John Day, MD, FACC, FHRS,
The Journal of Innovations in Cardiac Rhythm Management
Director of Heart Rhythm Services
Intermountain Medical Center, Salt Lake City, UT
Our latest issue is packed full of interesting contributions from diverse institutions worldwide. We are confident that each manuscript will serve as a helpful resource of information that is directly applicable to your individual practices.
We begin with the review article from Hohnloser and colleagues on the topic of innovative pharmacological approaches to managing atrial fibrillation. As we are all aware, there are significant economic considerations in the management of the atrial fibrillation epidemic. The review from Hohnloser and colleagues provides a great assessment of the challenges we face in daily practice to best manage our patients. In particular, they outline the benefits and limitations of dronedarone in the management of atrial fibrillation.
It was once hoped that dronedarone would be the “Holy Grail” of atrial fibrillation medical management with all the benefits of amiodarone and without any of the toxicities. Unfortunately, we soon realized that dronedarone lacked the efficacy of amiodarone in maintaining sinus rhythm. Nevertheless, given its excellent safety profile in clinical studies, dronedarone was recently selected as a first-line antiarrhythmic medication for atrial fibrillation (http://www.ncbi.nlm.nih.gov/pubmed/21182985). However, on January 14, there was an FDA Drug Safety Communication reporting severe liver injury associated with the use of dronedarone (http://www.fda.gov/Drugs/DrugSafety/ucm240011.htm). The following week on January 22, The Wall Street Journal reported that the European Medicines Agency would also conduct a review of dronedarone in light of this new information of possible liver failure (http://online.wsj.com/article/SB10001424052748704754304576095913618867664.html).
So what are we to do with this new information? The manufacturer of the medication, Sanofi-Aventis, is emphasizing that although no causal association between the drug and liver injury has been established, physicians should consider periodic liver function tests during the first six months of treatment. Until further information is available, the possible association of liver failure with dronedarone should at least be part of the informed consent process for patients taking dronedarone. Consideration should also be made for periodic liver function tests during the first six months when starting patients on this medication.
In my practice, I am having a frank discussion with patients on the potential liver issues that may be associated with dronedarone. When starting dronedarone, I now obtain liver function tests when I see patients back one month after starting the medication. I get a second set of liver enzymes four months after starting the medication. For patients who have already been on dronedarone for a period of time, I will get one set of liver enzymes. Stay tuned for further information as to whether there is actually potential liver toxicity with dronedarone.
Also in this month’s issue is Part II of the article from Niazi and colleagues, which is a continuation of the manuscript from the January issue that examined innovative strategies for cardiac resynchronization therapy implantation. The current article, A Review of Innovative Strategies for CRT Implantation: Part II — Coronary Venous Stenting, explores in depth procedural approaches employed by Niazi and colleagues with regards to the role of coronary sinus stenting with CRT implantation. Unfortunately, we are often limited as to where we can place left ventricular pacing leads based on coronary sinus anatomy. In this article, they discuss the role of coronary sinus stenting to allow lead placement as well as their tips and tricks to accomplish this procedure. In addition, they discuss the role of stenting to fixate the left ventricular lead in the coronary sinus to prevent dislodgement.
Coronary sinus stenting has emerged as an effective technique to potentially increase the left ventricular acute implantation success rate. At our center, we have occasionally used coronary sinus stenting to allow left ventricular lead placement in difficult cases. We have not encountered any complications yet with this approach. It has allowed us on several occasions to avoid surgical placement of an epicardial left ventricular pacing lead. As more data emerge on this approach, I’m sure we will use this technique more in the future.
Currently, most electrophysiology training programs do not teach this new technique. This is definitely a new technique to keep on the “radar screen.” If further studies demonstrate the utility and safety of this approach, this may need to be an important skill set that is available at all implanting centers. Likewise, if this can be demonstrated to have significant benefit, then guidelines, medical societies, and training programs will need to address this new skill set and devise ways to learn this new procedure to facilitate left ventricular lead placement.
In a related discussion, Singh and colleagues provide a review of techniques that may better utilize CRT therapy in today’s practice. Unfortunately, about one-third of all patients will end up as non-responders to this critical therapeutic option. This illustrative approach article does an excellent job of demonstrating expert lead placement techniques in order to best utilize this important therapy in practice.
On behalf of the editorial board, I would like to extend a thank you to each of this month’s contributors. We greatly appreciate your wonderful articles!
We sincerely hope that you enjoy the current issue of The Journal of Innovations in Cardiac Rhythm Management, and we look forward to hearing your thoughts.
As always, your feedback is welcomed.