subcutaneous lead dislodgement. Not unexpectedly, a subcutaneous lead explantation/extraction is much safer than TLE10.

Figure 1: Position of S-ICD, the heart and vasculature remain untouched from the S-ICD (From S-ICDTM manual; Boston Scientific Corp., Marlborough, MA, USA)

07 SICD FUTURE PERSPECTIVES AND SHARING EXPERIENCE FROM A SINGLE CENTER IN THAILAND

Figure 2: The patient screening tool for S-ICD(From S-ICDTM manual; Boston Scientific Corp., Marlborough, MA, USA)

Figure 3: Acceptable ECG that best matches the amplitude of the QRS complex(From S-ICDTM manual; Boston Scientific Corp., Marlborough, MA, USA)

Compared to TV-ICD, S-ICD cannot terminate VA by anti-tachycardia pacing (ATP) and may lead to several unnecessary shocks in VA, which could be terminated by ATP11. Furthermore, S-ICD is not suitable for patients who concomitantly need pacing function, such as those with symptomatic bradycardia. In clinical practice, some physicians also concern about inappropriate shocks due to T wave oversensing of S-ICD. Regardless, a recent clinical trial of S-ICD, PRAETORIAN, demonstrated that S-ICD was not inferior to TV-ICD in terms of device-related complications and the number of inappropriate shocks12. Each candidate for S-ICD has to pass the ECG screening test using the patient screening tool that best matches the QRS complex’s amplitude (ECG gains must < 20 mm/mV). The QRS complex peak needs to fit in one of the peak zones then align the onset of the QRS complex to the left edge. The horizontal line is used as a guide of the ECG baseline and confirms that the entire QRS complex, including T wave in all collected postures [supine and upright (sitting or standing)], contains the color profile, as Figure 2. If at least one surface ECG lead (QRS complex and T wave) passes the screening for all tested postures, the patient will be considered a suitable candidate for S-ICD implantation (Figure 3).

08 SICD FUTURE PERSPECTIVES AND SHARING EXPERIENCE FROM A SINGLE CENTER IN THAILAND

Patient characteristics and outcomes of S-ICD Our center started to implant our first S-ICD in 2015 and increased patients in the past few years. These preliminary data were collected from 13 patients with S-ICD implantation at Her Majesty Cardiac Center, Siriraj Hospital, Bangkok, Thailand, from Nov 2015 to Aug 2020. They were 92.3% male with a mean age of 45.3 years old. The indications for their ICD implantation were Brugada Syndrome (76.9%) in both primary and secondary prevention, primary prevention for Ischemic cardiomyopathy (15.4%), and secondary prevention of Nonischemic cardiomyopathy (7.7%). Since our center is a tertiary care referral center for TLE, the most common reasons for our S-ICD implantation were switching from an infected TV-ICD system and transvenous lead malfunction to reimplantation with S-ICD. Of all S-ICD patients, which were 100% successfully implanted, 46.1% were infected patients; therefore, they were reimplanted with S-ICD later after TLE and recovery from their infection. In contrast to the non-infected lead malfunction, patients (23.1%) had their S-ICD immediately after TLE, and the remaining 30.8% were those who were first ICD implantation patients regarding their primary or secondary prevention indication. Defibrillation testing (DFT) was performed to every patient; the conversion rate was 100% successfully at 65 J.

Post-procedural complications were extremely low, twelves of our patients (92.3%) had 30 days freedom from complications and one had wound pain, compared to the rates seen in IDE (95.6%)13, EFFORTLESS (95.9%)14 and PAS (96.2%)15, the complications were mostly related to postoperative healing and pain management16. If device infection does happen again, S-ICD system extraction will not be as harmful as the TV -ICD system. During follow-up, our concern is the sensing issue. Oversensing of any noise or double counting T wave will cause an inappropriate shock, while undersensing signal may lead to an undetectable fatal VA. Fortunately, our patients had a clear signal and excellent sensing; no inappropriate shock or undetectable fatal VA was observed. Based on our center’s experience, S-ICD is a useful device for patients who need defibrillator therapy but have limited venous access or previous TV-ICD infection.

Discussion

In patients who meet the indication for defibrillator therapy but do not need other pacing functions, S-ICD is an alternative device in our clinical practice. S-ICD could be used in inherited arrhythmic syndromes, ischemic or nonischemic cardiomyopathy, and congenital heart diseases17. There are still special considerations for each cardiac condition, such as the risk of T wave oversensing in Brugada syndrome, one of the common inherited arrhythmic syndromes in the Asia-pacific region. However, the incidence of appropriate versus inappropriate shock between S-ICD and transvenous ICD was similar during long-term follow-up18. Due to more effective treatment for cardiovascular diseases, our patients may have a longer life and longer duration to live with ICD. They may also have a higher probability of developing device/ lead-related complications and vascular complications. S-ICD will be widely used in the upcoming future, considering it preserves venous access. As a result, this will avoid potential complications associated with vascular injury, reducing the potential for systemic infection and TLE complications. Last-mentioned, S-ICD requires very few or no upper extremities restriction and will compatible with an active lifestyle undoubtedly. Besides, it could be used alone, or it can also be implanted together with a leadless pacemaker in patients who essentially need pacing function together with defibrillator therapy in those without venous access. Finally, when the technology of S-ICD overcomes the remaining limitations of pacing function and inappropriate shock, S-ICD may become the first choice for defibrillation therapy.

09 SICD FUTURE PERSPECTIVES AND SHARING EXPERIENCE FROM A SINGLE CENTER IN THAILAND

References

1.Katritsis DG, Josephson ME. Sudden cardiac death and implantable cardioverter defibrillators: two modern epidemics? Europace. 2012;14(6):787-94.

2.Mirowski M, Reid PR, Mower MM, Watkins L, Gott VL, Schauble JF, et al. Termination of malignant ventricular arrhythmias with an implanted automatic defibrillator in human beings. N Engl J Med. 1980;303(6):322-4.

3.Kleeman T, Becker T, Doenges K et al. Annual Rate of Transvenous Defibrillation Lead Defect in Implantable Cardioverter-Defibrillators over a Period of >10 Years. Circulation. 2007;115 (19):2474-2490.

4.Atwater BD, Daubert JP. Implantable cardioverter-defibrillators: risks accompany the life-saving benefits. Heart. 2012;98(10):764-72.

5.Gasparini M, Nisam S. Implantable cardioverter defibrillator harm? Europace. 2012;14(8):1087-93.

6.Wilkoff BL. How to treat and identify device infections. Heart Rhythm. 2007;4(11):1467- 1470.

7.Byrd CL, Wilkoff BL, Love CJ, et al. Intravascular Extraction of Problematic or Infected Permanent Pacemaker Leads: 1994–1996. PACE. 1999;22(9):1348-1357.

8.Kalahasty G, Ellenbogen KA. Management of the patient with implantable cardioverter-defibrillator lead failure. Circulation. 2011;123(12):1352-4.9.El-Chami MF, Merchant FM, Levy M, Alam MB, Rattan R, Hoskins MH, et al. Outcomes of Sprint Fidelis and Riata lead extraction: Data from 2 high-volume centers. Heart Rhythm. 2015;12(6):1216-20.

10.Westerman SB, El-Chami M. The subcutaneous implantable cardioverter defibrillator-review of the recent data. J Geriatr Cardiol. 2018;15(3):222-8.

11.De Maria E, Giacopelli D, Borghi A, Modonesi L, Cappelli S. Antitachycardia pacing programming in implantable cardioverter defibrillator: A systematic review. World J Cardiol. 2017;9(5):429-36.

12.Knops RE, Olde Nordkamp LRA, Delnoy P-PHM, Boersma LVA, Kuschyk J, El-Chami MF, et al. Subcutaneous or Transvenous Defibrillator Therapy. 2020;383(6):526-36.

13.Weiss R, Knight BP, Gold MR et al. Safety and efficacy of a totally subcutaneous implantable-cardioverter defibrillator. Circulation 2013; 128: 944–53.

14.Boersma L, Barr C, Knops R et al. Implant and midterm outcomes of the subcutaneous implantable cardioverter-defibrillator registry: The effortless study. J Am Coll Cardiol 2017; 70: 830–41.

15.Gold MR, Aasbo JD, El-Chami MF et al. Subcutaneous implantable cardioverter-defibrillator post-approval study: Clinical characteristics and perioperative results. Heart Rhythm 2017; 14: 1456–63.

16.Boersma LV, El-Chami MF, Bongiorni MG et al. Understanding outcomes with the emblem S-ICD in primary prevention patients with low EF study (UNTOUCHED): Clinical characteristics and perioperative results. Heart Rhythm 2019; 16(11):1636-1644.

17.Bögeholz N, Willy K, Niehues P, Rath B, Dechering DG, Frommeyer G, et al. Spotlight on S-ICD™ therapy: 10 years of clinical experience and innovation. Europace. 2019;21(7):1001-12.

18.Lewandowski M, Syska P, Kowalik I. Children and young adults treated with transvenous and subcutaneous implantable cardioverter-defibrillators: a 22-year single-center experience and new perspectives. Kardiol Pol. 2020.

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References1 El-Chami MF, Al-Samadi F, Clementy N, et al. Updated performance of the Micra transcatheter pacemaker in the real world setting:

A comparison to the investigational study and a transvenous historical control. Heart Rhythm. December 2018;15(12):1800-1807.2 Crossley GH, Biffi M, Johnson B, et al. Performance of a novel left ventricular lead with short bipolar spacing for cardiac resynchronization therapy:

primary results of the Attain Performa quadripolar left ventricular lead study. Heart Rhythm. April 2015;12(4):751-758.3 Crossley GH, et al. Performance of a Novel Active Fixation Quadripolar Left Ventricular Lead for Cardiac Resynchronization Therapy. Presented at HRS 2019 (poster). 4 Tarakji KG, Mittal S, Kennergren C, et al. Antibacterial Envelope to Prevent Cardiac Implantable Device Infection. N Engl J Med. May 16, 2019;380(20):1895-1905.

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