LAHRS Content 2023-Current Challenges in Diagnosis and Treatment of Cardiac Arrhythmias 2023

Current Challenges in Diagnosis and Treatment of Cardiac Arrhythmias 2023
Video Transcription
Good afternoon everyone, please attend this session on diagnosis and challenges in the treatment of cardiac arrhythmias. It is an honor for me to be sharing this session with you.  teachers of extraordinary level and well this session we are going to carry out thanks to the sponsorship of Medtronic. In this session we are going to talk about  technological innovations, on first-line therapies that can benefit our patients with arrhythmias and well it is an honor for me  have a group of extraordinary teachers. We already heard a brief overview of their curricula at the opening session of our LARS conference. All  They are world leaders in electrophysiology, each of them has collaborated very closely and proactively with the growth of the  electrophysiology in Latin America and not only with its great academic quality but also with ties of friendship. So well without further ado we will give the  Welcome to Dr. Luis Aguinaga. He is going to talk to us about Leadless Facemaker. This is a therapy for everyone or for a special selection of patients. Go ahead, Dr. Aguinaga.  Thank you very much, Dr. Berni. Good afternoon, everyone. Well, it is a pleasure to share lectures with my professor Brugada, with Dr. Vidal, a great friend.  and well we are going to talk about a topic that I am really passionate about. I did not choose the title, they put if it was for everyone or for a select group. I am going to tell you  Trying to convey something good is one of the ultimate passions we have as a work group. Everyone knows, everything has an evolution  If not only ideas evolve, technology evolves, we evolve, and this is no exception in cardiac stimulation devices. Here the option  is to choose, especially for some patients, between a conventional device versus a wireless device. We can say that in some cases  directions the world is pointing towards cordless. Well why? Let's talk a little bit about efficacy and safety in the first ten slides. First  Because conventional devices generally have a complication rate of around 10%. In large series, they show  That's it. 700,000 stimulation devices are implanted every year in the world. Well, let's say 70,000 can have complications of various kinds. It's  So one of the great advances comes wireless stimulation and to mention a little bit the chronological evolution of these new technologies  We can mention from the year 2015 this publication with the first studies on Lidl. In this case Micra where compared to the conventional ones  Well, it began to be seen that not only was there a great success rate of implants, more than 90%, but also compared to conventional ones, well, they had not only  very acceptable levels of capture or thresholds that were followed over time but also in terms of, for example, sensitivity, parameters  and 48% fewer major complications than the conventional comparison series. This is important because for some groups  This is going to be very valuable. After this, in the chronology, it continued in the real world, with almost 2,000 patients, as this record shows.  Initial. Well, not only were these initial numbers confirmed, but in the real world it was better than in the initial study 63% fewer complications  older. Some changes had already been made initially, I tell you if they were implemented in the Apex, already in the registry we learned that more had to be implemented  Well, in the Septum for an electrical safety issue and then a larger one came, two years later Medicare, right, with thousands.  of patients where this finding is also confirmed. A study where it shows that there is a 60 or 68, 66 percent less complications and these were already  Patients with more comorbidities and older patients are already patients who are no longer in the clinical study. More recently, this year, three-year follow-up  publication with very similar data, for example 32% less chronic complications, always talking about major complications. Then came the  Micra AB with the ability to look at the atrium stimulating the ventricle and do something sequential only mentioned one study the Marvel study that showed  that this was possible from the ventricle to censor the atrium and do an AB follow-up. Well, this is confirmed by different series and you can see the  quality of life that is not minor this is a very large Chinese study where it is shown that not only do leadless pacemakers improve the quality of life in  general questionnaires but also fewer complications related to surgery, less limitation of activity, etc., less stress for the patient.  Implant technique only two slides and this must be insisted upon and I remember a lot when we learned the ablation for example of pathways  accessories that we learned that the best application was the first one. Well this is very similar not only do you have to be careful in all the steps for example  the approach but choosing the place very well to avoid multiple attempts to release the device. If one goes mapping in the obliques with  Contrast is careful where you are going to release it, probably the first release will be the effective one and there are no more attempts that are proven that with  many attempts obviously increases the risk of complications. The second thing and to answer a little to the question of this in which patients if it is  for everyone or not. Well this is what the guidelines say, the latest European guidelines on stimulation, especially for patients who do not have vascular access with high  risk of infection or in hemodialysis with a 2A indication. Then in a paper it is not a recommendation but a position statement led by Lucas  Permac from Holland on behalf of the European Society of Cardiology more or less some recommendations or similar recommendations. The subject of  venous access, the issue of infection risk and here they add tricuspid valve dysfunction. A very important issue in infection for all  truth. The complication probably most feared when we are working with devices and it is known and in the real world and this is also quite recent  series of almost 50,000 patients shows that almost 1% of the initial implants will have a major complication in terms of infection and 2% 2.08  As for revision or re-implantation, it is also known that when a patient is re-implanted, there is already a much higher risk than when there is an initial implant.  that you have to wait a while to test negative, for example if there is a positive culture, it is said to be two or three days after the last culture, etc. etc. Well  This can be changed with the listless even there is very challenging work or study with listless implant at the same time of extraction of a  infected alit and there are publications like the one I show here the microcrap patients with active infection where the extraction is done and the implant is  good device without infection in the newly implanted device. This image wants to show for example the upper part of the transesophageal echo where  in asterisk are the warts then here below image of the defibrillator cable implant of micra in the second image then extraction and  stimulation through the micra. This patient who had an infection  active then negative cultures etc. etc. and was protected by the patient. It has been discussed why infection is so rare in these devices without  cable and the causes are many if this graph tries to summarize we do not have a pocket we do not have a cable the glove never touches the device if they are in  release system are smaller the material is encapsulated is different etcetera etcetera they are in an area of greater turbulence unlike what  It can be the lid in the venacaba or the pocket etc. etc. This image shows how these devices can be encapsulated if which would give a certain  additional protection for infection. A very important point is hemodialysis and that we all have a patient, the patient on hemodialysis  has five times more risk of needing a pacemaker than a patient of the same age group but without hemodialysis, which is something  The vascular theme is frequent, we all understand that we want to preserve the veins or they are already used, it is an immunocompromised person who has bacteremia in  Every dialysis there is probably a new bacteremia if we all know that almost 70% of patients with subclavian implants have some  degree of stenosis most are subclinical but in the high flow dialysate it becomes good in clinics in this subgroup of patients  The benefit is really very high. Look at more than 200 patients in this series of Chamí 0 0 infection problem with the patient on hemodialysis  and zero major complications also analyzed and this publication from two years ago, sorry, from this year comparing but only in groups of  high risk and what you see here patients with COPD patients with end-stage renal disease dialysis that we have already mentioned cancer etc.  etc. in all these subgroups the liles was better versus the conventional one while the patient is more compromised probably the impact  clinical that we can have is greater vascular access is understood a lot we have anatomies like this true subclavian occlusions occlusions  the upper venous territories if altered, for example the tricuspid valve when there are many cables and this must be resolved, this is one of  those of the literature examples if stenosed valves dysfunctional valves also some cases reported in the literature of teacher  With an implant via the jugular vein, this is also possible in patients with node ablation. It has been shown that everything can be done in the same procedure.  time truth to do the ablation and implantation of the device and even in the emergency and recently a large European registry has been published where it has been  implanted these liles devices in the emergency if the time of arrhythmia emergency implantation of liles this is possible good and finally to finish  Two words from the future. In the future there are things that are already being done in some clinical cases, for example, a combination like what is seen here of subcutaneous CDI.  with maicra in patients with access difficulties or this that was initially shown in the year 14 by Dr. Auricio el Guasi Arti where we have a route  aortic retrograde the implantation of one of these devices which was later confirmed by this study the select the good where it is shown that basically via  retrograde aortic valve can be implanted with a liles device then here by ultrasound by this source which in turn has a battery to stimulate the  resynchronize from the endocardium of the left ventricle all this is something that is obviously under study and feasibility and if we talk about liles  We can also talk about batteries, yes, without batteries, and this that was published in the garden a few years ago is how it can be done and in fact this is an experiment  animal was shown that the same cardiac activity generates energy and that has been taken and in turn activate the stimulation, that is, without a battery  external with the heart's own activity or even some are batteries that are activated by or with solar type energy well then we can say that  to undertake a project a successful program in this new device and we are fully committed I can tell you in  Argentina we started just a year and two months ago with almost 50 implants throughout the country I can say zero complications and 100% effectiveness of  implant with which if one follows these training rules one must be trained for this technology this is very technology dependent we have to be a team not  not only the electrophysiologist but also who refers the patients to us, etc. and time to see the evolution of this therapy, then the indications are those that are  Summary here to answer the initial question which is all we have talked about today if you did not mention I mentioned some professions  We have some young implanted patients who are fighters etc.  who preferred to have the chest area free from all this, aesthetic issues arise, etc., so it is not for everyone but it is a  therapy that is growing some patients can benefit greatly from this therapy we always remember a patient from La Plata yes with the doctor  ugly that he had had five processes of endocarditis if by conventional devices then two processes of infection by pericardial implant and  Finally, well, that patient with congenital heart disease had an attempt at suicide and finally the maicra was the great solution for the patient already  almost a year without infection that's all thank you very much for your attention thank you very much doctor aguinaga and well next I have the pleasure of  introduce Dr. Josef Brugada, well known to all of you, who in addition to his impeccable career as an electrophysiologist has been a mentor and  trainer of many electrophysiologists here in our region of Latin America and well Dr. Brugada is going to talk to us about cryoablation versus  Radiofrequency as a first-line treatment for atrial fibrillation, go ahead doctor, thank you very much doctor bernie doctor vidal doctor aguinaga, it's a pleasure to be here  In the next few minutes I will actually try to talk about cryoablation as a first line of treatment and also going into a little bit of the  Presentation of Dr. Vidal on early ablation I was lucky in the late 80s and early 90s to work for four years with Professor Vidal  Moritz Alessi Professor Moritz Alessi who has published absolutely fundamental articles on the pathophysiology of atrial fibrillation is the inventor  of the notion that atrial fibrillation causes atrial fibrillation and this came from a study that he did in goats where he stimulated the  heart the atrium of goats for different periods of time and realized that the longer he stimulated them the easier it was to provoke the  atrial fibrillation until a time came when that atrium had already been stimulated for a sufficient time and atrial fibrillation had already occurred.  permanent and he then coined the term atriofibrillation bigots atriofibrillation we are talking about 30 years ago an advanced for his time when nobody  He was interested in atrial fibrillation and he coined this notion and today we are all very, very concerned about atrial fibrillation.  It turns out that it is exactly what he had predicted that we are seeing and that is that patients are progressing in their atrial fibrillation that they begin  often with sporadic episodes of proxistic atrial fibrillation that become more frequent and then become more prolonged, which then require  that we act with cardioversion or with drugs and finally if we do nothing the patient finally enters into persistent or permanent fibrillation and  All this is due to a whole process of structural and electrical remodeling of the atrium, which is what Dr. Alesí predicted at the time that all this rhythm  fast and regular ended up causing a structural alteration that modified the electrophysiological parameters and even modified the anatomy  Fibrosis appeared and everything that was later called atrial cardiomyopathy appeared and well, that represented a little bit of the patient's evolution.