Highlighted Sessions From Heart Rhythm 2022

New Technologies in the Electrophysiology (EP) Lab:

Patrick Boyle, PhD, FHRS, session cochair: I’m an Assistant Professor of Bioengineering at the University of Washington. I’m here with my colleagues and friends, Christine P. Hendon and Stacey Rentschler. They’ll introduce themselves and say where they’re from when they start talking. We just finished a exciting session at Heart Rhythm 2022 on new innovations in the EP lab. This is one of our translational sessions in which the idea is to bring together an intellectually diverse group of people who are studying the intersection between scientific development, technology development, and clinical applications especially relevant to patient care. We’ll start with Christine, who is an Associate Professor of Electrical Engineering at Columbia University. Her lab collaborates heavily with physicians at the Columbia University Medical Center, and today she’ll be telling us about a couple of different exciting techniques they have been developing that could foreseeable be used someday to optically map the properties of cardiac tissue in vivo during procedures in the EP lab. Christine, tell us about the work that you’ve been doing with your team.

Christine Hendon, PhD: Thank you very much, Pat. Our lab has been integrating optical fibers into radiofrequency ablation catheters, and with this, we can send light into the tissue and then detect the reflectance properties and reflective signal changes depending on the scattering and absorption of the tissue, and those intrinsically change due to remodeling of the heart. So, if there is increased amounts of adipose or fibrosis, we can see those structural and scattering changes. We’ve been utilizing that to produce what we called optical substrate maps, and hopefully in the future, they can be integrated with electroanatomic maps to help improve ablation procedures.

Boyle: One of the things that really excited me was your emphasis on using these optical tools to characterize transmurality of ablation scars. I think the EP audience is always looking for new and innovative ways to know “Did I burn what I thought I burned?” Could you elaborate on how you see this making an impact on the EP lab of 2025, 2026, or maybe even sooner, 2024?

Hendon: Yes. In a lot of our work, we’ve been trying to ensure that our tools can be used in real time. We’ve been pushing to have optical systems that have enough signal so we can do this at very rapid rates. So, as the doctors move the catheter around, they get real-time feedback. Also, on the analysis side, we can do very complex analysis of our spectra, extracting absorption coefficients and scattering coefficients, but those are computationally intensive. That is why, within our talk, we focus on these optical indices, which are very fast parameters that we can calculate in real time to help predict things like transmurality.

Boyle: The second lecture in our session was from Stacey Rentschler. Stacey is an MD, PhD cardiologist, unlike me and Christine, who are engineers. Her lab is world renowned in their study of different signaling pathways within the heart, and studying reprogramming of cells. It has been super exciting to watch, for me personally, over the past few years since the first publication of findings from Phillip Cuculich and colleagues using stereotactic body radiation therapy as a means of what was originally built as a new type of ablation. Much of the community, including me, saw this and thought they’ve found a new way to ablate. But what we’ve learned from Stacey’s lab and the team at Washington University is that that’s far from the truth—it’s actually doing something much different to the tissue. Could you elaborate on what you talked about today?

Stacey Rentschler, MD, PhD: I’m from Washington University, and I’m fortunate to have wonderful colleagues there. I’m in the department of medicine, developmental biology, and biomedical engineering. My program started out studying basic mechanisms to induce reprogramming in cardiomyocytes with the thought that someday we should be able to do this clinically as a theoretical way to treat arrhythmia. I struggled for a very long time to think about how to translate that. Then, my colleague, Phil Cuculich, conversely was giving this radiation therapy to patients and it seemed to be remarkably effective at treating the arrhythmia. We were sitting at dinner one night and he said, “Can you help me figure out how this is working?” So, the first thing we did was to look at the patients to see what was happening after this radiation therapy. We didn’t find significant fibrosis in the patients, and that was our first clue that this was something that is different from what a catheter is doing.

So then we dug deeper into the mechanisms, and there are several ways that a treatment can be antiarrhythmic. One theoretical mechanism is by increasing conduction velocity, which is a requirement to sustain these arrhythmias. But, to date, there had been no therapies that actually could accomplish this in a human. It turns out that radiation is able to change the properties of the myocardium to kind of rejuvenate or reprogram it to a younger self. In that way, it can be antiarrhythmic.

We still have a lot to learn from the successes, as well as those patients who have recurrences and why are they recurring. But, in general, this is a very exciting new area, and I’m hopeful that the more we learn, the better we can make this treatment for our patients.

Boyle: Yes. As I said, Christine and I are engineers, so I remember the first time I learned about catheter ablation. I was like, “No, there’s no way they do that. You’re burning down the house to save the farm. You’re killing tissue to make an arrhythmia better.” So, it’s always been tantalizing, the idea of what if there was a better way? What if we could rejuvenate the tissue instead of killing it to make the problem better? So, I think the development that has been there has been amazing. This is something that I find amazing about the way that your team works—can you talk about the way the basic science team collaborates and works in an interleaved way with the clinical team on this research?

Rentschler: That’s a great point, and I think that that is what is also special about this team. I, myself, am a physician scientist and a cardiologist, so I speak both of those languages. I think there is a willingness of all members of our team to learn the other languages of the people who are working on the team. We work together on other projects and I think there is a lot of willingness to reach out and learn. So, I know Cliff Robinson, who is in radiation oncology, had a lot to learn about arrhythmias. Phil, who is in cardiology, learned a lot about radiation oncology. So, we built this team out. It’s really multidepartmental, and we involve everybody at the level that they have unique things to bring. We just have to learn each other’s language enough to make treatments better for our patients. So, it’s been a lot of fun, it is a great group, and we’re always looking for more people to join us.

Boyle: It’s always obvious to see the enthusiasm and how much fun you and your team were having. I would be remiss not to mention that we had a third speaker in our session—Dr Natalia Trayanova from Johns Hopkins University, who couldn’t be here for this recording. These are 3 amazing examples of interdisciplinary research in action of translational research. Natalia’s presentation was about multimodal imaging. Her talks are like the kitchen sink. It’s like, “Okay, so we’re going to do image analysis, we’re going to use artificial intelligence to see what insights we can glean from that, and then we’re going to build biophysically realistic simulations, and then we’re going to get positron emission tomography (PET) scans.”

Rentschler: Incorporate some clinical information to make it even better.

Boyle: Get the chart from the patient, and all of that goes into this carefully crafted machine learning algorithm. I think that this is a wonderful time to be a researcher in this field, and I couldn’t be happier with the way the session went.

Rentschler: Yes.

Boyle: Thank you to the two of you!

Rentschler: Thank you for making our jobs easier as well!

Controversies in Arrhythmia Management in Athletes:

Eugene Chung, MD, MS, MPH, FHRS, session cochair: I’m an electrophysiologist at the University of Michigan, and I’ve practiced both in Ann Arbor and West Michigan. I’m also chair of the American College of Cardiology’s Sports and Exercise Member Section and Leadership Council. I had the pleasure of cochairing a session on controversies in arrhythmia management in athletes with Dr Rachel Lampert at Yale.

We had 3 topics covered in this session with an amazing group of speakers. The first session was a pro-con debate on Wolff-Parkinson-White ablation as first-line therapy, with Drs Susan Etheridge and Taya Glotzer. I think they both came to agreement that shared decision-making is very important—we have to weigh the risks and benefits of the procedure, as well as the risks and benefits for the patient for their risk of sudden death. One thing we didn’t get to talk about was the potential risk of the particular location, the pathway that needs to be factored into the discussion about the procedure.

The second topic was atrial fibrillation ablation and whether it should be first line or not in athletes. The pro was discussed by Dr Jared Bunch from Utah, and Dr John Mandrola from Baptist Health in Louisville, Kentucky, did the con. Again, shared decision-making very important. Dr Bunch presented data on the benefits of catheter ablation both in athletes and nonathletes. Dr Mandrola highlighted that catheter ablation may be on the table, but we may not have to rush and do it, that we can take time to work on modifiable risk factors. Also, we need to be cautious about the use of antiarrhythmics in athletes, particularly those on flecainide or class 1C agents, which can put patients and athletes at particular risk for having fast, wide-complex arrhythmias.

The third topic in this session was on the asymptomatic athlete with hypertrophic cardiomyopathy (HCM). In the program, they mentioned the asymptomatic athlete with late gadolinium enhancement, but the debaters—Dr Michael Ackerman doing the pro, and Dr Marty Maron from Tufts doing the con—decided to change the topic to HCM. Unlike the other 2 topics of the session, we didn’t quite come to as much of a resolution in shared decision-making, and that is perhaps because this topic is subject of much debate and ongoing research. Dr Ackerman did highlight that the lower risk HCM patients probably with the shared decision and discussion, could return to exercise, that genetic tests alone should not preclude someone from doing what they want to do, and that we need to keep the mental health of the patient at the forefront of any shared decision and discussion.

Dr Maron highlighted the pathophysiology behind HCM, the increased risk of arrhythmias with HCM, and that we need to provide our best judgment on having these shared decisions and discussions. It’s okay for the physician to provide what they think is best practice and in best interest—it’s okay to be part of that shared decision. This area, as I mentioned, is subject of much debate. As we continue to accumulate new data in patients with inherited arrhythmias, including patients with HCM, both low and moderate risk, hopefully we’ll have more and more clarity on recommendations going forward.

Use of Social Media in Clinical and EP Practice:

Sandeep Saha, MD, MS, FHRS, session cochair: I am a practicing cardiac electrophysiologist at the Oregon Heart Center in Salem, Oregon. We had a very engaging session on the use of social media in the EP practice that was presented at Heart Rhythm 2022. This was a session that was very well attended and had some very esteemed speakers, including some true pioneers and heavy hitters in the social media space, especially as it pertains to EP. We had Drs Gopi Dandamudi, John Mandrola, Hafiza Khan, and Ed Schloss, who all brought their perspectives on the use of social media as it stands now, and more importantly, where it’s going in the future.

In the process of the session, we talked a lot about the different social media platforms that electrophysiologists use. Some are used more than others. We talked about Twitter, Instagram, a little bit about Facebook, and also other platforms such as TikTok and Clubhouse. I’ll try to summarize the hour-long session and provide a few highlights.

Each of these social media platforms have different capabilities and different levels of user engagement. More importantly, they have different demographic profiles of the users that primarily use those social media platforms. We talked about the different platforms and which one is better for electrophysiologists to use. It really depends upon what we’re trying to do as well. It depends on the type of content that is being posted and the audience being targeted. Regarding capabilities and usability of these different platforms, platforms such as Twitter are very popular among electrophysiologists. The hashtags #EPeeps and #cardiotwitter are extremely popular. Twitter is used extensively by cardiac electrophysiologists and has been for many years. Other platforms, such as Instagram or TikTok, tend to be used for more personal use and have more content that is meant as entertainment and not directed at being too serious. It was interesting to talk with individuals who use Instagram to post clinically relevant content and talk about their lives outside of their professional lives. Dr Khan had a very passionate talk on that during the session, which was very well received.

Regarding using social media for someone sort of on the fence, especially in the realm of cardiac EP, it’s important to know some of the strengths and weaknesses of using social media in general, regardless of the platform. One of the major strengths, of course, is the worldwide reach of the content that is posted, whether it’s a tweet, post, or video clip. The reach that one can have, with a very minimal investment of time and effort, is brilliant. It gives the user access to some of the best minds in the field—in this case, EP—virtually at their fingertips. It’s a tremendous tool, especially for trainees or early career medical professionals, EPs included, as they’re developing their skillset and clinical acumen. I think Twitter, for example, has been a remarkable tool for my own professional development in the first few years of my independent practice.

On the other hand, one of the pitfalls is also the widespread reach. The kind of content that is posted, especially if it’s controversial or political, can invoke a very strong response. It’s important to be aware of that possibility and go in with your eyes open, realizing that some of these ideas may be met with resistance, and in some cases, vitriolic resistance. One needs to be aware of that.

But, in general, for the democratization of academic discourse and being able to discuss important questions and research ideas for collaboration, social media is a tremendous tool when used appropriately.

Some of the take-home points from the session would be to first try and identify which platform would be most appropriate or best suited for the kind of content that you’re trying to post.

If it’s professional content for a more mature audience, then one platform may be better than others. If it’s a younger demographic or if the content has an educational basis, but has an entertainment factor as well, maybe another platform might be better. It’s important to choose the right social media platform and tailor the content to what users would expect to see on that platform.

The second take-home message would be, just as we would do with any kind of early career development, identify mentors within that space. These could be mentors who you work with in the course of your academic training, or mentors who are just good at using social media, whether it’s within EP or within the space that you are in, or even outside of your intended space. It’s not a bad idea to use their posts as a rubric or template early on as you’re trying to develop your own social media presence. Then, once you are comfortable with the platform, feel free to branch out and make it your own.

The third thing is to be authentic. It’s okay to have multiple social media accounts, with one social media account predominantly for professional content, another for personal content, another for things that you’re passionate about, such as hobbies, charities, or social causes. It’s okay to have different social media accounts to allow you to compartmentalize the messaging and express different aspects of yourself in your social media activities.

At the end of the day, have a good sense of humor. We have to realize that these are essentially public platforms, so whatever content is posted is essentially accessible to everyone who has an account on that particular platform. This includes individuals who may have varying backgrounds or views on some of the content or positions that you are proposing in the content that you post. Be ready to roll with the punches, because just like there are individuals who will support you in your social media journey and development of your personal brand in the social media space, there may also be individuals who will post negative content or be very vocal in their resistance or views that are contrary to yours. It’s important not to get emotionally upset over it. At the end of the day, everyone is entitled to their own opinion, and the same level of democratization and freedom of speech that social media offers you as you’re posting content online is given to every single user on that platform. In general, have fun and don’t feel daunted. Start slow, choose a mentor or 2, and be mindful of the public nature of the content that is posted.