1. From Pills to wires SMEL meeting April 2009 Joseph Macari

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

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

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

7. Electrodes were salt water Father of Electrocardiography

8. An entire lab was dedicated to the ECG (EKG)

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

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

12. 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

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

14. T / I * * Atrial lead Ventricular Lead Pacing in both the atrium and 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

15. Ventricular fibrillation Sinus rhythm …Degenerate to a lethal rhythm... unless a shock is delivered to restore sinus rhythm

17. Battery Pacing/ShockingCircuit Sensing Circuit

18.  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

20. 1. Extremely Common 2. Extremely Deadly 3. Extremely Expensive 4. Solution?

21. Testicular Cancer Mild Heart Failure

22. 93% 60% Testicular Cancer Heart Failure 15 Million People world wide suffer from HF

23. 1. Breast Cancer 2. Car Accidents 3. Lung Cancer 4. Heart Failure

24. 0100000200000300000400000500000600000700000800000 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

25. CigarettesHF bed timeAlcohol $28 billion $9 billion $1 billion Malek M, Heart 1999; 82 (suppl. IV):IV11 - IV13

26.  Pump Failure  Sudden Cardiac Death

27.  Dyspnea  Reduced exercise capacity  Fatigue / weakness  Nocturia  Confusion  Pulmonary Oedema ◦ Shortness of breath ◦ Congestion ◦ Global fatigue ◦ Ankle oedema  None

28. 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 failure

29. Chronic HF MD’s Office Emergency Room Hospitalization SOB  Weight PO Lasix IV Lasix or Admit Diuresis & Home

30. Therapy All measures under stages A,B, and C Mechanical assist devices Heart transplantation Continuous (not intermittent) IV inotropic infusions for palliation Hospice care 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

32.  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 Modifications Medical Considerations

33.  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 Diuretics

34. Reduce the number of sacks on the wagon

35.  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-blockers 1  When combined with conventional HF therapy, beta-blockers reduce the combined risk of morbidity and mortality, or disease progression 1 1 Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001 p. 20. Beta-Blockers

36. Limit the donkey’s speed, thus saving energy

37.  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 Digoxin

38. Like the carrot placed in front of the donkey

40. Increase the donkey’s (heart) efficiency

41. Merlin.net Patient Care Network (PCN) Remote Patient Management

42. Patient Waiting Room Required Programming Changes

43. 1 Merlin.net Server Housecall 3180-T Transmitter Physician Patient 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 Physician Any PC CLINIC ANYWHERE + internet access

44. 1 Merlin.net Server Housecall 3180-T Transmitter Physician Patient 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

45. Virtual Patient Waiting Room

46. Which is the most important part?