CANet - On Track: Atrial Fibrillation

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Atrial Fibrillation FALL 2019 - ISSUE 3

trial Fibrillation Atrial Fibrillation is the most common kind of arrhythmia or irregular heart rhythm. It is a progressive, chronic condition that may get worse without treatment but can be treated effectively. Atrial fibrillation affects approximately 350,000 Canadians.

Atrial refers to the top two chambers of the heart, known as the atria. The atria are designed to send blood efficiently and rhythmically into the ventricles by way of regular electrical signals. The ventricles then pump the blood to the rest of the body. In atrial fibrillation, the electrical signals are rapid, irregular and disorganized and the heart may not pump efficiently. Atrial fibrillation increases the risk of stroke significantly.

Cover Artwork Jennifer Fairman Fairman Studios

In This Issue Earlier the better? Intervening to halt the progression of atrial fibrillation Baylis-CANet partnership - fruitful, innovative, and going strong As far as eyes can see: CANet project sees old target in new light Catheter Contact-Force Controller (CCFC)

Cardiac Arrhythmia Network of Canada The Cardiac Arrhythmia Network of Canada (CANet) is a not-for-profit organization dedicated to transforming Canada’s arrhythmia health care system through integrated trans-disciplinary research and development. The network’s strategy is to invent, prove, and implement innovative solutions to enable patients to take ownership and co-manage their arrhythmia health.

CANet is funded in part by the federal government’s Networks of Centres of Excellence (NCE), Canada’s flagship science and technology program.

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Illustration: Medtronic’s Cryoablation Catheter

EARLIER THE BETTER? INTERVENING TO HALT THE PROGRESSION OF ATRIAL FIBRILLATION “I am always looking for ways to help patients with atrial fibrillation lead full lives,” says Dr. Jason Andrade, University of British Colombia Cardiology Professor.

He is currently leading a CANet-funded project, ‘Early Invasive vs. Delayed Intervention for Atrial Fibrillation’ which explores the first line of treatment for atrial fibrillation (AF).

This is a major advance in the interventional treatment of AF, and a significant Canadian accomplishment.

AF, a heart rhythm disorder, results in rapid, irregular heartbeats.

Patients are at a greater risk for stroke and death.

“We have pretty good information on how to manage atrial fibrillation at its later stages,” Andrade says, “but can we intervene sooner to improve outcomes?”

Andrade’s quest for an improved, more rapid treatment for AF might just come down to a matter of when to intervene.

He has teamed up with CANet’s industry partners Baylis and Medtronic CryoCath.

Medtronic has developed a revolutionary new technology to advance AF treatment, Medtronic’s Cryoablation Catheter freezes and destroys the faulty cardiac tissues.

“This is a major advance in the interventional treatment of AF, and a significant Canadian accomplishment,” Andrade says.

The combination of implantable rhythm monitors and home monitoring devices will permit us a fairly intense, yet minimally intrusive follow-up. In addition, this combination of monitoring will enable us to definitively determine the best possible treatment for early AF. Importantly, it reduces the patient’s dependence on antiarrhythmic drugs (AADs), which are often ineffective, and can have severe side-effects such as organ toxicity.

CANet’s industry partnerships, such as with Medtronic, demonstrate the network’s commitment to commercialize technologies that improve the efficiency, effectiveness, and accessibility of arrhythmia care delivery in Canada and the world.

The combination of implantable rhythm monitors and home monitoring devices will permit us a fairly intense, yet minimally intrusive follow-up.

Andrade’s CANet-funded project is currently evaluating the use of the therapy early in the course of the disease before progressing to an advanced condition with the consequence of further complications, such as heart failure and stroke.

“I hope to determine which approach to the early management of atrial fibrillation will result in optimal improvement patient outcomes and reduce the burden of AF in Canada,” Andrade says.

The research study will ask patients who have undergone the cryoablation procedure to undergo implantation of a cardiac monitoring devices that will continuously track the heart rhythm, and determine the amount of AF patients are experiencing per day.

“The combination of implantable rhythm monitors and home monitoring devices will permit us a fairly intense, yet minimally intrusive follow-up. In addition, this combination of monitoring will enable us to definitively determine the best possible treatment for early AF,” Andrade says.

His work is aligned with CANet’s Strategic Goal of achieving a 20 per cent drop in atrial fibrillation hospitalization and emergency department visits.

More effective treatment also means less healthcare costs, and increased economic productivity because fewer people are missing out on work due to illness.

In fact, a significant portion of AFrelated healthcare costs come from hospitalization and acute care.

Andrade is working with healthcare economists to look at the budgetary and cost-savings impact of this treatment strategy.

“More effective treatment also means less healthcare costs, and increased economic productivity because fewer people are missing out on work due to illness,” Andrade says.

The CANet project is also training Highly Qualified Personnel (HQP) like Dr. Christopher Cheung, reflecting its goal to cultivate the next generation of researchers in patient engagement and partnership.

“Research is a great way to learn about gaps in our knowledge, and how we can improve it moving forward,” Cheung says.

Our patient partners, who have been involved with the project since the very beginning, have been critical in designing the project questionnaires and making sure that the study has a meaningful impact on their healthcare Andrade and CANet are also working with the Heart and Stroke Foundation – a nonprofit organization – to develop a patient decision support tool.

“As someone who is clinically trained, it is a privilege to work with these patients and hear their stories,” Cheung says.

The decision support tool is an online platform of educational materials, interactive information, and social media.

It will empower patients to be more involved in their own healthcare decisions, and improve their quality of life.

“Our patient partners, who have been involved with the project since the very beginning, have been critical in designing the project questionnaires and making sure that the study has a meaningful impact on their healthcare,” Andrade says.

Eventually, we want to be able to deliver an optimal, tailored treatment strategy for each patient The questionnaires – open to patients and medical professionals (general practitioners, internal medicine specialists, and cardiologists) – will help Andrade and his team capture patient experiences associated with AF and its treatment.

“Eventually, we want to be able to deliver an optimal, tailored treatment strategy for each patient,” he says.

Meet Dr. J. Andrade Dr. Jason Andrade is a Cardiac Electrophysiologist at Vancouver General Hospital (VGH), with a joint appointment at St. Paul’s Hospital and the Montreal Heart Institute. He is also an Associate Professor of Medicine at the University of British Columbia, and Adjunct Professor at the Université de Montréal.

At VGH, Dr. Andrade is director of the Electrophysiology Program. He serves as medical lead for Provincial Atrial Fibrillation Care, and is co-chair of the CCS Atrial Fibrillation Guidelines. Previously, Dr. Andrade was the Education Chair for the Canadian Heart Rhythm Society.

Baylis-CANet partnership - fruitful, innovative, and going strong “When our employees see technology being used to help patients, it gives us strong motivation to work harder and stronger,” says Kris Shah, President of Baylis Medical.

A few months ago, CANet investigator and Western University Medicine professor Peter Leong-Sit became the world’s first physician to use a pioneering medical device developed and manufactured by Baylis to make atrial fibrillation (AF) ablation procedures safer and more effective. The procedure was a success.

“That event helped lift the entire company to a new level,” Shah remembers fondly.

For almost three decades, Baylis, located in Mississauga, Ontario, has developed and distributed state-of-the-art medical products in Canada and across the world.

There is a critical need for innovative minimally invasive cardiac procedures that improve patient outcomes without increasing healthcare costs and treatment time.

When CANet launched in 2015, it sought out organizations that shared the Network’s vision - to significantly improve the efficiency, effectiveness, and accessibility of arrhythmia care delivery in Canada and around the world.

Baylis fit the bill.

“We are very fortunate to be associated with CANet since inception,” Shah says. “As a result of our strong association with CANet, we feel our company has grown at a much faster rate than we otherwise would have. It created a number of meaningful jobs in Ontario, as well as helped deploy our technology on a worldwide basis.”

When CANet started, Baylis had roughly 350 employees in 2015, To date, the company has almost doubled its number of employees.

“I can honestly say that a big chunk of that has been a direct result of our strong partnership with CANet,” Shah says.

Access to CANet’s leading-edge network of investigators allows us to introduce our therapies to even more hospitals, and bring relief to patients, faster.

Currently, Baylis is working with CANet on several projects to help reduce atrial fibrillation (AF)-related emergency department visits and hospitalization. AF is the most common heart arrhythmia abnormality and accounts for the majority of arrhythmia-related emergency room visits and hospital admissions.

The collaboration is critical in helping achieve a 20 percent drop in AF hospitalization and emergency department visits, a key strategic goal of the Network.

“There is a critical need for innovative minimally invasive cardiac procedures that improve patient outcomes without increasing healthcare costs and treatment time,” says CANet’s Scientific Director and CEO, Dr. Anthony Tang.

The Baylis-CANet partnership will help improve patient care and allow hospitals to adopt safer and more effective technologies.

CANet members have been educating us on clinical needs and how our technology can play a meaningful role in their everyday practice.

They have provided clinical input, medical expertise and helped us design and execute clinical trials.

“Access to CANet’s leading-edge network of investigators allows us to introduce our therapies to even more hospitals, and bring relief to patients, faster,” Shah says.

For example, in CANet’s Early-AF study, Baylis deployed its tools across Canada at 30 sites.

The study was successful, and Shah hopes it will help Baylis and CANet commercialize and disseminate cutting-edge technologies—another key CANet strategic goal.

Shah also highlights the critical role of CANet members in helping Baylis grow, all the while encouraging the company to develop technologies to help cardiac arrhythmia patients.

“CANet members have been educating us on clinical needs and how our technology can play a meaningful role in their everyday practice,” Shah says.

“They have provided clinical input, medical expertise and helped us design and execute clinical trials.”

The Baylis-CANet partnership, according to Tang, is a stellar example of how clinicians and industry partners can work together to improve patient outcomes and enhance productivity in the healthcare system.

Kris Shah, President of Baylis Medical Company Inc.

“This more accurate understanding will help doctors pick the right AF treatment,” Prato says.

Currently, the go-to AF therapy is catheter ablation. The treatment locates and destroys (ablates) faulty cardiac tissues by either burning or freezing them - restoring normal function.

But the procedure works only 50 to 70 percent of the time.

Patients often undergo a second procedure, which may or may not be successful.

“We are unable to accurately predict AF ablation outcomes as the extent of atrial disease is often underestimated,” Skanes says.

As far as eyes can see: CANet project sees old target in new light Look once. Look twice. Look again.

Drs. Frank Prato and Allan Skanes are taking no chances when it comes to improving atrial fibrillation (AF) therapies.

The CANet Investigators and Professors of Medicine at Western University are putting faulty heart tissues – one of the main culprits of AF – under microscopes, MRIs, X-rays, nuclear medicine procedures, and a myriad of other imaging technologies to develop “a clear, rational approach to selecting the right kind of treatment for AF patients.”

In doing so, they are helping provide effective, efficient and accessible arrhythmia care in Canada and worldwide, all critical CANet targets.

Cardiac tissues called atria generate electric signals that subsequently produce heartbeats. Diseased tissues and/or faulty electric signals result in rapid, irregular heartbeats - or atrial fibrillation - with frequent symptoms of chest pain, shortness of breath, light-headedness and heart palpitations.

This pioneering project "Atrial Image-guided Decision to Optimize Treatment of Atrial Fibrillation (AID-AF)" scrutinizes diseased atria through a battery of medical imaging techniques utilizing, for example, microscopy, x-rays, and MRI. It also studies, among other things, those faulty electric signals.

In other words, they are looking at AF repeatedly, in a variety of ways.

We expect that by identifying patients with severe atrial disease and poor outcomes predicted, other non-ablation treatments, such as pacemakers can be used to maintain a high quality of life without repeated ineffective ablation procedures So how does one measure the severity of AF prior to ablation?

What kind of information would allow patients and their physicians to make better decisions?

Prato’s new imaging tools (along with information on electric signals) will be combined with other patient characteristics such as age and duration of AF to predict accurate outcomes for catheter ablation of AF. “Our hope is to identify those patients who are both likely and unlikely to benefit from AF ablation, and provide alternative therapies,” Skanes explains.

He continues, “We expect that by identifying patients with severe atrial disease and poor outcomes predicted, other non-ablation treatments, such as pacemakers can be used to maintain a high quality of life without repeated ineffective ablation procedures.”

Canada’s increasing seniors population is one of the leading contributors to the growth of AF cases in the country, with related healthcare costing millions of dollars per year.

Our work is bringing together Canada’s most skilled heart imaging scientists from multiple centers - Ottawa, London and Calgary - to collaborate on multiple methods of atrial disease imaging.

By recommending the correct AF therapy for seniors for example, the CANet-funded research can help achieve the Network’s goal to reduce hospitalizations and emergency department visits by 20 per cent.

“Our work is bringing together Canada’s most skilled heart imaging scientists from multiple centers - Ottawa, London

and Calgary - to collaborate on multiple methods of atrial disease imaging,” Prato says. This is unlike most other large, well-known medical centres both in Canada and the US, who work independently, and use a single imaging method.

Apart from a multi-disciplinary team of imaging scientists, engineers and clinician scientists, Prato is also working with industry partners such as Siemens, Medtronic, Biosense, St. Jude Medical, and CUBE Medical Solutions to develop commercially viable novel imaging technologies.

These industry partnerships will help CANet move forward with its strategic business and capacity development targets.

This CANet-funded project also helps train and mentor Highly Qualified Personnel in arrhythmia research in Canada.

“Trainees in medical imaging and technology, junior clinicianscientists and early stage research fellows will benefit from multi-disciplinary collaborations, and exposure to state-of-theart technology,” Prato says.

The project contributes to CANet’s vision of creating highly qualified personnel at the forefront of arrhythmia research and management.

Patients will give insight into tolerability, appropriateness and acceptability of complex imaging studies as well as strategies for efficient patient engagement and enrolment.

Importantly, Prato is collaborating with patients who bring with them a variety of experiences.

“Patients will give insight into tolerability, appropriateness and acceptability of complex imaging studies as well as strategies for efficient patient engagement and enrolment,” he says.

Ultimately, Skanes hopes that the research will empower patients to predict their clinical course, avoid futile procedures, and select alternative therapies more appropriately.

For their part, Prato and Skanes will not stop looking for better solutions.

Catheter ContactForce Controller Percutaneous radiofrequency (RF) catheter ablation is a minimally invasive, fluoroscopically-guided procedure, which has become the established therapeutic modality for treating patients with atrial fibrillation (AF). The challenge to create durable transmural lesions around the ostia of the pulmonary veins (PV) remains, as 50% of patients with persistent AF require multiple treatments due to AF recurrence post-ablation.

To address the problem of varying contact force during lesion formation, a Catheter Contact-Force Controller (CCFC) has been developed by CANet Discovery Award recipient Dr. Daniel Gelman, Western University.

The CCFC is a hand-held electromechanical device that monitors catheter-tissue CF and autonomously adjusts the position of an ablation catheter within a steerable sheath (a tubular catheter introducer).

The patient's voice There are the obvious physical issues, but there isn’t as much attention paid to the mental and emotional difficulties that often occur, as arrhythmias can be a life-long challenge for some people.

Alison Headland, CANet Patient Partner After working with her local arrhythmia physicians and the cardiac rehabilitation unit, Alison's interest in the experience of the arrhythmia sufferer led to the initiation of a support group for patients with atrial fibrillation.

Join us in our goal of improving heart rhythm health Learn more about how you can get involved with the Cardiac Arrhythmia Network of Canada (CANet) by visiting www.canet-nce.ca or by emailing getinvolved@canet-nce.ca.

Patients

Investigators

Trainees

We believe that patients should play a key role in developing research agendas and conducting research and the Network involves patients in all aspects of decisionmaking, operations, and participation in research programs.

We bring together Canada’s globally recognized experts in a wide array of related disciplines to share ideas and advance the field of arrhythmia research and treatment.

We provide valuable resources and opportunities for our trainees to network with like-minded colleagues as well as, participate in events and competitions across Canada that help strengthen their research and career development.

Atrial Fibrillation (AF): Quick Facts • AF affects approximately 350,000 Canadians.

• Often the cause is not known, but AF is more common in older people.

• AF is a progressive, chronic condition that may get worse without treatment but can be treated effectively.

• Some people with AF feel perfectly fine and may not even know they have the condition until they have a routine electrocardiogram.

• AF increases the risk of stroke significantly.

The Cardiac Arrhythmia Network of Canada (CANet) is a not-for-profit organization dedicated to transforming Canada’s arrhythmia health care system through integrated trans-disciplinary research and development. The network’s strategy is to invent, prove, and implement innovative solutions to enable patients to take ownership and co-manage their arrhythmia health.

CANet is funded in part by the federal government’s Networks of Centres of Excellence (NCE), Canada’s flagship science and technology program.

Cardiac Arrhythmia Network of Canada 1465 Richmond St., Suite 3105 London, Ontario N6G 2M1 519-661-2111 x80011 info@canet-nce.ca www.canet-nce.ca