HRS Sessions to Honor the Wireless Revolution in Healthcare

April 30, 2014

SAN FRANCISCO, CA — With much of arrhythmia management already a hardware-oriented field, the Heart Rhythm Society(HRS) 2014 Scientific Sessions , kicking off here May 7, takes its theme "Technology and Medicine" to another level: the interactivity of personal and technological networks and how they are driving some radical changes in healthcare delivery. That theme has helped shape not only the speaker lineup for the meeting's popular opening plenary session but also many of the included late-breaking clinical trials, debates, cases, and other presentations.

Opening Plenary: Wednesday May 7, 4:15 PM

Every year, this session "is rated very high by our meeting attendees," according to HRS first vice president Dr John D Day (Intermountain Medical Center, Salt Lake City, UT), chair of this year's program. "In the past few years, we've tried to bring in very high-caliber speakers. When we queried our attendees, of course Bill Clinton [in 2013] ranked the highest, but number two was a panel discussion that we had several years ago. So we decided to revisit that with a focus on the intersection of technology and healthcare."

Dr John D Day

The four panelists will each give four short " TED -style talks" followed by a panel discussion, moderated by Susan Dentzer, senior policy advisor at the Robert Wood Johnson Foundation, he noted. "There will be questions and I'm sure comments from the audience that will impact the direction the panel discussion goes."

Scheduled speakers include David Pogue, formerly of the New York Times and now a technology writer for Yahoo Tech and Scientific American and a correspondent for shows on CBS and PBS television. He's on the panel as a "futurist voice," Day said, to provide "a different perspective as someone not part of the cardiology world per se."

In that respect, Pogue is balanced by another speaker, also a futurist but someone very much a part of the cardiology world, Dr Eric Topol (Scripps Health and Scripps Research Institute, La Jolla, CA). Among other accomplishments, Topol is a medical genomics expert and author of the best-seller The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care, released in 2012. The book explores the emerging world of portable electronics, connectivity, and networking in healthcare. He is also editor-in-chief of Medscape.

Also on the bill is Dr Silvia Priori (New York University, NY and University of Pavia, Italy), "who has done just phenomenal work over the years on the genetic aspects of inheritable heart conditions. Genetic testing is really moving into prime time. Genetic testing for these conditions—for example long-QT syndrome or arrhythmogenic right ventricular dysplasia—was thousands of dollars and not covered by insurance plans. Now that has all changed. For most of my patients, I can do genetic testing for $49. The whole field is going to shape and impact the way we deliver care to our patients," Day said.

Finally, Dr Leslie A Saxon (University of Southern California, Los Angeles), cardiologist and expert in medical telemonitoring, body computing, and other arenas of digital healthcare, is joining the panel. Saxon is filling in for Jay Walker, the inventor and technology start-up wizard who is listed on the meeting's promotional web pages but is unable to attend. Day said Saxon has also organized a novel series of presentations on "Body computing and digital health," including one she is chairing called the "Ubiquitous ECG and the consumerization of medical device data" (Friday, May 9, 10:45 AM).

Late-Breaking Clinical Trials I: Thursday May 8, 1:30 PM

The next morning's first late-breaking clinical-trials session highlights several studies aimed at enhancing the safety of device implantation and ablation procedures. They include the Shockless Implant Evaluation (SIMPLE), a randomized evaluation of routine defibrillation threshold testing (DFT) at defibrillation implantation, a topic with a long history of observational data, for and against, but little randomized-trial support. "It's long been dogma that you need to intentionally induce ventricular fibrillation to make sure the device can successfully resuscitate the patient in a controlled setting," Page observed. "But what happens in a controlled setting during implantation is generally not the same thing that happens when a patient may go into cardiac arrest in the real world. So, is DFT testing necessary or not? Finally we have the randomized trial."

Soon afterward there is the randomized VISTA trial on standard ablation of stable post-MI ventricular tachycardia (VT) vs substrate-based ablation, the latter guided by scar mapping. "Ventricular tachycardia is for most patients an unstable rhythm. Is there was a way to ablate it without having to put the patient in ventricular tachycardia? That's certainly a very important question," Day said.

Next up will be the randomized, single-blind first Prophylactic Pulmonary Vein Isolation During Isthmus Ablation for Atrial Flutter trial (PREVENT AF Study I). "Atrial flutter is something we can easily ablate, but there's about a two in three chance that someday they will develop atrial fibrillation," according to Day. "So this is a very provocative trial in patients with atrial flutter [asking whether] you should just go ahead and ablate atrial fibrillation—that is, perform an invasive procedure for a disease with which they've never been diagnosed and then follow them long term."

Another late-breaker presentation is called "Increased adherence to remote monitoring is associated with reduced mortality in both pacemaker and defibrillator patients," a rare pacemaker and implantable-defibrillator trial evaluating the effect of remote monitoring on hard clinical end points. Although retrospective data suggest remote monitoring may confer a survival advantage, Day noted, the current trial raises the question, "Is it the technology that improves survival, or does somehow the technology cause patients to change their behavior?"

Other late breakers in the session are entitled "Adenosine-guided pulmonary-vein isolation for the treatment of atrial fibrillation: Results of the prospective multicenter randomized ADVICE trial," and "Dual-targeted thoracic spinal cord stimulation for heart failure as a restorative treatment ( SCS HEART ): First-in man experience."

Late-Breaking Clinical Trials II: Friday May 10, 8:00 AM

Leading off the next day's late-breakers, the LEADLESS trial one-year follow-up is a sequel to the study's early "first-in-human" experience, reported at the 2013 HRS sessions, with the Nanostim/St Jude Medical LCP (leadless cardiac pacemaker), available in Europe but investigational in the US. It's a self-contained 42-mm-long, 6-mm-diameter cylindrical pulse generator and endocardial pacing electrode, designed for permanent placement in the right ventricle, which avoids the need for leads or a subcutaneous pocket. "How does this [device] perform over a longer period of time, since long-term reliability is something that's so critically important in our field, especially [given] all of the lead problems [we've had] with implantable defibrillators?" Day asked.

Following soon after: a presentation of long-term clinical-outcomes trial of left-atrial-appendage (LAA) ligation using the LARIAT suture delivery device (SentreHEART) in patients with contraindications to oral anticoagulation. The device has been available in the US, Day noted, only because the FDA considered its use substantially equivalent to conventional suture ligation. In contrast, the agency is expected soon to approve the Watchman (AtriTech/Boston Scientific) LAA closure device only after years of trials demonstrating effectiveness, he noted. "So this is an important late-breaking trial for the LARIAT, because we haven't had any robust data that it works or it's safe."

Also in the session: primary results of the Alternate-Site Cardiac Resynchronization (ALSYNC) study that explored the safety and efficacy of LV pacing using an endocardial lead in cardiac resynchronization therapy (CRT). If a patient is among the third of CRT recipients who don't respond to the therapy, "and you have nothing else to offer the patient, if this is an effective approach, then perhaps it can be considered." Traditionally, LV endocardial pacing-lead placement is avoided because of a potential for thrombosis and possible embolic events. "The question has always been, is it safe?" Day said. "That's what we're going to find out."

Other presentations in the session are " Botulinum Toxin Injection in Epicardial Fat Pads Can Prevent Recurrences of Atrial Fibrillation After Cardiac Surgery : Results of a randomized pilot study," "Baseline characteristics, outcomes, and comparison of edoxaban vs warfarin by AF subtype in 21 105 patients enrolled in the ENGAGE AF-TIMI 48 trial," and "Point-by-point radiofrequency ablation vs the cryoballoon or a novel combined approach: A randomized trial comparing three methods of pulmonary-vein isolation for paroxysmal atrial fibrillation (the Cryo vs RF trial)."

Late-Breaking Clinical Trials III: Saturday May 10, 2014, 10:30 AM

The third late-breaking trials session features a presentation exemplifying the meeting's technology and medicine theme, on the Smartphone Pediatric Electrocardiogram (SPEAR) trial of the AliveCor Heart Monitor (AliveCor), which transmits ECG impulses to a handheld device. "I probably have 20 patients in my practice who have this AliveCor device as part of their iPhone or Android smartphone," Day said. "This isn't just a pediatric topic. Is every cardiac patient going to have their own ECG monitor with their iPhone, is that where we're going? It has huge ramifications."

Also in the lineup are two trials exploring the use of ranolazine (Ranexa, CV Therapeutics/Gilead Sciences), primarily a second-line antianginal agent, for two different indications: the Ranolazine in Atrial Fibrillation Following an Electrical Cardioversion (RAFFAELLO) study and the HARMONY trial exploring the combination of ranolazine and low-dose dronedarone (Multaq, Sanofi) in paroxysmal AF.

"We've learned over the years that ranolazine has very potent antiarrhythmic effects as a sodium-channel blocker, and in clinical practice, there's been a lot of off-label use. At least anecdotally it appears to be very effective in combination with dronedarone as well as amiodarone and also appears to be safe," according to Day. "So it's really nice that we'll have some new data looking at these antiarrhythmics, because there just hasn't been a whole lot of action in this area for a long time."

The other late-breaker presentations scheduled for Saturday include "Is it safe to delay detection in all ICD patients? A randomized evaluation of prolonged ICD detection intervals in secondary prevention patients enrolled in the PainFree SST trial," "Use of remote monitoring is associated with improved outcomes among patients with implantable cardioverter defibrillators," and "The effects of reactive atrial antitachycardia pacing on the progression of atrial tachyarrhythmias: Results of the randomized MINERVA trial."

Complication Theater: Thursday and Friday, May 8-9, 2014

"We've heard from our attendees that they want more interactive, more case-based, rather than the traditional didactic, presentation," Day said. "So new this year, we’re going to have a dedicated space, running all day, where leaders in the field will be presenting the cases that didn't go quite as planned, where there were complications."

Audience members and thought leaders will put their heads together and dissect the cases for the lessons they offer, he said. "So often the experts present the latest and the greatest, and for many meeting attendees, one is almost left with the impression that they walk on water and can do nothing wrong. This is a chance to show that they're human, that cases don't always work perfectly, and what can be learned from them."


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.