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Physicians engaged in cardiovascular implantable electronic device (CIED)–related practice come from diverse training backgrounds with variable degrees of CIED implant training. The objective of the Canadian Heart Rhythm Society Task Force on CIED Implant Training was to establish a common structure and content for training programs in CIED implantation, related activities and maintenance of competency. This executive summary presents the essence of the report with key recommendations included, with the complete version made available in a linked supplement. The goals are to ensure that future generations of CIED implanters are better prepared for continuously evolving CIED practice and quality care for all Canadians.

Magnetic resonance imaging (MRI) is often considered the gold-standard test for characterizing cardiac as well as noncardiac structure and function. However, many patients with cardiac implantable electronic devices (CIEDs) and/or severe renal dysfunction are unable to undergo this test because of safety concerns. In the past 10 years, newer-generation CIEDs and gadolinium-based contrast agents (GBCAs) as well as coordinated care between imaging and heart rhythm device teams have mitigated risk to patients and improved access to MRI at many hospitals. The purpose of this statement is to review published data on safety of MRI in patients with conditional and nonconditional CIEDs in addition to patient risks from older and newer GBCAs. This statement was developed through multidisciplinary collaboration of pan-Canadian experts after a relevant and independent literature search by the Canadian Agency for Drugs and Technologies in Health. All recommendations align with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Key recommendations include: (1) the development of standardized protocols for patients with a CIED undergoing MRI; (2) patients with MRI nonconditional pacemakers and pacemaker dependency should be programmed to asynchronous mode and those with MRI nonconditional transvenous defibrillators should have tachycardia therapies turned off during the scan; and (3) macrocyclic or newer linear GBCAs should be used in preference to older GBCAs because of their better safety profile in patients at higher risk of nephrogenic systemic fibrosis.

Canadian electrophysiology (EP) fellowship programs have evolved in an ad hoc fashion over 30 years. This evolution has occurred in many fields in medicine and is natural when innovators and pioneers attract research fellows who help change the status quo from predominantly research to a predominantly clinical application and focus. Fellows not only push their supervisors and their centres into new areas of inquiry but also function at the most advanced level to encourage and teach junior trainees and to provide examples of excellence to residents, medical students, and other health professionals. Funding for fellows has never been provided in the traditional way through the Ministry of Health or the Ministry of Advanced Education. Each Canadian centre has over the years found novel ways to fund fellowship programs, and many centres have used value-adds from procurement programs. These sources of funding are eroding as provincial government agencies are beginning to assume procurement responsibilities and local flexibility to fund fellowships is lost. In particular, provincial government agencies feel that valuable financial resources should be restricted to Canadian trainees only, despite the international consensus that fellowship is an essential time for advanced trainees to travel abroad to acquire a broad a range of experience, learn new techniques and approaches, make lifelong research connections, and hopefully return home with these skills and expertise. This article summarizes the long history of EP fellowship training in Canada, as well as EP fellowship experiences at home and abroad by Canadian electrophysiologists, in an attempt to contextualize these new realities.

Pulmonary vein (PV) isolation (PVI) has emerged as an effective therapy for paroxysmal atrial fibrillation (AF). However, AF recurs in up to 50% of patients, generally because of recovery of PV conduction. Adenosine given during the initial procedure may reveal dormant PV conduction, thereby identifying the need for additional ablation, leading to improved outcomes. The Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) study is a prospective multicentre randomized trial assessing the impact of adenosine-guided PVI in preventing AF recurrences.Patients undergoing a first PVI procedure for paroxysmal AF will be recruited. After standard PVI is completed, all patients will receive intravenous adenosine in an attempt to unmask dormant conduction. If dormant conduction is elicited, patients will be randomized to no further ablation (control group) or additional adenosine-guided ablation until dormant conduction is abolished. If no dormant conduction is revealed, randomly selected patients will be followed in a registry. The primary outcome is time to first documented symptomatic AF recurrence. Assuming that dormant conduction is present in 50% of patients post PVI and symptomatic AF recurs in 45% of controls, 244 patients with dormant conduction will be required to obtain90% power to detect a difference of 20%. Thus, a total of 488 patients will be enrolled and followed for 12 months.The ADVICE trial will assess whether a PVI strategy incorporating elimination of dormant conduction unmasked by intravenous adenosine will decrease the rate of recurrent symptomatic AF compared with standard PVI.

Background Patients with Brugada syndrome (BrS) are at risk for ventricular arrhythmias (VAs) and sudden death. Identification of high-risk individuals beyond those with syncope or resuscitated sudden death remains a major challenge. Methods We assessed the value of clinical, electrophysiological, and electrocardiographic (ECG) features, including depolarization and repolarization metrics, in predicting arrhythmic events and sudden death in consecutive patients with BrS diagnosed between 2002 and 2013 in Quebec, Canada. Qualifying electrocardiograms with the highest type 1 ST-segment elevations were reviewed and analyzed by 2 electrophysiologists who were blinded to clinical history. Survival analyses were adjusted for Firth bias correction and left truncation. Results A total of 105 patients, 79.8% of whom were men, were diagnosed with BrS at a mean age of 46.2 ± 13.3 years and were followed for 59.6 ± 16.4 months. Ten (9.5%) had a history of cardiac arrest, 37 (35.2%) had syncope, and 7 (6.7%) experienced 20 arrhythmic events during follow-up, all consisting of appropriate ICD therapy (7 antitachycardia pacing; 13 shocks). In multivariate Cox regression analyses, a spontaneous type 1 electrocardiographic (ECG) pattern (hazard ratio [HR], 10.80; 95% confidence interval [CI], 1.03-113.87; P = 0.0476), maximal T peak-end (T p-e ) duration ≥ 100 ms (HR, 29.73; 95% CI, 1.33-666.37; P = 0.0325), and QRS duration in lead V 6 > 110 ms (HR, 15.27; 95% CI, 1.07-217.42; P = 0.0443) were independently associated with VAs or aborted sudden cardiac death. Conclusions In a multicentre cohort with BrS from Quebec, Canada, VAs and sudden death were independently associated with standard 12-lead ECG features, including a spontaneous type 1 pattern, depolarization (QRS in lead V 6 ), and repolarization (maximal T p-e duration) criteria.

s S333 537 LONG-TERM SURVIVAL AFTER IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IMPLANTATION: A POPULATION-BASED STUDY M Bennett, D Ayers, L Ding, H Jackson, A Krahn Vancouver, British Columbia BACKGROUND: In the era of potential differences in Implantable Cardioverter Defibrillator (ICD) complexity and longevity, an estimation of patient lifespanmay allow for patient specific device selection that influence both clinical utility and cost-effectiveness of the device.We sought to evaluate patient survival from British Columbia’s Implantable Arrhythmia Device Registry. METHODS: All BC patients aged 20 or older, who underwent ICD implants or generator replacement from 01 January 2000 to 31 December 2012, were included in this study. Patient demographic, clinical, procedural, device-related data were obtained from the BC Cardiac Services Registry. Mortality data were obtained from the Vital StatisticsAgency.Theprobabilities of survivalwere estimatedby the Kaplan-Meier method with all-cause mortality as the end-point. RESULTS: 5241 patients (4282 male, 81.7%; 959 female, 18.3%) underwent 6929 ICD implantations (4369 initial implants; 2560 generator changes) with a total of 268,001 patientyears of follow-up. Five and 10year survival rateswere 76.6%and 60.9% respectively. The median patient age was 66 years (IQR: 57, 73). Patients were divided into 10 year age groups. The percentage of patients surviving greater than 5 years from last procedure in the 41-50, 51-60, 61-70, 71-80, and 81-90 year age groupswas 91.0, 86.2, 78.7, 63.0, and49.0, respectively.The percentage of patients surviving greater than 10 years in the 4150, 51-60, 61-70, 71-80, and 81-90 year age groups was 81.6, 73.5, 58.4, 39.0, and 28.1, respectively. Overall, women had a significantly longer survival thanmen (5 year survival rate 82.9 vs. 75.1%), as a consequence of amarkedly lower age at implantation (median 62 years vs. 66 years, P

BACKGROUND: It has been well described that women who undergo ICD implantation receive less appropriate ICD therapy than men, but suffer a similar mortality. The benefit of ICD implantation in women has been questioned. We sought to investigate this observation further to better understand how sex affects the occurrence of ventricular arrhythmia in an ICD population. METHODS: All patients who were included in a registry of patients receiving ICDs in Nova Scotia were assessed for inclusion into the study. Patients who received ICDs for inherited cardiomyopathies and ion channelopathies were excluded from the study. Data collection was performed in the form of a retrospective chart review from 20042006, but then was carried on prospectively from 20062013. Follow-up for the patients in the registry conformed to current guidelines for patients with ICDs. All arrhythmic events including ATP and ICD shocks were adjudicated by two electrophysiologists. Baseline characteristics were collected through chart review. Procedural complications were collected through chart review. Mortality was collected through linkage with Vital Statistics in Nova Scotia. RESULTS: A total of 776 patients were included in the study; 135 (17.4%) of these were women. Overall, women had a lower risk of ischemic heart disease (49.6% vs 76.8%, p

Among them, 14 were referred for IUGR and 14 for previous family history of congenital heart disease. Umbilical artery Doppler velocities, weight and height at birth were extracted from maternal charts. At approximately 14 yrs of age, aortic diameters, pulse wave transit time around the aortic arch, ascending aorta M-mode were measured and blood pressure recorded. Pulse wave velocity, aortic input impedance (Zi), characteristic impedance (Zc), stiffness index, and elastic modulus were calculated. RESULTS: There was no significant difference between groups in z scores for weight or height. The two groups were contrasted in the following table. In summary, there was an increase of vascular impedance as well increased systolic blood pressure in IUGR patients. Zc, correlated with birth-weight (Y 180.313 -0.017*X; p 0.025, R 0.192), and Zi yielded a similar trend without reaching statistical significance (Y 207.101 -0.01*X; p 0.08, R 0.118). CONCLUSION: Patients born with IUGR present early risk factors of vascular disease. Early interventions in these specific populations might delay the progression and onset of clinical manifestation.

propriate management of patients presenting with AF is critical to the mitigation of these risks. Currently, however, care is fragmented and heavily reliant on hospital resources,especially the emergency departments (ED). We sought to examine the number of patients presenting to the emergency departments in a small Canadian centre, Kingston, with a static population. We hypothesized a large percentage of patients would re-present to the ED and this signifies both a failure to manage the arrhythmia in the community and an economic burden. METHODS: The ‘MUSE’ ECG database was used to create query for visits to ED with the main reason for presentation being atrial flutter or fibrillation between January 1, 2008 and December 31, 2010. All ECGs were read over by a cardiologist and ECG diagnosis confirmed prior to inclusion. Each subsequent visit was numbered manually, and time elapsed between visits calculated. RESULTS: We included 3095 patients in our study, who presented a total of 5486 times. 37.7% of patients presented twice or more in the 3 year period. Mean time for re-presentation was 161.6 days / 189.84. Median time was 83.5 days. 17.5% of the patients presented three times or more with a mean time for re-presentation being 251.9 days / 206.7 and median being 198.6 days. 9.6% of patients presented 4 times or more, with a mean of 334.7 days / 240.5 days and a median being 278.6 days. CONCLUSIONS: The first presentation of AF often occurs in the ED. Subsequent re-presentation of a third of patients strongly suggests a lack of appropriate intervention and puts this cohort at significant risk of adverse outcomes. Prior studies have shown poor compliance with guidelines over anticoagulation and the optimal rhythm strategy in these patients. Our study confirms the need to target this population with resources aimed at prevention of readmission and mitigation of risks. Moreover the presentation to the ED and in particular the re-presentation metric provides a valuable marker of care for this population and a benchmark to assess interventions.