A P H R S N E W S L E T T E R

Contents02 Summary of APHRS 2019: Bangkok

07 APHRS Allied Professional Course 2019

09 APHRS-HRS U.S Immersion Program 2019

12 Reducing Recurrent Stroke Risk in Cryptogenic Stroke

14 Sudden Cardiac Death

16 Advertisement: Biosense Webster

NOVEMBER 2019 | NO.45

Chief Editor: Anil Saxena

Deputy Editor: Kazuo Matsumoto

Managing Editors: Hsuan-Ming TsaoDavid HeavenPipin KojodjojoNwe NweKatsuhiko ImaiJae-Min Shim

Toshiko NakaiMing-Shien WenJacky ChanYuanning XuArisara SuwanagoolPreecha Uerojanaungkul

02 SUMMARY OF APHRS 2019: BANGKOK

THE 12th ASIA PACIFIC HEART RHYTHM SOCIETY ANNUAL SCIENTIFIC MEETING REPORT

Tachapong Ngarmukos, M.D. 1st Vice President APHRS

After a few years of preparation, the 12th Asia Pacific Heart Rhythm Society Annual Scientific Meeting was successfully held at the Bangkok convention center, Bangkok, Thailand from 24-27 October 2019. The meeting was hosted by Asia Pacific Heart Rhythm Society (APHRS) and was organized by the Thai EP club under the Heart Association of Thailand under the Royal Patronage of H.M.the King (HAT).

Registration:Breakdown of Participants by Country Region

Lectures and FacultiesThis year’s APHRS Scientific Session had 268 sessions, in 15 concurrent rooms. We had 27 joint sessions with international societies; HRS/EHRA/LAHRS, WSA, national societies CSEP/JHRS/KHRS/THRS, Pediatric society PACES/PediRhythm. Local societies STST/CIAT/Cardiac Imaging, and ISHNE.

SUMMARY OF APHRS 2019: BANGKOK 03

There were a total of 1197 abstracts submitted from 36 countries. There were 6 categories of YIA, including the topic of; AF ablation, AF general, basic sciences, CIED, general EP and VT.

Abstract Submission

Total of 7 live cases from 3 hospitals - Faculty of Medicine Siriraj Hospital, Faculty of Medicine Ramathibodi Hospital and Bumrungrad. All cases were successful and eventful.

Live cases

The opening ceremony was held on October 24th, at the convention center. The opening speech was given by Prof. Chu-Pak Lau, the president of APHRS followed by a welcome speech from Assoc. Prof. Khanchit Likittanasombat, the president of HAT. A short opening show was “Khon”; a Thai classical masked dance telling a story of Ramakien, a Thai version of Ramayana, an epic from ancient India.

Opening ceremony

04 SUMMARY OF APHRS 2019: BANGKOK

On the evening of October 24th, a welcome reception in the theme of “Sanook night” (fun night in Thai). The theme was inspired by “Ngarn Wat” a festive night usually held in a Buddhist temple. The reception integrated the 1st APHRS fellow convocation ceremony at the beginning of the reception. These fellows were selected by Prof. Masayasu Hiraoka, the 1st President of APHRS and the chairman of nomination subcommittee and the subcommittee.

The FAPHRS recognizes outstanding contributions to every aspect of clinical practice for patient care, research, scientific work and organizational activity in the APHRS organization. A long drum parade, usually used in traditional Thai wedding or Buddhist monk ordination ceremony, led the procession of fellows on to the stage.

In this modified for APHRS version, Tosakanth or Ravana; the demon king, who could not be killed because he took out his heart to be safe-guarded at his mentor hideaway. The demon king will need his AF heart taken care of by Prof. Chu-Pak Lau. The Opening Keynote lecture was given by Prof. Koonlawee Nademanee on “Brugada syndrome” and Prof. Douglas L. Packer on “Evolution of ablation: from DC shock to particle therapy”

Welcome reception and the 1st APHRS fellow convocation

SUMMARY OF APHRS 2019: BANGKOK 05

The Faculty night was held on October 25th at the exclusive Royal Bangkok Sports Club under the theme of Bangkok street food parade. 10 of the famous Michelin street food vendors were invited to provide the delicious taste of Bangkok. The music was provided by an international award-winning Suanplu Chorus, alternating with a live band. Gratuity plaques were given to our generous sponsors.

Faculty night

06 SUMMARY OF APHRS 2019: BANGKOK

On October 23th, the news of the 12th APHRS in Bangkok was broadcasted on National television. A press conference on Sudden Cardiac Death (SCD) was arranged on October 25th. Dr. Ngai-Yin Chan, the chairman of APHRS Public Affairs Subcommittee, produced a video clip in different languages to increase public awareness on how to use an Automated External Defibrillator (AED). In this video, the hero “Hardy” the Siamese cat for its 9 lives, from the planet Meow will teach you how to use AED. In this press conference, a collaboration between European Heart Rhythm Association (EHRA) and APHRS project on first responder application was launched. This application was used in Germany successfully by Dr. Christian Elsner and his colleagues. Now a pilot project will be initiated in Thailand with the coordination of Dr. Nalinas Khunkhlai from the Thai resuscitation council (TRC). In this conference Prof. Heid Heindbuchel (President of EHRA), Assoc. Prof. Khanchit Likittanasombat and Dr. Charn Sriratanasathavorn the organizing committee chairman were present to preside over the conference.

I would like to take this opportunity to thank everyone involved in making 12th APHRS Bangkok a successful meeting. I wish to express my sincere gratitude to my mentor, my inspiration and my role model, Prof. Koonlawee Nademanee. My EP teachers - Dr. Lawrence Rosenthal and Dr. Theofanie Mela. To all my colleagues and EP team at Ramathibodi – Assoc. Prof. Khanchit Likittanasombat, Assoc. Prof. Pakorn Chandanamattha and Assoc. Prof. Sirin Apiyasawat who was responsible for arranging most of the scientific program, Prof. Wee Siong Teo who got me started with APHRS. Also to all the past presidents of APHRS, Prof. Masayasu Hiraoka, Prof. Shih-Ann Chen, Prof. Young-Hoon Kim, Prof. Wee Siong Teo, Prof. Shu Zhang, Prof. Jonathan Kalman and Prof. Chu-Pak Lua, these were founding father of APHRS who gave me the chance to work in APHRS, allowing us an opportunity to organize APHRS in Bangkok and entrusted me to lead the society into the next decade. Thanks to all my colleagues and staffs at the EP club/HAT, who has been very helpful in organizing the meeting, Assoc. Prof. Khanchit Likittanasombat, Dr. Buncha Sunsaneewitayakul, Dr. Charn Sriratanasathavorn the EP club president, Dr. Thoranis Chantrarat and his team on abstracts, Dr. Satchana Pumprueg on live cases, Dr. Arisara Suwanagool for social events and Dr. Voravut Rungpradubvong on YEP program and emergency response team.

Last but not least our international faculty liaison, Carla Drew, for helping out with the international faculties and CMO team our PCO, whom has been working very hard to ensure good meeting.

The annual scientific session would not be possible without the support from our industry partners. This year in Bangkok we were fortunate enough to have 8 main sponsors and 12 exhibitors, as well as support from the Thailand Convention and Exhibition Bureau and Thai Airways. On behalf of APHRS and the HAT local organizing committee, I would like to express our sincere gratitude to our sponsors and supporters of this meeting.

News and Press conference

Thank You Message from APHRS 2019 Scientific Chairman Tachapong Ngarmukos, M.D.

Sponsors

APHRS ALLIED PROFESSIONAL COURSE 2019 07

Title : APHRS Allied Professional Course on Cardiac ElectrophysiologyPlace : National Cardiovascular Center Harapan Kita, Jakarta, IndonesiaTime : September 2 -11, 2019

The course consists of knowledge transfer, animal laboratory and case hand-on study

Participant: 24 APs (17 APs from Indonesia, 4 APs from Malaysia, 1 APs from Brunei Darussalam, 2 APs from Sri Lanka).

The APHRS Allied Professional Course 2019 was held in Jakarta on September 2-11, 2019 hosted by the Asia Pacific Heart Rhythm Society and Indonesia Heart Rhythm Society.

The APHRS Allied Professional Course was initiated by the Allied Professional Subcommittee of APHRS since two years ago. The course aims to increase knowledge and competency of allied professionals from developing countries in Asia Pacific region

Recent Activities:

Case Observation in Hospital Classroom

Animal Lab Attendees at the course

APHRS ALLIED PROFESSIONAL COURSE 2019Prof. Yoga Yuniadi, MD, PhD

08 APHRS ALLIED PROFESSIONAL COURSE 2019

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FINAL REPORT FOR APHRS U.S IMMERSION PROGRAM 2019 09

I am currently practicing Electrophysiology and Pacing in Myanmar. I am very passionate and for excellent patients care service in providing the best possible experience in Myanmar, where we lack different resources. I was very delighted to be given the opportunity to attend this program. This program helped increase my prospective career. I have learnt different approaches to the complex ablation procedures as well as tips and tricks of implanting devices at the Good Samaritan Hospital. Moreover, I have a great opportunity to get in touch with international expertise and share the knowledge and experiences to colleagues back in Myanmar.

First of all, I would like to send my gratitude to APHRS HRS fellowship subcommittee, Medtronic company, HRS program development committee and Good Samaritan Hospital. Specifically, heart felt thanks to Professor Chin Chee Keong, Senior Consultant Cardiologist and Director of Cardiac Electrophysiology and Pacing from Singapore National Heart Institute, Dr. Ivan Ho, Senior Consultant Electrophysiologist and his EP team from Good Samaritan Hospital. Also I would like to say thanks to Mr. Tonia D. Jones, MS, Manager, Corporate Relations and Program Development, Heart Rhythm Society, Ms. Susan Powell, Senior Director, Global medical education from CRHF, Medtronic Company and all the people who willingly help us to participate in this program. Without their support, we couldn’t participate in such kind of valuable education program.

Upon receiving the acceptance letter from the HRS office, I was very excited but yet worried as it is my first trip to the United States. The most time-consuming part in preparation for the trip was to get my full vaccination coverage and able to complete my full vaccination coverage on time. All the itinerary and accommodation arranged by the Medtronic CHRF and HRS committee were very well arranged and welcoming.

FINAL REPORT FOR APHRS U.S IMMERSION PROGRAM 2019

Soe Thu Zar Win, Consultant Physician, Department of Cardiology, North Okkalapa General Hospital, Yangon, Myanmar

10 FINAL REPORT FOR APHRS U.S IMMERSION PROGRAM 2019

The first part of the trip was staying in Los Angeles and observing the EP cases in the Good Samaritan Hospital for two-weeks. The accommodation at the historic hotel was within walking distance from the hospital which was perfect for us. We were observing some EP procedures and device implants under the guidance of Dr. Ivan Ho, whose special interest is in AF ablation. He has a good EP team and many outstanding EP fellows. Dr. Ivan Ho is not only a great EP physician but also a good leader. I have learned some difficult AF and VT ablation cases with him during this two-weeks training. Due to the short time frame given, I could only pick up a small portion of the skills from Dr. Ivan Ho. However, I could get in touch with his good attitude; how he trained his fellows; how kindly he communicates with his patients and how he handles the difficult procedures. In future, I hope to learn and experience advanced AF ablation procedures as well as device implantation and troubleshooting problems under the guidance of such a fantastic electrophysiologist, like Dr. Ivan Ho.

During my visit, I met Dr. Vien Hoang Long from Vietnam who at that point in time was also attached to the Good Samaritan Hospital. Not only is he an outstanding and hardworking electrophysiologist from Vietnam, but he is also helpful and eventually he became my good international friend. All the people I met in the Good Samaritan hospital were very hospitable and helpful. We created a lot of sweet memories in the Good Samaritan Hospital.

The second part of our journey was attending Heart Rhythm Society Annual Scientific Session 2019 in San Francisco. I attended the “AF summit” on the first day which provided a comprehensive update on discoveries and advancement in AF management. Subsequently, I joined another session which focused on device therapy for heart failure and present state of the art on LV implantation, programming and follow up considerations.

On the second day, I learned “His bundle pacing 360 degrees” which has recently become increasingly recognized as an important tool for improved and synchronized Ventricular pacing. Other interesting topics such as Navigating difficult SVT; tips from experts. SVT ablation can sometimes present challenges in terms of diagnosis and ablation location was also covered. And the session highlighted ways to safely overcome these challenges.

The topic “Real-world experience and clinical trial insights in CRT” was covered during the third day. The session touched on the guidelines directed device therapy in HF patients, and novel insights on bipolar vs quadripolar pacing, multipoint pacing, and novel wireless CRT system which I enjoyed attending. Moreover, I also attended the last session “How to avoid and manage CIED implant-related complications”. On the last day of HRS, the topics on “The preparation for device questions” and “Late-breaking clinical trial sessions”, were the reason why I stayed through the last day of the conference. After attending HRS Annual Scientific Session 2019, I eagerly look forward to attending the 41st HRS annual scientific session in San Diego, 2020.

FINAL REPORT FOR APHRS U.S IMMERSION PROGRAM 2019 11

Travelling and especially on solo trip was one of my hobby. I get to view the country’s landscape, learn their culture and lifestyle in different countries and most importantly make more friends. We venture around Los Angeles and San Francisco on weekend. I visited places like Universal studios and Huntington’s Library, the Golden Gate Bridge, the Sea Lion center in Pier 39 and the beautiful crookedest Lombard Street in the Fog City. I am grateful for HRS and Medtronic for the great chance and financial support for the scholarship recipients. However, personally I felt two-weeks is too short to learn and experience in detail.

Currently in Myanmar, we continue to face limitations in doing some difficult EP procedures, limited resources and funding for the supply of ICD and CRT devices. We need to conduct more training for EP fellows, more technicians for EP study and device programming. Financial support plays an important part in us when attending an educational program in abroad and it is a great experience especially to resource-limited country. Therefore, I would like to send my gratitude to my mentors, Dato Dr Razali, Senior Consultant Electrophysiologist from Malaysia and Professor Myint Soe Win, Senior Consultant Electrophysiologist from Myanmar who introduced and encouraged me to apply for this program

REDUCING RECURRENT STROKE RISK IN CRYPTOGENIC STROKE – A UNIQUE “HEAD AND

HEART” COLLABORATION.Dr Swee-Chong SEOW, National University Hospital Singapore

Introduction:

Stroke is a leading cause of morbidity and mortality. Despite extensive investigations, no known cause is found in up to 40% of strokes (“cryptogenic stroke”).

Occult atrial fibrillation (AF) can result in embolic stroke and is an important modifiable cause.

Since 2014, the Cardiology Department of the National University Hospital Singapore has collaborated with the Neurology Department in detecting AF in cryptogenic stroke patients. These patients are routinely referred to Cardiology and all patients with an ILR subsequently implanted are recruited to remote (home) monitoring, where an alert will be triggered to the cardiologist if an AF event is detected. These patients are then counseled for anticoagulation.

Traditionally, “intermittent” methods of ECG monitoring like the ambulatory Holter suffer from lack of sensitivity. The diagnosis of AF in the setting of stroke is of paramount importance as it mandates anticoagulation, which reduces the risk of recurrent stroke. On the other hand, initiating anticoagulation empirically on suspicion of, but without confirmation of AF exposes patients to the risks of bleeding without definite protection from recurrent stroke.

The incidence of AF has been reported to be lower in the Asian population (about 1%) compared to the West (2%). However, the risk of stroke for any CHA2DS2VASc score appears to be higher in Asians with AF. For instance, the annual rate of ischemic stroke in East Asian patients with AF and a CHA2DS2VASc score of 1 was 1.66% compared to 1.3% in the West. It would appear therefore, that the diagnosis of occult AF is even more important in Asians since anticoagulation is expected to result in a proportionally bigger reduction in the risk of recurrent stroke.

12 REDUCING RECURRENT STROKE RISK IN CRYPTOGENIC STROKE

Results:In our study (J Stroke Cerebrovasc Dis. 2018 Aug ; 27 (8) : 2182-2186), we found that in patients with cryptogenic stroke implanted with an ILR, the median time to first AF detection was 50 days. The pick-up rate for AF at 6 months was 12.9% and at 12 months it was 15.2%. (Figure 1). All the episodes of AF were asymptomatic. A typical example of a patient with occult AF detected by ILR is depicted in Figure 2.

REDUCING RECURRENT STROKE RISK IN CRYPTOGENIC STROKE 13

Figure 1 : Time to first detection of atrial fibrillation (AF) Figure 2: Transmission report of patient with occult AF

Conclusion:

The fact that most episodes of atrial fibrillation are asymptomatic underscores the unreliability of using symptoms to diagnose AF.

Cardiac implantable electronic devices (CIEDs) like ILRs represent the “gold standard” for the detection of occult AF because of the continuous long-term nature of the recording. The longer a patient is monitored, the higher the chance of detecting occult AF.

The incidence of occult AF in Asian cryptogenic stroke patients is high. Using ILRs to detect AF episodes is efficient, practical and positively impacts the management of such patients. Anticoagulation was initiated in almost all patients for secondary stroke prevention in whom AF was detected.

The unique collaboration between Neurology and Cardiology translates into a more effective and efficient way to pick up patients with occult AF and intervene to reduce the heavy burden of recurrent stroke on the patient and the society.

The incidence of occult AF in Asian cryptogenic stroke patients is high. Using ILRs to detect AF episodes is efficient, practical and positively impacts on the management of such patients. Anticoagulation was initiated in almost all patients for secondary stroke prevention in whom AF was detected.

The unique collaboration between Neurology and Cardiology translates into a more effective and efficient way to pick up patients with occult AF and intervene to reduce the heavy burden of recurrent stroke on the patient and the society.

14 SUDDEN CARDIAC DEATH

ICARE | SAVE A HEART, SAVE LIVES! | WWW.SAVEHEARTSFOUNDATION.ORG

PROJECT ICARECARDIAC ARREST RESUSCITATION FOR EVERYONE

www.saveheartsfoundation.org

Sumaiya Raghavan, Anand Shrivastav, Dr. Brian Pinto, Dr Yash Lokhandwala.

Educating & preparing citizens on how to handle Cardiac Arrest emergencies at public places before medical help arrives

| Facilitating installations of free-for-public-use Defibrillators

Initiated in 2017, iCARE is a non-profit, FIRST project of its kind in India that dedicates itself to the cause of providing crucial knowledge and hands-on training to members of public on how to keep a victim of a Sudden Cardiac Arrest alive until Emergency Medical help arrives.

Heart disease is one of the commonest causes of death in India today. Nearly 30% of the population (2 Million in the country per year, 24000 in Mumbai, 2 every hour) drop dead suddenly at home or at public places due to what is medically known as “SUDDEN CARDIAC ARREST” (SCA).

Although SCA victims CAN BE SAVED by bystanders, such victims do not survive due to zero public awareness and knowledge on how to handle such emergencies.

To increase the rate of SCA survival, we have launched a citywide effort, choosing Bandra (w) as the pilot area to begin from. Our effort primarily includes awareness and practical hands-on sessions on how to handle SCA emergencies, to all citizens (govt. and private) by Cardiologists/BLS certified professionals.

Each awareness session includes:

How to recognize Sudden Cardiac Arrest Hands-on practical training on the techniques of Resuscitation (CCR) How to make use of the life saving device called an Automated External Defibrillator (AED)

SUDDEN CARDIAC DEATH 15

Spearheading the project are eminent Cardiologists Dr Yash Lokhandwala, Dr Brian Pinto and Dr Armida Fernandez (Ex-Dean, Sion Hospital Mumbai, India; Medical Director, Holy Family Hospital, Mumbai, India (Retd)) supported by various doctors, BLS certified professionals, volunteers and Holy Family Hospital, Mumbai India.

The iCARE team has also found support from various dignitaries and the government run, state-wide ‘108’ emergency services, whereby they understand our objectives and have stationed one of their Bike Ambulances at the iCARE office.

iCARE is a non-profit entity run under the aegis of the Holy Family Hospital, Bandra and has imparted this training to many entities and our trainings are completely free of cost.

Project iCARE aims to make a sizable difference in saving precious lives and paving the way for such initiatives throughout India.

ICARE | SAVE A HEART, SAVE LIVES! | WWW.SAVEHEARTSFOUNDATION.ORG

Expected Results:

Implementation so far:

The project aims to achieve the following results (within pilot area of Bandra west):

a) An increase in SCA revival percentage to a significant level b) Sizable number of lifesaving AEDs installed every 500 meters across the cityc) A major chunk of population ready in handling cardiac emergencies at public places

Project iCARE has successfully accomplished the following in Bandra west area, since its inception:

a) Imparted FREE trainings to Over 14,000 members of public and govt. officials throughout the city of Mumbai (Railway Stations, Fire stations, Colleges, Corporates, Gymnasiums, Clubs, Hotels, Hospitals, etc)b) The whole of Mumbai Law Enforcement Department (Police) is being trained by iCARE. 26 out of 93 Police stations has covered till datec) Facilitated installations of 25 AEDs in the city at various public access locations.d) Officially certified 165 citizen Heart Marshals.

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