1. Update in Cardiology: 2012 James A. Coman MD, FACC President and Founder, Heart Rhythm Institute of Oklahoma Tulsa, Oklahoma

2. Disclosures

3. Ischemic Heart Disease Ranolazine (Ranexa) – indicated for reduction of angina Dose 500 mg BID and increase to 1000 mg BID Avoid concomitant CYP3 inhibitors Fish Oil nonhelpful

4. Ischemic Heart Disease Post Cardiac Arrest Cooling Lowers mortality and improves neurologic outcomes 32º C for 24 hours Watch for infection and coagulopathy Can’t be used in patients with head trauma, CVA, or preexisting coagulopathy

5. Acute MI Drug Eluting Stents account for 75% of all stents lower restenosis rates require one year of ASA, and plavix, prasugrel, or ticagrelor IABP placement found non helpful in AMI shock

6. Valvular Heart Disease

7. Prevalence of valve disease in the population The Next Cardiac Epidemic Nikomo et al, Lancet 2006; 368: 1005 Prevelance of moderate or severe valve disease (%)

8. Severe Aortic Stenosis Without Surgery: Worse Than Most Metastatic Cancers 5-Year Survival Survival, % * National Institutes of Health. National Cancer Institute. Surveillance Epidemiology and End Results. Cancer Stat Fact Sheets. http://seer.cancer.gov/statfacts/. Accessed November 16, 2010. † Using constant hazard ratio. Data on file, Edwards Lifesciences LLC. †

9. Transcatheter Aortic Valve Implantation (TAVI) Smith CR et al. N Engl J Med 2011;364:2187-2198.

10. All Cause Mortality (ITT) Landmark Analysis All Cause Mortality (%) Months Mortality 0-1 yr Mortality 1-2yr Standard Rx TAVR HR [95% CI] = 0.57 [0.44, 0.75] p (log rank) < 0.0001 HR [95% CI] = 0.58 [0.37, 0.92] p (log rank) = 0.0194 50.7% 30.7% 35.1% 18.2% Numbers at Risk TAVR TAVR17913812411083 Standard Rx Standard Rx179121856242

11. Mean Gradient (mm Hg) Error bars = ± 1 Std Dev EOA Mean Gradient N = 158 N = 162 N = 137 N = 143 N = 84 N = 89 N = 65 N = 9 AVA (cm ² ) Mean Gradient & Valve Area Transcatheter valves provide excellent hemodynamics and appear very durable to 3 years

12. Months 34828925214365 35124723213863 No. at Risk TAVR AVR 28.0 26.5 HR [95% CI] = 0.95 [0.73, 1.23] P (log rank) = 0.70 PARTNER COHORT A (high risk) All-Cause Mortality or Stroke (ITT) All Patients (N=699)

13. Complications Device embolization Aortic insufficiency Coronary occlusion Root rupture Stroke AV block – pacemaker Vascular complications – bleeding Acute Renal Failure

14. Device Embolization

15. Para-valvular Regurgitation

16. Iliac Avulsion

17. Embolic Material after TAVR Embolic Material

18. Day 6 Post-implant

19. Who Might Be a Candidate for TAVR? Severe aortic stenosis – AVA < 0.8 Symptomatic Chest pain, CHF, syncope Inoperable Opinion of two surgeons Porcelain aorta Multiple sternotomies Chest radiation COPD General frailty

20. What the Patient Should Know Survival (inoperable cohort) – 70% one year and 60% two year survival. Late deaths mostly noncardiac Stroke – 5% Pacemaker – 3.5%

21. Radiofrequency Ablation Targeted Rhythms AVNRT Accessory Pathway Rhythms Atrial Flutter Ectopic Atrial Rhythms Post Congenital Repair Rhythms Normal Heart VT AF

22. Radiofrequency Ablation Success rates of 95-100% for all but atrial fibrillation Complication rates approaching zero Home after 4 hours

23. Atrial Fibrillation Mechanism: starts from high frequency impulses from the pulmonary veins and continues from vortices of re-entry within the atria Treatment with membrane active drugs carries risk, making treatment appropriate only for the young OR symptomatic patients

24. Atrial Fibrillation RFA Success rate from 40 to 80% Complication rate: 1% chance of CVA 1% chance of pulmonary vein stenosis Long procedure time High doses of radiation for patient and physician Ideal patient has highly symptomatic AF, failed multiple drugs, and has PAF with a normal heart

25. Cryoballoon

26. Atrial Fibrillation CVA risk can ONLY be addressed by warfarin long term (INR 2-3), dabigatran, or rivaroxaban Risk factors necessitating anticoagulation include: HTN, DM, CHF, h/o thrombus formation elsewhere, age > 65-75, vascular disease, or female gender CHADS2-Vasc Score: CHF, HTN, Age>65 (1) >75 (2), DM, CVA or Thromboembolism (2), Vascular Disease, and female gender Scores of 0 and 1 need ASA, others anticoagulation

27. Atrial Fibrillation Drug treatment Dofetilide Amiodarone Sotalol Flecainide Dronedarone

28. CHF

30. Courtesy of Dr. Auricchio, University of Magdeburg, Germany. The Implanted LV Lead LAO View Lateral Coronary Vein Placement

31. Patient Selection Any Class of CHF on appropriate medical therapy with IVCD (QRS > 120ms) and LVEF <35% Patients post AV nodal ablation “Candidates for living” Be cautious of choosing only the “healthy”

32. Sudden Cardiac Death 350,000 to 550,000 people die each year in the US from SCD 97% of people die from their first episode of SCD

33. ANNUAL DEATHS IN U.S. 1 NASPE, May 2000 2 American Heart Association 2000 3 National Cancer Institute 2001 4 National Transportation Safety Board, 2000 5 Center for Disease Control 2001 6 NFPA, US Facts & Figures, 2000

34. CAST-I and other AAD Trials 80 85 90 95 100 091182273364455 Days After Randomization Patients Without Event (%) Placebo (n = 743) Encainide or Flecainide SWORD – D sotolol CASH -propafenone EMIAT - amiodarone

35. Primary Prevention ICD Trials 1.0 0.8 0.6 0.4 0.2 0.0 01234 5 Year Probability of survival MADIT I - Conv Tx MADIT I - ICD MADIT II - ICD MUSTT - ICD

36. Sudden Cardiac Death One patient dies each minute in the US from SCD 1440 patients died yesterday Statistically, 600 saw a health care provider in the past year

37. Cost Analysis

38. Conclusions Cooling post cardiac arrest is beneficial Angina can be treated even when revascularization can no longer be performed AS can be treated easily percutaneously for inoperable patients

39. Conclusions Most abnormal rhythms can be ablated Atrial fibrillation is potentially ablatable Many patients with AF need anticoagulation. Risk assessment with CHADS2-Vasc should be done Cardiac Resynchronization Therapy (BiV pacing) is the treatment of choice for CHF after appropriate medications in patients with a wide QRS

40. Conclusions ICD’s are the best protection against SCD – America’s number one killer Patients with LVEF < 35% likely need an ICD Patients with LVEF 120ms need CRT-D