The Electric Heart: When to call your friendly neighbourhood electrician?Jeff S. HealeyCardiology Division Director, Hamilton Health SciencesSenior scientist and Connolly Chair for Cardiology Research, PHRIProfessor and Yusuf Chair in Cardiology, McMaster University

The Electric Heart: When to call your friendly neighbourhood electrician?Jeff S. HealeyCardiology Division Director, Hamilton Health SciencesSenior scientist and Connolly Chair for Cardiology Research, PHRIProfessor and Yusuf Chair in Cardiology, McMaster University Conflict of Interest Disclosures•Grants/research support: Boston Scientific, Medtronic, Abbott, Servier, Novartis, Bayer, BMS/Pfizer, ARCA Biopharm•Consulting fees: Boston Scientific, Medtronic•Speaker fees: Boston Scientific, Medtronic, Servier, Bayer, BMS/Pfizer, Cipher•Other: •I willdiscussoff-label uses for _____N/A______ Controversies in electrical therapy for heart failure…made simple!•1. ICD implantation in patients with non-ischemic cardiomyopathy•2. CRT: who and how?•3. Tachycardia-induced myopathy•4. Management of atrial fibrillation: drugs, pacing and ablation•5. Ambulatory monitoring and physiologic sensors 76% idiopathic, 11% HTN4% valvular, 9% other Gene-specific prognosisUnrecognized Fabry’sdisease with HCMUnrecognized AmyloidUnrecognized muscular or myotonic dystrophyUnrecognized sarcoidosis Phospholamban(PLN) ARVC Laminin A/C 1.RBBB if QRS > 160 msec2. Permanent AF uncertain-RAFT-Perm AF trial-role of AVJ ablation3.Use of direct LBB pacing4. Endocardial LV pacing5. Role of optimizationSon-R algorithm Frequency of arrhythmiaRate of arrhythmiaDuration of arrhythmiaCharacteristics (e.g. interpolation)NICM; chicken or egg? Tachycardia-Induced Cardiomyopathy Atrial Fibrillation and Heart Failure •Worsen prognosis of the other condition•Burden of AF correlates with outcomes•Possible reduced benefit of HF therapies among AF patients•Pharmacotherapy•Rhythm control no better than rate control•Moderate rate control (<110/min) appears sufficient•Catheter ablation•CASTLE-AF results encouraging/provocative•RAFT-AF results this summer w SCAF Progression Predicts HF Decompensation OutcomeSubclinical Atrial Tachyarrhythmia ProgressionUnadjusted Risk*Multivariable Adjusted Risk* Present Absent Events/ patients %/yearEvents/ patients %/yearHR95%-CIp-valueHR95%-CIp-value HF hospitalization 7/608.918/3552.54.101.65 –10.20.0024.581.64 –12.80.004Any stroke0/6508/3501.10.00––0.00--Vascular death4/654.517/3502.31.990.66 –6.020.231.710.53 –5.580.37MI1/651.13/3500.42.400.21 –27.10.481.940.15 –25.10.61Stroke/MI/Vascular death5/655.724/3503.31.550.58 –4.150.381.510.53 –4.350.44Wong JA, et al. JACC 2018 –In Press Study Design—CASTLEAF Eligibility Assessment3013pts Enrolled/ Randomized 397pts Runin 5weeks Ablation21 ptsexcluded 179pts 200pts 197pts 153 pts (26crossovers) Followup: 3, 6, 12, 24, 36, 48, 60months ICD/CRTD checkAdverse event documentation Echocardiography6minute walk testOptimization of medication for HFHome Monitoring programming NYHA, weight, BP, QoL Patients’ diary13 pts excludedConventional165 pts (18 crossovers)184 pts •Investigator initiated, Prospective, Multicenter ( 31 sites, 9 countries), Randomized, Controlled ResultsCASTLEAFAll-CauseMortality 0 Patients at RiskAblation179154130947127Conventional184168138976319 10.80.60.40.2HR, 0.53(95% CI,0.32-0.86);P=0.011 Ablation Conventional SurvivalProbability RiskReduction47% 12©2018 Boston Scientific Corporation or its affiliates. All rights reserved. CRM-488804-AG JAN2018 Boehmer, J et al., JACC-HF, 2017;5(3),2 1 6 –2 5 Heart SoundsS1 & S3ImpedanceThoracicRespirationRate & VolumeActivityTime Spent ActiveHeart RateNight multiple sensor measurements combined into a single, simple index with alert HeartLogic™incorporates multiple sensors with a single composite alertAvailable on LATITUDE™NXTfor patients with Resonate™family of ICDs & CRT-Ds HeartLogic™shifts heart failure patient management from reactive treatment to proactive care, and was validated in the MultiSENSE Study to have: •High sensitivity of 70% for detecting heart failure events•Weeks of advance noticeof a potential heart failure event•Low burden of less than 2 alerts per patient per year ICD-Base Physiologic Sensors: Heart Logic MULTISENSE Trial: JP Boehmer JACC - HF 2018 Controversies in electrical therapy for heart failure…made simple!•1. ICD implantation in patients with non-ischemic cardiomyopathy•2. CRT: who and how?•3. Tachycardia-induced myopathy•4. Management of atrial fibrillation: drugs, pacing and ablation•5. Ambulatory monitoring and physiologic sensors