European Heart Journal (2015) 36, 133–140 doi:10.1093/eurheartj/ehu451
Free advice for young scientists to design research projects Senior researchers from the European Association for Cardiovascular Prevention and Rehabilitation are providing a mentoring service to help young scientists get good projects off the ground Senior researchers from the European Society of Cardiology’s European Association for Cardiovascular Prevention and Rehabilitation (EACPR) have set up a mentoring service to help young scientists design projects. The EACPR Research Support Project was conceived after acknowledging that over the past 10 years as many as 50% of all abstract submissions to the Association’s Annual Congress EuroPRevent would have benefited from guidance at the very onset of the study. Prof. Joep Perk (Sweden), chairperson of the EACPR Cardiovascular Prevention Implementation Committee, says: ‘There were quite some occasions where I felt that if I’d been there at the very start of the project I could have helped them not to make basic methodological mistakes’. Perk had some experience with junior doctors from other countries calling him on Skype and he had the idea that his advice had been useful for them in starting their research. He and a few colleagues set out to find a group of dedicated senior researchers within the EACPR willing to make themselves available for young researchers, who could contact them at the very onset of their project to exchange ideas and point the project in the right direction. ‘It’s like being there at the starting of an engine’, says Perk. ‘We help them to turn the key but also help them to drive their car in the right street’. A total of 22 senior colleagues – now called the mentor team of the EACPR – signed up within all four fields of the association: basic and translational science and exercise physiology; cardiovascular epidemiology, prevention and population science; cardiac rehabilitation; and sports cardiology. Perk says: ‘We asked people are you willing and the response was fantastic – almost everybody said yes’. Members of the EACPR who are under the age of 36 years are eligible for support. There are already .500 people who fit the criteria and membership is free. Perk says: ‘We will be delighted to open up to researchers beyond EACPR if it’s in our field but then it’s appreciated if they join our association’. Researchers looking for support should submit a summary of their project via the EACPR web pages that is no .500 words and describes the aim, proposed method, what/who will be
studied and how it will contribute to new knowledge in the field of preventive cardiology. They should also include the main question they want help with. Submissions will be directed to the most appropriate mentor. The mentor and the junior researcher will then receive information on how to contact each other to arrange an informal discussion. ‘It’s an extremely simple website based [submission]’, says Perk. ‘We have made it as uncomplicated as possible. It follows a bit the line of when you submit articles where Massimo Piepoli and I function as editors. We give it to our reviewers, in this case to our mentors, and then it runs by itself’. The service is intended as a one off consultation, preferably on FaceTime, Skype or similar media, of half an hour or so to exchange ideas and help the researcher start their project in the right direction from the very beginning. ‘This is one occasion to speak with a senior researcher and see is your idea valid, needed, feasible’, says Perk. ‘It’s up to our mentors to decide if this is so extremely exciting that [we should keep] our finger on the pulse a little bit longer’. Perk anticipates that the greatest area of need will be choosing the right methods for the hypothesis. Other issues may be ensuring that small projects avoid attempting to answer too many questions and confirming that the research is original and needed. ‘There are still so many questions in epidemiology that are unanswered and even more in prevention’, says Perk. ‘How do we get prevention messages across so that they really work? Locally adapted research programmes that will help preventive cardiology to become effective – that’s what we really feel is needed’. The advice is not intended to replace existing guidance systems in local institutions, but to translate a young researcher’s vision into a workable, high-quality project. A few months after the discussion both the researcher and mentor will be asked for feedback on whether it was useful of not. When results of the project are available, researchers should submit an abstract to EuroPRevent and/or a paper to the association’s journal, the European Journal of Preventive Cardiology. Support from the EACPR mentor should be acknowledged. Perk hopes the project – which will run for one year initially – will improve the qualityof abstracts submitted to EuroPRevent, but most importantly he wants to see more top notch science in the field as a whole.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
134 ‘It’s a way to give direction to new science so we get research that [asks] the questions we still need answers for’, he says. ‘And not publishing just because there’s a need to, but because there is a message there’. He concludes: ‘The need is mainly from countries where people have a long distance to well qualified support – Central and Eastern Europe but also the Mediterranean Basin. There are a lot of young, enthusiastic doctors out there but they are scientifically fairly isolated so we hope we will be able to reach out to them’.
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For more information or to submit a project, visit http://www. escardio.org/communities/EACPR/education/Pages/eacpr-researchsupport-project.aspx
EACPR mentors Basic and translational science and exercise physiology Volker Adams, Marco Guazzi, Martin Halle, Ulf Landmesser, Alessandro Mezzani, Luc Vanhees Cardiovascular epidemiology, prevention, and population science Pedro Marques-Vidal, Eva Prescott, Grethe S. Tell, Guy de Backer, Helmut Gohlke, Joep Perk, Torben Jørgensen Cardiac rehabilitation Hugo Saner, Miguel Mendes, Werner Benzer, Massimo Piepoli, Birna Bjarnason-Wehrens, Hannah McGee Sports cardiology Mats Borjesson, Josef Niebauer, Franc¸ois Carre
People’s corner: Marie-Claude Morice MD FESC FACC
‘Une Grande Dame’ of Interventional Cardiology received the Transcatheter Cardiovascular Therapeutics 2014 Geoffrey O. Hartzler Master Clinical Operator Award in 2014 The award is for consummate clinical skills and technical prowess in the cath lab and achievements over the course of a career which have a pro-found impact in the field of interventional cardiovascular medicine! It is presented at the Transcatheter Cardiovascular Therapeutics (TCT) meeting held annually in the USA. Past Honourees have included: Eberhard Grube, O. Katoh, H. Tamai, T Suzuki, Horst Sievert, Barry D. Rutherford, and Bernhard Meier. Marie-Claude was born and raised on the outskirts of Paris mainly by her mother, who was a great model of determination and strong will. She had a modest happy childhood. As a teenage schoolgirl, she experienced her initial exposure to gender inequality. The most arduous and selective school tracks were reserved for boys. A talented and beautiful teenager she showed a rebellious streak, growing a new hairstyle every year.
Marie-Claude began her medical studies in 1967 and received her MD in 1973 from the University of Medicine –Paris, followed by a cardiology degree in 1975. A year later, she was head of the Department of Haemodynamics at Centre Cardiologique du Nord in Paris until 1984. From 2008 to the present she has been founder and CEO of Centre Europeen de Reserche Cardiovasculaire . Marie-Claude has received many international achievement awards, including the Ethica ‘Best Clinical Researcher’ Award in 1995 (Rotterdam). A brilliant clinical interventionist – she is intuitive, creative, and bold. She makes ‘the difficult case seem easy’. An advocate of the ‘simple’ approach [keep it simple stupid KISS)], she does the most complex cases!
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Clinical research achievements have included, leader of most impactful clinical trials! MUST (stenting without Coumadin) RAVEL (first DES randomized trial) REALITY (Cypher vs. Taxus) SYNTAX (DES vs. CABG in MV/LM disease) EXCEL (DES vs. CABG in LM disease). Despite having to overcome gender bias, she has won the respect and admiration of her peers, rising to the highest levels of achievement with grace and professionalism! Jacques Crepeau, Montreal said ‘She came from Paris in 1985 with her young daughter to learn angioplasty in a world dominated by men. We rapidly noticed that this frail, feminine, and soft-spoken woman had a great technical ability but also, tremendous determination and poise, especially with patients. By her kindness and accomplishment, she conquered in only a few months the whole staff of the Montreal Heart Institute. Now, in 2014, she has conquered the world of invasive cardiology’.
Patrick W. Serruys has said of her: ‘If there was not a Marie-Claude Morice in interventional cardiology, we would have to create one’. Why is Marie-Claude so deserving of the Geoffrey O. Hartzler Master Clinical Operator Award? Because she is a superb clinical and technical interventionist in the best tradition of Geoffrey Hartzler! She embodies the triad of special skills, clinician, academician, and educator! Marie-Claude is a remarkable pioneering woman who has mentored a generation and has overcome many obstacles to achieve greatness! She is loved and respected by EVERYONE! Transcatheter cardiovascular therapeutics Transcatheter cardiovascular therapeutics is the world’s largest and most important educational meeting specializing in interventional cardiovascular medicine. For 26 years, TCT has been at the centre of new cutting-edge educational content. Transcatheter cardiovascular therapeutics showcases the latest advances in current therapies and clinical research and continues to provide a long-standing commitment to present life-saving innovations to translate into improved patient care. Transcatheter cardiovascular therapeutics attracts over 11 000 attendees from 90 different countries, over 1400 submitted abstracts from 60 countries, 40 h of live case transmissions from 21 sites around the world and over 1000 key opinion leaders as speakers for the programme. Andros Tofield
Advising patients about electronic cigarettes E-cigarettes are a new item on the market for smokers delivering nicotine and not regulated as drugs or devices. Nancy A. Rigotti MD Professor of Medicine, Harvard Medical School, discusses their place in the physician’s repertoire to help smokers. Cardiologists are well aware of the harms caused by cigarette smoking and are urged to treat tobacco use as vigorously as they do other cardiovascular risk factors.1 Recently, however, these conversations with patients may have a new twist. Smokers may be asking questions about the electronic cigarette, often called an e-cigarette. Should they try it? Is it safe? Will it help them to quit smoking or at least reduce their cardiovascular risk? The smokers asking these questions are often the ones who have failed other tobacco cessation treatments. Clinicians need to be ready to answer these questions. E-cigarettes are innovative battery-operated nicotine delivery devices that resemble conventional cigarettes and simulate the experience of smoking for the user.2,3 Unlike conventional cigarettes, which burn tobacco and generate smoke, e-cigarettes heat a liquid containing nicotine, flavourings, propylene glycol, and other chemicals, producing a vapour that the user inhales. Both products deliver nicotine, the addictive agent in tobacco, but e-cigarettes do not expose the user to the other constituents of cigarette smoke
such as tar and carbon monoxide that cause cardiovascular disease and tobacco’s other harms.2,3 Theoretically, using e-cigarettes to stop smoking or even just switching from conventional cigarettes to e-cigarettes should reduce an individual smoker’s health risk. Some observers have even suggested that e-cigarettes might become sufficiently attractive to consumers in the future that they could replace conventional cigarettes altogether.2,4,5 In fact, little is actually known about e-cigarettes’ benefits and harms because they entered the marketplace without having been regulated as either drugs or devices. Invented by a Chinese pharmacist in 2003, e-cigarettes came to European and US markets 2006.2 Since then, their use has increased dramatically among both adults and adolescents, primarily among smokers.2,3 Initially produced by small companies and marketed and sold through non-traditional channels such as the Internet, they are now available in traditional retail outlets. Large tobacco manufacturers have begun to invest in developing these products, in part to offset the loss of revenue
136 from falling conventional cigarette sales.6 Government regulatory agencies have only recently begun to take notice.2,7 Consequently, few restrictions now exist on their contents, manufacturing, marketing or sales. In the meantime, e-cigarettes are evolving products, with newer generation products delivering more nicotine to the user but resembling conventional cigarettes less.3 Little research has yet been done about e-cigarettes’ safety, health effects, or efficacy as smoking cessation aids for the individual cigarette smoker.2,3 Even less is known about indirect effects that they might have on the overall population including children and adolescents. The absence of data has produced a vigorous debate about the potential effects of e-cigarettes. Despite the absence of studies, most experts expect that cigarette smokers who switch to e-cigarettes will reduce their risk of tobacco-related disease, whether or not they quit smoking entirely.2 Even if inhaling e-cigarette vapour has some risks, most experts agree that they are likely to be much less than the risks of inhaling cigarette smoke.2 Whether e-cigarettes are effective as tools for smoking cessation or reduction is unclear. Cross-sectional and prospective observational studies report mixed results regarding efficacy.8 – 10 One published randomized controlled trial has compared e-cigarettes with nicotine patches; it found no significant difference between the two products, which each were only modestly effective in the study.11 Nonetheless, e-cigarette advertising, while carefully not making explicit claims, strongly implies that e-cigarettes are safer products that can help smokers quit using conventional cigarettes.12 E-cigarettes’ potential impact on public health is more controversial. Two principal concerns exist. First, if e-cigarettes appeal to children, they might be a gateway to promoting conventional cigarette smoking. This could occur if children who would not have tried cigarettes use e-cigarettes, become nicotine dependent, and progress to smoking combustible cigarettes. There is ample evidence that e-cigarettes are already marketed using tactics that tobacco companies previously used to market conventional cigarettes.12 For example, e-cigarettes are commonly marketed with flavourings, including candy, fruit, soda, and alcohol flavours that appeal to youths and are banned in conventional cigarettes for this reason.13 A second public health concern is that if e-cigarettes are allowed where cigarette smoking is not, they could reverse the ‘de-normalization’ of smoking that followed the passage of smoke-free laws and which is credited with contributing to reducing smoking prevalence.2,5 These adverse effects could theoretically be mitigated, though perhaps not completely prevented, by appropriate governmental regulation that would treat e-cigarettes such as conventional
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cigarettes, banning their use where conventional cigarettes are banned and subjecting e-cigarettes’ content, sales, and marketing to the regulatory constraints similar to those that apply to conventional cigarettes. Regulatory agencies in the USA and Europe are currently deciding how to proceed.7,14 In the meantime, clinicians need to know what to recommend to the individual smokers in their practice who ask about using e-cigarettes. We suggest explaining that e-cigarettes are new nicotine delivery devices about which we currently have more questions than answers. We do not know how safe they are because their manufacturing and sale is not regulated, but they are likely to be safer than continuing to smoke cigarettes. We remind smokers that the ultimate goal is to stop all cigarette use, and that safe and effective treatments to help them reach that goal already exist. We tell smokers that we recommend these evidence-based methods first, because we do not yet know if e-cigarettes help smokers to quit. Smokers who previously failed conventional treatments can be reluctant to try them again but they often did not use them optimally and can be willing to try newer approaches that we now know are more effective, such as using combinations of nicotine replacement therapy products or other combinations of smoking cessation medications. However, if a smoker is not able or unwilling to use conventional treatment we do not discourage the use of e-cigarettes while stressing the uncertainty about their safety and efficacy as therapeutic devices. Most of all, we make it clear to the smoker that their efforts to become smoke-free will continue to receive our strong support and assistance.
Conflict of interest: Neither author has any conflicts to disclose.
References References are available as supplementary material at European Heart Journal online.
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Electronic cigarettes: the pulmonologist’s point of view Since their emergence in 2003, electronic cigarettes (e-cigarettes), battery-operated devices that mimic the look and feel of smoking by vaporizing a chemical mixture usually composed of nicotine, propylene glycol, and other chemicals, have been heavily advertised as a harmless but effective tool for smoking cessation. As such they have been purchased by millions of smokers to help them quit (http://smokinginengland.info/latest-statistics/) and sales have surpassed more than half a billion Euros a year in Europe in 2013. Recent data from the US Center for Disease Control and Prevention showed that e-cigarette use has doubled among US students during 2011 –12 and an estimated 1.8 million students have used e-cigarettes. This is concerning because nicotine may have an impact on adolescent brain development, induce nicotine addiction and trigger the use of conventional cigarettes. Thus, e-cigarettes may undermine the efforts to de-normalize smoking by smoke-free legislation. There is also concern that e-cigarettes cause other adverse health effects by emission of fine and ultrafine liquid particles that are inhaled. A public health dispute has evolved on the basis of the rapidly growing market and the perceived potential benefits and harm. Concerning this debate from a respiratory physician’s point of view, the essential question is, whether e-cigarettes are safe and effective in helping smokers to quit and thus are a welcome contribution to our armamentarium for the prevention of smoking induced diseases such as chronic obstructive pulmonary disease, lung cancer and cardiovascular disease, among many others. There is evidence from research that e-cigarettes are capable of delivering nicotine to the lung and consequently to the bloodstream, thereby attenuating tobacco withdrawal symptoms with an effectiveness comparable with conventional nicotine replacement therapy (NRT).1 Although there are many reports on e-cigarettes available, to date there are only two randomized placebo-controlled trials which included a smoking cessation endpoint at 6 months or more.2,3 In the trial by Caponetto et al.,2 300 adult Italian smokers unwilling to quit were randomized to one of three groups: 7.2 mg nicotine cigarettes for 12 weeks, 7.2 mg cigarettes for 6 weeks followed by 5.4 mg cigarettes for 6 weeks, and cigarettes containing no nicotine for 12 weeks. At 12 months, 39% of the participants had been lost to follow-up, possibly reflecting the included population of smokers unwilling to give up smoking; 13, 9, and 4% had quit in the
two nicotine e-cigarette groups and the placebo e-cigarette group, respectively. The differences in quit rates between the groups were not statistically significant. In the other trial, Bullen et al.3 randomized 657 smokers to one of three groups (289 to nicotine e-cigarettes, 295 to nicotine patches, and 73 to placebo e-cigarettes) and abstinence was assessed at 6 months. E-cigarette use was associated with few adverse events comparable with nicotine patches. In the nicotine e-cigarette group, 7.3% stopped smoking compared with 5.8% in the nicotine patch group and 4.1% in the placebo e-cigarettes group (differences not statistically significant). However, due to the lower than anticipated achievement of abstinence, the trial was underpowered to draw definitive conclusions regarding the comparative effectiveness of e-cigarettes in inducing smoking abstinence. In both trials no behavioural support was provided to the study participants, possibly explaining the modest quit rates which are much the same as in trials of NRT products without behavioural support. Thus, for the time being, it must be concluded that e-cigarettes are modestly effective at helping smokers to quit and seem no more effective than nicotine patches. Much desired data from controlled trials looking at hard end-points such as the occurrence of smoking-related diseases chronic obstructive pulmonary disease, lung cancer, major adverse cardiac events or death, are currently not available and possibly will not be for a long time. In light of the available evidence, there is uncertainty regarding the role of e-cigarettes in tobacco control, and more high-quality research including long-term safety and effectiveness outcomes is needed to define their possible benefits and harms with more certainty. M.K. has no conflict of interest regarding this article.
References References are available as supplementary material at European Heart Journal online.
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Physician, engineer, inventor and entrepreneur: Dr Johannes Mu¨ller has contributed to Berlin’s reputation as a hot-spot for Med-Tech companies Dr Johannes Mu¨ller, a highly accomplished physician and engineer, has developed cutting-edge medical devices that have reshaped diagnostics and treatments in cardiac surgery and cardiology. His name is also linked to Berlin’s surge as a Mecca for medical technology in Germany over the past years. Awards, such as the City of Berlin Research Award, the Medical Oscar for transferring a cardiac-assist device for newborns from a university lab-based system to a medically approved commercially available worldwide device, the European Society of Artificial Organs Award and many others, refer to Johannes Mu¨ller’s fundamental contributions in a unique innovative field during the past several years. However, looking back at this impressive list of achievements in medical device development, it is striking how simply and modest Mu¨ller explains his inventions. Johannes Mu¨ller describes the decisive steps, which allowed him to design several pioneering medical devices. His first contribution, during his clinical training, was the development of a method, allowing the non-invasive detection of rejection episodes after heart transplantation by an implantable device (IMEG System) instead of performing endomyocardial biopsies. Another of his important contributions was the development of a mobile driving unit for the pulsatile cardiac-assist device for children with heart failure. Based on his idea, Berlin Heart extended the famous EXCOR device, which has in the meantime emerged as a new treatment standard in the USA for bridge to transplantation in paediatric heart failure patients. Based on his patent, another major contribution in cardiac device technology was an implantable, magnetically levitated axial flow pump. The pump has no touching parts and magnetic levitation causes free flotation of a spinning impeller, resulting in almost frictionless rotor movement. This axial blood pump, which entered the market as the INCOR device, again distributed by Berlin Heart, provides continuous forward flow as well as unloading of the impaired left ventricle. Compared with external-assist devices, it has the advantage of greater simplicity, less vulnerability, and smaller size. Roland Hetzer, former chair and head of the German Heart Center implanted the first INCOR devices in 2002 in Berlin. Mu¨ller’s name is not only linked to the successful cardiac-assist devices. As an engineer and physician he had learned to understand physiology and was driven by ambition to use his knowledge for contributions in the development of heart failure therapies. When he was still a medical student, he designed a small neurostimulating electric device, similar to a pacemaker, based on physiological principles, which activates baroreceptors in the wall of the carotid artery. Nowadays, this device distributed as a vagus nerve stimulator takes advantage of the body’s natural baroreflex system
to relax blood vessels, to slow the heart rate and reduce fluid retention in the body. Another example of Mu¨ller’s entrepreneurship is a recently launched start-up company, Berlin Cures, which takes up the cause of developing a drug against diseases induced and/or maintained by autoantibodies directed against G-protein-coupled receptors. Johannes Mu¨ller’s career and impressive contributions as inventor and entrepreneur in health care technology is closely linked to Berlin, the capital of Germany and currently one of the most attractive cities for High Tech companies in the European Union. Berlin provides a particularly exciting environment for innovative start-ups in the medical-technology sector. This is due to the fact, that one of Europe’s largest University Hospital, the Charite´ is among over 100 regional hospitals in the greater city area and several renowned research institutes, such as Max Delbru¨ck Center for Molecular Medicine, the German Arthritis Research Center and the Technical University Berlin are located in Berlin. If innovation is to turn into economic strength, a critical mass of academic environment is always required. Excellently trained professionals, strong research performance, and high reputation of academic institutes are all critical. In addition Germany’s capital developed a reputation as a creative, multicultural, and vibrant city with high, but still affordable quality of life. The city’s authority’s support for start-up business boosted the local medical-technology scene. Johannes Mu¨ller has again chosen Berlin as the location for his recently founded Berlin Heals. Berlin Heals, a medical engineering company, aims to distribute a novel cardiac device for heart failure treatment. Mu¨ller explains: ‘heart failure has become one of the most important causes of hospitalization and mortality in the Western world. Current evidence-based therapies are mainly on pharmacologic concepts aimed at the vicious cycle between progressive loss of cardiac function and the resulting counter-regulatory but further harmful mechanisms such as salt and water retention or sympathetic activation. Specific groups of patients take advantage of cardiac resynchronization, but real causal treatment approaches are lacking’. Johannes Mu¨ller gets excited. You can feel his commitment, when he outlines his novel therapeutic concept. ‘We realized that a weak electrical current prevents and even reverts pathological remodelling, including the functional impairment of cardiomyocytes, tissue fibrosis and dilation of heart chambers. These reparative effects are reproducible in vivo, in rats with heart failure using an external cardiac device delivering a microcurrent over a specially designed silicone based platinum electrode’. At the moment, a preproduction model of a microcurrent device for use in humans is under development. Mu¨ller is convinced, that initial preliminary studies in patients will be coming within the next
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2 years. ‘The concept is simple, but the effects are impressive’ Mu¨ller says. ‘Very low electric current improving microtexture and cardiomyocyte contractility sounds weird, but our data look great’. Despite his enthusiasm, Johannes Mu¨ller is well aware that the biological mechanisms of his appealing microcurrent concept are still poorly understood. This might be disappointing from an academic point of view. But from the perspective of an inventor and entrepreneur the focus is on his commitment to provide a novel strategy against a deadly disease – and on business as well. Berlin is a hot spot – for health care, for research and for medicaltechnology companies. Johannes Mu¨ller represents one of the masterminds, who analyses clinical problems, offers innovative technical
treatment concepts, and translates them into novel devices and business ideas. This is a way to go and Berlin is a place where medicine, academics, and industry meet.
Conflict of interest: U.R. is a member of the Berlin Heals scientific advisory board, collaborates with several Research groups in Berlin and has received speaker invitations from Charite´ University.
Dr Sabine Ernst, FESC presented the latest innovations to improve atrial fibrillation therapies at European Society of Cardiology Congress 2014 It is now increasingly clear that atrial fibrillation (AF) is an inherited disease as demonstrated by M. Olesen (Copenhagen, DK) in the first presentation of the session. Genome wide association studies are used to detect genetic loci associated with AF. However, the precise pathophysiological consequences of the AF susceptibility loci are still not completely understood and further investigations in larger cohorts are warranted. Morten O’Neill (London, GB) reported on the clinical studies focusing on the substrate of AF which all demonstrated a clear association between AF and atrial fibrosis. Late gadolinium enhancement in cardiac magnetic resonance imaging as well as electro-anatomical voltage mapping techniques is employed to visualize and quantify atrial fibrosis. Reproducibility and prospective analysis of the imaging results as a personalized roadmap for the individual patient is still limited, mostly due to the lack of spatial resolution during image acquisition. Novel multi-electrode mapping systems have recently entered the arena of EP mapping of AF, which allow simultaneous recordings even outside the catheter lab. Sebastian Knecht’s (Brussels, BE) presentation focused on the use of the body surface mapping system ecVUE (Cardiolnsight) in a multicentre trial of AF
mapping and ablation. Using this ‘global’ electrical information, concurrent electrical activation can be identified that presents like drivers or foci of AF. Ablation strategies aiming at these novel targets are investigated at present, but multicentre outcome data are only preliminary as of now. Petr Neuzil (Praha, CZ) presented on the multitude of novel ablation catheters that all aim at improving lesion quality and durability. Alternative energy sources such as laser, cryo, and ultrasound energy have been investigated in recent years. However, great caution needs to be applied to avoid ‘overshooting’ with lesion formation and thereby risking collateral damage (which could in the worst case be life-threatening). Combinations of geometry acquisition and lesion deployment in a single device (e.g. by ultrasound) are currently being investigated. In summary, the understanding of the individual substrate for AF is still very limited and adequate ‘tailoring’ of the applied ablation strategy is not widely applicable at present. Further improvements in imaging, mapping, and catheter technologies are necessary to improve the outcome of this treatment option for AF patients. ESC Congress Report
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Visualizing a safe place reduces pain during ablation of atrial fibrillation Visualizing a safe place reduces pain during ablation of atrial fibrillation (AF), according to research from Denmark. In the first clinical study of visualization during ablation of AF, the researchers compared outcomes between 76 patients who used visualization and 71 patients who received conventional care. Patients using visualization were asked to focus on a safe place during the procedure, for example the beach or the woods. All the patients were awake during the 2– 4 h treatment and received local anaesthesia plus painkillers when they signalled the nurse using a push button. During the procedure patients scored their pain and anxiety levels every 15 min and after specific painful experiences. Patients who used visualization during the procedure were in pain less often and asked for fewer painkillers. When the patients perceived pain, there were no differences between groups in the
perception of pain intensity and no differences in anxiety levels. These results were published last year in Pacing and Clinical Electrophysiology. The current investigation explored in more detail the experiences of 14 patients who had used visualization during the clinical study. Qualitative interviews were conducted and subjected to inductive content analysis. Lead author Marianne Wetendorff Nørgaard said: ‘Patients told us that visualising their own safe place during the procedure made them feel involved and helped them cope with pain and anxiety. Before the intervention patients were anxious and afraid of being on the operating table for a long time but afterwards they said visualisation had made it seem short and that it was a positive and pleasant experience’. The qualitative study is published in the European Journal of Cardiovascular Nursing.
CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]
Free advice for young scientists to design research projects Senior researchers from the European Association for Cardiovascular Prevention and Rehabilitation are providing a mentoring service to help young scientists get good projects off the ground Senior researchers from the European Society of Cardiology’s European Association for Cardiovascular Prevention and Rehabilitation (EACPR) have set up a mentoring service to help young scientists design projects. The EACPR Research Support Project was conceived after acknowledging that over the past 10 years as many as 50% of all abstract submissions to the Association’s Annual Congress EuroPRevent would have benefited from guidance at the very onset of the study. Prof. Joep Perk (Sweden), chairperson of the EACPR Cardiovascular Prevention Implementation Committee, says: ‘There were quite some occasions where I felt that if I’d been there at the very start of the project I could have helped them not to make basic methodological mistakes’. Perk had some experience with junior doctors from other countries calling him on Skype and he had the idea that his advice had been useful for them in starting their research. He and a few colleagues set out to find a group of dedicated senior researchers within the EACPR willing to make themselves available for young researchers, who could contact them at the very onset of their project to exchange ideas and point the project in the right direction. ‘It’s like being there at the starting of an engine’, says Perk. ‘We help them to turn the key but also help them to drive their car in the right street’. A total of 22 senior colleagues – now called the mentor team of the EACPR – signed up within all four fields of the association: basic and translational science and exercise physiology; cardiovascular epidemiology, prevention and population science; cardiac rehabilitation; and sports cardiology. Perk says: ‘We asked people are you willing and the response was fantastic – almost everybody said yes’. Members of the EACPR who are under the age of 36 years are eligible for support. There are already .500 people who fit the criteria and membership is free. Perk says: ‘We will be delighted to open up to researchers beyond EACPR if it’s in our field but then it’s appreciated if they join our association’. Researchers looking for support should submit a summary of their project via the EACPR web pages that is no .500 words and describes the aim, proposed method, what/who will be
studied and how it will contribute to new knowledge in the field of preventive cardiology. They should also include the main question they want help with. Submissions will be directed to the most appropriate mentor. The mentor and the junior researcher will then receive information on how to contact each other to arrange an informal discussion. ‘It’s an extremely simple website based [submission]’, says Perk. ‘We have made it as uncomplicated as possible. It follows a bit the line of when you submit articles where Massimo Piepoli and I function as editors. We give it to our reviewers, in this case to our mentors, and then it runs by itself’. The service is intended as a one off consultation, preferably on FaceTime, Skype or similar media, of half an hour or so to exchange ideas and help the researcher start their project in the right direction from the very beginning. ‘This is one occasion to speak with a senior researcher and see is your idea valid, needed, feasible’, says Perk. ‘It’s up to our mentors to decide if this is so extremely exciting that [we should keep] our finger on the pulse a little bit longer’. Perk anticipates that the greatest area of need will be choosing the right methods for the hypothesis. Other issues may be ensuring that small projects avoid attempting to answer too many questions and confirming that the research is original and needed. ‘There are still so many questions in epidemiology that are unanswered and even more in prevention’, says Perk. ‘How do we get prevention messages across so that they really work? Locally adapted research programmes that will help preventive cardiology to become effective – that’s what we really feel is needed’. The advice is not intended to replace existing guidance systems in local institutions, but to translate a young researcher’s vision into a workable, high-quality project. A few months after the discussion both the researcher and mentor will be asked for feedback on whether it was useful of not. When results of the project are available, researchers should submit an abstract to EuroPRevent and/or a paper to the association’s journal, the European Journal of Preventive Cardiology. Support from the EACPR mentor should be acknowledged. Perk hopes the project – which will run for one year initially – will improve the qualityof abstracts submitted to EuroPRevent, but most importantly he wants to see more top notch science in the field as a whole.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
134 ‘It’s a way to give direction to new science so we get research that [asks] the questions we still need answers for’, he says. ‘And not publishing just because there’s a need to, but because there is a message there’. He concludes: ‘The need is mainly from countries where people have a long distance to well qualified support – Central and Eastern Europe but also the Mediterranean Basin. There are a lot of young, enthusiastic doctors out there but they are scientifically fairly isolated so we hope we will be able to reach out to them’.
CardioPulse
For more information or to submit a project, visit http://www. escardio.org/communities/EACPR/education/Pages/eacpr-researchsupport-project.aspx
EACPR mentors Basic and translational science and exercise physiology Volker Adams, Marco Guazzi, Martin Halle, Ulf Landmesser, Alessandro Mezzani, Luc Vanhees Cardiovascular epidemiology, prevention, and population science Pedro Marques-Vidal, Eva Prescott, Grethe S. Tell, Guy de Backer, Helmut Gohlke, Joep Perk, Torben Jørgensen Cardiac rehabilitation Hugo Saner, Miguel Mendes, Werner Benzer, Massimo Piepoli, Birna Bjarnason-Wehrens, Hannah McGee Sports cardiology Mats Borjesson, Josef Niebauer, Franc¸ois Carre
People’s corner: Marie-Claude Morice MD FESC FACC
‘Une Grande Dame’ of Interventional Cardiology received the Transcatheter Cardiovascular Therapeutics 2014 Geoffrey O. Hartzler Master Clinical Operator Award in 2014 The award is for consummate clinical skills and technical prowess in the cath lab and achievements over the course of a career which have a pro-found impact in the field of interventional cardiovascular medicine! It is presented at the Transcatheter Cardiovascular Therapeutics (TCT) meeting held annually in the USA. Past Honourees have included: Eberhard Grube, O. Katoh, H. Tamai, T Suzuki, Horst Sievert, Barry D. Rutherford, and Bernhard Meier. Marie-Claude was born and raised on the outskirts of Paris mainly by her mother, who was a great model of determination and strong will. She had a modest happy childhood. As a teenage schoolgirl, she experienced her initial exposure to gender inequality. The most arduous and selective school tracks were reserved for boys. A talented and beautiful teenager she showed a rebellious streak, growing a new hairstyle every year.
Marie-Claude began her medical studies in 1967 and received her MD in 1973 from the University of Medicine –Paris, followed by a cardiology degree in 1975. A year later, she was head of the Department of Haemodynamics at Centre Cardiologique du Nord in Paris until 1984. From 2008 to the present she has been founder and CEO of Centre Europeen de Reserche Cardiovasculaire . Marie-Claude has received many international achievement awards, including the Ethica ‘Best Clinical Researcher’ Award in 1995 (Rotterdam). A brilliant clinical interventionist – she is intuitive, creative, and bold. She makes ‘the difficult case seem easy’. An advocate of the ‘simple’ approach [keep it simple stupid KISS)], she does the most complex cases!
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Clinical research achievements have included, leader of most impactful clinical trials! MUST (stenting without Coumadin) RAVEL (first DES randomized trial) REALITY (Cypher vs. Taxus) SYNTAX (DES vs. CABG in MV/LM disease) EXCEL (DES vs. CABG in LM disease). Despite having to overcome gender bias, she has won the respect and admiration of her peers, rising to the highest levels of achievement with grace and professionalism! Jacques Crepeau, Montreal said ‘She came from Paris in 1985 with her young daughter to learn angioplasty in a world dominated by men. We rapidly noticed that this frail, feminine, and soft-spoken woman had a great technical ability but also, tremendous determination and poise, especially with patients. By her kindness and accomplishment, she conquered in only a few months the whole staff of the Montreal Heart Institute. Now, in 2014, she has conquered the world of invasive cardiology’.
Patrick W. Serruys has said of her: ‘If there was not a Marie-Claude Morice in interventional cardiology, we would have to create one’. Why is Marie-Claude so deserving of the Geoffrey O. Hartzler Master Clinical Operator Award? Because she is a superb clinical and technical interventionist in the best tradition of Geoffrey Hartzler! She embodies the triad of special skills, clinician, academician, and educator! Marie-Claude is a remarkable pioneering woman who has mentored a generation and has overcome many obstacles to achieve greatness! She is loved and respected by EVERYONE! Transcatheter cardiovascular therapeutics Transcatheter cardiovascular therapeutics is the world’s largest and most important educational meeting specializing in interventional cardiovascular medicine. For 26 years, TCT has been at the centre of new cutting-edge educational content. Transcatheter cardiovascular therapeutics showcases the latest advances in current therapies and clinical research and continues to provide a long-standing commitment to present life-saving innovations to translate into improved patient care. Transcatheter cardiovascular therapeutics attracts over 11 000 attendees from 90 different countries, over 1400 submitted abstracts from 60 countries, 40 h of live case transmissions from 21 sites around the world and over 1000 key opinion leaders as speakers for the programme. Andros Tofield
Advising patients about electronic cigarettes E-cigarettes are a new item on the market for smokers delivering nicotine and not regulated as drugs or devices. Nancy A. Rigotti MD Professor of Medicine, Harvard Medical School, discusses their place in the physician’s repertoire to help smokers. Cardiologists are well aware of the harms caused by cigarette smoking and are urged to treat tobacco use as vigorously as they do other cardiovascular risk factors.1 Recently, however, these conversations with patients may have a new twist. Smokers may be asking questions about the electronic cigarette, often called an e-cigarette. Should they try it? Is it safe? Will it help them to quit smoking or at least reduce their cardiovascular risk? The smokers asking these questions are often the ones who have failed other tobacco cessation treatments. Clinicians need to be ready to answer these questions. E-cigarettes are innovative battery-operated nicotine delivery devices that resemble conventional cigarettes and simulate the experience of smoking for the user.2,3 Unlike conventional cigarettes, which burn tobacco and generate smoke, e-cigarettes heat a liquid containing nicotine, flavourings, propylene glycol, and other chemicals, producing a vapour that the user inhales. Both products deliver nicotine, the addictive agent in tobacco, but e-cigarettes do not expose the user to the other constituents of cigarette smoke
such as tar and carbon monoxide that cause cardiovascular disease and tobacco’s other harms.2,3 Theoretically, using e-cigarettes to stop smoking or even just switching from conventional cigarettes to e-cigarettes should reduce an individual smoker’s health risk. Some observers have even suggested that e-cigarettes might become sufficiently attractive to consumers in the future that they could replace conventional cigarettes altogether.2,4,5 In fact, little is actually known about e-cigarettes’ benefits and harms because they entered the marketplace without having been regulated as either drugs or devices. Invented by a Chinese pharmacist in 2003, e-cigarettes came to European and US markets 2006.2 Since then, their use has increased dramatically among both adults and adolescents, primarily among smokers.2,3 Initially produced by small companies and marketed and sold through non-traditional channels such as the Internet, they are now available in traditional retail outlets. Large tobacco manufacturers have begun to invest in developing these products, in part to offset the loss of revenue
136 from falling conventional cigarette sales.6 Government regulatory agencies have only recently begun to take notice.2,7 Consequently, few restrictions now exist on their contents, manufacturing, marketing or sales. In the meantime, e-cigarettes are evolving products, with newer generation products delivering more nicotine to the user but resembling conventional cigarettes less.3 Little research has yet been done about e-cigarettes’ safety, health effects, or efficacy as smoking cessation aids for the individual cigarette smoker.2,3 Even less is known about indirect effects that they might have on the overall population including children and adolescents. The absence of data has produced a vigorous debate about the potential effects of e-cigarettes. Despite the absence of studies, most experts expect that cigarette smokers who switch to e-cigarettes will reduce their risk of tobacco-related disease, whether or not they quit smoking entirely.2 Even if inhaling e-cigarette vapour has some risks, most experts agree that they are likely to be much less than the risks of inhaling cigarette smoke.2 Whether e-cigarettes are effective as tools for smoking cessation or reduction is unclear. Cross-sectional and prospective observational studies report mixed results regarding efficacy.8 – 10 One published randomized controlled trial has compared e-cigarettes with nicotine patches; it found no significant difference between the two products, which each were only modestly effective in the study.11 Nonetheless, e-cigarette advertising, while carefully not making explicit claims, strongly implies that e-cigarettes are safer products that can help smokers quit using conventional cigarettes.12 E-cigarettes’ potential impact on public health is more controversial. Two principal concerns exist. First, if e-cigarettes appeal to children, they might be a gateway to promoting conventional cigarette smoking. This could occur if children who would not have tried cigarettes use e-cigarettes, become nicotine dependent, and progress to smoking combustible cigarettes. There is ample evidence that e-cigarettes are already marketed using tactics that tobacco companies previously used to market conventional cigarettes.12 For example, e-cigarettes are commonly marketed with flavourings, including candy, fruit, soda, and alcohol flavours that appeal to youths and are banned in conventional cigarettes for this reason.13 A second public health concern is that if e-cigarettes are allowed where cigarette smoking is not, they could reverse the ‘de-normalization’ of smoking that followed the passage of smoke-free laws and which is credited with contributing to reducing smoking prevalence.2,5 These adverse effects could theoretically be mitigated, though perhaps not completely prevented, by appropriate governmental regulation that would treat e-cigarettes such as conventional
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cigarettes, banning their use where conventional cigarettes are banned and subjecting e-cigarettes’ content, sales, and marketing to the regulatory constraints similar to those that apply to conventional cigarettes. Regulatory agencies in the USA and Europe are currently deciding how to proceed.7,14 In the meantime, clinicians need to know what to recommend to the individual smokers in their practice who ask about using e-cigarettes. We suggest explaining that e-cigarettes are new nicotine delivery devices about which we currently have more questions than answers. We do not know how safe they are because their manufacturing and sale is not regulated, but they are likely to be safer than continuing to smoke cigarettes. We remind smokers that the ultimate goal is to stop all cigarette use, and that safe and effective treatments to help them reach that goal already exist. We tell smokers that we recommend these evidence-based methods first, because we do not yet know if e-cigarettes help smokers to quit. Smokers who previously failed conventional treatments can be reluctant to try them again but they often did not use them optimally and can be willing to try newer approaches that we now know are more effective, such as using combinations of nicotine replacement therapy products or other combinations of smoking cessation medications. However, if a smoker is not able or unwilling to use conventional treatment we do not discourage the use of e-cigarettes while stressing the uncertainty about their safety and efficacy as therapeutic devices. Most of all, we make it clear to the smoker that their efforts to become smoke-free will continue to receive our strong support and assistance.
Conflict of interest: Neither author has any conflicts to disclose.
References References are available as supplementary material at European Heart Journal online.
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Electronic cigarettes: the pulmonologist’s point of view Since their emergence in 2003, electronic cigarettes (e-cigarettes), battery-operated devices that mimic the look and feel of smoking by vaporizing a chemical mixture usually composed of nicotine, propylene glycol, and other chemicals, have been heavily advertised as a harmless but effective tool for smoking cessation. As such they have been purchased by millions of smokers to help them quit (http://smokinginengland.info/latest-statistics/) and sales have surpassed more than half a billion Euros a year in Europe in 2013. Recent data from the US Center for Disease Control and Prevention showed that e-cigarette use has doubled among US students during 2011 –12 and an estimated 1.8 million students have used e-cigarettes. This is concerning because nicotine may have an impact on adolescent brain development, induce nicotine addiction and trigger the use of conventional cigarettes. Thus, e-cigarettes may undermine the efforts to de-normalize smoking by smoke-free legislation. There is also concern that e-cigarettes cause other adverse health effects by emission of fine and ultrafine liquid particles that are inhaled. A public health dispute has evolved on the basis of the rapidly growing market and the perceived potential benefits and harm. Concerning this debate from a respiratory physician’s point of view, the essential question is, whether e-cigarettes are safe and effective in helping smokers to quit and thus are a welcome contribution to our armamentarium for the prevention of smoking induced diseases such as chronic obstructive pulmonary disease, lung cancer and cardiovascular disease, among many others. There is evidence from research that e-cigarettes are capable of delivering nicotine to the lung and consequently to the bloodstream, thereby attenuating tobacco withdrawal symptoms with an effectiveness comparable with conventional nicotine replacement therapy (NRT).1 Although there are many reports on e-cigarettes available, to date there are only two randomized placebo-controlled trials which included a smoking cessation endpoint at 6 months or more.2,3 In the trial by Caponetto et al.,2 300 adult Italian smokers unwilling to quit were randomized to one of three groups: 7.2 mg nicotine cigarettes for 12 weeks, 7.2 mg cigarettes for 6 weeks followed by 5.4 mg cigarettes for 6 weeks, and cigarettes containing no nicotine for 12 weeks. At 12 months, 39% of the participants had been lost to follow-up, possibly reflecting the included population of smokers unwilling to give up smoking; 13, 9, and 4% had quit in the
two nicotine e-cigarette groups and the placebo e-cigarette group, respectively. The differences in quit rates between the groups were not statistically significant. In the other trial, Bullen et al.3 randomized 657 smokers to one of three groups (289 to nicotine e-cigarettes, 295 to nicotine patches, and 73 to placebo e-cigarettes) and abstinence was assessed at 6 months. E-cigarette use was associated with few adverse events comparable with nicotine patches. In the nicotine e-cigarette group, 7.3% stopped smoking compared with 5.8% in the nicotine patch group and 4.1% in the placebo e-cigarettes group (differences not statistically significant). However, due to the lower than anticipated achievement of abstinence, the trial was underpowered to draw definitive conclusions regarding the comparative effectiveness of e-cigarettes in inducing smoking abstinence. In both trials no behavioural support was provided to the study participants, possibly explaining the modest quit rates which are much the same as in trials of NRT products without behavioural support. Thus, for the time being, it must be concluded that e-cigarettes are modestly effective at helping smokers to quit and seem no more effective than nicotine patches. Much desired data from controlled trials looking at hard end-points such as the occurrence of smoking-related diseases chronic obstructive pulmonary disease, lung cancer, major adverse cardiac events or death, are currently not available and possibly will not be for a long time. In light of the available evidence, there is uncertainty regarding the role of e-cigarettes in tobacco control, and more high-quality research including long-term safety and effectiveness outcomes is needed to define their possible benefits and harms with more certainty. M.K. has no conflict of interest regarding this article.
References References are available as supplementary material at European Heart Journal online.
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Physician, engineer, inventor and entrepreneur: Dr Johannes Mu¨ller has contributed to Berlin’s reputation as a hot-spot for Med-Tech companies Dr Johannes Mu¨ller, a highly accomplished physician and engineer, has developed cutting-edge medical devices that have reshaped diagnostics and treatments in cardiac surgery and cardiology. His name is also linked to Berlin’s surge as a Mecca for medical technology in Germany over the past years. Awards, such as the City of Berlin Research Award, the Medical Oscar for transferring a cardiac-assist device for newborns from a university lab-based system to a medically approved commercially available worldwide device, the European Society of Artificial Organs Award and many others, refer to Johannes Mu¨ller’s fundamental contributions in a unique innovative field during the past several years. However, looking back at this impressive list of achievements in medical device development, it is striking how simply and modest Mu¨ller explains his inventions. Johannes Mu¨ller describes the decisive steps, which allowed him to design several pioneering medical devices. His first contribution, during his clinical training, was the development of a method, allowing the non-invasive detection of rejection episodes after heart transplantation by an implantable device (IMEG System) instead of performing endomyocardial biopsies. Another of his important contributions was the development of a mobile driving unit for the pulsatile cardiac-assist device for children with heart failure. Based on his idea, Berlin Heart extended the famous EXCOR device, which has in the meantime emerged as a new treatment standard in the USA for bridge to transplantation in paediatric heart failure patients. Based on his patent, another major contribution in cardiac device technology was an implantable, magnetically levitated axial flow pump. The pump has no touching parts and magnetic levitation causes free flotation of a spinning impeller, resulting in almost frictionless rotor movement. This axial blood pump, which entered the market as the INCOR device, again distributed by Berlin Heart, provides continuous forward flow as well as unloading of the impaired left ventricle. Compared with external-assist devices, it has the advantage of greater simplicity, less vulnerability, and smaller size. Roland Hetzer, former chair and head of the German Heart Center implanted the first INCOR devices in 2002 in Berlin. Mu¨ller’s name is not only linked to the successful cardiac-assist devices. As an engineer and physician he had learned to understand physiology and was driven by ambition to use his knowledge for contributions in the development of heart failure therapies. When he was still a medical student, he designed a small neurostimulating electric device, similar to a pacemaker, based on physiological principles, which activates baroreceptors in the wall of the carotid artery. Nowadays, this device distributed as a vagus nerve stimulator takes advantage of the body’s natural baroreflex system
to relax blood vessels, to slow the heart rate and reduce fluid retention in the body. Another example of Mu¨ller’s entrepreneurship is a recently launched start-up company, Berlin Cures, which takes up the cause of developing a drug against diseases induced and/or maintained by autoantibodies directed against G-protein-coupled receptors. Johannes Mu¨ller’s career and impressive contributions as inventor and entrepreneur in health care technology is closely linked to Berlin, the capital of Germany and currently one of the most attractive cities for High Tech companies in the European Union. Berlin provides a particularly exciting environment for innovative start-ups in the medical-technology sector. This is due to the fact, that one of Europe’s largest University Hospital, the Charite´ is among over 100 regional hospitals in the greater city area and several renowned research institutes, such as Max Delbru¨ck Center for Molecular Medicine, the German Arthritis Research Center and the Technical University Berlin are located in Berlin. If innovation is to turn into economic strength, a critical mass of academic environment is always required. Excellently trained professionals, strong research performance, and high reputation of academic institutes are all critical. In addition Germany’s capital developed a reputation as a creative, multicultural, and vibrant city with high, but still affordable quality of life. The city’s authority’s support for start-up business boosted the local medical-technology scene. Johannes Mu¨ller has again chosen Berlin as the location for his recently founded Berlin Heals. Berlin Heals, a medical engineering company, aims to distribute a novel cardiac device for heart failure treatment. Mu¨ller explains: ‘heart failure has become one of the most important causes of hospitalization and mortality in the Western world. Current evidence-based therapies are mainly on pharmacologic concepts aimed at the vicious cycle between progressive loss of cardiac function and the resulting counter-regulatory but further harmful mechanisms such as salt and water retention or sympathetic activation. Specific groups of patients take advantage of cardiac resynchronization, but real causal treatment approaches are lacking’. Johannes Mu¨ller gets excited. You can feel his commitment, when he outlines his novel therapeutic concept. ‘We realized that a weak electrical current prevents and even reverts pathological remodelling, including the functional impairment of cardiomyocytes, tissue fibrosis and dilation of heart chambers. These reparative effects are reproducible in vivo, in rats with heart failure using an external cardiac device delivering a microcurrent over a specially designed silicone based platinum electrode’. At the moment, a preproduction model of a microcurrent device for use in humans is under development. Mu¨ller is convinced, that initial preliminary studies in patients will be coming within the next
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2 years. ‘The concept is simple, but the effects are impressive’ Mu¨ller says. ‘Very low electric current improving microtexture and cardiomyocyte contractility sounds weird, but our data look great’. Despite his enthusiasm, Johannes Mu¨ller is well aware that the biological mechanisms of his appealing microcurrent concept are still poorly understood. This might be disappointing from an academic point of view. But from the perspective of an inventor and entrepreneur the focus is on his commitment to provide a novel strategy against a deadly disease – and on business as well. Berlin is a hot spot – for health care, for research and for medicaltechnology companies. Johannes Mu¨ller represents one of the masterminds, who analyses clinical problems, offers innovative technical
treatment concepts, and translates them into novel devices and business ideas. This is a way to go and Berlin is a place where medicine, academics, and industry meet.
Conflict of interest: U.R. is a member of the Berlin Heals scientific advisory board, collaborates with several Research groups in Berlin and has received speaker invitations from Charite´ University.
Dr Sabine Ernst, FESC presented the latest innovations to improve atrial fibrillation therapies at European Society of Cardiology Congress 2014 It is now increasingly clear that atrial fibrillation (AF) is an inherited disease as demonstrated by M. Olesen (Copenhagen, DK) in the first presentation of the session. Genome wide association studies are used to detect genetic loci associated with AF. However, the precise pathophysiological consequences of the AF susceptibility loci are still not completely understood and further investigations in larger cohorts are warranted. Morten O’Neill (London, GB) reported on the clinical studies focusing on the substrate of AF which all demonstrated a clear association between AF and atrial fibrosis. Late gadolinium enhancement in cardiac magnetic resonance imaging as well as electro-anatomical voltage mapping techniques is employed to visualize and quantify atrial fibrosis. Reproducibility and prospective analysis of the imaging results as a personalized roadmap for the individual patient is still limited, mostly due to the lack of spatial resolution during image acquisition. Novel multi-electrode mapping systems have recently entered the arena of EP mapping of AF, which allow simultaneous recordings even outside the catheter lab. Sebastian Knecht’s (Brussels, BE) presentation focused on the use of the body surface mapping system ecVUE (Cardiolnsight) in a multicentre trial of AF
mapping and ablation. Using this ‘global’ electrical information, concurrent electrical activation can be identified that presents like drivers or foci of AF. Ablation strategies aiming at these novel targets are investigated at present, but multicentre outcome data are only preliminary as of now. Petr Neuzil (Praha, CZ) presented on the multitude of novel ablation catheters that all aim at improving lesion quality and durability. Alternative energy sources such as laser, cryo, and ultrasound energy have been investigated in recent years. However, great caution needs to be applied to avoid ‘overshooting’ with lesion formation and thereby risking collateral damage (which could in the worst case be life-threatening). Combinations of geometry acquisition and lesion deployment in a single device (e.g. by ultrasound) are currently being investigated. In summary, the understanding of the individual substrate for AF is still very limited and adequate ‘tailoring’ of the applied ablation strategy is not widely applicable at present. Further improvements in imaging, mapping, and catheter technologies are necessary to improve the outcome of this treatment option for AF patients. ESC Congress Report
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Visualizing a safe place reduces pain during ablation of atrial fibrillation Visualizing a safe place reduces pain during ablation of atrial fibrillation (AF), according to research from Denmark. In the first clinical study of visualization during ablation of AF, the researchers compared outcomes between 76 patients who used visualization and 71 patients who received conventional care. Patients using visualization were asked to focus on a safe place during the procedure, for example the beach or the woods. All the patients were awake during the 2– 4 h treatment and received local anaesthesia plus painkillers when they signalled the nurse using a push button. During the procedure patients scored their pain and anxiety levels every 15 min and after specific painful experiences. Patients who used visualization during the procedure were in pain less often and asked for fewer painkillers. When the patients perceived pain, there were no differences between groups in the
perception of pain intensity and no differences in anxiety levels. These results were published last year in Pacing and Clinical Electrophysiology. The current investigation explored in more detail the experiences of 14 patients who had used visualization during the clinical study. Qualitative interviews were conducted and subjected to inductive content analysis. Lead author Marianne Wetendorff Nørgaard said: ‘Patients told us that visualising their own safe place during the procedure made them feel involved and helped them cope with pain and anxiety. Before the intervention patients were anxious and afraid of being on the operating table for a long time but afterwards they said visualisation had made it seem short and that it was a positive and pleasant experience’. The qualitative study is published in the European Journal of Cardiovascular Nursing.
CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]
