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The 8th Annual Kansas City Heart Rhythm Symposium
The 8th annual Kansas City Heart Rhythm Symposium (KCHRS) took place on August 27-28th, 2016 at the Sheraton Hotel in Crown Center. Attendees were treated to lectures from EP experts and thought leaders from throughout the United States, including past and current Heart Rhythm Society presidents, Drs. John Day and Michael Gold, an excellent keynote address delivered by EP pioneer Dr. Hein Wellens, and reflections by Dr. Melvin Scheinman on Dr. Wellens’ lasting legacy and the evolution of the EP field. In the following summary, we will recap the highlights of the conference, focusing on current therapies, ongoing controversies, and directions for the future as discussed by the many speakers and panelists who devoted their time to make this KCHRS the best yet.
Fellows’ and Allied Health Professionals’ Conference
Dr. Dhanunjaya Lakkireddy, the course director, inaugurated the second iteration of the fellows’ and allied health professionals’ course. The session began with a talk by Dr. Marye Gleva on closed loop stimulation (CLS) in the setting of bradyarrhythmias and syncope, as well as a discussion on the benefits of the technology in providing physiologic heart rate variability to device-dependent patients. She reviewed the role of CLS and accelerometers in contemporary device therapy, emphasizing patient and sensor characteristics to help tailor therapy.
Dr. Gleva was followed by Dr. John Papagiannis, who taught attendees on the topic of integrated atrial sensors, weighing the benefits and risks of dual-chamber versus single-chamber devices with atrial sensors in primary prevention of sudden cardiac death (SCD). Dr. Martin Emert then discussed his systematic approach to cardiac resynchronization therapy (CRT) non-responders, highlighting the role of quadripolar left ventricular (LV) leads in optimizing biventricular (BiV) pacing, but also reminding attendees to maintain a broad differential in patients with suboptimal pacing. He emphasized the findings from an ALTITUDE cohort and the significance of 98.47% BiV pacing as the cutoff that conferred the greatest magnitude of mortality reduction, while further increases provided additive benefit.
In keeping with the theme of lifesaving interventions, Dr. Rakesh Gopinathannair presented on remote monitoring, reviewing its evolution and current implementation as part of a broader device management strategy. He highlighted the findings of several studies, including ALTITUDE, IN-TIME, and an analysis from Varma et al1, all of which showed significant mortality benefit from utilization of remote monitoring and a graded relationship based on patient adherence in the latter study. He concluded with strategies to promote increased utilization of remote monitoring technology among physicians and allied health professionals.
The session was completed with a discussion by Dr. Madhu Reddy on ablation mechanisms and the evolution of various catheter-based technologies. Afterwards, Dr. Reddy and Dr. Gleva led the fellows in a case-based discussion, focusing on clinical problem solving in EP, utilization of intracardiac electrograms for diagnosis, and appropriate treatment of various arrhythmias.
Opening Ceremony and Conference Overview
The conference officially opened with Dr. Lakkireddy welcoming the audience and giving an overview of the conference format, including the scientific program, social events, industry exhibitor hall, and an abstract competition for fellows, before yielding to the session moderators to introduce the speakers for the scientific program. The conference was covered extensively in social media, particularly Twitter, with live tweeting of sessions from @KC_HRS and some lively audience participation as well. KCHRS has served the heart rhythm education needs of the greater Midwest over the last 8 years. This meeting has gained a significant national reputation as one of the premier EP meetings, with faculty from all over the world.
SESSION 1: Heart Failure Therapies - MultiPoint Pacing, Neuromodulation, Catheter Ablation, and Stem Cell Therapy
The first session focused on heart failure (HF) management from the electrophysiologist standpoint. CRT using BiV pacing is an established therapy for patients with HF and reduced ejection fraction. Despite technological advances, one-third of patients have no response to CRT, and poor lead placement is thought to be a common culprit. In this context, Dr. Jie Cheng discussed evidence supporting the use of MultiPoint Pacing pioneered by St. Jude Medical’s quadripolar LV lead technology, in which four electrodes could be programmed to simultaneously deliver two pulses from a single lead, and thereby optimize biventricular pacing (also discussed by Dr. Emert in the fellow’s conference). Dr. Cheng went on to comment that MultiPoint Pacing, as compared to conventional BiV pacing, achieved better response rates and improved hemodynamic outcomes.
Dr. Michael Gold continued the session, emphasizing that HF is characterized by both sympathetic overdrive and parasympathetic withdrawal. He highlighted how current established therapies target the sympathetic overdrive, but that there is a growing interest in neuromodulatory therapies to address the important issue of parasympathetic withdrawal. On the heels of the recently published INOVATE-HF trial, for which he was the lead investigator, he provided an overview of vagal nerve stimulation (VNS) and its hypothesized effects on HF outcomes. He concluded that although the trial did not meet its primary efficacy endpoint, it did show improvement in HF symptoms and quality of life, as reflected by six-minute walk distance and New York Heart Association (NYHA) classification in patients with VNS.
Dr. Amin Al-Ahmad discussed the deleterious effects of atrial fibrillation (AF) in heart failure patients and the utility of AF ablation strategies to promote successful CRT, improve left ventricular ejection fraction (LVEF), and promote quality of life. Citing a number of recent studies of catheter ablation for AF rhythm control in the setting of HF, including the PABA CHF, ARC-HF, CAMTAF, and AATAC studies, he concluded that HF patients with concomitant AF have relatively poor outcomes, but that AF ablation seems to be associated with improved outcomes as compared to more conservative strategies.
Dr. Buddhadeb Dawn summarized the current evidence on the role of stem cell therapy in the management of heart failure. He examined the findings of various small studies that did not seem to show convincing benefit from stem cells, and compared these findings to large meta-analyses in which there did seem to be a statistically and clinically significant benefit with stem cell therapy in patients with chronic ischemic cardiomyopathy. He emphasized the need for more careful study to determine the optimal cell preparation and patient candidates to truly harness the potential of this therapy.
The session was concluded by Dr. Pugal Vijayaraman discussing the role of His bundle pacing as an alternative to CRT. He highlighted his group’s success in being able to reverse bundle branch block in nearly 85% of patients, narrowing QRS duration from 165 to 115 msec, and improving left ventricular ejection fraction from 30% to 47% with concomitant improvement in NYHA classification. He proposed to consider this therapy in patients with LVEF <50% who have failed LV lead placement or were CRT non-responders, as well as those who were thought to benefit from a more physiologic pacing approach.
SESSION 2: Keynote Address, CIED Infections, and Leadless Pacemakers
Dr. Robert Simari began this session by presenting the KU Pioneer in Electrophysiology Award to Dr. Hein J. Wellens of the University of Limburg in Maastricht, Netherlands. Unfortunately, he was not able to accept this award in person due to unforeseen circumstances, but Dr. Melvin Scheinman, a previous recipient of the same honor and close friend of Dr. Wellens, accepted the award on his behalf. A testament to his commitment to the broader field of cardiac electrophysiology, Dr. Wellens had prepared his keynote address and recorded it for KCHRS attendees. In it, he discussed major developments in the field throughout the course of his career, and gave credit to the innumerable contributions from the global EP community that have propelled the field to its current degree of sophistication. He concluded with five slides outlining his vision for the future of EP research and areas which he felt were particularly exciting, ending with the following comment:
“For me, personally, the past 50 years have been exciting and rewarding, not only thanks to the people I had the pleasure to work with in my “home base”, first in Amsterdam (1964-1977), thereafter in Maastricht, but also because of the numerous international colleagues who taught and stimulated me, with many of them becoming good friends. My gratitude goes to all of them.”
Dr. Wellens’ address was followed by a presentation from Dr. Marye Gleva on how to minimize cardiac implantable electronic device (CIED) infections, controversies surrounding capsulectomy, and the utility of an antibiotic pouch for CIED implantation. Dr. Paul Friedman concluded this session with a discussion on leadless pacemaker utilization, focusing on both the technical aspects of implant/explant and the current evidence pertaining to long-term efficacy and safety.
SESSION 3: Esophageal Injuries, S-ICDs, and Wearable Cardioverter Defibrillators
Dr. Lakkireddy discussed the role of mechanical esophageal deflection tools in minimizing the risk of esophageal injury during AF ablation. Dr. Loren Berenbom provided an overview on contemporary use of subcutaneous ICDs as well as considerations for patient selection and implantation. This was followed by a spirited debate between Dr. Martin Emert and Dr. Gerald Naccarelli on wearable cardioverter defibrillators (WCDs). Each made their arguments for and against utilization of this therapy in clinical practice, but ultimately they seemed to agree that despite its shortcomings, it’s worth offering to patients at risk for sudden cardiac death until guideline-based ICD therapy is initiated.
SESSION 4: Remote Monitoring of CIEDs, DFT Testing, and MRI Compatibility
Dr. Gold presented on remote monitoring (RM), reviewing past evidence suggesting that it helps detect AT/AF/VT earlier (TRUST trial) and decrease hospitalizations for arrhythmias (COMPASS-HF trial) and overall mortality (IN-TIME study). Furthermore, he explained RM has a graded effect on mortality tied to patient adherence, not only with ICD therapy, but also in the pacemaker population. He then reviewed some potential barriers to widespread implementation, noting that the single most important determinant of enrollment into RM is provider institution. He concluded by emphasizing that the scientific data on RM is overwhelming, hence making it a Class 1A recommendation for all patients undergoing CIED implant and predicting that in the future, its use will likely be a requirement rather than a goal to work towards. Following Dr. Gold, Dr. Timothy Smith summarized the arguments for and against the routine use of defibrillation threshold (DFT) testing, alluding to the recent SIMPLE trial, and concluding that routine DFT testing seems to have less value than once thought. He noted that induced ventricular fibrillation (VF) is a poor model of “field VF” and that DFT testing may not be as benign as once thought, but also conceded that it may be of use in select populations. Dr. Raghuveer Dendi ended the session with a discussion on MRI safety and CIEDs, discussing the evolution of MRI-compatible devices and the potential consequences and management of patients with non-compatible devices undergoing MR imaging.
SESSION 5: OAC, NOACs, and Periprocedural Anticoagulation in AF, Anesthesia Considerations, and Tachycardia-Induced Cardiomyopathy
This session focused primarily on oral anticoagulation (OAC) in AF. Dr. Thomas Deering discussed an interesting paradox wherein at least 38% of patients with a CHADS2 score of >2 are not on OAC, while 42% of patients with a CHADS2 score of 0 are currently on OAC. He explained how this situation can be remedied by implementing standard hospital-based policies for OAC use. This was followed by a summary from Dr. Naccarelli on the major non-vitamin K OAC drugs and appropriate use based on pertinent clinical trial data. Dr. Vijayaraman then discussed some considerations for periprocedural anticoagulation in various EP procedures. Next, anesthesiologist Dr. Amy Ortman discussed the mechanics of high-frequency jet ventilation as it pertains to EP procedures. She elaborated on how high-frequency, low-tidal volume jets minimize respiratory motion of the heart during radiofrequency ablation, and explained the technical challenges and current limitations of this strategy. Dr. Rakesh Gopinathannair finished the session with his talk on the pathophysiology and current management of tachycardia-induced cardiomyopathy.
SESSION 6: Multimodal Imaging, Cardiac Dysautonomia, Novel Heart Rhythm Monitors, and Tips for Pericardial Access
Dr. Douglas Packer opened the session with a wonderful talk on the effective utilization of available imaging modalities, including cardiac CT, MRI, 3D transesophageal echocardiography, and intracardiac echocardiography, in understanding cardiac anatomy and guiding successful EP procedures. This was followed by a presentation from Dr. Scheinman summarizing the current management options for cardiac dysautonomic syndromes like neurocardiogenic syncope. Dr. Moussa Mansour then presented on novel external heart rhythm monitors, demonstrating the ability of these devices to stretch and bend. BioStampRC™ (MC10, Inc.) has continuous ECG monitoring with a rechargeable battery and Bluetooth capability, while the WiSP™ (MC10, Inc.) is an ultra-thin episodic ECG monitor with near-field communication abilities. The session was concluded by Dr. Madhu Reddy, who provided tips and tricks for achieving good access and effectively navigating the pericardial space.
SESSION 7: LAA Closure vs NOACs in Stroke Prevention, and Interesting Cases from Dr. Wellens
The session started with a debate on left atrial appendage (LAA) closure vs non-vitamin K oral anticoagulants (NOACs) for stroke prevention. Although they have not been compared in a head-to-head fashion, Dr. Mevan Wijetunga showed data from a recent network meta-analysis by Li et al2 comparing LAA closure and NOACs, and suggested that in the absence of strong evidence, these procedures must be offered to a select subset of the population who are at high stroke risk and cannot tolerate long-term anticoagulation. Dr. Randall Lee then discussed the neurohormonal aspects of LAA physiology and the impact of subsequent closure. Day 1 of the conference was concluded with interesting cases from Dr. Wellens’ personal collection.
SESSION 8: Manohar Sai Gowda Memorial Young Investigator Cardiovascular Research Award
The second day of the conference started early with poster presentations by fellows participating in the annual abstract competition. Conference faculty made the rounds and critiqued the posters, after which the Dr. Manohar Sai Gowda Memorial Young Investigator Cardiovascular Research Award was presented. This award was established in appreciation of the late Dr. Gowda’s contributions to cardiovascular research, both as an investigator and as a mentor to those interested in pursuing research. Fellows from various cardiovascular disciplines were invited to submit their original research. Among abstracts submitted for review from all over the world, the top three abstracts were recognized at the symposium.
Dr. Indranill Basu Ray received the first place award for his abstract entitled, “Reclassifying stroke risk by addition of pectinate muscle to LAA morphology.” He found that in addition to non-chicken wing morphology, the presence of pectinate muscle is associated with increased stroke risk. Dr. Mohit Turagam received second place for his research on “Oral anticoagulation after radiofrequency ablation of atrial fibrillation and the risk of thromboembolism and bleeding.” Dr. Mohammad-Ali Jazayeri accepted the third place award for his abstract entitled “Atrioventricular Junctional Radiofrequency Ablation Guided by Pacing: A Simple and Reliable Technique.”
SESSION 9: Hemodynamic Monitoring, Ablation and Mapping Strategies, Arrhythmogenic Inflammatory Cardiomyopathy, Underuse of IV Sotalol, and Lifestyle Modifications
Post-infarction cardiomyopathy patients with severely reduced systolic function may require hemodynamic support to safely undergo ventricular tachycardia (VT) ablation. No formal guidelines or data predict the need for mechanical support, but it may be considered in patients with severely reduced systolic function, in whom spontaneous VT is not hemodynamically tolerated. The drawbacks of hemodynamic support are added procedural complexities and additional risks with large-bore arterial access of particular concern among patients with significant peripheral vascular disease. Dr. Andrea Natale suggested that substrate modification techniques that do not require the need for mapping during sustained VT may be preferable, and hence minimize the need for hemodynamic support. Dr. Packer presented an opposing view, providing arguments for the use of hemodynamic monitoring, especially in patients with unstable VT.
Dr. Mansour then discussed the role of ablation of non-pulmonary vein triggers in improving success rates in persistent AF ablation. He concluded by saying that the data on complex fractionated atrial electrogram (CFAE) ablation and focal impulse and rotor modulation (FIRM) ablation are controversial, and require further study to define their role in routine ablation.
Dr. Kalyanam Shivkumar discussed the role of positron emission tomography (PET) imaging in patients with unexplained cardiomyopathy and ventricular arrhythmias. He found that nearly 50% of patients referred with unexplained cardiomyopathy and ventricular arrhythmias demonstrated ongoing focal myocardial inflammation on FDG-PET imaging.3 He concluded that these data suggest a significant proportion of patients diagnosed with “idiopathic” arrhythmias may have occult arrhythmogenic inflammatory cardiomyopathy, which may benefit from early detection and immunosuppressive medical therapy. Dr. Gopinathannair then spoke on the underutilization of intravenous sotalol for chemical cardioversion in AF, raising interesting points on its potential to decrease hospital length of stay. Later, Dr. Al-Ahmad provided a summary of currently available mapping technologies, weighing the advantages and drawbacks of each. The session was concluded with an energetic presentation by Dr. John Day on the role of lifestyle modifications in the treatment of cardiac rhythm disorders.
SESSION 10: SVT Therapy, Genetic Testing for Inherited Cardiac Arrhythmias, and Balloon-Based Therapies for PVI
Dr. Scheinman opened this session by reviewing the history of SVT therapy with catheter ablation. Next, Dr. Rhea Pimentel summarized the current recommendations on genetic testing for inherited cardiac arrhythmias and cardiomyopathies. She highlighted that genetic testing is cost-effective for patients with LQTS, CPVT, HCM, and dilated cardiomyopathy with cardiac conduction disease or a family history of SCD. However, she pointed out, genetic testing identifies only 75% of mutations. She concluded that with the right patient, genetic testing can be helpful in treatment, but a negative genetic test result does not completely rule out the diagnosis. Dr. Deering finished the session with an overview on both the current status and future of balloon-based therapies (e.g., cryo, laser, and ultrasound) as an alternative to radiofrequency ablation for pulmonary vein isolation in AF.
SESSION 11: AF and Dementia, OSA Therapy, Surgical Options
Dr. Day summarized current data on the neurocognitive outcomes in AF, suggesting that decreasing AF burden through ablation may have a favorable effect on the long-term risk of developing dementia. Dr. Natale provided an overview on the relationship between obstructive sleep apnea (OSA) therapy and AF burden, emphasizing that people with OSA often have non-pulmonary vein triggers for AF, resulting in high recurrence rates. He suggested that these patients may benefit from more extensive ablation strategies early on, and noted that CPAP therapy after catheter ablation improves arrhythmia-free survival. The session was concluded with a surgical perspective on AF treatment provided by Dr. Gansevoort Dunnington. He provided an overview on the evolution of the Cox Maze procedure, minimally invasive approaches to surgical ablation, and the emergence of hybrid ablation procedures for complex and refractory AF.
SESSION 12: Industry Partners
Following the completion of presentations from KCHRS faculty, a panel discussion was held featuring representatives from major EP industry partners such as BIOTRONIK, Medtronic, St. Jude Medical, and AtriCure. Each representative was given an opportunity to speak to the audience regarding their company’s vision for the future. Afterward, Dr. Lakkireddy led a panel discussion in which he asked each company to comment on the greatest contemporary challenges to biomedical innovation and their approaches to solving these issues.
Conclusion of the Symposium
The 2016 Kansas City Heart Rhythm Symposium was a tremendous success thanks to the many speakers and panelists who traveled from all over the country and the world to be present for the scientific session. The turnout was excellent, and there were many opportunities for interaction between attendees and faculty, both during the conference and during evening social events. Outstanding lectures by EP pioneers like Drs. Wellens and Scheinman further created an atmosphere of excitement and inspiration for current and future generations of electrophysiologists in attendance, particularly the fellows.
The conference would not have been possible without the tireless efforts of Donita Atkins, RN, BSN and Melissa Jaeger, RN, BSN. For their efforts, the conference faculty and those in attendance are greatly indebted to both of them.
On the heels of this conference, planning for the 2017 Kansas City Heart Rhythm Symposium has already begun. Course director Dr. Lakkireddy and the conference organizers look forward to an even better conference in the year to come, and extend a warm invitation to any and all who are interested. For further information, please visit www.kchrs.com.
References
- Varma N, Piccini JP, Snell J, Fischer A, Dalal N, Mittal S. The relationship between level of adherence to automatic wireless remote monitoring and survival in pacemaker and defibrillator patients. J Am Coll Cardiol. 2015;65(24):2601-2610.
- Li X, Wen SN, Li SN, et al. Over 1-year efficacy and safety of left atrial appendage occlusion versus novel oral anticoagulants for stroke prevention in atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials and observational studies. Heart Rhythm. 2016;13(6):1203-1214.
- Tung R, Bauer B, Schelbert H, et al. Incidence of abnormal positron emission tomography in patients with unexplained cardiomyopathy and ventricular arrhythmias: The potential role of occult inflammation in arrhythmogenesis. Heart Rhythm. 2015;12(12);2488-2498.
