The 9th annual Kansas City Heart Rhythm Symposium (KCHRS) took place August 12-13th, 2017 at the Kansas City Marriott Downtown. Once again, KCHRS shared its podium with both national and international researchers and experts in the field of electrophysiology (EP), who spoke about their experiences, innovative ideas, and research in an effort to pass the legacy onto the next generation of electrophysiologists. Among some of the noteworthy speakers were EP pioneers such as Dr. Sanjeev Saksena, Dr. Andrea Natale, Dr. George Van Hare (President of the Heart Rhythm Society), and Dr. David Wilber (Editor-in-Chief of JACC: Clinical Electrophysiology). In addition to talks, the conference included a lively exhibition of innovative technologies and cutting-edge tools from the leading companies in the field.
Here we recap the main highlights of each session, focusing on current clinical practice, constructive criticism raised, and future directions as discussed by those who put their time and effort into making KCHRS 2017 a huge success.
FELLOWS AND ALLIED HEALTH PROFESSIONALS CONFERENCE
Course Director Dr. Dhanunjaya Lakkireddy started by introducing the 4th annual Fellows Boot Camp, which is dedicated to cardiovascular and EP fellows.
Dr. Sandeep Duggal began the session with a talk on CRT therapy, including indications, challenges, and advancements thus far. He was followed by Dr. Natale, who discussed effective implementation of three-dimensional mapping in clinical practice.
Dr. Lakkireddy then described the utility of intracardiac echo inside the EP lab and how it has simplified the EP procedures. Afterward, Dr. Lakkireddy welcomed Dr. Saksena onto the stage to give a brief account on programming ICD therapies for optimal patient care.
Later, a workshop for fellows was held under the leadership of all the above-mentioned speakers but mainly coordinated by Dr. Rakesh Gopinathannair, who presented some interesting clinical scenarios and visuals from his own experience. The main focuses of the workshop were device interrogations and clinical problem solving using visuals of EKG strips involving different types of arrhythmias. The fellow’s conference concluded with a reception, during which attendees interacted with one another to discuss their career plans and goals. (Figure 1)
OPENING CEREMONY AND CONFERENCE OVERVIEW
The conference officially opened with Dr. Lakkireddy welcoming attendees from across the country and the world (Figure 2). He gave a brief overview of the conference format, and then opened the stage for the Session 1 moderators. KCHRS 2017 was covered extensively on social media platforms such as Facebook and Twitter. With live tweeting from speakers and the audience, our social media presence was a great source of information for interested parties who could not attend. KCHRS has served the heart rhythm education needs of the greater Midwest for 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.
This session was chaired by Dr. Raghuveer Dendi and Dr. Jesus Val. Dr. Martin Emert opened the session with an excellent discussion on the role of multipolar pacing in heart failure (HF). CRT using biventricular pacing is an established therapy for patients with HF and reduced ejection fraction (EF); however, over a third of patients are nonresponders. He went on to say that lead placement is a common culprit in the majority of nonresponders. Multipolar pacing offers an alternative strategy in these patients — capturing a larger area of the LV, engaging areas around the scar, and improving hemodynamics. He pointed out that most of the current studies are nonrandomized, single center, and had small patient populations. He concluded by saying that multipolar pacing continues to be a reasonable alternative in patients who are non-responders.
Next, Dr. Andrew Sauer spoke in great detail about the current state of VAD therapies. He gave the audience a brief overview of hemodynamic optimization with VAD therapy, growing trends of VAD usage, and the evidence supporting their use. He reported the adverse events from various studies and factors such as peri-implant hospitalization, which drive costs. He emphasized potential areas of collaboration between HF and EP physicians, including VT ablations, ICD implantation in VAD patients, and atrial fibrillation (AF) treatments.
Dr. Luigi Di Biase discussed optimization of HF treatment and CRT response. Arrhythmias are common causes of suboptimal CRT response. PVCs can significantly reduce the percentage of biventricular pacing and hamper positive CRT response. When the PVC burden is significant, RF ablation can be an effective tool in restoring a desirable percentage of biventricular pacing. He went on to discuss the observational study by Lakkireddy and Di Biase et al, which showed RF ablation in patients with high PVC burden improved the overall CRT response.
Next, Dr. Gopi Dandamudi talked about the role of His pacing and how it fares in comparison to CRT therapy. He captured the audience’s attention with his remarks on His pacing and how it replicates true physiology of the conduction system. After discussing evidence supporting the use of His pacing, he presented a case of a patient with non-ischemic cardiomyopathy (EF of 20%), NYHA class III symptoms despite optimal medical therapy, and progressively widening LBBB. After undergoing His pacing, this patient showed remarkable improvement of symptoms (NYHA class I) and EF (50%).
Dr. Andrea Russo then discussed the large body of literature supporting CRT use and the practical limitations for using His pacing. This was followed by a spirited debate between Dr. Dandamudi and Dr. Russo on His pacing versus CRT. Each made their arguments for and against His pacing in clinical practice, but ultimately, they seemed to agree that despite the limited evidence, it is worth considering in patients who are CRT nonresponders and have failed CRT due to inability to place LV lead.
Dr. Lakkireddy began by introducing the keynote speaker Dr. Saksena, whose work in the field of EP is an inspiration to many. Dr. Robert Simari and Dr. Lakkireddy then presented the KU Pioneers in Electrophysiology Award to Dr. Saksena (Figure 3). In his keynote address, Dr. Saksena reflected on his journey through three decades of electrophysiology. He walked the audience through the major breakthroughs in the field, including the development of the external defibrillator, tools for ablation, and transvenous defibrillation systems. He later outlined his vision for the future of EP and areas that he felt were particularly exciting. He concluded by thanking several of his friends, mentors, and collaborators that he worked with over the years.
Dr. Saksena’s address was followed by a presentation by Dr. Davendra Mehta on how to minimize cardiac implantable electronic device (CIED) infections. He went on to say that intraoperative antibiotics are the only proven measure to prevent infections, that lead manipulations should be avoided as much as possible, and evacuation of pocket hematomas should be considered in critical cases. Dr. Lakkireddy concluded this session with a discussion on the current state of leadless pacemakers, focusing on current clinical trials, premature battery depletion, technical aspects of implant/extracts, and future directions.
Dr. Duggal, who chaired this session, invited Dr. Natale to talk about preventing esophageal injuries during AF ablation. Dr. Natale started by discussing the anatomical considerations associated with esophageal injuries. He then spoke about the nuances with esophageal temperature monitoring, the utility of contact force catheters, and the mechanical esophageal deflection tools available for minimizing the risk of esophageal injury. Dr. Loren Berenbom then discussed the use of subcutaneous ICDs and how they fared when compared to conventional ICDs.
Next, Dr. Madhu Reddy talked about wearable cardiac defibrillators, going over the recommendations regarding their use from various scientific societies.
Dr. Seth Sheldon discussed the use of MRI in CIED patients. He reported the results of the recent MagnaSafe Registry, which included 1500 patients with non-conditional devices implanted after 2002 who underwent MRI. There were no major adverse events other than partial electrical resets in very few patients. He emphasized exercising caution when using MRI in pacemaker-dependent patients, due to concern for power reset.
Next, Dr. Bradley Knight spoke about premature battery depletion, putting special emphasis on lithium cluster formation. He reported the occurrence of major adverse events (0.28%) in these patients. He later discussed battery failure in leadless pacemakers, caused by insufficient electrolyte availability, and pointed out the differences in mechanisms of battery depletions.
Dr. Mehta then discussed the differences between single- vs dual-coil ICD leads, including how single-coil leads are associated with higher DFT. Considering the increased risk and complexity of extracting dual-coil leads, he was a proponent of the use of single-coil leads for routine left-sided ICD implants. He said dual-coil leads can be used in situations expected to have high DFT, such as cardiomegaly, right-sided implants, and renal failure.
Dr. Thomas Deering, HRS President-Elect, talked about the impact of lifestyle modification on AF (Figure 5). He divided his talk into physical and lifestyle considerations affecting AF. Based on current evidence, moderate and regular exercise has a salutary effect on AF. He went on to report that obesity and obstructive sleep apnea have a detrimental effect on AF; their management would result in better outcomes. He then discussed the role of lifestyle choices such as alcohol and tobacco on AF. He concluded by saying early identification and treatment of modifiable risk factors are critical steps toward primary prevention of AF.
Next, Dr. Gerald Naccarelli discussed the current state of NOACs and available reversal agents. He mentioned there are no trials comparing NOACs with one another, and that all the RCTs thus far compared NOACs to warfarin. Before discussing reversal agents, he stressed the importance of conservative management of bleeding prior to considering these agents. Dr. Dandamudi then summarized periprocedural anticoagulation during CIED implants and ablations. He reported oral anticoagulation can be continued periprocedurally for both CIED and AF ablation procedures.
Dr. Christine Albert later discussed AF and stroke risk. In summary, oral anticoagulation is recommended in patients with clinically detected AF who are at high risk for stroke, irrespective of AF subtype and burden. In patients with subclinical AF, the absolute risk of stroke and net clinical benefit of anticoagulation is unknown, and clinical trials are underway to determine this. Dr. Dipen Shah finished with a talk on the pathophysiology and current management of tachycardia-induced cardiomyopathy. (Figure 4)
Dr. William Sauer began with a presentation on the advances in 3D mapping, discussing the various mapping systems and how they similarly achieve accurate catheter position using impedance or magnetic sensors. He also described the non-arrhythmic applications of mapping systems. This was followed by Dr. Gopinathannair, who summarized the current management options for cardiac dysautonomic syndromes. Dr. Dendi then presented on heart rhythm monitors, pointing out that the wearable device market is growing rapidly and the gross expenditure is estimated to be close to $41.4 billion by 2020. He then discussed the various monitoring options available as well as briefly mentioned how novel mobile monitors like AliveCor and AfibAlert can be good screening tools. The session was concluded by Dr. Naccarelli, who discussed rate vs rhythm control in current-day practice.
This session, chaired by Dr. Knight and Dr. Alap Shah, began with Dr. Moussa Mansour’s talk on challenges and the role of LAA occlusion in stroke prevention for AF patients, including their approach at Massachusetts General Hospital. He stressed the importance of an integrated multidisciplinary approach for stroke prevention in complicated patients. Dr. Wilber further complimented the role of LAA exclusion in AF by throwing light on its adjunctive role in AF ablation. He also gave a brief synopsis on the current status of the ongoing aMAZE trial evaluating the efficacy of the LARIAT procedure (SentreHEART, Inc.) combined with PVI in terms of AF recurrence. This was followed by a presentation by Dr. Di Biase on the role of octreotide in mitigating the risk of gastrointestinal bleeding associated with oral anticoagulation, which can act as a bridge to other strategies for stroke prevention. Dr. Saksena then gave a talk on left atrial scarring, focusing mainly on the role of delayed enhanced (DE)-MRI in detecting LA fibrosis. The session was concluded by Dr. Van Hare, who spoke on the role of different societies in professional enrichment, with a brief background about HRS structure and ways to get engaged with this society. (Figure 6)
This session was dedicated to interesting cases encountered by fellows and attendings in their practices. The first case was presented by Dr. Omair Yousuf, demonstrating how AVNRT can masquerade as a disturbing wide complex tachycardia, with implications on management strategies. The second case, presented by Dr. Sandeep Gautam, was on catecholaminergic polymorphic ventricular tachycardia and risk of sudden cardiac death in other family members. The third case, presented by Dr. Valay Parikh, showed how an underlying arrhythmogenic inflammatory cardiomyopathy can be responsible for presumed “idiopathic” PVCs and respond dramatically to anti-inflammatory medications with no need for invasive ablation procedures to cure the arrhythmia. Dr. Van Hare presented a final case on supraventricular tachycardia (SVT)/WPW syndrome and its management (catheter ablation) in a pediatric patient with situs inversus.
The second day of the conference started with Dr. Reddy giving a brief background about the Dr. Manohar Sai Gowda Memorial Young Investigator Cardiovascular Research Award. Among abstracts submitted for review from all over the world, the top three abstracts are selected and the respective authors receive this award named after the late Dr. Manohar Sai Gowda. This award was established in appreciation of Dr. Gowda’s contributions to cardiovascular research, both as an investigator and as a mentor to those interested in pursuing research. After oral presentations of the top three award-winning abstracts, the award was presented.
Dr. Bharath Yarlagadda received the first place award for his abstract entitled, “Utility of Simplified Protocol for Assessing Thoracic Aortic Dimensions and Pathology with Non-Contrast MRA.” Dr. Tawseef Dar received second place for his research: “Mechanical Function of the Left Atrium is Improved with Epicardial Ligation of the Left Atrial Appendage: Insights from the LAFIT-LARIAT Registry.” Dr. Jeet Mehta accepted the third place award for his abstract entitled, “Effectiveness of Vagal Maneuvers in SVT: A Network Meta-Analysis.” (Figure 7)
This session, chaired by Dr. Emert and Dr. Obadah Al Chekakie, began with a very interesting debate on ablation strategies for non-paroxysmal AF between Dr. (William) Sauer and Dr. Natale. The focus of the debate was whether a strategy of PVI combined with CTI is sufficient for such cases, or if some adjunctive measures are needed in order to improve the success rate. The debate was followed by a presentation by Dr. Mansour on the utility of contact force catheters in PVI, concluding that contact force catheters improve the durability of pulmonary vein isolation and success rate with a lower risk of major complications compared to conventional RF catheters. The next presenter was Dr. Russo, who pointed out that there is no clear benefit of empiric atrial flutter ablation (CTI) combined with PVI unless an atrial flutter was documented prior or during the procedure, as evident from randomized studies, but suggested that empiric PVI isolation combined with CTI ablation might be a more reasonable approach in a subset of patients at high risk for subsequent AF. The next talk was by Dr. Ravi Mandapati, who talked about the role of rotors and drivers in AF and their ablation, and concluded with the impression that there is not enough evidence to support that rotors are the underlying mechanisms for AF. This was followed by Dr. Lakkireddy’s presentation on LAA closure device-related leaks, thrombus formation, and post-procedure anticoagulation regimens currently being practiced. Dr. Lakkireddy concluded the session with a presentation on myocarditis and its association with ventricular arrhythmias, saying that clinically manifest myocarditis (VT, HF, and heart blocks) only represents the tip of the iceberg; therefore, clinicians should be more vigilant about this potentially treatable condition.
Dr. Van Hare opened this session with a talk on inappropriate sinus tachycardia and junctional ectopic tachycardia, focusing mainly on management aspects. His presentation was followed by Dr. (Dipen) Shah’s talk on the role of obstructive sleep apnea in the pathogenesis and progression of cardiac failure and in promoting AF recurrence, and how use of CPAP in such cases favorably impacts the outcome of management strategies. The next presentation was by Dr. Wilber, who discussed best approaches currently for ablation of VT in non-ischemic dilated cardiomyopathy. He also discussed future directions, focusing on intramural origins of VT to solve the problem of high recurrence rate in such cases. This session was concluded by Dr. Knight, who presented on appropriate utilization of percutaneous LV assist devices in VT ablation for patients anticipated to require mapping during a VT that is expected to be hemodynamically unstable. This would include cases with multiple episodes of same VT, fast VT in the presence of advanced HF, VT demonstrated to be hemodynamically unstable, and failed prior substrate ablation.
The final session began with a very interesting talk by Dr. Rhea Pimentel on the association of AF and dementia. The next presentation was by Dr. Marmar Vaseghi, who provided an update on the latest results from the International VT Ablation Center Collaboration (IVTCC), a collection of 12 centers formed in 2014 to get a better evaluation of a larger number of patients undergoing ablation for scar-related VT. This was followed by Dr. Trip Zorn’s presentation on the current state of surgery in the management of AF. Next, Dr. Mandapati gave a talk on the origin, presentation, long-term complications, and ablation strategy of PVCs. He concluded that PVCs should be looked upon more comprehensively before ablating. Next, Dr. Deering talked about pacing therapy in TAVR patients, re-emphasizing that heart block is a common complication of TAVR; therefore, we might see a higher trend in pacer implants as TAVR usage increases. Dr. Phillip Cuculich concluded with his thrilling presentation on EP-guided noninvasive cardiac radioablation (ENCORE), which employs “fully informed” noninvasive mapping (by combining MRI, PET, and CT, and adding noninvasive EP mapping-ECGI) to know the origin of VT followed by full thickness, gap-free ablation inducing an apoptotic (more physiological) response, which is done noninvasively in an outpatient setting, while the patient is fully awake.
CONCLUSION OF THE SYMPOSIUM
KCHRS 2017 was a phenomenal success. We sincerely thank all the speakers and panelists who traveled from the across the country to make it to the conference. The turnout was excellent, and the meeting was very educational. There were several opportunities for interaction between attendees and faculty, both during the conference and evening social events. Lectures by EP pioneers such as Dr. Saksena were inspirational for current and future generations of electrophysiologists in attendance.
We would also like to thank Donita Atkins, RN, BSN and Misty Jaeger, RN, BSN for their tireless efforts in preparation for the conference. Dr. Lakkireddy concluded the conference after extending a warm invitation for all to attend KCHRS 2018!
For further information, please visit: www.kchrs.com