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News
Mar. 2013, No. 6
Kiyo Tokyo Building 6F, 2-5 Kanda Ogawamachi, Chiyoda-ku, Tokyo 101-0052
E-mail: [email protected]
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Chief editor: Kazuo MATSUMOTO
Associate editor: Yenn-Jiang LIN
Editor: Vanita ARORA
Kathy LEE
Yasushi MIYAUCHI
Hiroshi NAKAGAWA
Young Keun ON
Teiichi YAMANE
Kohei YAMASHIRO
Tan Boon YEW
Yoga YUNIADI
CONTENTS
P1
What is a “MRI Conditional” Pacemaker?
-The Heating Issue of Conductor Wire in the MRI-
P4
Technology Update:
Subcutaneous Implantable Defibrillator (S-ICD)
P8 EP World: Electrophysiology in New Zealand
P10 EP World: Cardiac Electrophysiology in Thailand
What is a “MRI Conditional” Pacemaker?
- The Heating Issue of Conductor Wire in the MRIRitsushi Kato, MD
Department of Cardiology, International Medical Center, Saitama Medical University,
Hidaka, Saitama Japan
Since October 2012, the “MRI conditional” Advisa MRI®
pacemaker, CapSureFix® lead and SureScan® pacing system
(Medtronic Inc., Minneapolis, MN, USA) have all been available in Japan. What is a MRI “conditional” pacemaker and how
is it different from a “conventional” pacemaker? It is natural
that these questions may occur to most cardiology physicians,
because there are many reports1,2 which showed the safety of
MRI procedures for those patients with pacemakers and ICDs.
I asked a German friend and colleague who is an EP physician
about the status of MRI conditional pacemakers in Europe;
the MRI conditional pacemaker was introduced in Europe in
2008. He replied that “we only implant those if patients ask
for it or if MRI scans are really scheduled for the near future.
You can do MRIs with almost all other pacemakers as well, you
only have to check these PM afterwards.” Actually, a group at
Johns Hopkins showed3,4 the imaging protocol for the patient
who has a strong clinical indication for MRI. So, the first question again comes to mind: what is MRI conditional? In fact, the
answer to this question is that the phrase “MRI conditional”
has already been formally defined. In terms of the safety of
device use within an MRI environment, the American Society
for Testing and Materials (ASTM) International developed a
new classification5 in 2005, that is, ‘MR unsafe’, ‘MR safe’ and
‘MRI conditional’. ‘MR unsafe’ is considered for a device that
is known to pose hazards in all MRI environments. MR unsafe
items which include magnetic items such as ferromagnetic scissors and knives. ‘MR Safe’ is appropriate for an item that poses
no known hazard in all MRI environments. “MR Safe” items include non-conducting, non-metallic, non-magnetic items such
as a plastic cups, and ‘MRI conditional’ is considered for an
item that has been demonstrated to pose no known hazards
in a designated MRI environment with specified conditions of
use. For approval of this category, strict definition of these conditions is required. Issues of theoretical concern for implanted
devices under the MRI circumstance include:  forces and
torques on generator and leads,  generator damage and/or
reprogramming - (power on reset),  inhibition of pacemaker
– noise detection,  rapid pacing,  image distortion, and 
heating of tissue – pacing threshold. To overcome these issues
and become a bona fide MRI conditional device, there were
several technological steps taken to address such concerns6.
Both the minimization of ferromagnetic material and replacement of the reed switch with a solid state Hall sensor are important design mechanisms intended to limit magnetic field interactions. Circuit filters and shielding were also implemented
to impede or limit the transfer of certain unwanted electromagnetic effects as well. These changes resolved the  to 
issues listed above. Although  image distortion still remains,
this issue would not arise if the image plane is far from the device or lead. The final issue regarding heating will be discussed
below.
Figure 1 (upper panel) is not the result of radiofrequency
(RF) catheter ablation. Actually, it is one of the results of the
study which evaluated the effect of heating using the MRI
compatible EP catheter under the MRI. This study was one of
the MRI-guided EP projects performed by Henry Halperin and
his colleagues at Johns Hopkins University about 10 years ago.
Within the MRI environment, pacing leads and EP catheters
can potentially act as antennae for electromagnetic energy im-
What is a “MRI Conditional” Pacemaker? -The Heating Issue of Conductor Wire in the MRI
If the RF energy was given to the phantom, the
sudden temperature rise was usually recorded from
the tip of the catheter (Figure 1). We calculated the
maximal d T / d τ using the initial slope. The specific
heat of water, 4.2 (J / g T) was used for the calculation of this equation.
• SAR amplification = measured peak SAR / estimated peak SAR; where estimated SAR is the
peak SAR without the catheter (This value was
obtained from the MRI machine)
Figure 1
pulses. Therefore, in a worst case scenario, they may
ablate heart muscle. We performed a preliminary
investigation7 to determine how much heat is produced during MRI imaging using a 120cm, 7 Fr, 4 mm
gold tip MRI “compatible” bipolar catheter. First, we
placed three catheters in the right atrium, the right
ventricular apex and the left ventricular apex of a
dog heart. The temperature change of each catheter
was measured during MRI scanning using several different SAR scan protocols (SAR; 0.0049-1.8013). The
lower panel of Figure 1 showed the result using the
relatively high (but notunusual in a clinical setting)
SAR (1.8013) protocol. The temperature of the catheter tip increased suddenly, just after the beginning
of the scanning, and it maintained the plateau value
during scanning. Luechinger et al.8 also showed the
same extent of heating using a chronic animal study.
Next, we calculated the SAR amplification using the
calorimetric method for evaluating the effectiveness
of the EP catheter in terms of the heating.
To prevent local burns, the FDA sets limits on
the allowable power deposition measured by peak
specific absorption rate (SAR, 8 W/kg), and temperature change (2 degree C in torso). Therefore, the
estimated SAR of MRI should be less than 8 / SAR
amplification for safe operation, even if this catheter is placed in the bore of MRI. The upper panel
of Figure 2 showed the setting of this experiment.
We measured the temperature change during scanning at 30 different points in the half saline phantom
and calculated the SAR amplification. The highest
SAR amplification was calculated as 521.6 when the
catheter was placed in the edge of the bore with
a straight shape, and disconnected from the cable
(Figure 2, lower panel). Therefore, the safety limit
of estimated SAR was predicted as 8 / 521.6 = 0.015
(W/kg). This value of SAR corresponds approximately
Setting of experiment.
A electrode-catheter made from non-ferromagnetic materials was connected with ECG
cable and temperature gauge.
Temperature-measurement was performed at 30 different points.
We placed a distal tip of the catheter at 30 different points in an MRI.
• Calorimetric method
dQ=dT×m×c
(Q, energy, joule; T, temperature, degree; m,
mass, kg; c, specific heat)
SAR = d Q / ( m × d τ ) = ( d T × m × c ) / ( m × d τ )
= c × d T / dτ
(τ, time, second)
The effect of positioning on the SAR amplification
(Left, straight; Right, loop shape)
Figure 2
Consequently, doesn’t the MRI conditional
pacemaker induce any heating? Because the condition where the conductor wire exists under the MRI
circumstance is the same, the answer to this question is no. As described above, a strict definition of
the conditions is required for being considered as
‘MRI conditional’. This sentence indicates that there
might be some heating under the MRI, but the heating could be suppressed considerably by the ‘conditional’ devices, and it becomes clinically irrelevant in
a defined condition. According to the Medtronic brochure, the CapSureFix® lead has a decreased number of coiled filars and increased winding turns to
increase the lead inductance. This lead modification
decreased the heating about 1/2~1/6 compared with
conventional lead. Susil et al.9 reported on the filter
using the capacitor and RF chokes for combined EP/
MRI compatible catheter. To reduce the potential for
heating at the tip of the catheter, they have proposed
the use of RF tip chokes. These chokes are tuned to
the imaging frequency (64 MHz) and selectively decouple the electrodes from the rest of the circuit at
this frequency (where heating can occur). Therefore,
the effective ends of the wire leads are buried within
the catheter, proximal to the chokes, and the heating potential is reduced. At other frequencies, where
the electrodes are needed to record the IEGM (~100
Hz) and to ablate tissue (kHz), the electrodes remain
connected. I suspect this kind of technology may be
used in some of the ‘MRI conditional’ leads.
Multicenter clinical trials10,11 for the first generation of MRI conditional pacemakers have been already published. In one controlled, worldwide trial11,
464 patients were randomized to either undergo a
1.5T MRI scan between 9 - 12 weeks after implantation, or forego MRI. This study showed there was
no MRI-related complication, and no significant difference could be observed between the 2 groups in
the pacing threshold and sensed electrogram amplitude. Currently, we anticipate that this device will be
widely used, because the safety and efficacy of MRI
conditional pacemaker have been demonstrated in
the randomized trial. On the other hand, this device
may have created new unresolved issues, leading to
possible confusion. This confusion includes several
situations:  MRI conditional high power devices are
not yet available on the market;  new MRI conditional pacemakers could be implanted for patients
who have abandoned leads;  scanning using 3.0 T
or higher MRI system could be performed;  manufacturer mismatch between the device and lead may
occur. Shinbane et al.6 described other important issues raised by the advent of MR conditional devices
which require further study about patient selection,
medical coordination, study type/quality, impact on
care and cost. However, the MRI conditional pacemaker was originally invented for those patients who
needed to undergo an MRI ‘more easily’. If you make
a complicated restriction, it could be contrary to the
original purpose of the MRI conditional device. Accurate knowledge and a well-designed system for the
implementation of MRI are required for correct and
ideal progress in the proper use and distribution of
this new technology. Hopefully, “MRI safe” implantable devices will be invented in the near future.
References
1. Martin ET, Coman JA, Shellock FG et al. Magnetic resonance
imaging and cardiac pacemaker safety at 1.5-Tesla. J Am Coll
Cardiol. 2004;43(7):1315-24.
2. Sommer T, Naehle CP, Yang A. Strategy for safe performance of
extrathoracic magnetic resonance imaging at 1.5 tesla in the
presence of cardiac pacemakers in non-pacemaker-dependent
patients: a prospective study with 115 examinations. Circulation. 2006;114(12):1285-92.
3. Roguin A, Zviman MM, Meininger GR et al. Modern pacemaker and implantable cardioverter/defibrillator systems
can be magnetic resonance imaging safe: in vitro and in vivo
assessment of safety and function at 1.5 T. Circulation. 2004;
110:475-482.
4. Nazarian S, Roguin A, Zviman MM et al. Clinical utility and
safety of a protocol for noncardiac and cardiac magnetic resonance imaging of patients with permanent pacemakers and
implantable-cardioverter defibrillators at 1.5 tesla. Circulation.
2006 Sep 19;114(12):1277-84.
5. American Society for Testing and Materials (ASTM) International, Designation: F2503-05. Standard Practice for Marking
Medical Devices and Other Items for Safety in the Magnetic
Resonance Environment. ASTM International, West Conshohocken, PA, 2005.
6. Shinbane JS, Colletti PM, Shellock FG. Magnetic resonance
imaging in patients with cardiac pacemakers: era of “MR Conditional” designs. J Cardiovasc Magn Reson 2011;13:63-75.
7. Kato R, Yeung CJ, Susil RC et al. Safety of non-magnetic ablation electrode catheters during magnetic resonance imaging.
Circulation2001 suppl II 104, 17:II-566.
8. Luechinger R, Zeijlemaker VA, Pedersen EM, et al. In vivo heating of pacemaker leads during magnetic resonance imaging.
Eur Heart J. 2005;26:376-383.
9. Susil RC, Yeung CJ, Halperin HR, et al. Multifunctionalinterventional devices for MRI: a combined electrophysiology/MRIcatheter. Magn Reson Med. 2002;47:594-600.
10. Wilkoff BL, Bello D, Taborsky M, et al. Magnetic resonance
imaging in patients with a pacemaker system designed for
the magnetic resonance environment. Heart Rhythm. 2011;
8(1):65-73.
11. Forleo GB, Santini L, Della Rocca DG, et al. Safety and efficacy
of a new magnetic resonance imaging-compatible pacing system: early results of a prospective comparison with conventional dual-chamber implant outcomes. Heart Rhythm. 2010;
7(6):750-4.
What is a “MRI Conditional” Pacemaker? -The Heating Issue of Conductor Wire in the MRI-
to the SAR used in some MRI protocols such as the
Fast Gradient Recalled Echo sequence. According to
this preliminary study, we could find that the use of
non-magnetic wire during “limited” power MRI imaging does not result in significant unintentional tissue
heating. Additionally, we could also find that tiny
changes of the catheter-position led to remarkable
changes in the temperature. This uncertainty related
to heating may confuse the awareness of devicerelated safety under the MRI.
Technology Update: Subcutaneous Implantable Defibrillator (S-ICD)
Technology Update:
Subcutaneous Implantable Defibrillator (S-ICD)
Richard Sanders
VP Scientific Affairs
Boston Scientific Corporation
[email protected]
S-ICD Overview:
The S-ICD is the world’s first and only completely subcutaneous ICD. It provides effective defibrillation therapy without the use of transvenous leads,
leaving the heart and blood vessels untouched. The
entire system is implanted just below the skin; preserving a patient’s venous system, while offering the
same defibrillation protection of traditional, Transvenous ICDs (TV-ICD)1. The S-ICD System establishes
a new class of protection from sudden cardiac arrest
without touching the heart and will offer an important alternative to conventional cardiac defibrillation
therapy.
Conventional TV-ICD vs. S-ICD:
Implantable defibrillators are implanted in patients who are at risk of sudden cardiac death due
to ventricular fibrillation and ventricular tachycardia.
TV-ICDs require one or more electrode wires (leads)
to be placed through a patient’s veins and into the
heart. When an ICD senses a rate above the programmed cut-off threshold, it will send an electrical
pulse to the heart to reset its normal rhythm. ICDs
have been used for decades and have saved and prolonged hundreds of thousands of lives.1
With the introduction of the S-ICD, there will be
two different classes of ICDs being implanted: TV-ICD
and S-ICDs. Depending on a patient’s clinical needs,
both classes offer unique advantages.
Transvenous ICDs
Similar to TV-ICDs, the S-ICD is designed to provide lifesaving defibrillation
therapy whenever it is needed. In contrast, the S-ICDs do not require
electrical wires inside the venous system.1
The S-ICD represents a new class of ICD. The
implant procedure is completely subcutaneous. The
electrode is placed just under the skin near the sternum. When sudden cardiac arrest is detected, the
electrode will deliver a shock to the heart. Without
directly touching the heart, the shock can effectively
reset the heart’s normal rhythm.1
Implantation of the S-ICD System is straight forward and is performed using anatomical landmarks,
without the need for fluoroscopy (an x-ray procedure
that makes it possible to see internal organs in motion). Fluoroscopy is needed for placing the lead(s)
needed for a TV-ICD system. Because of this positioning, the S-ICD electrode, unlike transvenous leads, is
not exposed to constant bending or crushing forces
which is a frequent source of lead failure.
Patient Considerations for S-ICD
Therapy:
TV-ICDs administer shocks through one or more electrical wires attached
to the heart. Using x-ray imaging, the electrical wires are fed through the
veins, into the heart, and across the heart valve. Once in place, the wires are
attached to the heart wall.1
The S-ICD System
The S-ICD is intended to provide defibrillation therapy for the treatment of a life-threatening,
ventricular tachyarrhythmia. It may be considered
an appropriate alternative for a broad range of patients. For example, primary prevention patients, or
some secondary prevention patients like those with
idiopathic VF. Patients that will require long term
therapy in whom lead may be an issue. Patients with
poor venous access or whose TV-ICD is removed
S-ICD System Components:
subcutaneous ICD was developed. With appropriate
patient selection, the S-ICD is emerging as an effective alternative to transvenous systems for primary
and secondary prevention of sudden cardiac death.”3
Crozier: Cameron Health S-ICD® System: Addressing the Shortcomings of
Transvenous ICDs – New Zealand
The S-ICD system has two main components: (1)
the pulse generator, which provides the power, monitors heart activity, stores arrhythmic events, and
delivers a shock, if needed, and (2) the subcutaneous
electrode, which contains two, separate sensing electrodes and one shocking coil. Both components are
implanted just under the skin—the generator on the
side of the chest between the 4th and 6th intercostal
spaces, and the electrode against the breastbone.
“My experience with the S-ICD System is very
encouraging and shows that the S-ICD System has
the capability to prevent sudden arrhythmic death
by reliably detecting and treating ventricular arrhythmias, and with excellent rhythm specificity. ”5
What Clinicians are saying about
S-ICD Therapy:
START Study4
Arrhythmia and Electrophysiology
Center, IRCCS Policlinico San Donato,
Milan, Italy
“The S-ICD system represents a novel therapy
for the prevention of VT/VF induced sudden death
and may overcome several challenges related to TVICD technology. By simplifying implant techniques,
the S-ICD system also eases the use and management of ICDs in clinical practice. It may be indicated
in primary and secondary prevention of SCD (sudden
cardiac death), under current guidelines, in all patients with no indication to pacing therapy for bradyarrhythmias or cardiac resynchronization or ATP from
previously documented VT. Children, young adults,
and all cardiac patients without the need for TV pacing may find the S-ICD system a valuable alternative
to a TV-ICD.”2
Circ Arrhythm Electrophysiol 2012;5;
587-593; Christopher P. Rowley and
Michael R. Gold - US
“The subcutaneous approach to ICD implantation was developed initially for patients in whom a
transvenous approach was not feasible. Having demonstrated effective arrhythmia detection, discrimination, and termination, the first purpose built entirely
Clinical Performance and Clinical
Study Results:
The START study was a prospective, multicenter
trial that compared the performance of the rhythm
discrimination algorithm available in single and dual
chamber TV-ICDs head-to-head with the Cameron
Health INSIGHT algorithm found in the S-ICD. Both
sensitivity for detection of VF and specificity for
discrimination of AF/SVT from VF were tested using
identical arrhythmias to compare different algorithms.
Results:
o Sensitivity: S-ICD System appropriately detected 100% of VF/VT episodes.
▪
Importantly, appropriate detection of
VF/VT occurred even in the presence of
concomitant arrhythmias (e.g., VF + AF).
o Specificity: AF/SVT discrimination was higher at 98% for the S-ICD System compared to
any transvenous device tested4
References
1.CRM-88610-AA JUN2012.
2.Progress in Cardiovascular Diseases 54 (2012) 493-497.
3.Circulation Arrhythmia and Electrophysiology – Journal of the
American Heart Association 2012;5;587-593; Circ Arrhythm
Electrophysiol DOI: 10.1161/CIRCEP.111.964676.
4.Gold, S-ICD® System Rhythm Detection Technology featuring
the INSIGHT™ Algorithm from Cameron Health – White Paper Gold CAM-9263 SICD.
5.Crozier, Cameron Health S-ICD® System: Addressing the Shortcomings of Transvenous ICDs – White Paper – CrozierCAM-9410.
Technology Update: Subcutaneous Implantable Defibrillator (S-ICD)
due to infection or lead failure. The S-ICD does have
limitations in that it cannot provide long term brady
pacing or ATP. Therefore, the S-ICD is not indicated
for patients with symptomatic bradycardia, incessant
ventricular tachycardia, orspontaneous, frequently
recurring ventricular tachycardia that is reliably terminated with anti-tachycardia pacing.1
First joint and the largest arrhythmia meeting in the Asia-Pacific region
3-6 October 2013, Hong Kong
It is our
great pleasure
to announce
that the 6th APHRS & CardioRhythm will be held on 3 - 6 October 2013
Hong Kong
Convention
and Exhibition
Centre
at the Hong Kong Convention & Exhibition Centre.
First joint and the largest arrhythmia meeting in the Asia-Pacific region
This is the first joint and the largest arrhythmia meeting in the Asia Pacific region organised by Asia Pacific
It is our great
to announce
the 6th APHRS
& CardioRhythm
will be held
3 - 6 October
2013 atof Pacing and
Heartpleasure
Rhythm
Society that
(APHRS),
HK College
of Cardiology
andon Chinese
Society
the Hong Kong Convention & Exhibition Centre.
Electrophysiology. The meeting will present current and future management on sudden cardiac death, new
This is thedrug
first joint
the largest
arrhythmia
in the Asia-Pacific
region
by Asia Pacific
Heart
and and
ablation
treatment
for meeting
atrial fibrillation,
pacing
andorganised
ICD advances,
cardiac
resynchronization
Rhythm Society (APHRS), HK College of Cardiology (HKCC) and Chinese Society of Pacing and Electrophysiology
techniques, remote patient monitoring, and advances in neuromodulation for heart failure and
(CSPE). The meeting will present current and future management on sudden cardiac death, new drug and ablahypertension.
well received
certificate
Cardiac
Rhythm
Managementtechniques,
Course will
continue, and new
tion treatment
for atrial The
fibrillation,
pacing and
ICD advances,
cardiac
resynchronization
remote
patient monitoring,
advances
in neuromodulation
for experts
heart failure
and hypertension.
well received
courses onand
EPS/ECG
added.
A group of world
will share
with us theirThe
experiences
and insights, and
certificatethe
Cardiac
Rhythm
Management
Course
will
continue,
and
new
courses
on
EPS/ECG
added.
A
group
of
symposium will be a meeting point for both discussion and academic participation.
world experts will share with us their experiences and insights, and the symposium will be a meeting point for
both discussion and academic participation.
We are honour to have an extensive list of renowned experts to join our Scientific advisory board to
We are honour
to have
an extensive
list of programme.
renowned experts
to join
our out
scientific
advisory board
to organise
an
organise
an exciting
scientific
Please
check
our conference
website
for updates.
To be on
exciting scientific
programme.
Please
check
out
our
conference
website
for
updates.
To
be
on
top
of
the
firsttop of the first-hand information, download our mobile apps now!
hand information, download our mobile apps now!
www.aphrs-cardiorhythm2013.hk
We are now calling for abstracts. Don’t miss the chance to publish your abstracts in the Journal of
Call for
abstracts :
Arrhythmia!
We are now calling for abstracts. Don’t miss the chance to publish your abstracts in the supplement of
the Journal
of Arrhythmia!
Highlights
of Program :
Abstract- CRM
Submission
Deadline
: 26 May 2013 Course Practice
Workshop
Notification
of
Abstract
Acceptance
- Atrial Fibrillation (Ablation) : 30 June 2013
- Atrial Fibrillation (Drug &Device)
Highlights
of Program :
- Ablation
- Ablation- -Bradycardia
VT / SVT
Pacing
- Arrhythmias in Paediatric and Adult Congenital Heart Disease
- Basic Research
- Atrial Fibrillation (Ablation)
- Genetic(Drug
and Inherited
- Atrial Fibrillation
&Device) Syndrome
- Bard / EP
Tracing
- Heart Failure & Remote Patient Monitoring
- Basic Research
- Neuromodulation
- Bradycardia Pacing
- Arrhythmias
in Pediatric and Adult Congenital Heart Disease
- CRM Course
Practice Workshop
Sudden
Cardiac
Death
- Genetic -and
Inherited
Syndrome
- Heart Failure
&
Remote
Patient
Monitoring
- Surgical Therapy - Device
and Ablation
- Joint session with EHRA/HRS/ ISHNE/ WSA
- Syncope
- Live Transmission
Tachycardia
- Sudden -Cardiac
Death Therapy Device
- Surgical Therapy - Device and Ablation
- Syncope
- Tachycardia Therapy Device
- Workshops (AF Ablation, VT, CRT, ICD, Lead Extraction, SVT, Pacing, ECG)
Important Dates:
15 July 2013
15 September 2013
2 October 2013
3-6 October 2013
Early Bird Registration Deadline
Pre-Registration Cut off
Pre-conference Workshops
Main Conference & CRM Course
Organizing Committee:
Honorary Presidents
Co-Chairmen
Masayasu Hiraoka (Japan) Chris KY Wong (Hong Kong)
Chu-Pak Lau (Hong Kong)
Shih-Ann Chen (Taiwan)
Secretary General
Organization Committee Chairs
Hung-Fat Tse (Hong Kong)
Young-Hoon Kim (Korea)
Shu Zhang (China)
S cientific Committee
hairs
C
Sponsorship Committee
Chairs
Publicity & Hospitality Committee
Chairs
ung-Fat Tse (Hong Kong)
H
Jonathan Kalman (Australia)
Wee Siong Teo (Singapore) Kam-Tim Chan (Hong Kong)
Ngai-Yin Chan (Hong Kong)
Mohan Nair (India)
Abstract & Program Committee CRM Course & AP Committee Co-Director for Live Case
hiars
C
Chairs
Demonstration
Imran Zainal Abidin (Malaysia) David CW Siu (Hong Kong)
Kathy LF Lee (Hong Kong) Christine Chiu-Man (Canada)
Yoshinori Kobayashi (Japan)
Cathy TF Lam (Hong Kong)
6th APHRS & CardioRhythm 2013 – Conference Secretariat
MCI Hong Kong, Suites 2807-09, Two Chinachem Exchange Square, 338 King’s Road, North Point, Hong Kong
Tel: (852) 2911 7923 / 2911 7902 Fax: (852) 2838 7114 / 2893 0804
Email: [email protected]
Website: www.aphrs-cardiorhythm2013.hk
Co-organized by:
Asia Pacific Heart Rhythm
Society
Hong Kong College of Cardiology
Chinese Society of
Pacing and Electrophysiology
World Society
of Arrhythmia
EHRA & ESC
Endorsed by:
Heart Rhythm Society
Supported by:
Asia Pacific
Heart Association
Asia Pacific
Society of Cardiology
ISHNE
Japan Heart
Rhythm Society
Korea Society
of Cardiac Arrhythmia
Israel Heart
Society
MEHK
EP World: Electrophysiology in New Zealand
EP World:
Electrophysiology in New Zealand
New Zealand is situated in the South Pacific Ocean, 1,500 kilometres east of Australia and 1,000 kilometres south of the Pacific Islands. The estimated population is 4.4 million people spread across a land mass of
268,000km2. 68% of the population derives from European ancestry, 15% are Maori (indigenous people of New
Zealand) and there is an increasingly significant proportion of people whose ancestry is from Asia (9%) and
the South Pacific. New Zealand has a very close relationship with Australia in many spheres and this includes
the cardiology community. Heart Rhythm New Zealand is affiliated to the New Zealand branch of the Cardiac
Society of Australia and New Zealand. The Cardiac Society is the professional body of cardiologists, cardiac surgeons and affiliated health providers within Australasia and there are strong links between electrophysiologists
in New Zealand and those in Australia, most importantly at the Cardiac Society Annual Scientific Meeting which
is hosted in turn by each of the Australian States and New Zealand.
Full electrophysiology services are provided in four hospitals in New Zealand; Auckland City Hospital,
Waikato Hospital, Wellington Hospital and Christchurch Hospital. Additionally, there are several smaller centres
that implant pacemakers and other cardiac devices, as well as three private hospitals providing elective EP services. The vast majority of health care in New Zealand is provided by the public sector which is funded by general taxation.
Waikato Hospital, Hamilton, New Zealand
Waikato Hospital is a 600 bed regional base hospital
first established in 1886 and it performs a large proportion
of the work provided by the Waikato District Health Board.
Waikato DHB provides hospital and community-based health
services to a population of 365,000. Furthermore, Waikato
Hospital is a tertiary referral centre to the whole of the Midland region; a population of 850,000. This region stretches
from the middle of the North Island of New Zealand northward as far as Auckland. (See map inset).
Waikato Hospital Electrophysiology
The electrophysiology department at Waikato Hospital
sits within the Department of Cardiology. This has 13 Cardiologists and provides a full range of services to the Midland
health region including ambulatory clinics, echocardiography, angioplasty (including primary angioplasty for MI 24
hours a day), interventions for structural heart disease and
EP services. Their are two full-time electrophysiologists –
Dr Martin Stiles and Dr Spencer Heald, and they are joined
one day a week by Dr Dean Boddington from Tauranga Hospital (1½ hours drive away) to provide all electrophysiology services to the region. The electrophysiology community within New Zealand is small, comprising
just 12 electrophysiologists across the country. Dr Stiles is currently Chair of Heart Rhythm New Zealand and
represents New Zealand on the board of the Asia Pacific Heart Rhythm Society. Each of the four major EP centres also has a Fellow in training. Many of the Electrophysiologists have gained additional experience overseas,
mainly in the United Kingdom, United States or Australia.
Electrophysiology Procedures
Waikato and Tauranga Hospital together implant 370 pacemakers per year, plus 100 ICDs per year and 30
CRT devices (mainly CRT-D). In 2012, 230 invasive electrophysiology procedures were performed including 63
Research Interests
Waikato Hospital has been involved in a number of multicentre trials in electrophysiology, most recently
as lead centre in New Zealand for the
PALLAS Trial. Currently underway are
trials looking at ablation techniques
for atrial fibrillation (MiniMax Trial)
in collaboration with other centres
in Australia and the U.K, and Device
registry trials looking at ICD programDr. Martin Stiles at his hospital
ming. Recently published are the
New Zealand ICD programming guidelines which aim to reduce the number of inappropriate shocks for ICD patients without compromising safety. New Zealand has been one of the world-leading countries in the development and subsequent testing of the subcutaneous ICD. This is now being implanted for clinical indications (i.e.
outside of the research setting) since July 2011.
Summary
EP World: Electrophysiology in New Zealand
with 3D mapping (using both Carto and NavX systems). These procedures are spread across electrophysiology
studies for supraventricular tachycardia, atrial flutter, atrial fibrillation and ventricular tachycardia. Waikato
Hospital has an established AF ablation programme and is recently performing ablation for ischaemic ventricular tachycardia, in the main for cardiomyopathy patients with recurrent ICD shocks. Epicardial access for VT
ablation has been performed in a handful of cases. Ablation of atrial fibrillation to date has been point-by-point
radiofrequency ablation with the guidance of 3D mapping systems. Recently, cryoablation of pulmonary veins
has been added with the expectation that this may increase the number of operators able to perform AF ablation and thereby increasing throughput with equivalent success rates.
New Zealand is one of the more remote countries of the Asia Pacific region, if not the world. Its population base is small and some of its population is relatively remote (density of population 17 people per square
kilometre nationwide). New Zealand enjoys a comprehensive public health system (supplemented by a small
amount of private healthcare) and this includes four specialised electrophysiology units in the main population
centres. Rates of intervention for electrophysiology conditions and implant rates of cardiac devices are lower
than other countries in the developed world but there is an increasing provision of these services within the
usual constraints of expertise and funding. The small but busy EP community in New Zealand hope to contribute internationally to this expanding field, through their role in the Asia-Pacific Heart Rhythm Society.
An aerial view of Waikato Hospital
All 3 images are copyright Waikato Hospital Visual Communications
EP World: Cardiac Electrophysiology in Thailand
EP World:
Cardiac Electrophysiology in Thailand
Tachapong Ngarmukos, M.D., F.A.C.C.
The use of cardiac electrophysiology in Thailand began almost 20 years ago1, with the first case of electrophysiologic study and catheter ablation performed at the chest disease institute by Dr. Thada Chakorn, the
founding father of our Thai cardiac electrophysiology club.
Dr. Chakorn served as the first president of the club, and with the cooperation of fellow members helped
to advance the progress of the EP field in Thailand. Dr. Koonlawee Nadeemanee frequently visited from the
United States, providing assistance with difficult EP cases at various centers. With the collaboration of many local cardiologists and electrophysiologists, Dr. Nadeemanee also initiated a multi-center randomized controlled
trial, the DEBUT study, an implantable cardioverter defibrillator ICD in sudden unexplained death syndrome2,
and other projects involving multi-center cooperation.
Current state of cardiac electrophysiology in Thailand
Device implantation
The number of device implantations taking place
in Thailand has increased gradually, with a jump in the
number of ICD implantation in 2005 (Fig. 1). This was
due to the fact that government employees were allowed to be reimbursed for the cost of an implantable
cardioverter defibrillator (ICD). The EP club, through
the work of our then-president, Dr. Surapan Sithisook,
pushed for the reimbursement of these devices for government employees. This reimbursement scheme was
later adopted for universal coverage as well. Although
the devices are reimbursable, non-private hospitals are
still facing troubling issues of monetary under collection. Some of the high cost implants were actually performed for medical tourists.
Fig. 1. The number of ICD implantations increased markedly in 2005 due to the
ICD being reimbursable for use by government employees
Annual estimation of numbers of new device implantations in Thailand:
(unpublished data from the EP club)
Pacemaker: 1200 per year
ICD: 200 per year
CRT: 40 per year
Fig. 2. Numbers of EP cases at Ramathibodi Hospital, Mahidol University
10
Fig. 3. Number of device cases at Ramathibodi Hospital, Mahidol University
Electrophysiologic study and catheter ablation
Nationwide, we are currently performing more than 1000 cases of catheter ablation annually. Most cases
use the conventional system, but many centers have a 3D mapping system available. All forms of SVT and idiopathic PVC/VT are prevalent3.
EP centers in Thailand
At present, most EP centers are located in the Bangkok metropolitan region, in six medical schools, two
public and eight private hospitals. Four medical schools in major cities, Chiang Mai, Pitsanulok, Khon Khaen and
Songkhla, also provide comprehensive EP services. Other hospitals with cardiac catheterization laboratories or
operating rooms also provide additional device implantation service. One center in Chiang Mai has a comprehensive basic electrophysiology research facility.
EP education and training in Thailand
The Thai EP club holds an annual educational conference once a year for physicians and allied professionals. In addition, there are three to four conjoined lecture sessions in partnership with the Thai heart association, to update our cardiologist and internist colleagues.
Three medical schools in Bangkok, King Chulaongkorn memorial hospital, Siriraj and Ramathibodi hospital
provide an informal 1-2 years clinical cardiac electrophysiologist fellowship training.
The future of EP in Thailand
With more electrophysiologists being trained, a higher percentage of our population can be served by our
younger colleagues, providing more accessible care for our patients especially outside of Bangkok. This would
also promote more opportunities for research. The EP club is currently planning on a nation-wide ablation and
device registry, to collect data to provide new insights into our practice, and hopefully improve the care of our
patients and the quality of our research.
References
EP World: Cardiac Electrophysiology in Thailand
In addition to implantation, chronic lead extractions were performed approximately 10 times annually,
mostly using laser extraction at two centers in Bangkok.
1.EP practice in Thailand. Pumpreug S, Jongnarangsin K, Ngarmukos T. Heart Rhythm. 5(4):629, 2008 Apr.
2.Defibrillator versus β- blockers for unexplained death in Thailand (DEBUT). Nademanee K. Veerakul G. Mower M. Likittanasombat K. Krittayapong R. Bhuripanyo K. Sitthisook S. Chaothawee L. Lai MY. Azen SP. Circulation 107:2221–2226, 2003.
3.Feasibility, efficacy, and safety of radiofrequency catheter ablation for cardiac arrhythmias: a twelve-year experience in Thailand. Apiyasawat S. Prasertwitayakij N. Ngarmukos T. Chandanamattha P. Likittanasombat K. Journal of the Medical Association of Thailand.
93(3):272-7, 2010 Mar.
Fig. 4. Atmosphere of EP fellowship training at Ramathibodi. From left Dr. Sirin Apiyasawat, Dr. Pakorn Chandanamttha and Tech. Nicha during an ablation case
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