40 Years of Electrophysiology: The Wonder Years

Raymond Kawasaki, MD FACC December 3, 2016

Disclosures

• Speaker for Janssen Pharmaceuticals/J&J • Speaker for Zoll • Consultant for St. Jude Medical

1976: Do you remember gauze shirts?

1976: 40 Years Ago… • U2: first called Feedback, then The Hype • Apple Computer founded by Jobs and Wozniak • The Muppet Show • Rocky, the movie • The last American Slide Rule was made • Family Feud debuted • Hair Club for Men • Ramones’ first album, Ramones • Cray-1 the first supercomputer; weighed 11,500 lbs., cost

$8.8 million, cooled by liquid Freon • Taxi Driver, the movie • What was the #1 song of 1976?

“Silly Love Songs” Wings

Billboard Magazine #1 song of 1976

EP over the Last 40 Years

Electrophysiology

1970’s • Human EP started in the mid-1970’s

– Relatively new discipline of cardiology – Animal studies with extrapolation to human EP – Understanding of cardiac conduction and

electrophysiologic behavior of cardiac tissues • First His bundle recording in 1969

– Enhanced development of antiarrhythmic medications and drug treatment for arrhythmias

– Dr. Hein JJ Wellens, University of Maastricht, Netherlands develops modern invasive EP

1980’s • Further development of invasive EP

– Better understanding of arrhythmia mechanisms – Programmed stimulation – Multiple catheters – Mapping of arrhythmias

• Mapping in the OR for arrhythmia surgery • Catheter ablation techniques

– Dr. Mel Scheinman performs first U.S. DC catheter ablation for SVT; ablation of the AV node.

• Barotrauma! – Development of RF ablation

Late 1980’s-early 1990’s • RF ablation

– Started with neurosurgical generators – RF ablation of arrhythmias and catheters

• Not FDA approved at first – Discreet, controllable lesions

• Resistive heating similar to electrocautery

• Eliminated a subspecialty of cardiac surgery • Cure of arrhythmias; generates excitement

akin to Dr. Gruentzig’s development of coronary angioplasty

RF Ablation Generators

1980’s

1990’s

2000’s

Now

Ablation Now • Instruments have advanced to help facilitate

ablation procedures – Advanced recording and 3-D mapping systems – Intracardiac ultrasound – Ability to do cases without fluoroscopy! – Radiofrequency, cryothermal energy sources

• New endocardial, epicardial and hybrid (combination surgical and endocardial) techniques

Fluoroless Ablation of an Accessory Pathway on the Lateral Mitral Annulus

Ablating Atrial Fibrillation (AF)

• Started in Bordeaux, France, late 1990’s – Drs. Haisseguire and Jais, et al – Previously an untouchable entity – One of the most complex arrhythmias to ablate – One of the final frontiers of ablation

• Enhances our understanding of AF • Can’t cure AF, but we can make it better

– Nearing 20 years from the first reports

• Has transformed our practices

Pulmonary Vein Isolation Procedure for Atrial Fibrillation

Cardiac Implantable Electronic Devices (CIEDs) Pacemakers and Defibrillators (ICDs)

Dr. Albert Hyman, 1932

Medtronic Founder, Earl Bakken, 1958

1950’s

CIEDs

• Technology rolls on… – Improvements

• Battery technology • Chips, processors • Rhythm recognition algorithms and physiologic

responses • Size • Leadless systems • Totally subcutaneous systems

Plutonium powered, 1970’s

Leadless pacemaker

Dual chamber, 1980’s; Lasted two years!

1990’s; rate responsive

ICDs

• Multiple landmark trials expanding the role of ICDs – MUSTT – MADIT series – SCD-HeFT – AVID – CABG-Patch, etc…

• Change in Guidelines for implantation – Secondary prevention role gives way to primary prevention – Limited role of the EP study in prognosticating risk – ICD implantation becomes much less invasive

Abdominal implant, epicardial patches

Abdominal implant, transvenous lead

Subcutaneous ICD (SICD)

LifeVest

Biventricular ICD

Pharmacology

Pharmacology

• CAPS and CAST Trials (1980’s-early 1990’s) – PVC suppression in ischemic CMP

• Suppressed PVC’s, but higher mortality in doing so • Encainide, moricizine taken off market

– Concept of proarrhythmia • Has influenced how all antiarrhythmics are developed

and used

Antiarrhythmics: 1970’s-present • Class Ib

– Mexiletine • Class Ic

– Flecainide – Propafenone

• Class III – Oral and IV amiodarone – Sotalol – Dronedarone – Ibutilide – Dofetilide

• Class V – Adenosine

Genetics

Human Genome Project

• Launched in 1990, completed 2003 • Gene sequencing to elaborate genetic basis

for inherited arrhythmias – Inherited long QT syndrome – Brugada syndrome – CPVT – ARVC – And others…

Conclusions

• Just a brief take on some of the advances in EP over the last 40 years

• Much more to come • We will likely look back at what we thought

was state-of-the-art practice and think how backwards and barbaric it was…

“Everything is theoretically impossible, until it is done.”

Robert Anson Heinlein Science Writer

Thank You