From Pills to wires

SMEL meeting April 2009Joseph Macari

From Pills to wires…

Road Map

A bit of history of Electrophysiology Different disease needs different therapy Heart Failure the problem and the solution Future

Road Map

A bit of history of Electrophysiology Different disease needs different therapy Heart Failure the problem and the solution Future

Hippocrates (460 – 375 BC)

“Those who suffer from frequent and strong faints without any manifest cause die suddenly.”

Willem Einthoven 1860 - 1927

Electrodes were salt water

Father of Electrocardiography

Einthoven’s Electrocardiograph Machine

An entire lab was dedicated to the ECG (EKG)

Hand-operated “Pacemaker” by Albert Hyman

Hyman AS, Resuscitation of the stopped heart by intracardiac therapy, Arch Int Med 1932; 50: 283-305

Hyman’s Artificial Pacemaker and needles

Hymanotor mfg by Adlanco, a U.S. division of Siemens

1958 to 2008 - Side-by Side comparison

1958 to 2008 - Implant

1958 Open thoracotomy General anesthesia 3 to 4 hours

Weeks in hospital 38 cc, 83 grams

24 cm2, 16 mm thick

2 transistors

Longevity < 1 yr Modes of operation: 1 (preset)

Rates: 1 (preset)

Rate Response: None

Parameter combinations: 1

2008 Leads inserted through vein Local anesthesia / sedation One to two hours Same day discharge 12 cc, 29 grams 19 cm2, 6.0 mm thick 20,000,000+ transistors Up to 20 years, at least 5 yr Modes of operation: Over 20 Rates: 30 to 180 pulses/min Rate Response: Tailored to

patient Parameter combinations:

Trillions

Road Map

A bit of history of Electrophysiology Different disease needs different therapy Heart Failure the problem and the solution Future

Bradycardia and Pace Maker

T / I

*

*Atrial lead

Ventricular Lead

• Pacing in both the atriumand ventricle

• Sensing in both the atrium and ventricle

• Intrinsic P wave and intrinsic QRS can inhibit pacing

• Intrinsic P Wave can “trigger” a paced QRS

I

Ventricular Tachycardia and defibrillator

        

Ventricular fibrillation

Sinus rhythm

…Degenerate to a lethal rhythm...

unless a shock is delivered to restore sinus rhythm

Heart Failure and cardiac resynchronization therapy

Pulse Generator

BatteryBattery

Pacing/Shocking Pacing/Shocking CircuitCircuit

Sensing CircuitSensing Circuit

Components of an Implantable System Heart

◦Disease state - signal quality◦Therapy requirements

Lead◦Receives signals from the heart◦Carry therapy to heart

Implantable Device (Pace Maker, ICD, CRT)◦Processes signals from lead◦Generates & delivers therapy to the Heart

through the Lead

Who’s at risk?

1.Extremely Common2.Extremely Deadly3.Extremely Expensive4. Solution?

Heart Failure

Testicular Cancer

Mild Heart Failure

Which would you prefer ?

0

20

40

60

80

100

5 year Survival0

20

40

60

80

100

5 year Survival

93%

60%

Testicular Cancer Heart Failure

Survival rate

15 Million People world wide suffer from HF

Which kills the most people ?1. Breast Cancer 2. Car Accidents 3. Lung Cancer4. Heart Failure

0 100000 200000 300000 400000 500000 600000 700000 800000

heart failure

sudden cardiac death

All cancers combined

lung cancer

breast cancer

prostate cancer

bowel cancer

myocardial infarction

HIV

Car Accidents

Murdoch RD et al. Importance of heart failure as a cause of death. Eur H J 1998;19

Which kills the most people ?

Cigarettes HF bed time Alcohol

$28 billion $9 billion $1 billion

Malek M, Heart 1999; 82 (suppl. IV):IV11 - IV13

Which costs society the most ?

Pump Failure Sudden Cardiac Death

How does Heart Failure Kill you?

Symptoms Of Heart Failure Dyspnea Reduced exercise capacity Fatigue / weakness Nocturia Confusion Pulmonary Oedema

◦ Shortness of breath◦ Congestion◦ Global fatigue◦ Ankle oedema

None

Jessup M, Brozena S. Medical Progress-Heart Failure. N Eng J Med 2003; 348: 2007-2018. Copyright 2002 Massachusetts Medical Society. All rights reserved.

The treatment of heart failureThe treatment of heart failure

The Vicious Cycle of Heart Failure Management

Chronic HF

MD’s Office

Emergency Room

Hospitalization

SOB

Weight

PO LasixIV Lasix or Admit

Diuresis & Home

Therapy

• All measures under stages A,B, and C

• Mechanical assist devices

• Heart transplantation

• Continuous (not intermittent) IV inotropic infusions for palliation

• Hospice care

Treatment Approach for the Patient with HF

Stage A

At high risk, no structural disease

Stage B

Structural heart disease,

asymptomatic

Stage D

Refractory HF requiring

specialized interventions

Therapy

• Treat Hypertension

• Treat lipid disorders

• Encourage regular exercise

• Discourage alcohol intake

• ACE inhibition

Therapy

• All measures under stage A

• ACE inhibitors in appropriate patients

• Beta-blockers in appropriate patients

Therapy

• All measures under stage A

Drugs:

• Diuretics

• ACE inhibitors

• Beta-blockers

• Digitalis

• Dietary salt restriction

Stage C

Structural heart disease with prior/current

symptoms of HF

Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001

Heart Failure and the Donkey Analogy

General Measures

Weight reduction

Discontinue smoking

Avoid alcohol and other cardiotoxic substances

Exercise

Treat HTN, hyperlipidemia, diabetes, arrhythmias

Coronary revascularization

Anticoagulation

Immunization

Sodium restriction

Daily weights

Close outpatient monitoring

Lifestyle ModificationsLifestyle Modifications Medical ConsiderationsMedical Considerations

Pharmacologic Management

Used to relieve fluid retention Improve exercise tolerance Facilitate the use of other drugs indicated for heart failure Patients can be taught to adjust their diuretic dose based on

changes in body weight Electrolyte depletion a frequent complication Should never be used alone to treat heart failure Higher doses of diuretics are associated with increased mortality

DiureticsDiuretics

Diuretics, ACE Inhibitors

Reduce the number of sacks on the wagon

Pharmacologic Management

Cardioprotective effects due to blockade of excessive SNS stimulation

In the short-term, beta blocker decreases myocardial contractility; increase in EF after 1-3 months of use

Long-term, placebo-controlled trials have shown symptomatic improvement in patients treated with certain beta-blockers1

When combined with conventional HF therapy, beta-blockers reduce the combined risk of morbidity and mortality, or disease progression1

1Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001 p. 20.

Beta-BlockersBeta-Blockers

ß-Blockers

Limit the donkey’s speed, thus saving energy

Pharmacologic Management

Enhances inotropy of cardiac muscle

Reduces activation of SNS and RAAS

Controlled trials have shown long-term digoxin therapy:◦ Reduces symptoms◦ Increases exercise tolerance◦ Improves hemodynamics◦ Decreases risk of HF progression◦ Reduces hospitalization rates for decompensated HF◦ Does not improve survival

DigoxinDigoxin

Digitalis Compounds

Like the carrot placed in front of the donkey

Device Therapy save and enhance lives

Cardiac Resynchronization Therapy

Increase the donkey’s (heart) efficiency

Merlin.net Patient Care Network (PCN)

Remote Patient Management

Today Without Remote Care

Patient Waiting Room

Required Programming Changes

1

Merlin.net Server

Housecall 3180-T Transmitter

PhysicianPatient

Patient makes appt. & calls on analog phone line

HC+ 3180-R Receiver

Any PC

Merlin@home RF Transmitter

w/InvisiLink

2

Physician

EMR

Office Visit for reprogramming

PhysicianAny PC

CLINIC

ANYWHERE

+ internet access

Merlin@home EMEAC (Q3 2008)

1

Merlin.net Server

Housecall 3180-T Transmitter

PhysicianPatient

Patient makes appt. & calls on analog phone line

HC+ 3180-R Receiver

Any PC

Physician

+ internet access

Merlin@home RF Transmitter

w/InvisiLink

2

Physician

EMR

Any PC

Office Visit for reprogramming

InvisiLink reprogramming

CLINIC

ANYWHERE

Merlin@home EMEAC (Q2 2009)

Virtual Patient Waiting Room

Tomorrow with Remote Care Model

The stethoscope analogy

Which is the most important part?

Thank you