Presentation by Philippe Ritter

As in previous years, we are in the process of preparing comprehensive programs dedicated to pacing, ICD and CRT, though, as stated in our previous newsletter and 3rd announcement, a larger space will be reserved for educational sessions.

The general program is divided among several sessions, including the traditional Didactic Course focusing on a) CRT, organized by Serge Barold, David Hayes, and the Cardiostim Team , and b) ICD, chaired by David Cannom . John Helland and Rick McVenes will be in charge of 2 sessions dedicated to Leads, and Charles Kennergren is preparing 3 sessions assigned to lead extractions. Finally, 6 purely educational sessions will be based on patient records and on the interpretation of electrograms retrieved from device programmers.

• 1/ Advanced Didactic course on CRT organized by David Hayes, Philippe Ritter, Cardiostim Team

• 2/ Advanced Didactic course on ICD organized by David Cannom

• 3/ Leads, in charge John Helland and Rick McVenes

• 4/ Leads extractions organized by Charles Kennergren

• 5/ Educational sessions

The program of the 12th Advanced Didactic Course includes standard sessions and debates pertaining to major aspects of CRT, based on patient clinical records.

• The 1st session will recapitulate recent information and discuss a) the state of the art and conclusions of recent studies, b) new indications, likely to supplement existing international recommendations, c) which type of device to choose (pacemaker versus defibrillator), and d) evolution of techniques worldwide.

• The objective of this 2nd session is the teaching of latest techniques, with a view to optimize CRT. It will review ongoing studies and what is expected from cardiac resynchronization, including a) choice of candidates in the context of their clinical status and concomitant disorders, b) role of surgical techniques, and c) manual and automated optimization techniques.

• The 3rd session will discuss the optimal implantation of atrial and left and right ventricular leads. This should prompt a vigorous debate among pugnacious experts, who will share practical tricks and recipes.

• Left ventricular endocardial stimulation will be the highly debated subject of the 4th session. New approaches are needed to improve the quality of left ventricular stimulation, as the coronary sinus approach has reached its limits. Although it offers unequivocal advantages, left ventricular endocardial stimulation is risky, and associated with potentially major complications. If the initial, tightly monitored, controlled trials yield the expected hemodynamic results, it will spark a medical revolution. This session will be the object of a major debate and richly illustrated.

• Multipoint ventricular stimulation will be the subject of the 5th session. The unacceptably high rate of non-response to CRT has remained nearly unchanged since its inception. Might multipoint ventricular stimulation be the solution? Will it complement endocardial stimulation? We hope that this discussion will shed some light on the potential efficacy of this concept, as well as on its feasibility. In these last 2 sessions, the rationale will be explained, the results of completed feasibility studies will be presented, the techniques will be described, and their limitations discussed in their proper perspective.

• Pending the availability of solutions requiring tools and devices that have yet to be manufactured, our profession is preoccupied with the care of non-responders to CRT. While major efforts are being made to limit their numbers, attempts to convert non-responders to responders are rarely described. The 7th session will a) be entirely based on clinical cases, b) present means of optimizing CRT devices, and c) offer solutions when nothing seems to help. This task has been assigned to Berry Van Gelder and Daniel Gras, both renowned for their expertise in the hemodynamic programming of devices and operative skills, respectively.

• The 8th and last session of this course will take a look in the future of CRT. What will be the part played by remote monitoring? Will it enable a major decrease in the rate of non-response to therapy and of hospitalizations for management of heart failure? What are the tools needed for the follow-up of CRT system recipients? What is the status of cardiac contractility modulation, and what is the place of hemodynamic sensors in implantable devices?
These questions all have their answers in upcoming technologic advances.


The second series of sessions of the 12th Advanced Didactic Course is dedicated to ICD.

• The 1st session will review in detail the results of MADIT CRT and REVERSE, and will be presented by the principal investigators. Complementary results will undoubtedly be presented, shedding new light on these trials.

• As in the part I of this Didactic Course, the 2nd session will discuss practical challenges, with a view to prevent the delivery of inappropriate ICD shocks. A distinction of this session will be the use of the patient’s heart disease as a basis for device programming.

• The 3rd session will present cases, which do not closely fit the international guidelines. How often is the question asked: “This patient falls outside the guidelines, though he logically should receive a defibrillator or, at least, I am very tempted to recommend one”?

• Finally, the 4th and 5th sessions will discuss clinical cases, allowing the participants interactions with renowned experts in the field.

The group of sessions pertaining to leads is important. Isn’t the lead the weak link in a pacing or, especially, in a defibrillating system?

• The 1st session will explain in detail the tests imposed to the development and production of pacing and defibrillation leads. The presentations, delivered by engineers, will explain to physicians the steps that precede the marketing, the fragile areas of leads and, accordingly, the care to take at the time of implantation and follow-up.

• The 2nd session intends to be interactive between engineers and physicians toward the design of an ideal lead. In particular, the physicians will be able to express their wishes to facilitate the extraction of leads. What precedes will serve as an introduction to the series of 3 sessions on leads extractions.

We are launching a program on leads extractions, which has become a major preoccupation as a result of a) the increase in the number of patients presenting with infected implanted material, and b) the challenge represented by safe procedures.

• The 1st session will discuss the procedural safety measures to adopt. Despite its formal structure, this presentation will have an important practical impact. A lead extraction procedure requires experience and meticulous planning.

• All currently available techniques will be reviewed and illustrated in the 2nd session. The participants will be shown a) how to avoid pitfalls, and b) means of enhancing the safety and efficacy of the procedures. All speakers will be experts in the subject, bringing a rare level of competency.

• The 3rd session will review the indications for lead extraction in various clinical contexts, including leads that have become useless, infected, encased in dense fibrosis, or recalled because of safety issues. Since each case is different, the participants will understand that each indication must be discussed individually, by a multidisciplinary team.

These formal sessions will be supplemented by purely educational sessions, solely based on clinical cases, and organized by the Cardiostim Team, with Stéphane Garrigue and Philippe Ritter for the EDUSTIM program in English language, and Pierre Bordachar and Sylvain Reuter for the STIMUPRAT program in French.

A series of actual case presentations, based on electrograms stored in implanted devices and retrieved by programmers, will represent 1/3 of these sessions. The program organizers and engineers from various manufacturers will be present with the programmers, to interpret with the participants actual events memorized mainly in ICD and CRT devices. This interactive, friendly and dynamic format will be implemented at Cardiostim, after having been successfully tested in our Bordeaux region. Beware that the number of seats will be limited. EBAC and SFC credits will be asked for.

Finally, be sure to keep an eye on our web pages for regular updates of the general program.