Download Prof. Raimund Erbel and Prof. Victor Aboyans discuss the 2014

European Heart Journal (2014) 35, 2989–2995
doi:10.1093/eurheartj/ehu379
Prof. Raimund Erbel and Prof. Victor Aboyans
discuss the 2014 European Society of Cardiology
Guidelines on the diagnosis and treatment of aortic
diseases with Emma Wilkinson
Raimund Erbel
Victor Aboyans
It has been more than a decade since the European Society of
Cardiology last issued advice on aortic disease.
With advances in imaging, surgery, and treatment, the topic has
once again been looked at, but this time the guideline covers not
just acute aortic syndromes but the full aorta—thoracic and abdominal—issuing recommendations on acute and chronic disease as well
as genetic and congenital diseases.
Co-chair Prof. Raimund Erbel, Director of the Department of Cardiology at the West-German Heart Center in Essen said that, back in 2001,
aortic dissection was discussed more within the fields of surgeryand vascular surgery than cardiology. But advances in transoesophageal imaging
gave cardiologists a tool with which to guide decision-making.
Add in vastly improved capabilities of CT scanning and several developments in treatment options and the time had come to revisit the
aorta, he says.
‘We have new information and that there is wider application of
this technology. And people are getting older so the problem of
aortic diseases has become more obvious’.
He adds that while it may be a big step to consider the aorta as one
whole organ, in the clinic and emergency room that is in effect what
happens. Clinicians are confronted with the full disease, not just one
isolated part.
Prof. Victor Aboyans, Head of Department of Cardiology at the
Dupuytren University Hospital, Limoges, France, who also chaired the
guidelines, says the focus on the whole organ is important in that, for
the first time, clinicians have a rigorous document covering everything
from acute aortic syndrome, to aneurysms, atherosclerosis, and genetic
disease, including practical recommendations on when to test and how.
Which leads to one of the most key recommendations in the
guideline—the set-up of aortic teams made up of several experts,
including surgeons, cardiologists, and radiologists.
‘Such teams would manage the majority of cases and discuss cases
as a group in a similar way to what has been proposed for the
management of coronary heart disease’, says Prof. Aboyans. ‘It is
really important to emphasise that it cannot just be about one
expert deciding a course of action alone’.
Prof. Erbel adds that the availability of hybrid operating theatres,
where catheterization and surgery can be done simultaneously while
carrying out thoracic endovascular aortic repair, is just one example
where different specialties are collaborating to treat the patient.
The guidelines point out that in many cases, such as those with
genetic disorders, tandem lesions may exist, making the distinction
between thoracic and abdominal aortic aneurysms—historically
dealt with by cardiovascular and vascular surgeons, respectively—
an arbitrary one.
Consequently, the guidelines are not just for cardiologists.
A key section is a standardized approach for the diagnosis of acute
aortic syndrome in the emergency room.
Acute aortic syndrome is a term that has gained popularity over the
past decade and obtaining a quick diagnosis and differentiating
between that and acute coronary syndrome is difficult but vital
because of the widely different treatment approaches.
‘It was not clear how we handled these patients in the emergency
room’, says Prof. Erbel. ‘So we put together a flow chart which divides
patients into those who are stable and those who are unstable.
Where we have a higher pretext for suspicion the guidelines make
it clear how to handle’.
‘And if a lower pretext for suspicion, clinicians should use echo, CTand
lab testing in order to rule out aortic disease. This is something which is
very new for those dealing with this in the emergency room’, he says.
‘The purpose’, adds Prof. Aboyans, ‘is to have a rapid and accurate
diagnosis’. And he likens the approach to what happens now with
acute coronary syndrome.
A similar standardized protocol is outlined for follow-up of aortic
lesions. This includes clear information on which imaging technologies to use (including a series of gold standard high-quality images
for comparison) and a very comprehensive table of the normal variables, and at what point clinicians should intervene.
While screening programmes for abdominal aortic aneurysm are
being introduced across Europe, the guidelines point to the need
for cardiologists to consider AAA screening during their practice.
‘We know there is data demonstrating the accuracy of the ultrasound probe. An aneurysm is very easily identified and you can immediately rule it out. Cardiologists already look for thoracic aneurysms
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected].
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and it only takes another couple of minutes to check the abdominal
aorta’, says Prof. Aboyans.
‘Sometimes people are focused on the thoracic or abdominal aorta
but we considered the aorta as a whole organ and we want cardiologists to be screening for AAA’.
While there are no major disagreements or controversies in diagnosis and treatment of diseases of the aorta, there are areas where
more evidence is needed before clear recommendations can be
made, both experts stress. The use of biomarkers in the diagnosis
of acute aortic syndrome is one such area.
‘There was some difficulty relating to paucity of trials’, says
Prof. Aboyans. ‘Many recommendations are only level C. The
technology has progressed rapidly but we need several welldesigned trials to clarify several points where there are gaps in
evidence’.
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He adds that one particular issue which would benefit from greater
research is medical therapies, as the investment and advancement in
this area is not what it should be. It is another reason why aortic teams
should be in place—to make such research easier to conduct.
‘What we have seen is the introduction of new techniques and surgical interventions and approaches without doing randomised
studies’, says Prof. Erbel.
‘It is difficult to do this work but it can be done and it is something
which needs to be more supported by the societies’.
The ‘Ten Commandments’ for European Society
of Cardiology Guidelines on Aortic Diseases
(1) The first-ever guideline on diseases of the thoracic and abdominal
aorta as one organ including not only acute aortic syndromes,
but also aortic aneurysms, genetic and congenital diseases,
aortic inflammation, and aortic tumours.
(2) Modern imaging of the aorta permits visualization of the total
aorta requiring standardized reports and measurements,
and at given landmarks.
(3) An additional 2 min scan of the abdominal aorta should be used in
all elderly patients undergoing transthoracic echocardiography
to effectively screen for abdominal aortic aneurysm (AAA).
(4) A comprehensive list of standard values is given for all imaging
techniques.
(5) A flow chart for the emergency room is designed to enhance
the efficiency of decision-making in acute aortic syndromes—survival is highly time-dependent.
(6) Diagnostic steps and therapeutic options are described not only
for aortic dissection, but also for intramural haematoma,
penetrating aortic ulcer, and traumatic aortic injury.
(7) The progress of interventional and vascular surgery required
a detailed discussion of AAA management to find the
optimal time window for treatment and selection of
endovascular or open surgery.
(8) Hybrid rooms have paved the way for developing new diagnostic and treatment options such as thoracic endovascular aortic
repair (TEVAR), debranching aortic arch surgery, and the
‘frozen elephant trunk’ technique.
(9) New information on genetic and congenital aortic diseases
with detailed recommendations, particularly for genetic
testing.
(10) We should now set up Aortic Teams and Centres to provide full
access to specialists in cardiology, radiology, paediatric cardiology, genetics, aortic, and vascular surgery, required not only
for the acute, but also for the intensive follow-up of patients
with aortic diseases.
The Guidelines will appear in Issue 45. For more information see:
http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/
essential-message-slideset.aspx
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European interventionists leading treatment
of valvular heart disease
At the outset of a 2-year term as President of the European Association
of Percutaneous Cardiovascular Interventions, Prof. Stephan
Windecker MD, FESC outlines his priorities with Barry Shurlock
Stephan Windecker
Cardiovascular interventionists are facing unprecedented opportunities in the years ahead. Percutaneous coronary interventions will
continue to be the ‘bread and butter’ of the subspecialty, but much
more emphasis will be given to structural heart disease. Transcatheter aortic valve implantations (TAVIs) will move from high-risk to
lower-risk patients, while advances in the mitral space seem set to
follow a similar pattern. Add to this closure of left atrial appendages
in those patients with atrial fibrillation who are unable to take nonvitamin K antagonist oral anticoagulants, and the future for interventionists looks extremely promising.
These are the views of the new President of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), Prof.
Stephan Windecker MD, FESC (physician-in-chief, Department of
Cardiology, Bern University Hospital Switzerland), who recently
started a 2-year term together with newly elected board members.
These include Prof. Michael Haude (Germany) as president-elect,
Dr Jean Fajadet (France) as past-president, Prof. Andreas Baumbach
(UK) as secretary and Dr. Javier Escaned (Spain) as treasurer. Conscious of the fact that the pioneering work in interventional cardiology is continuing to revolutionize the treatment of cardiovascular
disease, he is determined to ensure that, during his presidency, full advantage is taken of the opportunities ahead. European Association of
Percutaneous Cardiovascular Intervention has a membership of
.5700 members and has now grown to be the second largest association of the ESC (only bettered by the Heart Failure Association).
Outlining his priorities, he said: ‘One of my goals is to increase the
scientific visibility of EAPCI and interventional cardiology. Frequently,
interventionists are seen more as “doers” than clinician-scientists.
However, interventional cardiology is one of the subspecialties in
cardiology which has contributed immensely to evidence-based
medicine through the conduct of numerous randomized clinical
trials investigating devices and antithrombotic drugs. Many of these
findings have directly impacted clinical practice and I wish to put
them in the right context, by producing guidelines for clinical practice
and similar communications. A new Scientific Documents Committee, chaired by Dr Marco Valgimigli (The Netherlands), and Dr
Robert Byrne (Germany), will identify areas of interest and
commission position and consensus papers to be published not
only in our specialist journal EuroIntervention, but more widely, in
others such as the EHJ’.
Commenting on transcatheter treatment of valvular heart disease,
he said: ‘This is a key priority in EAPCI. Treatment options were until
recently limited to surgery, but the advent of TAVI has tremendously
changed the field by fulfilling an unmet need in the care of patients previously deemed inoperable. Moreover, TAVI offers a less invasive therapy
in patients at high risk for conventional surgical aortic valve replacement
with recent data indicating superiority. Ongoing randomized clinical trials
directly compare TAVI with surgical aortic valve replacement among
intermediate-risk patients, with results [expected] within the next two
years. In addition, technological advances in transcatheter heart valve
therapies continue to emerge at a breath-taking pace. This year,
several new devices have introduced innovative features to reduce paravalvular aortic regurgitation to a minimum. There is the question of valve
durability, but there is no difference between the devices used in surgery
and those implanted via a catheter through 5 years of follow-up so far,
though we will need to monitor this over the next 10 years. Our task
is now to lead the field and provide opportunities for education and
widespread implementation according to the available evidence’.
‘Transcatheter mitral valve replacement/repair has been slower to
achieve. However, possibilities in the mitral space are opening up.
Several mitral repair devices are being explored, and this year we
have seen the advent of 3 types of prosthetic heart valves implanted
into the native mitral valve using transcatheter techniques. Notwithstanding this, valves are still investigational and a long journey is ahead
of us to bring these therapies to clinical practice’.
Also high on his list of priorities is education, with the Euro PCR
course in Paris as the annual EAPCI course, and the more recent
PCR London Valves course, established as the largest held on valvular
heart disease interventions. He said: ‘The EAPCI Scientific Programme Committee, under the leadership of Prof Jean-Philippe
Collet (France), Prof Christoph Naber (Germany) and Dr Giulio
Guagliumi (Italy) take great care to introduce highly educational sessions during ESC and other EAPCI-supported congresses. This year,
the Training and Education Committee, chaired by Prof Lino Goncalves and Dr Ramiros Trillo, both from Spain, will award the first
Certificate of Excellence in Training in Interventional Cardiology
during the inaugural ceremony of the 2014 ESC Congress’.
Commenting on initiatives for helping young interventionists to
develop their career, Prof. Windecker said: ‘We have set up New
Initiatives for Young Interventional Cardiologists of the EAPCI,
chaired by Davide Capodanno (Italy), Gregory Ducrocq (France)
and Maria Daru (Denmark), not only to set up an optimal educational
platform, but also to facilitate transition from junior to senior
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positions. With the website CathGO Fellows can now search for a
suitable interventional cardiology training site, just by clicking on a
map and using other criteria in a matching process. ResearchGO
will soon be available to do the same for Fellows seeking research
positions. Another initiative of the Young Committee is the
Fellows Course on Interventional Cardiology, which has just been
held over one and a half days at the European Heart House’.
Another concern is gender, which is the remit of the EAPCI
Women’s Committee chaired by Prof. Julinda Mehilla (Germany),
and Dr Josepa Mauri (Spain). Prof. Windecker said: ‘We need to
address gender issues, both for patients and interventionists. There
are important differences in the access to care, response to different
cardiovascular interventions and post-procedural management
which require careful consideration. We also note that interventional
cardiology is rarely chosen as a subspecialty and career by female cardiologists in training. We need to collect more information on these
matters and raise awareness of heart disease in women’.
Tackling Heart Failure in Africa via innovative
research: setting the agenda
The Global Heart Failure Awareness Programme of the World
Heart Failure Alliance held an endorsement meeting on 16 May
2014 in Athens, Greece, during
Heart Failure 2014, the Congress
of the Heart Failure Association
(HFA) of the European Society of
Cardiology (ESC).
After an introductory speech by Prof. Stefan Anker, past president
of the HFA ESC, Prof. Piotr Ponikowski presented the Global Heart
Failure Awareness Programme, followed by lectures on improving
acute care (Martin Cowie) and prevention of heart failure (Gerasimos Filippatos).
Regional perspectives were provided on heart failure in Africa,
Arab countries, Australia, India, Indonesia, and the USA.
As outlined in the White paper,1 heart failure is a serious lifethreatening disease and addressing it should be considered a global
health priority. At present, 26 million people worldwide are
living with heart failure, with one in five persons expected to
develop the condition at some point during their lifetime. The
outlook for such patients is poor, with survival rates worse than
those for bowel, breast, or prostate cancer.
Furthermore, heart failure places great stresses on patients, caregivers, and health-care systems. Despite the burdens that heart failure
imposes on society, awareness of the disease is poor. As a result,
many deaths occur prematurely. This, in spite of the fact that most
types of heart failure are preventable and that a healthy lifestyle can
reduce risk. Even after heart failure has developed, premature
deaths could be prevented if people were taught to recognize the
symptoms and seek immediate medical attention.
There is a profound lack of data from Africa. No population-based
studies have reportedly been conducted to estimate the proportion
of the population living with heart failure in Africa. Heart failure is not
a disease of the elderly in Sub-Saharan Africa, where half of the
patients hospitalized with the disease are under 55 years of age.2
During the meeting, Prof. Karen Sliwa presented the African
perspective on causes of HF on the African continent, highlighting
the priorities for prevention, treatment, and research in Africa as
recently published (Figure 1).
Action was taken with a meeting and workshop, supported by a
grant from the Bundesministerium Bildung und Forschung (BMBF)/
German Ministry for Research and Education, to further collaborative research and education between Germany and Africa. This
meeting took place at the Hatter Institute for Cardiovascular
Research in Africa, Cape Town, 25 –27 May 2014 and the participants
included physicians and basic researchers from Germany,
Figure 1 Priorities for prevention, treatment, and research in
Africa.3
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Figure 2 Group photo Cape Town 26 May 2014. Dr George Karariges (Charité Berlin, Germany), Prof. M. Böhm (Homburg,
Germany), Prof. S. Lecour (Cape Town, SA), Prof. E. Ogola
(Kenya), Prof. Wim de Villiers (Dean, Faculty Health Sciences
centre), Prof. Bongani Mayosi (Cape Town, SA), Prof. Charles
Mondo (Uganda), Prof. Pascal Kenge (MRC, SA), Dr O. Ogah
(Nigeria), Prof. A. Damaceno (Mozambique), Prof. M. Sani
(Nigeria), Dr D. Ojji (Nigeria), and Dr A. Dzudie (Cameroon)
among other researchers from Africa.
Mozambique, Kenya, Zimbabwe, Senegal, Cameroon, Nigeria, and
Tanzania. Also in attendance were members of the Medical Research
Council South Africa and Prof. Wim de Villiers, Dean of the Faculty of
Health Sciences at the University of Cape Town (Figure 2).
The workshop was used to set the agenda for a large area of outreach of research and to facilitate capacity development in Africa.
The group defined the mission statement:
To understand, prevent and cure Heart Failure in Africans via innovative
technologies, training, and networking
The collaborative research will span from basic science (e.g. genetics in cardiomyopathy, research into cardiac signalling pathways,
sex differences in heart failure) to clinical studies in acute heart
failure [by treatment with hydralazine/nitrates vs. placebo in Africans
admitted with acute HEart Failure (BAHEF) and right heart failure],
rheumatic heart disease (RHD), the Stop RHD A.S.A.P. Programme,
and the Investigation of the Management of Pericarditis studies. A
special focus will be on early detection of heart failure and arrhythmias in women presenting in the peripartum period, using implantable ECG devices and by the collection of samples for biomarkers.
However, the project, which will hopefully be supported in the
long term by funding via the BMBF and the South African Medical Research Council, will have a strong focus on capacity building in Africa,
through the strengthening of clinical research sites, a PhD and Masters’
student mentoring programme, as well as clinical and device training.
Continuing research is essential if we are to address unmet needs
in caring for patients with heart failure. New therapies are required
for patients with heart failure where current treatment only relieves
symptoms. More affordable therapies are desperately needed in the
economically developing world, such as Africa.
International collaborative research focusing on the causes and
treatment of heart failure worldwide has the potential to benefit
tens of thousands of people in Africa and beyond.
The Global Heart Failure Awareness Programme is supported by
Novartis Pharma AG and Servier in the form of an unrestricted educational grant.
References
1. Ponikowski P, Anker SD, AlHabib KF, Cowie MR, Force TL, Hu S, Jaarsma T, Krum H,
Rastogi V, Rohde LE, Samal UC, Shimokawa H, Budi Siswanto B, Sliwa K and Filippatos
G. Heart failure: preventing disease and death worldwide. ESC Heart Failure
2014;1:425.
2. Damasceno A, Mayosi BM, Sani M, Ogah OS, Mondo C, Ojji D, Dzudie A, Kouam CK,
Suliman A, Schrueder N, Yonga G, Ba SA, Maru F, Alemayehu B, Edwards C, Davison
BA, Cotter G, Sliwa K. The causes, treatment, and outcome of acute heart failure in
1006 Africans from 9 countries. Arch Intern Med 2012;12:462 –468.
3. Silwa K, Mayosi BM. Recent advances in the epidemiology, pathogenesis and prognosis
of acute heart failure and cardiomyopathy in Africa. Heart 2013; 99:1317 –1322.
The 62nd Annual Scientific Session of the
Japanese College of Cardiology
The Japanese College of Cardiology held its 62nd Annual Scientific
Session in Sendai, Japan, 26– 28 September 2014, with participants
from all over the world as well as from the Asia-Pacific region
Founded in 1987 as a successor to the Society of Clinical Electrosonography, which started in 1970, the Japanese College of Cardiology (JCC) has been the leading academic society in clinical
cardiology in Japan, with 9000 members as of March 2014. The
primary objectives of the JCC are the development and spread of clinical cardiology as well as the education of the next generation of
medical, paramedical, and other health-care professionals.
In 2007, 21% of the population of Japan was older than 65 years.
This rose to 25% as of September 2013, making Japan the so-called
‘super-aged society’ in the world. Since then, there has been an
urgent need to effectively examine and establish the best management for cardiovascular diseases (CVDs) in this ageing society.
Along with the rapid ageing of society, lifestyles have been westernized and the number of patients with CVD has been increasing in
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Japan. In Asia, as well as in Japan, the burden of CVDs has recently occurred along with increasing comorbidities, westernized lifestyles,
and ageing of societies. Therefore, our attempts are directed to shedding light on the resolution of an epidemic of CVD in Asian countries
including Japan.
In addition to the management of CVD patients, we are forced to
improve hospital management, e.g. by reducing the length of hospital
stay and the introduction of advanced technology such as electronic
medical records and data management systems. However, in fulfilling
these streamlined requirements, doctors and medical staff forfeit
personal contact time with their patients.
Under such conditions, many of us have a sense of crisis because
we want to make eye-to-eye contact with sick patients and
perform a sufficient interview and careful physical examination in
daily practice. It is also required that we be able to support the
patient’s self-healing ability with minimum medical treatment.
Therefore, as president of the 62nd scientific meeting of the JCC, I
employed the theme ‘The Spirit of Clinical Cardiology’, emphasizing
the importance of returning to the origin of clinical cardiology. For
this reason, we formed the programme so that ‘education’ is
focused as one of the core curriculums. As part of the process, we
organized educational lectures in collaboration with the Japanese
Educational Clinical Cardiology Society (JECCS) and special lectures
by the experts in clinical cardiology. Moreover, we had sessions highlighting the importance of understanding the pathophysiology of
CVD based on functional and physiological information, which is
sometimes invisible (e.g. vasospasm, myocardial ischaemia).
In the 62nd JCC scientific meeting, besides .1300 abstracts being
presented, we had many international programmes, including official
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joint sessions with the American College of Cardiology and Asian
countries, attracting many cardiologists from abroad. Of note, we
had a special presentation by Prof. Thomas F. Lüscher, the
editor-in-chief of European Heart Journal (EHJ), for the Sakamoto Memorial Lecture, entitled, ‘All the Presidents Men? The Rise of Cardiovascular Medicine in Case Reports’.
There was a special session in collaboration with EHJ, entitled ‘The
Year in Cardiology: the EHJ Perspective/the 62nd Annual Japanese
College Scientific Session of Cardiology’ in which four renowned cardiologists delivered lectures in their fields
Prof. Paolo G. Camici (Italy): cardiac imaging,
Prof. Peter Ganz (USA): basic science and prevention,
Prof. Filippo Crea (Italy): coronary artery disease and acute coronary syndromes, Philippe H. Kolh (Belgium): cardiac surgery.
In addition to these programmes, we provided special opportunities for everyone interested in cardiology. The scientific programmes
offered various educational opportunities including ‘how to’,
‘clinical case’, and ’state-of-the-art’ sessions in each field of clinical
cardiology.
During the 3 days of the 62nd JCC meeting, attendees were able to
see new directions, solutions, and ideas to be incorporated into their
daily practice.
Leadless pacing debate: current issues in pacing
Arguments for and against the statement that leadless pacing is the
solution to most current weaknesses of pacing were presented at
Cardiostim-EHRA Europace 2014
Pro: Philippe Ritter
Leadless pacing is a revolution in the field of
cardiac pacing. The challenge has been to
provide a device small enough to be placed into
the right ventricle that offers at least the same features as a conventional modern VVIR pacemaker.
Two devices exist: Nanostim from Saint-Jude
Medical and Micra from Medtronic. Why are
people developing such a device when the current technology
already offers a good answer to patients’ needs?
The goal is to avoid the major lead-related complications: pneumothorax and haemothorax, lead dislodgement, pocket haematoma and
pain, and later on, lead/valve conflict, venous thrombosis, pocket infection favouring bacteraemia, and endocarditis that requires lead
and device extraction.
There will still be complications with the leadless systems similar to
conventional pacing: at the moment of implantation, cardiac arrhythmias, perforation and tamponade, diaphragmatic stimulation, and
more specifically groin haematoma, AV fistula (femoral access), impossibility of reaching the ventricle (iliac tortuosity’s, IVC filter or tricuspid prosthesis), device migration; in the long term, the risk of
infection is probably quite minimized.
So far (I have no experience with Nanostim), the implant procedure is pretty simple; no complication was encountered, and electrical
performance is optimal. The number of ventricular pacing, ventricular sensing, inhibition response, and rate-adaptive (VVIR) indications
will probably increase at our centre.
Con: Paul A. Friedman
Leadless pacing is an exciting, paradigm-shifting
innovation as to how antibradycardia therapy
is delivered. A number of potential complications related to current pacing therapy are eliminated, including pocket infection/erosion, lead
failure, tricuspid valve disruption, to name a
few. However, single-chamber pacemakers
account for fewer than 15% of all current cardiac implanted
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electronic devices. Development of dual chamber leadless pacemakers will face important challenges, including battery depletion
due to increased communication between separate elements, and
the increased risk associated with placing devices in the very thinwalled right atrium. Additionally, information regarding infection
risk, MRI performance, and whether the device can be removed percutaneously following chronic implantation is minimal at present. Appropriate management following battery depletion is uncertain.
Lastly, the greater complexity of implantation, and the risk of perforation with excessive implant force vs. pacemaker embolus with inadequate implant force will necessitate careful implanter training and
human factors assessment as leadless programmes are developed.
However, with careful development of implanter training programmes, refinement of the technology, and future integration with
leadless ICDs, leadless pacemakers will be an important tool in the
therapeutic armamentarium.
Conflict of interest: P.R. is a speaker or consultant for Sorin and
Medtronic. P.A.F. has received research support from Medtronic,
Biotronik, SJM, with Intellectual property rights for Bard EP,
Medical Positioning, Inc., Aegis Medical, NeoChord, Preventice,
and Sorin, and as speaker or consultant for Medtronic, Biotronik,
Leadex, and Boston Scientific.
Jennifer Taylor MPhil
CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]