Live Better Electrically - idsMED Steve Higgins.pdf · 2018-05-15 · Chapter Title Here Additional...

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Live Better Electrically

Steven L. Higgins, MD, FHRS

Chairman, Dept. of Cardiology

Director, Cardiac Electrophysiology

Scripps Memorial Hospital, La Jolla

San Diego, California

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So, what exactly does that mean?

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Electro-Acupuncture

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Cardiac Electrophysiology (a specialty of cardiology that deals just with heart rhythm disorders)

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Chapter Title Here Additional copy if necessary

Year

Mortality Percent change

In the past half-century, we have made huge advances in heart disease

-80

-70

-60

-50

-40

-30

-20

-10

0

10

20

30

50 55 60 65 70 75 80 85 90 95 00 05 10

Coronary Heart Disease Stroke Non-CVD

Modified from National Heart, Lung

and Blood Institute data, NIH, 2010. 9


0

5

10

15

20

25

30

35

40

45

40.9

21.8 16.5

10.4 3.4 3.1 2.8 0.3 0.3

Heart Disease Still #1 Cause of Death in U.S.

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• Obesity causes diabetes

• Cigarette smoking

• Aging population

• Genetics

4 reasons why heart disease mortality remains #1

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• Diet, exercise

4 reasons why heart disease mortality is improving

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• Diet, exercise

• Statins

• Stents


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• Diet, exercise

• Statins

• Stents

• Defibrillators


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Cardiac Implanted Electrical Devices (CIEDs) • Pacemakers • Defibrillators (ICD)

One Inch

Over 50 years of progress

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30 Years of ICD Implants by Year 1986-2016

0

50000

100000

150000

200000

250000

1986 1990 1995 2000 2005 2010 16


1 Moss AJ. N Engl J Med. 1996;335:1933-40. 2 Buxton AE. N Engl J Med. 1999;341:1882-90. 3 Moss AF. N Engl J Med. 2002;346:877-83. 4 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002. 5 The AVID Investigators. N Engl J Med. 1997;337:1576-83.

Mortality Benefits in All ICD Trials

0

20

40

60

80

MADIT MUSTT MADIT-II AVID

Overall Death

Arrhythmic Death

1 2 3, 4

54%

75%

55%

73%

31%

61%

27 Months 39 Months 20 Months

% M

ort

ali

ty R

ed

ucti

on

w/ I

CD

31%

56%

5

24 Months

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If Implanted Defibrillators are so great,

shouldn’t we all get one?

0

20

40

60

80

MADIT MUSTT MADIT-II AVID

Overall Death

Arrhythmic Death

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To prevent heart disease, which is more important to know

Cholesterol? Ejection fraction?

Schatz I et al. The Lancet 2001;358:351 Tribouilloy C et al. Eur Heart J 2007;554:339.

Reduced EF, mortality 46% at 5 years,

regardless of etiology

Elevated cholesterol, mortality 19%

at 5 years

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With the advent of statin therapy and angioplasty, marketing focused on cholesterol

AHA/ACC and industry partnership

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Normal echo

Low EF

(Cardiomyopathy)

EF = 65% EF = 15%

EF = Ejection Fraction the percentage of blood pumped out with each heartbeat

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MADIT Multicenter Automatic Defibrillator Implantation Trial

54% decrease in mortality with ICD P=0.009

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Why do people with low EF die suddenly?

Reentrant

Ventricular

Tachycardia

around scar

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Why do people with low EF die suddenly?

Reentrant

Ventricular

Tachycardia

around scar

Catheter ablation to wall-off or destroy irritable area

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The Latest in Device Therapy Cardiac Resynchronization Therapy

CRT

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Next: without open heart surgery

Transvenous biventricular pacing 2nd Patient in World at Scripps, 2002

Atrial lead

Shocking Lead

Generator

Coronary Sinus Lead

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Cardiac Resynchronization Therapy Technique for Transvenous Approach

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Cardiac Resynchronization Therapy (CRT)

Works with pacemaker or defibrillator

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So why don’t we all get a “bivent” device?

Only works if low EF and wide QRS (bundle branch block)

In selected patients, CRT: • Improves EF an average of 5%, some back to normal

• Improves activity an average of 1 NYHA class

• Decreases mortality, even with just the pacemaker version

Cardiac Resynchronization Therapy (CRT)

Works with pacemaker or defibrillator

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Contak CD Trial Results Primary Endpoint

HF Progression Index

Imp

rov

em

en

t (%

)

-30

-20

-10

0

Death HF

Hosp VT/VF

23%

13%

9%

26%

Overall

21%

Worsening

HF

Modified from Higgins et al.

JACC 2003:42:1454-1459.

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So, who should get this new technology?

Atrial lead

Shocking Lead

Generator

Coronary Sinus Lead

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Chapter Title Here Additional copy if

necessary

So, who should get this new technology?

Pacemaker Slow heart rate with symptoms (pulse below 30 or 3 second or more pause)

Biventricular Pacemaker (cardiac resynchronization therapy)

Above plus EF below 50 (normal 55-70) and plus wide EKG complex (over 120 msec)

Implantable defibrillator EF below 35%, that’s it!

Biventricular Defibrillator (Lexus)

Above plus wide EKG QRS complex (over 120 msec)

INDICATIONS

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Cardiology Simplified

1978 1st of 5 heart attacks, beginning at age 37

1988 Quadruple bypass surgery after 3rd heart attack

2001 (March) At least his 8th cardiac cath and stent

2001 (June) First ICD

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Cardiology Simplified

1978 1st of 5 heart attacks, beginning at age 37

1988 Quadruple bypass surgery after 3rd heart attack

2001 (March) At least his 8th cardiac cath and stent

2001 (June) First ICD

2007 ICD upgraded to biventricular device (with WiFi feature disabled)

2010 Artificial heart pump inserted, called LVAD (Left Ventricular Assist Device)

2012 Heart transplant, removing old heart, stents, ICD and leads 36


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Live Better Electrically Current Trends in EP

(EP = ElectroPhysiology = heart rhythm management)

2 Basic EP procedures to help you:

– Devices (pacemakers, defibrillators)

– Ablation (catheter based treatment)

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Chapter Title Here Additional copy if

necessary

• SVT (supraventricular tach) 95%

• Atrial flutter 95%

• WPW 95%

• Some ventricular tachycardias 90%

• Atrial Fibrillation (AF) 60%

Arrhythmias Treated With Ablation

Approximate Success Rate

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The Normal Heartbeat

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Slow AVN pathway

Accessory pathway of WPW

CTI Isthmus for atrial flutter

The “Soul” of the Heart Where most arrhythmias begin

Fast AVN pathway (His)

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RF Ablation, 40 watts, first attempt, left lateral pathway

Delta wave of WPW

No delta wave;

Patient cured

A person’s life changed forever in one heartbeat

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How To Do An Ablation in 3 Easy Steps

Step 1. Find an EP doc to put in catheters

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Step 2. Reproduce and map the arrhythmia


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Cold (Cryo) Heat (RF)


Step 3. Ablate, ablate, ablate

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CTI Line for Atrial Flutter 47


CTI Line for Atrial Flutter 48


Atrial Fibrillation

Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.

U.S. population

Age, yr

<5 5-

9

10-

14

15-

19

20-

24

25-

29

30-

34

35-

39

40-

44

45-

49

50-

54

55-

59

60-

64

65-

69

70-

74

75-

79

80-

84

85-

89

90-

94

>95

U.S. population

x 1000

30,000

20,000

10,000

0

500

400

300

200

100

0

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Atrial Fibrillation

Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.

U.S. population

Population with

atrial fibrillation

Age, yr

<5 5-

9

10-

14

15-

19

20-

24

25-

29

30-

34

35-

39

40-

44

45-

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50-

54

55-

59

60-

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65-

69

70-

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75-

79

80-

84

85-

89

90-

94

>95

U.S. population

x 1000

Population with AF

x 1000

30,000

20,000

10,000

0

500

400

300

200

100

0

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Why treat AF?

Thromboembolism – A Devastating Risk

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Why treat AF?

To Prevent a Stroke!

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Why treat AF?

To Prevent a Stroke!

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What is your risk of stroke with AF?

CHADSVASc score CHADS-VASc

Risk

Score

Heart Failure or

LVEF < 40%

1

Hypertension 1

Age > 75 1+1

Diabetes 1

Stroke/TIA/ Thromboembolism

2

Vascular

Disease

1

Age 65 - 74 1

Female 1

• The score equals your chance of having a stroke in % per year

• The average person is <1%

• 2 or more points, usually results in recommendation to begin a daily anticoagulant

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How to treat AF? Cardioversion on meds

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Atrial septum

Ablation and Mapping Catheters for AF

How to treat AF? Catheter Ablation

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• Cool New Treatments in EP

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Pacemaker/Defibrillator Advances

Leadless Pacemakers 60


Leadless Pacemaker

• Single chamber pacemaker

– Battery lasts 15-25 years

– No lead or surgical scar

– Under FDA investigation, only San Diego site is Scripps

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Robotic assisted ablation procedures

• Here today at Scripps La Jolla, SPCI

• 2 Robots available – Amigo, Hansen

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Artificial Heart, LVAD (Left Ventricular Assist Device)

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Noninvasive Cardiac Ablation?

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So, what is so great about Scripps?

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#19 Nationwide in Cardiology and Heart Surgery again (3rd year in top 20) The only SD hospital ever to be top 20 • Reputation score • Survival • Patient safety • High risk patient volume • Nurse staffing, Magnet recognition • Advanced technologies • Key patient services • Trauma center • Intensivist staffing

2013-14 2015-16 2014-15

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San Diego’s Best Heart Care Just Got Better.

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SPCI = Scripps Prebys Cardiovascular Institute

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Scripps Prebys Cardiovascular Institute San Diego’s first free standing heart hospital

• Completed, opened on SMH-LJ campus, March 2015

• Over 350,000 SF; 8 floors

• 167 cardiac patient rooms (59 CCU)

• New cath labs, EP labs and cardiac operating rooms

• Combined expertise of Scripps-LJ, Scripps Clinic, other Scripps

• New Outpatient AMP opened June 1, 2016

• $610 Million for SPCI/AMP/ER; Donations:

• $105 M for SPCI (Prebys +)

• $20 M for ER & Trauma Center

• Total of $154 M for cardiac campaign

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Scripps EP Program

• 6 EP Labs (plus 7 cath labs + 2 hybrid)

• More EP Labs than anywhere west of the Mississippi

• Volume = Quality

• Nearly 4000 EP studies a year

• 16 EP docs

• Investigational Trials

• Experienced Staff

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Paperback: Amazon, Barnes & Noble

EPUB: Amazon, iTunes

Website order

www.BookLiveBetterElectrically.com

Fung Summit affiliates use discount “LBE2” to save $5 off cost of $30

Live Better Electrically To learn more about EP:

Shameless plug for new book

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Steven L. Higgins, MD, FHRS

Chairman, Dept. of Cardiology

Director, Cardiac Electrophysiology

Scripps Memorial Hospital, La Jolla

San Diego, California

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