Good morning, everyone. My name is Michael Caine from the University of Buffalo, and on behalf of my co-chair, Jacob Hansen from Copenhagen, welcome to this session. We have four presentations. We would like each to last about 12 minutes and then have time for questions that can either be sent through the QR code that's in the app, or we have microphones in the room where they can be asked directly. So it's our pleasure to welcome you to San Diego and Heart Rhythm 2025, the 46th annual meeting of the Heart Rhythm Society. As I alluded to, if you've not already done so, please download the HRS 2025 mobile app from your preferred app store. This is how we can participate in live questions and answers during the session. Please scan the QR code on the screen to access the session's questions and answers, and when using the mobile app, log in with your HRS credentials. Please note that visual reproduction of Heart Rhythm 2025, either by video or still photography, is strictly prohibited. So with that, we'll go ahead and get started. So thank you for the introduction. This is a delightful pleasure for me to introduce the first speaker, which is Victoria Better from Children's Hospital of Philadelphia. She will speak on high school CPR education. Thank you. Thanks to the organizers and to the audience for your interest in this topic. I'm happy to speak with you this morning. The first slide I'm going to show you is a short video clip from a parent of a survivor of sudden cardiac arrest. Patty's life wasn't saved because one person did one thing. It was saved because one person called 911 immediately. It was saved because another person stepped in immediately and began chest compressions. Her life was saved because a third person recognized that the chest compressions weren't working and that an AED was in order. Those are the things that were essential to her recovery. So we all know that sudden cardiac arrest is a leading cause of death in those over 40 years of age, but 10% of sudden cardiac arrest occurs in those less than 40 years. 23,000 children or youth experience sudden cardiac arrest annually. The 20% of the population is at school daily, not only teachers and staff and children, but parents, grandparents, and other community members. Sudden cardiac arrest is a leading cause of death on school campuses and of non-accidental death in youth in the U.S., accounting for 75% of all athlete-related deaths. One in 70 schools will have a sudden cardiac arrest each year, with half being in students. But survival in schools with AEDs and cardiac emergency response plans is as high as 89% compared to 10% to 12% on the street. Mortality is decreased by early CPR and AED use and increased by delays. Bystander CPR doubles the odds of survival, which increases further in the presence of shockable rhythm and AED use. In adults in the U.S., bystander CPR rate is about 40% and in children, about 50%. This has been increasing over time related to the use of hands-only CPR, but children often need rescue breaths. Only 18% of the public report annual training in CPR, with 65% having received training at some point and 54% endorsing a working knowledge of CPR. This is important as training is associated with a four-fold willingness to perform CPR. Training a large population in school will increase the adult population who know and perform CPR. There are about 17 million high school students in grades 9 to 12. CPR and AED training increases importance and awareness of sudden cardiac arrest in early life. It provides life-saving skills just as children and adolescents are becoming engaged in public life and employment. Students are likely to have appropriate physical fitness to perform CPR, more likely to automatically respond in emergent situations. CPR and AED education can be distributed across cultural, social, and ethnic groups and it increases self-esteem, introduces social responsibility and normalizes response to an emergency with the potential for the student to extend this information and training materials to others in the home. We use the CARES cardiac registry to enhance survival established by CDC and Emory University. This is an EMS-based database to study the impact of CPR and AED education laws across the country. This represents about 820,000 records at the time that we studied this. The requirements for CPR and AED training in school are determined at the state level leading to nationwide variation in legislative mandates. This is the 2025 American Heart Association legislative mandate map. While mandates for CPR and AED education have been present since as early as 1984 in Iowa, there's been a recent upsurge in the number of states requiring CPR and AED training with currently 40 out of 50 states plus the District of Columbia requiring CPR and AED education for high school students. While the remaining states have no or limited legislation such as California that recommends CPR and AED education in their physical education classes and Colorado that does the same and Hawaii is just starting a pilot study this year. The results of our study show that bystander CPR, hospital discharge and neurologically favorable survival is higher in states with CPR and AED education laws. In fact, bystander CPR is significantly increased in states with laws at 41.6 percent compared to states with no laws at 39.5 percent. Social determinants have significant effects on the rates of bystander CPR and in states with CPR and AED education laws, groups with lower socioeconomic status had improvements through all domains. Assistance of schools to help CPR and AED education in minoritized communities has the potential for the greatest benefit. This is a recent study that came out of Kansas City but was multi-center. A survey was sent to all superintendents across the country through their association and they then provided this to their students. While only an 8 percent response rate or about 2400 high school students, it does show some interesting trends. All the students knew what CPR was. 86 percent had some training, 25 percent in the past year and 94 percent understood the importance of CPR with 26.9 percent having witnessed CPR. 58 percent said they knew how to use an AED and 57 percent felt they could rescue someone in cardiac arrest. But most of the students agreed that they needed more training. This is another study that used PubMed and Google to look at the state laws and then put together this information. They found that there were 43 states plus the District of Columbia that had some type of CPR and AED education law, 24 plus the District of Columbia that had AEDs, 22 of these states overlapped and five states had no legislation. So they found that the laws were variable and recommended standardizing the laws and the language. There was inadequate funding, especially in the lower socioeconomic zips, so they recommended increasing funding, allocating resources, allowing schools to accept gifts and donation. Education and training, it should be started earlier and tailored to age and development with low-cost training used in certification only for those people such as school nurses, perhaps PE teachers and coaches who are required to have this by law. Many of the state laws focus only on athletes and it should include all students in school areas. It may not address the school size. The recommendation now is one AED for 500 students, one per building, and you have to be able to get between the different floors of the building or from inside to outside, so all of those factors need to be taken into consideration. We need to engage the students, involve their student bodies, and community engagement, translation and education can help alleviate the disparities. Implementation requires a cardiac emergency response plan, other tools such as mapping the AED location so that everyone in the school knows where the AED is. This is a study out of Washington State and we all know that Washington State is the safest place to have a cardiac arrest, but they only train and they have a mandate to have training for their students, but only 64% of their high school students were found to be actively being trained. There was a big differential between the private and public schools, interesting not between rural and urban in that state, but the barriers they found is that it was an unfunded mandate, there was a lack of instructor availability or access to trainer or training organizations. Many schools don't have assigned nurses who are great advocates and champions in the schools, and the type of training was about a third American Red Cross, a third American Heart, and other types of training, and they had a lack of funding for these resources because there is a cost, although it is lowered for schools. They had a lack of equipment of mannequins and trainers and funding to buy these and a lack of sufficient class time, which is especially important for hands-on practice. Going to the East Coast, the study from Rhode Island found the same barriers to teaching CPR to high school students, 82% with budget concerns, 79% lacking funding for materials, 68% lacking the time, and one of the educators said legislation is not enough alone. This is a program that can help to implement these mandates, and it's called Project ADAMS, started in 1999 in Wisconsin, uses a checklist. We now have 50 affiliates in about 36 states, uses a 14-point checklist with five major categories, having an AED, having a cardiac emergency response team, a cardiac emergency response plan, training of an adequate number of people who can help that school nurse, and practicing cardiac emergency response drills. So we go into the schools, we train them, we have drills just like we have mock codes in the hospital, and we present them with a tangible banner that they can hang up and let their families know that they are invested in the safety of their students and anyone who uses the school. So in summary, we need to pass comprehensive model legislation that includes CPR and AED training for students and school staff, including all coaches, AED placement in public locations, cardiac emergency response plan, sudden cardiac arrest drills for schools, community organizations, sports groups and events. We need to institute oversight of implementation and help with facilitation and require annual reporting from institutions. The mandates or recommendations should be standardized and funded with appropriated funds, grants, donations and gifts. They need to have equipment, the mannequins and AEDs. Education needs to be early and sequential with hands-on training. There needs to be adequate personnel to provide the knowledge which will lead to confidence and willingness. There need to be AED preparedness, emergency preparedness programs that have cardiac emergency response plans and drills which will lead to increased bystander CPR and AED use and increased survival. So legislation is the beginning, but it is not enough. We need staff, funding, time and equipment. We need to execute and implement these plans, and this will decrease sudden cardiac death. Thank you. This presentation is now open for questions. Please come to the mic and identify yourself. Vicky, one question. Is the training a one-time session, or are there reinforcing subsequent sessions for students? With regard to Project Adam, when we call our Project Adam Youth Heart Watch at CHOP, it is an every-three-year renewal. We check in with them every year. We recommend that they do multiple drills throughout the year, just like they do fire drills and active shooter drills and that type of thing, and they have to go through the whole process and check off everything every three years. So it is repetitive. Dr. Idris. Dr. Vetter. Salim Idris from Duke University. Salim Idris from Duke University. Thank you for that. Hopefully folks learned a lot today who may not have heard that, but I want to emphasize the importance of what Dr. Vetter talked about with Project Adam and the end-to-end training, end-to-end resuscitation in a school setting, meaning you have an entire team. You are doing the practicing that Dr. Vetter is doing. It is not just about having hands on a mannequin at CPR and learning how to open the AED. We are boots on the ground doing this all the time, and it is absolutely critical, and the team that you're taking are citizens, and it's very important to emphasize that they go out into the community and they're important responders now in the community, even though you're doing it in schools, they live in the community. My question is related to the mandates related to CPR training in high schools and high school students. Are there any states or any other considerations of dialing that back? Why high school students? Why not middle school students learning CPR? There have been plenty of documented elementary school children who have done CPR on their parents or whatever and led to success. Is there anybody else that's looking at this in terms of younger ages? Yeah, there have been a number of studies looking at CPR and AED education across the timeline. A kindergarten kid can know how to call 911. You can always teach them to know what their address is, not just home, what their grandparent's address is, so they can learn the early components of an emergency response. By middle school, if they're big enough, they can actually do the CPR training. Yes, some states actually do have recommendations to have this into the middle schools, but it's variable across the country, and that's part of the problem. But the implementation has to be written into the law and some responsibility and accountability for not doing that. One more short question. I'm sorry. I'll try to be quick. This is Sarah Stevens at Texas Children's Hospital. Coming from a public health perspective and working in a state where, while we understand, obviously, the evidence I've had experience working with Project Adam and seeing firsthand the effect these kinds of initiatives obviously have within the community, but also living in a state where the words mandate are not necessarily welcomed by a lot of people in the community, do you have any tips, just practically speaking, in terms of being a public health professional, how to communicate this directly with more of our southern legislatures and with just educators and people to, I think, kind of get them on the same boat and recognize the importance of this? Yeah, so that's a very good question, and so is not to get political here in this apolitical environment. It's interesting, but in states that you might expect would not be in favor of some of these public health mandates, if you will, some of those states, Texas and Florida specifically, have been most forward-thinking about doing screening and having AEDs in their schools, and that relates to personal experiences. So if there's a personal experience in a community where there's been a student, a teacher, someone that has benefited from the AED programs and the education, bystander CPR education, then those stories are more powerful than anybody's fear of having the word mandate. In fact, those legislators are often the biggest champions to have this. So amplify your stories, because that's kind of what makes it work. And Matt was going to get up, Matt Sorensen, who's handling our database for us at Project Adam, but there have been at least 300 saves now. Matt, I don't want to steal your thunder for something else, but a lot in schools, both about two-thirds of the time it's an adult, about a third to a half of the time it's a child. But tell your stories, because that's what public health is about. Thank you. All right, thank you very much. Our second presentation will be given by Dr. Monique Starks from Duke University, and it's entitled Drum-Delivered AEDs for Out-of-Hospital Cardiac Arrests. Monique. Got it. Thank you. Well, it's great to be here talking about drones for the second year in a row. Here are my disclosures. Bystander AED application and defibrillation rates are low in the United States at less than 5%. More than 350,000 Americans have out-of-hospital cardiac arrest, and every one-minute delay is associated with a 10% reduction in survival. Survival rates have largely not changed over the past 40 years. They remain stuck at about 8.4% to 10%. Public access defibrillation, which came about in the early 2000s after the FDA approved AEDs for public use, just has not been met with the promise of rapidly improving out-of-hospital cardiac arrest care that was intended. And the elephant in the room is that most cardiac arrests occur in the home where public access defibrillators are not. But also, the location of AEDs are largely unknown in the United States, and when there is an AED in the building, the location can be unknown. We know that there's a large population in a large number of states, but that's largely not enforced. And also, importantly, the information isn't transferred to local counties who use the data. We also know that first responders are great for cardiac arrest, but may not carry AEDs, particularly volunteer firefighters and police officers in the United States. And rapid AED delivery by drone represents the promise. So these are graphs and tables that show the time-sensitive nature of cardiac arrest, an article from 30 years ago showing that if you start CPR and defibrillate right away, survival is greater than 50%, but it rapidly drops off to about 10%. And a study from one of our colleagues, Carolina Malta-Hanson, who using data from North Carolina, showed that when you can defibrillate within the first few minutes, you can get a survival of about 50 to 70%. But importantly, if you can do it within the first few minutes, it's the bystander who's actually defibrillating and represents a substantial target for treating cardiac arrest. And thus begins the genesis of drone AED delivery. What we know and understand about drone AED delivery has largely come from Sweden, with our colleagues there publishing a first paper on a save with a drone in 2022 in the New England Journal of Medicine, where the drone was able to arrive within three minutes and 19 seconds with a bystander having successful defibrillation. Recent publications have actually shown that drones can actually arrive to the scene earlier than EMS and first responders in a majority of cases with a median benefit about three minutes and 14 seconds. And now multiple countries are working on this concept, including here in the United States, Europe and Asia. So one of the first experiments we did at Duke was to use mathematical optimization to determine where drones needed to be placed across North Carolina to improve cardiac arrest care and to improve AED arrival. We had constantly heard from first responders and EMS that you don't really need drones if you can just give first responders AEDs. So the first task for us was to estimate what the response would be if we equipped all first responders with AEDs. And then we layered a drone network on top of that. This is a busy table, so I'll just have you look at all counties. In North Carolina, the median response time for out-of-hospital cardiac arrest or arrival time is eight minutes. And only 16% of cardiac arrests have an AED arrive within five minutes. If you equip all first responders with AEDs, that could improve modestly and significantly to seven minutes. But the amount of persons who have an AED arrive within five minutes goes up only to 22.3%. And when we modeled a drone program on top of that, we could reduce those times potentially to 4.8 minutes with more than 56% of cardiac arrests having a median AED arrival time within five minutes. And we only needed about seven drones per county to move that needle. And this is a map of our optimization. The first county is a county that we're working in, Forsyth County, and we're in the process of implementing our first drone base in Clements, North Carolina. They're in the bottom left. And essentially, the idea is that once a bystander calls 911, 911 is able to not only dispatch EMS and first responders, but they can dispatch a drone as well. And we are training our drone pilots to recognize cardiac arrests so that they don't actually have to wait for a CAT system call. The big elephant in the room for drone AED delivery are FAA regulations. We all know that Amazon said that they, that their business would be revolutionized by drone commercialization. Hasn't happened yet because of the restrictions that remain for drones and commercial use. But there is a separate program that's available to public health agencies where they are able to fly drones beyond visual line of sight. And there's actually been rapid incremental improvement in those regulations, allowing for beyond visual line of sight travel, which gave us an incredible opportunity. So we're funded by the American Heart Association to develop real-time protocols for integrating drone AED delivery into the standard of care for cardiac arrest. And we have developed the process from end to end, including software integration. We've also trained drone pilots and 911 dispatchers on recognizing cardiac arrest and the drone program. And even more importantly, we've gotten out into the community to intensively train and to help them to understand what drone AED delivery is all about. This shows the integrated process. We have a real-time intelligence center in Forsyth County with the Sheriff's Department. There are 10 drone pilots who man our drone stations or drone station throughout the day. The right shows a 911 dispatcher who is responding to a simulated cardiac arrest. And more importantly, you'll see that there's a screen where she can actually see what the drone sees and is able to know when the drone delivers the AED and when to have the bystander grab it. So the DFR program in Forsyth County has been ongoing for a few years. They've had more than 5,000 runs and they use it more for situational awareness in reducing crime. So it's been great to add drone AED delivery to it. I'm gonna show you. Before I begin, I'm gonna go into the simulator process. This is what it did for the media. The drone pilot is about 12 miles away from the actual drone. It goes up to 400 feet. This is able to carry more than six pounds, the AED delivers more than six pounds. It lowers to a hundred feet and winches the device to the ground. Stop there. And so aim three of our study, which is getting started soon, is to actually test out real-time drone AED delivery in four rural areas and two urban areas. And we'll be comparing the drone AED delivery to standard of care and collecting a rich set of data from CARES and from our drone dispatch team. The pilot will run 18 months and will include 100 patients, primary outcome of time from 911 call to AED arrival with a secondary endpoint of bystander AED application. The FDA and the FAA are heavily involved in our study as well as Stryker and Zoll. So there are still a lot of challenges with drone technology. There's not a specific drone made for AED delivery. Our batteries are currently limited in the miles that it's able to support of travel. And evolving FAA regulations are important, but also a limitation currently. So in conclusion, timely defibrillation carries the best chance of survival in the United States. An on-demand drone delivery could significantly improve AED application and hopefully survival rates. Technological advancements, community education and buy-in and evolution of regulations are needed to fully recognize these capabilities. And we very much hope for a large clinical trial one day to actually show that it improves survival. Thank you. I have a question. Very nice presentation, very intriguing. New technology that I'm sure will evolve. My question to you would be, is it all over the state that you think it has a role, or do you see particular hotspots in the area if you're very close to an EMS, would it then still be meaningful to have a drone delivery? Yeah, so that's actually a great question. We know that urban areas really have a great opportunity to move the needle at least towards the five minutes, but it's really important in rural areas. And to answer your question, we actually believe that dispatch, that dispatch rules are gonna be really important because if you know that an ambulance is only two miles away, it's probably not a good idea to dispatch that drone because as you all know with the cardiac arrest, once first responders or EMS is on the scene, they're basically gonna push the bystander out of the way. But we actually do want a statewide program. We actually do think it's important for all of the state. And I think that if I could be honest, we know that minority and rural areas may stand to benefit the most from this with the lowest survival and the lowest treatments. But technology will be the last to defuse there because these programs are really expensive. One question if I can just from the audience asks, how do you see where? I think that's a great question and I think that if wearables are connected to 9-1-1 dispatch, that's just one more added piece of the equation to get the response there immediately. So I'm personally excited about the future potential of wearables to be connected to entities like 9-1-1 dispatch. All right, thanks. I also am excited about the wearable possibility. There's enough representation. We know the pitfalls of, you know, photoplethysmography and things like that, so that's got to be nuanced. But my question is, Dr. Starks, thank you for what you're doing for our state, North Carolina, for sure. Are you looking at other AED manufacturer technology that is lighter and also cellular-enabled program? Yeah. That is a really great question. So we recently met with Avive, who, as you know, has an AED that weighs less than two pounds. For us, for this project, it was really, really important because we know that all first responders don't have AEDs to match the AEDs that they have, so that if they need to take over, they don't rip off those pads and not use the device that's there. But we think that there's an incredible role, particularly in more rural areas, where we might need drones that are not as expensive, that are only able to carry smaller weights. Yeah. And that's where regulation comes in, because that's where the FDA would have to weigh in and say, you have to have a universal connection. That's it. That's a great point. The FDA right now only cares that we're able to operate that device with the vibration of the drone and if it falls to the ground. But that's a great point. Sorry to keep on time. We're going to have to move on to the next presentation. So it's my pleasure to call upon Ishai Shekaly from Tel Aviv, who will talk about extracorporeal CPR for out-of-hospital cardiac arrest. Okay. So hi. Thank you for this opportunity. I would like to introduce you ECPR, or ECMO-CPR, that I think rewrites the rules of cardiac arrest survival. And I will start with a case that's a 65-year-old male who collapsed in a supermarket 10 minutes away from our hospital in Tel Aviv. Immediate CPR was initiated by bystanders. AED was connected, and he received two shocks before EMS team arrived and found he was still in VF. Three more rounds of ACLS, including a Mioduron, were not successful in achieving ROSC. At that point, they contact us at the hospital, and we activate the ECPR team. The patient is put on NUCCAS and brought preferably to the cath lab or the ED. And this video is a shot of educational purposes. The patient enters the cath lab. Around 35 minutes after arrest, we divide into two teams. One team is responsible for the operation. Here we have a nice example of how we can switch his cannulas under ultra-strong powers. This can be very challenging. This is a road-setter, which is a little bit better. During ultra-strong compressions and the extreme velocities of the road-setter, we do not have to demonstrate. We always keep flying ECMOs in front of our eyes, so we can learn about these kind of cases. And our standard going-to-ECMO drive is less than 10 minutes. We complete the connection. The air bubbles are seen in the circuit. There is pressure. After cannulation is completed and the ECMO circuit is connected, we can start the flow. And at that point, stop the chest compressions. We can pay attention to the cardiomechanical rhythm and mechanics. This patient has an electrocardiogram, which has compression waves in the normal rhythm. But as you can see in the bedside, there is no mechanical movement. After the electrocutions, fixed cytokines, acidosis and electrolytes, the heart usually regains mechanical function, as you can see here. Some patients remain in VF or VA for a couple of minutes until the metabolic environment is rebalanced. We even let patients remain in VF for more than an hour until they regain organized rhythm. All patients get coronary angiography, as ACS is the leading cause of cardiac arrest in these cases. This patient had an instant thrombosis in DLAD. And now you can hear how the physiologist speaks to the patient and obeys commands after 45 minutes of chest compressions. We complete the PCI of DLAD. And the next steps are to put distal perfusion formula in the leg to avoid leg ischemia from the large ECMO cannulas and consider a strategy for LV unloading, if needed, usually with an intraortic balloon pump or an impeller. The first 24 hours of these patients are usually very rough. These are the sickest patients you can imagine. They are after a long resuscitation. They're in cardiogenic shock, multi-organ failure, traumatized chest from the compressions, massive inflammatory response, coagulopathy, vasoplegia, but they can survive. And we have ACLS protocols, and we have education, and we have AEDs everywhere, even some of them fall from the sky, and great EMS teams and excellent hospitals, but the prognosis of patients with out-of-hospital cardiac arrest remains poor, with less than 10% survival to hospital discharge and even lower survival with good neuro-outcome. The group Ionopulus from Minneapolis developed this protocol, which we adopted. Candidates for this treatment for eCPR are patients with witnessed cardiac arrest who receive immediate CPR and have an initial rhythm of VT or VF, and estimated time from collapse to ECMO on is less than 60 minutes. Terminally ill patients or patients over 75 years old are usually excluded, and when the patient arrives in the cath lab or in the AED, their arterial blood gas and end tidal CO2 must show favorable parameters as a proof of effective resuscitation to the point of ECMO decision. Once ECMO is in, organized rhythm must be achieved within 90 minutes or death is declared. And this is the RCT they published in the Lancet in 2020. Based on that protocol, they randomized patients with out-of-hospital cardiac arrest refractory to standard ACLS, as I described, to either eCPR or standard ACLS. Pay attention to their times. They were able to connect the patients to the ECMO within seven minutes from door arrival and 12 minutes from randomization. Very, very quick. And 30 patients were randomized, and the study was stopped earlier than planned, with six survivors to hospital discharge in the eCPR group and one in the ACLS group, and it was six versus zero for the three-month analysis, all with good neuro outcome. This group also compared patients who received eCPR with similar patients from the ALP study. They are all patients with refractory VTVF. When standard ACLS is ongoing for more than 30 minutes, you see that it is almost impossible to survive with favorable neuro outcome. But with eCPR, when you connect the patient with less than 50 minutes from collapse, you still get almost 50% survival with good neuro outcome. This is basically a number needed to treat of two, because the alternative is almost 100% death or severe brain injury. I don't know many interventions in medicine that are as effective in saving a life. And this is the largest RCT that was done in Prague and included more than 250 patients, published in JAMA in 2022. One of the differences was that 40% of the patients included in this study presented with non-shockable rhythms. The primary outcome of 180-day survival with good neuro function just fell short of statistical significance, while the secondary 30-day outcome was significant in favor of eCPR. The subgroup analysis shows that in the shockable rhythm group, the survival was almost 50% and better than the standard ACLS. And the crossover and as-treated results were also in favor of eCPR. This is the latest RCT from the Netherlands with 130 patients that was published in the New England Journal of Medicine in 2023 with a neutral outcome. But the times from arrest to eCPR initiation and eCPR completion were much slower and lower than the trials from the U.S. and Prague. The mean door to ECMO was around 35 minutes, unlike around 10, and the time interval from arrest to ECMO was 74 minutes, 15 minutes longer than the other studies. So eCPR requires experience and expertise, and building an eCPR program is complex but possible. We have a team that we developed during the last two years, led by critical care and interventional cardiologists that also include general intensivists, perfusionists, nurses, and technicians. And we all need to work like a pit stop in Formula 1 in order to optimize both the time from door to ECMO and the treatment bundle afterwards. And these are our results from our two-year program. We have 25 patients without a hospital cardiac arrest that was refractory to standard ACLS, with one-third survived with good neuro outcome. Seven were declared brain dead, and four became organ donors. This is an important point. Sometimes you start eCPR only to discover later that the patient didn't actually receive immediate CPR on scene, and we unfortunately encounter brain death later on. In these cases, eCPR enables organ donation that was not possible in case of cardiac death, and studies show that eCPR programs increase the potential of organ donations. This also allows us to save patients who collapse inside the hospital, and we sometimes do eCPRs even at the bedside. During the last two years, we had 27 patients with refractory in-hospital cardiac arrest who received eCPR, with two-thirds of them surviving with good neuro outcome. As this is HRS, I should mention that two of them had sodium channel blockade intoxication, two had severe LV dysfunction and are rested in the EP lab during an ablation, and one had a VT storm. I don't believe any of them would survive if we kept on standard ACLS. eCPR can be a bridge to recovery or to advanced treatment such as LVAD or heart transplantation, and for every two to three times we initiate eCPR, we probably save a life. Some patients don't want to be saved, and that is their choice, but some patients like this out-of-hospital cardiac arrest patient in Tel Aviv we treated left us no choice. And we are grateful for our colleagues who inspire us to improve in what we do and save lives, maybe even in the pre-hospital environment like in the supermarket or the Louvre, and I hope that you agree that eCPR is at least part of the future of cardiac arrest treatment. Thank you very much. Very nice presentation. I have a question regarding your case selection. Do you have a pre-specified protocol for that? Would you share that? Definitely. First of all, as I said, the basic requirements are witnessed cardiac arrest, immediate CPR. When we say immediate CPR, we mean within one to three minutes someone started chest compressions. And the third one is initial shockable rhythm on arrival, either the AED that was put first or the EMS team. We do have changes for that when it's in hospital. We sometimes go for even non-shockable rhythm, but when it's out of hospital cardiac arrest, it must be a shockable rhythm. So this is the basics. When the patient arrives, we take blood gas from the artery when we puncture the femoral artery. If the PaO2 is above 50, that's a go. If the lactate is under 18, that's a go. If the end tidal CO2 is above 15, that's a go. If we have two of them which do not get these results, we stop at that point and we declare death because we want to make sure that the resuscitation the patient received to the point we decide to cannulate was effective enough. Thank you for that excellent presentation. It's very encouraging to see this information, and in pediatrics we've been using this perhaps a bit more than in the adult world. We have a team who are in the hospital. But I assume that your team, you said critical care and cardiologists were interventional cardiologists, are in the hospital so that they're always there? So during work times, we are always there. The question is what happens during night times and weekends. And in that case, we have some team members that live very close by to the hospital. And when the EMS gives us an alert of cardiac arrest that they just started working on, sometimes we get to the hospital even before the ambulance arrives. So that's our solution for now for the off hours, and it works pretty nicely. The logistics are always difficult, and sometimes I know in some emergency rooms here, the emergency room doctors would like to be the cannulators, but the surgeons are in control of the program. So I think that more information of the type of system that you have might be helpful in those health care systems to perhaps move the needle a little bit. I agree. Collaboration is the key. And I think the physician who is most experienced with cannulation with ultrasound guidance, vascular access, should lead the team. Thank you. Thank you. The last presentation today for this session will be given by my co-chair, Dr. Svell Hansen, from the University of Copenhagen. And the presentation is entitled Proarrhythmic Drugs and Polypharmacy, Victims of Sudden Arrhythmic Death. Good morning, everyone. Thank you for the very pleasant invitation to come here and share some of my thoughts. This is I will speak on drugs as if they have a role in sudden arrhythmic death. I'm an electrophysiologist by training, but I also am a professor at a forensic institute, which is why we have access to some special ways of doing it. So I was so lucky to be the chair, together with Katja Seppenfeld, on the ESC guidelines. And this central figure really shows all the causes of sudden cardiac death and VA. And now the role of this talk is to discuss whether drugs may play a role here. What is their role? And there you can see there are many disease entities. Some of them are very rare. Some of them are very common. We just heard that ischemic heart disease is the most common. This is also what we see. One thing I want to put out first is something that we discuss a lot when we do the publications, is in a lot of studies there is quite a few cases that were unknown to be occult OD. And, for example, this study from San Francisco that you may know, which was a prospective study collecting cases, showed that in 13.5% of the sudden death, so they went to autopsy, were then deemed after toxicology to be occult overdose. So, of course, this is very important. And those are mainly non-arrhythmic, but they are very important to see. And also, from my point of view, sitting in an inherited clinic, those families are not at risk. So this is important. So we went a step further to look at cardiac arrest survivors in our hospital. So we attach here in the center with a catchment area of 2.8 million where everyone comes in after cardiac arrest, if they survive the cardiac arrest, out of hospital for angiogram. And what we did was to look at almost 200 consecutive cases. And then immediately upon arrival, we did a blood sample. And with this blood sample, we sent it to forensic toxicology. Why do I say forensic toxicology? Because it's done by mass spec, so that means that we can really look into all the things that are in the blood, also the unknowns. And then, of course, we did the toxicology analysis. And what we found was, in this setting, 200 cardiac arrest cases survived to the hospital. There were no OD. So this was not what we saw in San Francisco. But on the other hand, we found a lot of proarrhythmic drugs, namely QT, Prolongin, and some that induced what we called brogadogenic drugs. And then, of course, quite a few drugs of abuse and also psychotropic drugs. So in Denmark, we have a quite unique system in the sense that when you are born, you get this unique number that follows you all the way into our hospital system. So it's one system. And then if you're prescribed a medication, then we can also see that whether you went to the pharmacy. And in case of death, this is also related to this number, including the autopsy and toxicology. So with that, we also looked at the circumstances of all the deaths in almost 20 years, and I'll give you some examples of that, and including the drugs in those. And I'll show you some data on that. But just to walk you through, so this study looked at a seven-year period, all deaths in the young. And what we found was that around 7% of all deaths, so those include traffic death, suicide, and so forth, are cardiac death. So this is a major contributor even at a very young age. And what's the age that they die? So the good part is that the numbers are quite low among the children, but they're still there. And then after 20, it really kicks off. So these are just crude numbers, but when you do what we call an incidence, so that's how many people at a certain age is dead, it's 2.8 at that time. So that was 2006. There's a male dominance. This is also something that we've seen. So in a publication in circulation last year, we looked at our 20-year experience. And what we found was quite amazingly, it's a dramatic decrease, and this is the incidence actually to half. So now the incidence seems to be more like below 2. And the causes that we found were similar to what we have found previously, and quite importantly, I think, among the young. And these are just four studies. And where you see the blue is sudden arrhythmic death syndrome. This is not a universal nomenclature, but this is a normal autopsy including toxicology that was not deemed to find the cause of death, no OD. So are there any populations that we know are at higher risk? One thing that has struck us a lot in our series is epilepsy. So epileptic patients are for sure at higher risk. This we know from numerous case reports. We now looked into the population, so we know all the people who have epilepsy at a certain age. And we looked at the young in two studies. And actually they have a very high risk, so 16 to 34-fold increase of sudden cardiac death compared to general population. So this is really a health issue. So one question that always pops up in these families, what is the reason for this? And one of the theories are that they are not taking their drugs. Some are they are taking multiple drugs. So we know some risk factors from epidemiology. But we were able to see in this study looking at actually what was in their blood, in the toxicology, whether or not it filled with what was prescribed. And what it actually showed is that these cases were taking their drugs. So in those, in SUDEP, it does not seem as if it's noncompliant or adherence problem. That is a problem, so maybe the drug could be the problem. And therefore we have been looking into what they prescribed from the pharmacy and also in the toxicology. And what is also nice in the toxicology is that you get drugs that were not prescribed and also abuse drugs that may also have effect on the heart. And what we did was to look at explained sudden cardiac death. So even at this early age, so below 50, the most common here is ischemic heart disease. And then looking at the drugs they had in their blood compared to those with a normal autopsy. And what you see that the ones with a blank autopsy, sudden arrhythmic death syndrome, had higher proportion of people taking QT-prolonging drugs. And to further study this, we looked at only the sudden arrhythmic death syndrome and looking into what drugs were in the blood. And what you can see here is it's not only if you take the drug, but also at what level is it found in the blood. And what you can see is that somewhere below what we call sub-pharmacologic level, somewhere at pharmacologic, but somewhere also super-pharmacologic. And quite interestingly, the QT-prolonging drugs were over-represented in the super-pharmacologic. And also what we saw were that there was something found. So this is what we term a positive toxicology in two-thirds of all the SADS cases. And what you can see here is that a lot of them had more than one drug, so now that's polypharmacy. And this is true for two-thirds of all with a positive toxicology. And quite interestingly also, the QT-prolonging drugs is very frequent, as well as brogadogenic drugs again. This is why we have now recommended that in a case of a sudden cardiac death, so that means that it did not work with the eCPR, but still we have an unknown cause, then we want to know. And toxicology is a class one in Europe at the level of evidence C. And the way that we envision it is in this flowchart. What you see, you should, of course, collect details of circumstances of death when you start the autopsy. But very early on upstream, save blood for potential toxicology. And if you have not found the cause of death, then it's a class one to do toxicology testing. Then it may show that it was an OD, which is in a way positive for the family, because then they are less at risk. When I speak to the families, and I am sitting in an inherited clinic where we get all the autopsy reports, collect the families, I often say that this is the risk for sudden cardiac death for the individual who died and for the family who is left behind is like a multiple hit, because it's not only the genetics. It's not only the lifestyle. But for sure there's also a role in legal and illegal drugs in reaching that threshold of getting the lethal arrhythmia. And with that, I'd like to have some take-home messages. Sudden cardiac death accounts for 5 to 20% of all death. The most common finding in sudden death in the young is a blank autopsy. Occult overdose plays a major role in sudden death for sure here in the U.S. Drugs and proarrhythmic drugs may play a role as risk factors in susceptible individuals. And this is also the thing that we found in a cardiac arrest. So there were three individuals who were diagnosed with long QT, and yes, they had QT-prolonging drugs in the blood. And therefore, toxicology screening is recommended in sudden death cases with uncertain cause of death. With that, I'd like to take questions. Hello. So I have a sister who's epileptic, and with the sudden cardiac death, do you think that's also brought on by their during seizure activity, that they're actually becoming apneic, and not because of a cardiac event, but because of a respiratory event brought on by the seizure? So that's a very good question. So there is a series of unfortunate occurrences at neurologic wards where they have actually seen cases of SUDEP. And there, what they witnessed was actually not tachyarrhythmia, but it was bradyarrhythmia leading to this. And they also saw breathing problems, but it's not solved. We don't know exactly why this comes across, whether drugs play a role. But, I mean, what is nice, I have not seen a pedigree, and we do not know whether it runs in families. So that somehow tells me that it should be something different from the genes here. Any other questions from the panel or the audience? If not, thank you, Jacob. And also on behalf of both of us and the panel, I want to thank the speakers and the audience for their participation. Enjoy the rest of HRS 25.

Heart Rhythm Society

cardiac health

CPR education

AEDs

drone-delivered AEDs

extracorporeal CPR

ECMO

proarrhythmic drugs

sudden cardiac arrests

polypharmacy