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NewsMay 2018, No. 36

Chief editor:Kazuo MATSUMOTO

Deputy editor:Yoga YUNIADI Hsuan-Ming TSAO

Managing editor:David HEAVEN Anil SAXENADavid O’DONNELL Pipin KOJODJOJONwe NWE Jacky CHANKatsuhiko IMAI Naomasa MAKITAJae-Min SHIM Toshiko NAKAYAMAMing-Shien WEN

C O N T E N T SP1 JHRS 2018: Welcome Message

P3 OnlineReal-timePhaseMappingSystem:TheExTRaMapping Project from Japan

P7 TheNewLeadExtractionSubcommitteeofAPHRS

P8 TheHistoryofEPinCambodia

P11 APHRS 2018: Taipei

JHRS 2018: Welcome Message

Nobuhisa HagiwaraCongress President,

Annual Meeting of the JHRS 2018

Department of Cardiology,Tokyo Women’s

Medical University

ItismygreatpleasuretoinviteyoutotheAnnualMeetingoftheJapaneseHeartRhythmSociety2018(JHRS2018),whichwillbeheldoverthefourdaysfromWednesday,July11toSaturday,July14,2018attheTokyoInternationalForum,Tokyo,Japan.

Thethemeofthismeetingis“InnovationandHarmonization:NewOutlookforJHRS”,andwewillattempttounderstandelectrocardiographicphenomenaandarrhythmiasfromawidevarietyofperspectives.

Recentyearshaveseenspectacularprogressinareasrangingfromregenerativemedicinetosimulationsandmonitoring,devicedevelopment,andtheclinicaladoptionofinnovations.Ratherthanbeinglimitedtoasinglefield,theserevolutionaryadvancesinmedicaltechnologyrequirecollaborationwithotherfields.Ontheotherhand,theheartisahumanorgan,andtheinvolvementofnotjustmedicalprofessionalsbutalsoofthecommunityandsocietyatlargeisimportantinthecareofarrhythmiapatients.ThispointsthewaytothefutureshapeoftheJHRS.

JHRS 2018: W

elcome M

essage

Nobuhisa HagiwaraAnnual Meeting of the JHRS 2018 Congress PresidentDepartment of Cardiology,Tokyo Women’s Medical University

Atthismeeting,opinionleadersfrombothJapanand abroadwill share the latest informationon thefuture of electrocardiology and arrhythmia research, andIhopethatdoctors,medicalstaff,andresearcherswill jointheminconsideringtheclinicalapplicationsofnewdiagnostictechnologies,monitoringsystems,non-pharmacological treatments such as devices and catheter ablation, and drug therapies as wellas their optimization. As indicated by the inclusionof the term “harmonization” in the conferencetheme, we will also debate matters from potentialcombinationsofmedicaltechnologiesandtreatmentmethodstocross-disciplinarycollaborationinthecareofarrhythmiapatients inabroadrangeofsymposiaand panel discussions. We are also planning theeducational sessions, hands-on workshops, casestudies, and workshops that are the trademarks of thisconference.

I hope that as many APHRS and JHRSmembers aspossiblewillattendthismeeting,inordertomakeitatrulyfruitfulevent.

Venue TokyoInternationalForum

5-1 Marunouchi 3-chome Chiyoda-ku, Tokyo 100-0005, Japan

TEL:+81-3-5221-9056FAX:+81-3-5221-9022

Access • JR Lines1-minutewalkfromYurakuchoStation5-minutewalkfromTokyoStation(connectedbyB1FUndergroundConcoursewith KeiyoLineTokyoStation)

• Tokyo Metro Yurakucho Line1-minutewalkfromYurakuchoStationD5Exit(connectedbyB!FUndergroundConcourse)

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Online Real-tim

e Phase Mapping System

: The ExTRa Mapping Project from

Japan

Real-time Imaging of Clinical Non-Paroxysmal Atrial Fibrillation by Newly Developed Online Real-time

Phase Mapping System: The ExTRa Mapping Project from Japan

Takashi Ashihara, MD, PhDAssociate Professor, Department of Cardiovascular Medicine

Shiga University of Medical ScienceOtsu-city, Shiga Prefecture 520-2192, Japan

than the indirect indicators based on intra-atrialelectrograms is required. Although optical mappingtechnique is available in animal experiments, suchdirect visualization is technically and ethically notavailableinclinicalpractice.

Insuchsituations,myprimaryconcernwashowtocreateanonlinereal-timeAFvisualizationsystemthatcanbeemployedduringcatheterablation.IamoneoftheseniorcardiacelectrophysiologistsinJapan,butatthesametimeIamoneofthebiomedicalengineerswhohasbeenworked incomputersimulationstudy(in silico) of cardiac arrhythmias for more than 20 years(Figure1).Inparticular,Ihavebeenworkingonelucidatingthemechanismsofrefractoryarrhythmias,suchasAFandventricularfibrillation.

Atrialfibrillation(AF)isthemajorcauseofcerebralinfarctionandheart failure.As thenumberof atrialfibrillation patients increases with aging of thepopulation,thetreatmentisconsideredasurgenttaskinthecountrieswithsuper-agedsociety.

In recent years, pulmonary vein isolation bycatheterablationhasbeenconductedforparoxysmalAF (lasting within 7 days). However, such ablationstrategy is not so effective for non-paroxysmal AF,i.e.,persistentAF(lastingmorethan7days)andlong-standingpersistentAF(lastingmorethan1year).

To improve the outcome of non-paroxysmalAF ablation, it has been suggested that directvisualization of the AF drivers (perpetuators) rather

Figure 1: In front of the online real-time phase mapping system (ExTRa MappingTM) developed by my group.

3

Online Real-tim

e Phase Mapping System

: The ExTRa Mapping Project from

Japan

Figure 3: A feature of the phase mapping algorithm of the ExTRa Mapping.

Figure 2: Schematic view of the ExTRa Mapping (patented).

Development of a Clinically-Available Phase Mapping System in Japan

In July 2014, via the personal meeting with Dr.Takeshi Tsuchiya, a famous clinical electrophysiologist in Japan, andwith Prof. KazuoNakazawa, a famousbiomedicalengineerinJapan,Idecidedtorealizeanidea regarding the arrhythmia visualization systemthatIconceivedsince1999.IwouldliketoexpressmyfaithfulthankstoNihonKohdenCorporationofferedahelpinghandtomyunfeasibleproject.

Thus, in 2015, the world’s first online real-time phasemappingsystem(ExTRaMappingTM, Nihon Kohden Co., Tokyo, Japan) capable of visualizing AF wave dynamicswasdevelopedbymygroupandapprovedbythePharmaceuticalsandMedicalDevicesAgencyinJapan.Evennow,thissystemcontinuestoimprove.

The real-time imaging of the complex AF wavedynamicswasachievedbyintroducingtheultra-high-speed computation system, equipping with in silico analysispartandspecializedartificialintelligencepart,

4

Online Real-tim

e Phase Mapping System

: The ExTRa Mapping Project from

Japan

Figure 4: Clinical cardiac electrophysiology lab in our university hospital. (Left) Dr. Kensuke Sakata; (Middle) me; and (Right) Dr. Tomoya Ozawa.

in order to spatio-temporally interpolate the intra-atrialbipolarsignals(Figure2).Thismappingsystemwas based on 41 bipolar intra-atrial electrograms,including9virtualelectrograms,recordedbya20-pole spiral-shapedcatheterwithadiameterof2.5cm (ReflexionHDTM,St.JudeMedicalInc.,MN,USA);therefore, a high signal density (~8 signals/cm2) was achieved. Based on the 5-second wavedynamics during AF, each phase map movie was fully automatically createdwith the ExTRaMappingwithin a few seconds and was immediately played at a 1/10speedfor50seconds.

By referring thetimingof the intra-atrial bipolarsignals,theinsilicopartcalculatedthevirtualactionpotentials duringAF (Figure3, toppanels). Becausethe phase mapping of this system was conducted accordingtotheconsecutivevirtualactionpotentials,thewavefrontandwavetail interaction,developingphasesingularitiesofrotors,wasabletobevisualized(Figure3,bottompanels).

Development of the ExTRa Mapping-guided Non-Paroxysmal AF Ablation

My group is now working on the research developing a novel ablation strategy for non-paroxysmal AF with the use of the ExTRaMapping(Figures4 to6). Thenmygroup’sfirstpaperon theExTRa Mapping was very recently published in theofficialjournalofAPHRS(SakataT,etal.JArrhythmia2018;34:176-184).

Inthisstudy,theExTRaMappingwasappliedto28patientswithnon-paroxysmalAFafterpulmonaryveinisolation.Then,non-passivelyactivatedareas(NPAs),in the forms of meandering rotors and/or multiplewavelets assumed to contain non-paroxysmal AFdrivers,wereautomaticallydetectedbythemappingsystem. Intriguingly, theNPAs, inwhich rotorswerefrequentlyobserved,didnotalwayscoincidewiththeconventionalindirectindicatorsofAFdrivers,suchascomplexfractionatedatrialelectrogramareasandlowvoltageareas.

5

Online Real-tim

e Phase Mapping System

: The ExTRa Mapping Project from

Japan

Furthermore,wefoundthatthecatheterablationtargeting such NPAs were effective in patients withnon-paroxysmalAFformaintainingsinusrhythm.TheendpointoftheablationfillingtheNPAsbydraggingtechnique with low-power radiofrequency wave was tomodifytheelectricaland/oranatomicalpropertiesof the NPAs rather than the AF termination duringthe procedure. Surprisingly, the freedom from non-paroxysmal AF and/or atrial tachycardia (AT) duringthe8.1±4.2-monthfollow-upaftertheExTRaMapping-

guidedNPAablationinadditiontoPVIwas79%,whichwasmarkedlyhigher than thatof theCFAE-targetedablation in our hospital (47%, unpublished data). Inaddition, the recurrence of atrial tachyarrhythmiaprobably due to the iatrogenic AT was very rarelyobservedduringthefollow-up.

Future Direction

Recently, there were some reports from USA and Europeas to the lowadditionaleffectivenessof therotor ablation. However, the online real-time rotorimaging by the ExTRaMapping was very useful forimproving the outcome of the non-paroxysmal AFablation in our hospital. The novel phase mappingsystem developed by my group has already beenemployed at several hospitals in Japan. In the nearfuture, Iwould like to conductmulticenter study toelucidatemoreeffectivestrategyoftherotorablation,and to contribute to further improvements of non-paroxysmal AF ablation. I also hope that the ExTRaMapping will spread throughout the world including Asiaandcancontributetoimprovingnon-paroxysmalAFablation.

Figure 6: Clinical data of the ExTRa Mapping was mainly analyzed by Dr. Kensuke Sakata.

Figure 5: Utilization of the ExTRa Mapping for non-paroxysmal AF ablation in our university hospital.

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The New

Lead Extraction Subcomm

ittee of APHRS

The New Lead Extraction Subcommittee of APHRSMorio SHODA

Chairperson of the APHRS Lead Extraction Subcommittee

It’s a great pleasure for me to announce the Lead Extraction subcommittee of APHRS has justestablished.

As the implantation number of cardiac pacingdevicessuchaspacemaker,implantablecardioverter-defibrillator and cardiac resynchronization device isdramatically increasing, the problem which shouldbe solved has become greater in size and deviceinfectionisthemajorcomplicationamongthem.Weknowtotaldeviceremovalwithleadextractionistheonlycurativeapproach for infection,however,manypatients are undertreated especially in the AsianPacificregion.

The initial aims of the Lead Extraction sub-committeeofAPHRSaretoinvestigatetheprevalenceof device infection and condition which needs leadextractionandtoeducatephysicianswhoarewillingtoparticipateinthisimportantmedicine.Wehopetoestablishtheregistrationprogramforleadextractionnear in the future and to provide appropriate managementtoallpatientsinAsianPacificcountries.

APHRS Lead Extraction Subcommittee

Chairperson Morio SHODA (Japan)

Members Nigel LEVER (New Zealand)

Wee Siong TEO (Singapore)

Hung-FatTSE(HongKong)

Neil Strathmore (Australia)

Tachapong Ngarmukos (Thailand)

XuebinLI(China)

YenbinLIU(Taiwan)

BoyoungJOUNG(Korea)

BalbirSINGH(India)

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The History of EP in Cam

bodia

The History of EP in CambodiaMAM Chandara, MD

Electrophysiologist and Interventional CardiologistCalmette Hospital, Phnom Penh, Cambodia

TheKingdomofCambodiaisacountryinSoutheastAsianborderedbyVietnam to theeast, Laos to thenorth, Thailand tot the northwest, and the Gulf ofThailandtothesouthwest.

Electrophysiology in Cambodia was started in2010atPhnomPenhHeartCenter,CalmetteHospital,contributedbytheeffortoftwoelectrophysiologists:Dr. MAM Chandara (a Cambodian EP who finishedhis training from Pitier Sapetriere Hospital in Paris,France)andDr.WilliamChoe (anAmericanEP fromDenver,Colorado).

At the beginning, we combined and installedthe donated materials from France and the USAwith help of American engineering supporters from Denver (Saint Jude Medical and Biotronik),Coloradotoestablishthelab.Atthetime,therewasonly one cardiac catheterization laboratory in thehospitaland itwasusedforboth interventionalandelectrophysiologyprocedures.

We(Dr.MAMChandaraandDr.WilliamChoe)didthe first case of AVRT ablation successfully withoutrecurrence to date. Over the years, we have alsotrained three nurses working alongside with us to assistintheablationprocedures.

Figure 2: Photos featuring my professors and colleagues (left) and myself after a successful AVNRT ablation (right) at Pitie Sapetriere Hospital, Paris, France in 2009.

Figure 1: Kingdom of Cambodia: Angkor Wat

KINGDOM OF CAMBODIA

Capital: Phnom Penh

Religion: 97% Theravada Buddhism

Current population:

16 184 620 peoples

Official language: KhmerArea: 181 035 km2

8

The History of EP in Cam

bodia

At Calmette Hospital, we perform cardiacablation for arrhythmia disorders such as supra- ventricular tachycardias, frequent PVCs and ventricular tachycardias (without structural heart disease). Wehaveyetbeenusing3Danatomicmappingsystemfordoingcomplexcaseslikeventriculartachycardia(withstructuralheartdiseases),atrialfibrillationandothers.

Figure 3: We (Dr. MAM Chandara and Dr. William Choe, Josh from St. Jude Medical) were doing a procedure at Phnom Penh Heart Center, Calmette Hospital in 2010.

Figure 4: Professor Melvin Scheinman, Dr. MAM Chandara, Dr. CHUN Hwang and EP fellows at Phnom Penh Heart Center’s EP lab, Calmette Hospital in 2016.

In 2017, we installed a new cath-lab operatingroomfor facilitating theactivityofall interventionalproceduresatCalmetteHospital.

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