FAREWELL LECTURE
Food
for thought and
thanks*
N.M. van Hemel
When Professor Frits Meyler signed my cardiology registration in April 1973, my future in Dutch cardiology was rather unclear. I had been well trained in electrocardiography by Meyler's weekly supervision of about 100 ECG recordings from professional and nonprofessional Dutch pilots. That experience resulted in sufficient skill to distinguish between a normal and a borderline ECG but you need more. With much devotion, the highly gifted teacher Etienne Robles de Medina showed me the way in the field of cardiac arrhythmias, not only on paper but also with the initial intracardiac His bundie recordings. And it was Wim Mosterd who taught me how to implant the modest VVI pacemaker of that time. From 1973 to 1975 I received postgraduate teaching from Dr Leo van Dijk, cardiologist at the Westeinde Hospital in The Hague, who showed me how to complete and report four extensive left- and right-sided heart catherisations in a single day. In the spring of 1975, I applied for the position of 'chef de clinique' at the St Antonius Hospital in Utrecht (figure 1) and after being accepted was faced with a department fully devoted to all aspects of coronary artery disease. As of 1970 the Sones technique was introduced by Albert Bruschke and extensively used by Jef Ernst, detection of ischaemia was the focus of Carl Ascoop's studies, and coronary artery surgery was being performed by a group ofvery skilled surgeons including Vermeulen, Huijsmans and Knaepen. Moreover, vectorcardiography, which was hardly appreciated by Durrer and his coworkers, was being performed routinely by Ge van Herpen. A small corner ofthe cardiology department was occupied by the Utrecht Institute of Medical Physics. The aim of this cooperation was to create a bridge between the medical information science section directed by Jan van Bemmel, Joop Duisterhout and the cardiology clinic. It was one of those stimulating initiatives of *
Title of 'Concluding Remarks' presented at the Conference on Current Topics in Electrophysiology, held in Nieuwegein at 20 May 2005, on the occasion of Prof. N.M. van Hemel leaving clinical cardiology at the St Antonius Hospital, Nieuwegein.
#C
Netherlands Heart Journal, Volume 13, Number 9, September 2005
Figure 1. Front view of t/e St Antonius Hospital, Utrechi photo from 1965.
Dr C.L.C. van Nieuwenhuizen, the former chairman of the cardiology department who set up the first Dutch 'Heart team'.
During my first steps in the cardiology department I discovered that the data on pacemaker patients were only stored in a brown box and that cardiac arrhythmias were considered of little importance. Because of the lack of attention for this realm of clinical cardiology, I thought the coronary care unit would offer the best opportunity for education and training of residents and nursing staff in cardiac arrhythmias and pacing. In 1977 Cees Swenne, affiliated with the former Institute ofMedical Physics in Utrecht, and I started our first long-term one-channel ECG recordings of patients with acute myocardial infarction and he designed the first automatic device for off-line analysis of arrhythmias, called CENSOR After seven tough but inspiring years, our efforts eventually resulted in a twin thesis on the detection of mechanisms of arrhythmias from the surface ECG. In retrospect, it was a hard job: for example in a three-month period I checked all computerised intervals and QRS types from 190 kilometres of single-channel ECG, the distance between Utrecht and Groningen. I gratefillly remember the inspiring autumn visits to Utica, Upper 327
FAREWELL LECTURE . 2. Dr Gordon K. Moe -----=Figure
MD PhD (1915-1989), Profrssor of Pbasiology at Se State UniversityofNew York
Cole ofMedicine, Syrause .and Director of Research Masonic Medical Research 9,
Lahiratory, Utica NYUS. I
State ,NY to present our data with the electro-
physiological giant Dr Gordon Moe (figure 2) and Dr Charles Antzelevitch. Professors Jan van Bemmel and Etienne Robles de Mediana were indispensable when we defended our thesis at Utrecht University in 1984.
Arrhythmia expertise and antlarrhythmlc drugs
In view ofthe ablative and electrical therapeutic options available today, one can question whether knowledge of the mechanism ofcardiac arrhythmias matters. For example, Willem Beukema and Lucas Boersma have presented data on isolation of pulmonary veins to eliminate atrial fibrillation by creating lines of block. These experts are naturally familiar with triggers and remodelling of atrial tissue due to atrial fibrillation, but the success of the isolation is determined by technical skill and facilities rather than by the precise knowledge of the mechanisms of the arrhythmia. This also holds for ablation of atrioventricular nodal reentry tachycardia: although it is still unclear how it works, the efficacy of treatment is now more than 90%. Ablative and electrical procedures are of course of clinical relevance but hardly promote - to quote Professor Herre Kingma - the community-oriented approach to cardiac arrhythmias and prevention of sudden arrhythmic death because these interventions are applied in only a very small portion of our population.
In addition, I am convinced that knowledge of the characteristics of a parasystolic focus or the significance of 'coupled premature beats' has no priority at all in daily cardiology and is only of relevance in academic and experimental cardiology: only arrhythmia experts as Professor Hein Wellens', Professor Richard Hauer and Dr Ruben Coronel can become fascinated by the effects of fiecainide on the membrane action potential. One of the consequences ofthe limited knowledge or interest in arrhythmias and antiarrhythmic drugs is the 328
Figure 3. Profrssor Karel Wenekebach (1864-1940), P.rofrssor of Internal Medicine in Groningen and Vienna. His observations on extrasystoes, heart block and quinidine are wcll cstablished.
average cardiologist's anxiety about prescribing antiarrhythmic drugs. Cardiologists tend to stick to five sorts: amiodarone, sotalol, flecainide, digitalis and n-blocking agents. Two recent large studies of atrial fibrillation from Germany, the PAFAC and SOPAT trials, rehabilitated quinidine in conjunction with verapamil for the prevention of paroxysmal atrial fibrillation. Despite the favourable results, to this day
these trials have not been able to convince the Dutch cardiology profession to again start prescribing this 100-year-old drug, propagated since 1916 by our own famous Karel Wenckebach (figure 3).
In 1985, Herre Kingma joined the cardiology staff of the St Antonius Hospital and pointed out that the impact of prescription of antiarrhythmic and other cardiac drugs should be compared with that of an invasive intervention. Such awareness was a novelty in our department and triggered more attention to the action and side effects of antiarrhythmic drugs and rethinking of the mechanisms of cardiac arrhythmias. Kingma initiated many drug studies for atrial fibrillation resulting in several academic theses. He strongly supported studies on arrhythmia surgery, for example the value of the wall motion score for selection of VT surgery and the prospective comparison of antiarrhythmic drugs and surgery for ventricular tachycardia. I am very grateful for the many products of his sparkling mind.
Nowadays, prescription of antiarrhythmic drugs has become more complex due to increased awareness of side effects and proarrhythmias and, fur-thermore, physicians have become much more defensive. Because this attitude also holds for drug companies, several antiarrhythmic drugs, such as oral procainamide, mexitlline and fiboran', have already disappeared from the market whereas the development of new antiarrhythmic drugs is not at all commercially attractive. Netherlands Heart Journal, Volume 13, Number 9, September 2005
FAREWELL LECTURE
The very small portion ofpatients worldwide who need antiarrhythmic drugs and the tremendous cost of development and marketing contribute to this unfavourable course of events for the patient with cardiac arrhythmias. Consequently more patients will be referred for ablative and electrical therapies and the cardiologist escapes from the arrhythmia problem by assuming that catheter or surgical ablation and electrical therapy with devices definitely eliminate the arrhythmias. This assumption is indeed true for Wolff-ParkinsonVWhite patients and in general for those who need chronic pacing for conventional reasons. However, in the remaining patients with ventricular tachycardia, atrial fibrillation and postincisional arrhythmias, the disorders appear to be only temporarily eliminated or persist despite all efforts and experience. Invasive arrhythmic studies and treatment In 1976 we started intracardiac recordings in the St Antonius Hospital and this initiative was the beginning of analysis and later in the 1990s ofcatheter treatment of several reentrant tachycardias, including mapping and ablation ofventricular tachycardia. Body surface mapping initiated by Arne Sippens Groenewegen and studied by several investigators such as Silvia Muijlwijk, Andee Linnenbank, Pascal van Dessel and Mark Potse offered more insight into the cardiac site of origin of ventricular tachycardia in relation to the QRS morphology in the ECG. It was an inspiring time of ongoing clinical research ofthe assessment ofwhat was known as the site of origin and propagation of postinfarction ventricular tachycardia as well as the mechanisms of onset and termination of these arrhythrnias in our invasive arrhythmia department. At the end of 1979 the French cardiac surgeon Dr Gerard Guiraudon performed the first endocardial encircling ventriculotomy for drug refractory postinfarction ventricular tachycardia in our hospital. The scientific and innovative input of Gerard Guiraudon in our cardiothoracic and cardiology departments was boundless; he was the driving force behind various types of arrhythnia surgery and afterwards in discussing cases with an unsuccessful outcome. For more details I advise you to go through the proceedings 'Exclusion or Targeting', published for the conference to honour Gerard Guiraudon in Utrecht in February 2005. To complete my historical view of the Dutch efforts in the treatment of postinfarction ventricular tachycardia, I need to recall our national study on this subject. Started in 1983, this prospective study was chaired by Professor Hein Wellens, Professor Michiel Janse and Dr Frans van Cappelle and supported by many Dutch cardiothoracic and cardiology centres, resulting in the thesis byDrAlbert Willems in 1990. From 1983 myrelationship with Professor Jacques de Bakker flourished by performing more than 335 map-guided operations for postinfarction ventricular tachycardia with the cardiac surgeons Freddy Vermeulen, Jo Defauw, and Henri van #
Nctherlands Heart Journal, Volume 13, Number 9, September 2005
Swieten. Many intraoperative studies of atrial fibrillation, scientific papers and several academic theses were the outcome of our common curiosity for arrhythmias. Our thoughts on gardening and astronomy could always be exchanged in the periods of waiting during the long arrhythmia surgical procedures.
Map-guided surgery for ventricular tachycardia is now out and has been almost completely replaced by the hybrid treatment of ICD and amiodarone or a 1blocking agent. Our recent retrospective study of 100 patients with postinfarction ventricular tachycardia who had undergone map-guided surgery with aneurysm resection and ventricular reshaping showed a very acceptable in-hospital mortality of2%, and a five-year cumulative freedom of all-cause mortality of 81%. These results can strongly compete with interventions of comparable patients, for example the five-year cumulative survival of 64% of the SCD-Heft study. In view ofthis outcome we advise performing an invasive examination of the patient with first postinfarction ventricular tachycardia or out-of-hospital cardiac arrest and discussing the data with cardiac surgeons to consider not only surgical elimination ofthe source of ventricular tachycardia but also ventricular reshaping with left ventricular aneurysmectomy. This approach contributes to an improved left ventricular function, thus delaying congestive heart failure. Because an aselective or selective endocardial resection influences neither survival nor arrhythmia suppression, this surgery does not require specific technical facilities and can be applied in many centres. A more liberate ICD implantation strategy can further improve the prognosis ofthe operated patients. Electrical device In 1996, the Pasman Chair for Clinical Heart Stimulation (figure 4) was established by Professor Jan Roos at Utrecht University. I am very grateful for my appointment and the continuous support from the Pasman Foundation. During my introductory lecture at Utrecht University in 1997, I addressed new indications for chronic cardiac pacing: biventricular pacing was one of them and at that time only performed with epicardial leads. Despite our always conservative attitude in bradycardia pacing, Dutch cardiologists are now distinctly active in biventricular pacing compared with other European centres. Very recently the number of Dutch centres that can combine implantation of biventricular pacing with ICD was expanded to 15 sites. This number should, in my opinion, be increased to 20 to cover all necessary RCT/ ICD implants in the near future, which can be estimated to rise to more than 1000 annually. Why this pacing mode attracts so much attention in the Netherlands is still unclear. It is neither because of the simplicity of implant nor follow-up nor the reimbursement, but probably the reflection of our belief
329
FAREWELL LECTURE
ventricle. In the past years only one report on chronic His bundle pacing has been published demonstrating that this method is hardly being used at the moment and will not become a standard approach unless better stimulation techniques become available. As opposed to the catheter approach, recent experiments have shown an alternative treatment for the failing sinus node and blocked atrioventricular conduction. Cells can be cultured that mimic cardiac pacemakers and can drive the heart. One can imagine that in the next decade Professors Pieter Doevendans, Jacques de Bakker and their associates will be implanting human pacemakers in the right atrium or ventricle in patients who need long-term pacing instead of an electrical pacing device.
Figure 4. Remembrance coin ofJan Hendrik Willem Pasman (1895-1980), succesful businessman and very active equestrian sorsman, who profitedgreatdyfiom his implantedpacemakerfor heart block.
that this electrical therapy prolongs life and improves the health perception of the patient with severe heart failure. As not unusual in medicine, we cannot actually fully explain why the patient benefits almost immediately after the implant but Dr Ducan Kocovic of Philadelphia (US) mentioned in his presentation of 'Current Topics in Electrophysiology' that ischaemic dilatation is very important and that more pacing leads on the left ventricle can increase the number of RCT responders. Fascinating aspects ofbiventricular pacing remain the preimplant assessment of the responder, and secondly the optimal programming of the biventricular pacemaker. Several Dutch investigators are now focusing all their attention on discovering the mysteries of electromechanical asynchrony of the dilated left ventricle and identifying the mechanisms of electrical resynchronisation. The left bundle branch model and ventricular pacing in animal studies by Dr Frits Prinzen's group (Maastricht University), and the nuclear isotope studies of chronically paced patients presented by Dr Fred Verzijlbergen (St Antonius Hospital) contribute to new insights into the relation between conduction delay and mechanical consequences of asynchrony. Molecular and genetic developments In my introductorylecture at Utrecht University in 1997, I proposed developing pacing methods with an implanted lead beneath the site of block in the right 330
These speculations display the domain of cellular, molecular and genetic cardiology. In my view two other important research lines need full attention. As I mentioned earlier in the 2003 Wenckebach Lecture, it is a challenge to identify proarrhythmia from antiarrhythmic drugs with genetic molecular studies in patients who are dependent on antiarrhythmic drugs. Application of a small and cheap genetic probe for testing of the vulnerable channels will become an attractive method to assess the proarrhythmia risk in the individual patient. In the pharmacology department of the St Antonius Hospital, Dr Vera Deneer has paved the way for genetic studies with flecainide in cooperation with Professor Arthur Wilde and his coworkers. Secondly, genetic prediction of fatal ventricular tachyarrhythmias is now an important target but the journey to success will be long, as elucidated by Arthur Wilde in this conference. However, it now appears to be becoming the most successful direction for community-oriented prevention of sudden arrhythmic death and ventricular arrhythmia. Health perep Finally, one should not forget that cardiac arrhythmias affect all parts of the human body and depend upon the influence of the human brain and the autonomic nervous system, whereas the 'burden' of arrhythmias is strongly determined by our emotions and mental perception. Recently it was demonstrated that paroxysmal atrial fibrillation occurs in 50 to 70% of patients without symptoms and many have symptomatic as well as asymptomatic attacks. On the other hand, a single premature ventricular beat can trouble the individual patient in such way that a visit to the emergency departnent is unavoidable. The modulating influence of the autonomic nervous system can now be investigated very precisely, for example by changes of the electrocardiographic repolarisation under various conditions, as presented by Dr Cees Swenne (Leiden). The outcome ofthese studies creates opportunities for prediction of a high risk for fatal arrhythmias in various populations. Netherlands Heart Journal, Volume 13, Number 9, Scptember 2005 fiC
FAREWELL LECTURE
The treatment of the fast or slow heart beat cannot be done without assessment of the perception of quality of life This aspect also determines our decision on whether or not to start a therapeutic intervention. I greatly appreciated the discovery tour with Professor Rick Grobbee and Dr Monique Stofhieel in the land of assessment of quality of life. One of the amazing findings was the observation that 'Ifyou feel well, it is very difficult to feel better'. This statement has serious consequences for many new developments in cardiology in the near future. I would like to finish by thanking the organisers of this conference, and specifically the unrestricted support
of many sponsors. For three decades I had a sincere cooperation with many ofthem. I also wish all the best to Dr Eric Wever, Dr Lucas Boersma and the coworkers of the invasive arrhythmia department, and the other staffmembers ofthe cardiology department of the St Antonius Hospital. Finally, I apologise that I was not able to mention the names ofall people who have contributed visually or not, to my professional development. m ProfessorNorbert M van Hemel Utrecht University Medical Centre Department of Cardiolo,gy, StAntonius Hospital, E-mail: n.m.vanhemel @hetnet.nl
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Article categores Original articles An original article should comprise about 2500 words, excluding abstract and references. A structured abstract not exceeding 200 words should be provided, induding the headings Background/Objectives, Methods, Results, Condusion. Aim for 30 references. An original article should contain a maximum of five figures and three tables. Please provide three to six key words. Review articles The article should not exceed 2750 words, exduding summay and references. A review article should contain a summary not exceeding 200 words. No more than six illustrations should be induded. Aim fbr a maximum of50 references. Please provide three to six keywords.
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qc
Nctherlands Hcart Journal, Volumc 13, Number 9, September 2005
of two figures and five references. For two pages, no more than 500 words with a maximum of fbur figures and ten references is required. Rhythm puzzle A rhythm puzzle comprises one page (200 words) for the question and one page (250 words) for the answer. A maximum oftwo figures and five references are allowed.
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331
Food
for thought and
thanks*
N.M. van Hemel
When Professor Frits Meyler signed my cardiology registration in April 1973, my future in Dutch cardiology was rather unclear. I had been well trained in electrocardiography by Meyler's weekly supervision of about 100 ECG recordings from professional and nonprofessional Dutch pilots. That experience resulted in sufficient skill to distinguish between a normal and a borderline ECG but you need more. With much devotion, the highly gifted teacher Etienne Robles de Medina showed me the way in the field of cardiac arrhythmias, not only on paper but also with the initial intracardiac His bundie recordings. And it was Wim Mosterd who taught me how to implant the modest VVI pacemaker of that time. From 1973 to 1975 I received postgraduate teaching from Dr Leo van Dijk, cardiologist at the Westeinde Hospital in The Hague, who showed me how to complete and report four extensive left- and right-sided heart catherisations in a single day. In the spring of 1975, I applied for the position of 'chef de clinique' at the St Antonius Hospital in Utrecht (figure 1) and after being accepted was faced with a department fully devoted to all aspects of coronary artery disease. As of 1970 the Sones technique was introduced by Albert Bruschke and extensively used by Jef Ernst, detection of ischaemia was the focus of Carl Ascoop's studies, and coronary artery surgery was being performed by a group ofvery skilled surgeons including Vermeulen, Huijsmans and Knaepen. Moreover, vectorcardiography, which was hardly appreciated by Durrer and his coworkers, was being performed routinely by Ge van Herpen. A small corner ofthe cardiology department was occupied by the Utrecht Institute of Medical Physics. The aim of this cooperation was to create a bridge between the medical information science section directed by Jan van Bemmel, Joop Duisterhout and the cardiology clinic. It was one of those stimulating initiatives of *
Title of 'Concluding Remarks' presented at the Conference on Current Topics in Electrophysiology, held in Nieuwegein at 20 May 2005, on the occasion of Prof. N.M. van Hemel leaving clinical cardiology at the St Antonius Hospital, Nieuwegein.
#C
Netherlands Heart Journal, Volume 13, Number 9, September 2005
Figure 1. Front view of t/e St Antonius Hospital, Utrechi photo from 1965.
Dr C.L.C. van Nieuwenhuizen, the former chairman of the cardiology department who set up the first Dutch 'Heart team'.
During my first steps in the cardiology department I discovered that the data on pacemaker patients were only stored in a brown box and that cardiac arrhythmias were considered of little importance. Because of the lack of attention for this realm of clinical cardiology, I thought the coronary care unit would offer the best opportunity for education and training of residents and nursing staff in cardiac arrhythmias and pacing. In 1977 Cees Swenne, affiliated with the former Institute ofMedical Physics in Utrecht, and I started our first long-term one-channel ECG recordings of patients with acute myocardial infarction and he designed the first automatic device for off-line analysis of arrhythmias, called CENSOR After seven tough but inspiring years, our efforts eventually resulted in a twin thesis on the detection of mechanisms of arrhythmias from the surface ECG. In retrospect, it was a hard job: for example in a three-month period I checked all computerised intervals and QRS types from 190 kilometres of single-channel ECG, the distance between Utrecht and Groningen. I gratefillly remember the inspiring autumn visits to Utica, Upper 327
FAREWELL LECTURE . 2. Dr Gordon K. Moe -----=Figure
MD PhD (1915-1989), Profrssor of Pbasiology at Se State UniversityofNew York
Cole ofMedicine, Syrause .and Director of Research Masonic Medical Research 9,
Lahiratory, Utica NYUS. I
State ,NY to present our data with the electro-
physiological giant Dr Gordon Moe (figure 2) and Dr Charles Antzelevitch. Professors Jan van Bemmel and Etienne Robles de Mediana were indispensable when we defended our thesis at Utrecht University in 1984.
Arrhythmia expertise and antlarrhythmlc drugs
In view ofthe ablative and electrical therapeutic options available today, one can question whether knowledge of the mechanism ofcardiac arrhythmias matters. For example, Willem Beukema and Lucas Boersma have presented data on isolation of pulmonary veins to eliminate atrial fibrillation by creating lines of block. These experts are naturally familiar with triggers and remodelling of atrial tissue due to atrial fibrillation, but the success of the isolation is determined by technical skill and facilities rather than by the precise knowledge of the mechanisms of the arrhythmia. This also holds for ablation of atrioventricular nodal reentry tachycardia: although it is still unclear how it works, the efficacy of treatment is now more than 90%. Ablative and electrical procedures are of course of clinical relevance but hardly promote - to quote Professor Herre Kingma - the community-oriented approach to cardiac arrhythmias and prevention of sudden arrhythmic death because these interventions are applied in only a very small portion of our population.
In addition, I am convinced that knowledge of the characteristics of a parasystolic focus or the significance of 'coupled premature beats' has no priority at all in daily cardiology and is only of relevance in academic and experimental cardiology: only arrhythmia experts as Professor Hein Wellens', Professor Richard Hauer and Dr Ruben Coronel can become fascinated by the effects of fiecainide on the membrane action potential. One of the consequences ofthe limited knowledge or interest in arrhythmias and antiarrhythmic drugs is the 328
Figure 3. Profrssor Karel Wenekebach (1864-1940), P.rofrssor of Internal Medicine in Groningen and Vienna. His observations on extrasystoes, heart block and quinidine are wcll cstablished.
average cardiologist's anxiety about prescribing antiarrhythmic drugs. Cardiologists tend to stick to five sorts: amiodarone, sotalol, flecainide, digitalis and n-blocking agents. Two recent large studies of atrial fibrillation from Germany, the PAFAC and SOPAT trials, rehabilitated quinidine in conjunction with verapamil for the prevention of paroxysmal atrial fibrillation. Despite the favourable results, to this day
these trials have not been able to convince the Dutch cardiology profession to again start prescribing this 100-year-old drug, propagated since 1916 by our own famous Karel Wenckebach (figure 3).
In 1985, Herre Kingma joined the cardiology staff of the St Antonius Hospital and pointed out that the impact of prescription of antiarrhythmic and other cardiac drugs should be compared with that of an invasive intervention. Such awareness was a novelty in our department and triggered more attention to the action and side effects of antiarrhythmic drugs and rethinking of the mechanisms of cardiac arrhythmias. Kingma initiated many drug studies for atrial fibrillation resulting in several academic theses. He strongly supported studies on arrhythmia surgery, for example the value of the wall motion score for selection of VT surgery and the prospective comparison of antiarrhythmic drugs and surgery for ventricular tachycardia. I am very grateful for the many products of his sparkling mind.
Nowadays, prescription of antiarrhythmic drugs has become more complex due to increased awareness of side effects and proarrhythmias and, fur-thermore, physicians have become much more defensive. Because this attitude also holds for drug companies, several antiarrhythmic drugs, such as oral procainamide, mexitlline and fiboran', have already disappeared from the market whereas the development of new antiarrhythmic drugs is not at all commercially attractive. Netherlands Heart Journal, Volume 13, Number 9, September 2005
FAREWELL LECTURE
The very small portion ofpatients worldwide who need antiarrhythmic drugs and the tremendous cost of development and marketing contribute to this unfavourable course of events for the patient with cardiac arrhythmias. Consequently more patients will be referred for ablative and electrical therapies and the cardiologist escapes from the arrhythmia problem by assuming that catheter or surgical ablation and electrical therapy with devices definitely eliminate the arrhythmias. This assumption is indeed true for Wolff-ParkinsonVWhite patients and in general for those who need chronic pacing for conventional reasons. However, in the remaining patients with ventricular tachycardia, atrial fibrillation and postincisional arrhythmias, the disorders appear to be only temporarily eliminated or persist despite all efforts and experience. Invasive arrhythmic studies and treatment In 1976 we started intracardiac recordings in the St Antonius Hospital and this initiative was the beginning of analysis and later in the 1990s ofcatheter treatment of several reentrant tachycardias, including mapping and ablation ofventricular tachycardia. Body surface mapping initiated by Arne Sippens Groenewegen and studied by several investigators such as Silvia Muijlwijk, Andee Linnenbank, Pascal van Dessel and Mark Potse offered more insight into the cardiac site of origin of ventricular tachycardia in relation to the QRS morphology in the ECG. It was an inspiring time of ongoing clinical research ofthe assessment ofwhat was known as the site of origin and propagation of postinfarction ventricular tachycardia as well as the mechanisms of onset and termination of these arrhythrnias in our invasive arrhythmia department. At the end of 1979 the French cardiac surgeon Dr Gerard Guiraudon performed the first endocardial encircling ventriculotomy for drug refractory postinfarction ventricular tachycardia in our hospital. The scientific and innovative input of Gerard Guiraudon in our cardiothoracic and cardiology departments was boundless; he was the driving force behind various types of arrhythnia surgery and afterwards in discussing cases with an unsuccessful outcome. For more details I advise you to go through the proceedings 'Exclusion or Targeting', published for the conference to honour Gerard Guiraudon in Utrecht in February 2005. To complete my historical view of the Dutch efforts in the treatment of postinfarction ventricular tachycardia, I need to recall our national study on this subject. Started in 1983, this prospective study was chaired by Professor Hein Wellens, Professor Michiel Janse and Dr Frans van Cappelle and supported by many Dutch cardiothoracic and cardiology centres, resulting in the thesis byDrAlbert Willems in 1990. From 1983 myrelationship with Professor Jacques de Bakker flourished by performing more than 335 map-guided operations for postinfarction ventricular tachycardia with the cardiac surgeons Freddy Vermeulen, Jo Defauw, and Henri van #
Nctherlands Heart Journal, Volume 13, Number 9, September 2005
Swieten. Many intraoperative studies of atrial fibrillation, scientific papers and several academic theses were the outcome of our common curiosity for arrhythmias. Our thoughts on gardening and astronomy could always be exchanged in the periods of waiting during the long arrhythmia surgical procedures.
Map-guided surgery for ventricular tachycardia is now out and has been almost completely replaced by the hybrid treatment of ICD and amiodarone or a 1blocking agent. Our recent retrospective study of 100 patients with postinfarction ventricular tachycardia who had undergone map-guided surgery with aneurysm resection and ventricular reshaping showed a very acceptable in-hospital mortality of2%, and a five-year cumulative freedom of all-cause mortality of 81%. These results can strongly compete with interventions of comparable patients, for example the five-year cumulative survival of 64% of the SCD-Heft study. In view ofthis outcome we advise performing an invasive examination of the patient with first postinfarction ventricular tachycardia or out-of-hospital cardiac arrest and discussing the data with cardiac surgeons to consider not only surgical elimination ofthe source of ventricular tachycardia but also ventricular reshaping with left ventricular aneurysmectomy. This approach contributes to an improved left ventricular function, thus delaying congestive heart failure. Because an aselective or selective endocardial resection influences neither survival nor arrhythmia suppression, this surgery does not require specific technical facilities and can be applied in many centres. A more liberate ICD implantation strategy can further improve the prognosis ofthe operated patients. Electrical device In 1996, the Pasman Chair for Clinical Heart Stimulation (figure 4) was established by Professor Jan Roos at Utrecht University. I am very grateful for my appointment and the continuous support from the Pasman Foundation. During my introductory lecture at Utrecht University in 1997, I addressed new indications for chronic cardiac pacing: biventricular pacing was one of them and at that time only performed with epicardial leads. Despite our always conservative attitude in bradycardia pacing, Dutch cardiologists are now distinctly active in biventricular pacing compared with other European centres. Very recently the number of Dutch centres that can combine implantation of biventricular pacing with ICD was expanded to 15 sites. This number should, in my opinion, be increased to 20 to cover all necessary RCT/ ICD implants in the near future, which can be estimated to rise to more than 1000 annually. Why this pacing mode attracts so much attention in the Netherlands is still unclear. It is neither because of the simplicity of implant nor follow-up nor the reimbursement, but probably the reflection of our belief
329
FAREWELL LECTURE
ventricle. In the past years only one report on chronic His bundle pacing has been published demonstrating that this method is hardly being used at the moment and will not become a standard approach unless better stimulation techniques become available. As opposed to the catheter approach, recent experiments have shown an alternative treatment for the failing sinus node and blocked atrioventricular conduction. Cells can be cultured that mimic cardiac pacemakers and can drive the heart. One can imagine that in the next decade Professors Pieter Doevendans, Jacques de Bakker and their associates will be implanting human pacemakers in the right atrium or ventricle in patients who need long-term pacing instead of an electrical pacing device.
Figure 4. Remembrance coin ofJan Hendrik Willem Pasman (1895-1980), succesful businessman and very active equestrian sorsman, who profitedgreatdyfiom his implantedpacemakerfor heart block.
that this electrical therapy prolongs life and improves the health perception of the patient with severe heart failure. As not unusual in medicine, we cannot actually fully explain why the patient benefits almost immediately after the implant but Dr Ducan Kocovic of Philadelphia (US) mentioned in his presentation of 'Current Topics in Electrophysiology' that ischaemic dilatation is very important and that more pacing leads on the left ventricle can increase the number of RCT responders. Fascinating aspects ofbiventricular pacing remain the preimplant assessment of the responder, and secondly the optimal programming of the biventricular pacemaker. Several Dutch investigators are now focusing all their attention on discovering the mysteries of electromechanical asynchrony of the dilated left ventricle and identifying the mechanisms of electrical resynchronisation. The left bundle branch model and ventricular pacing in animal studies by Dr Frits Prinzen's group (Maastricht University), and the nuclear isotope studies of chronically paced patients presented by Dr Fred Verzijlbergen (St Antonius Hospital) contribute to new insights into the relation between conduction delay and mechanical consequences of asynchrony. Molecular and genetic developments In my introductorylecture at Utrecht University in 1997, I proposed developing pacing methods with an implanted lead beneath the site of block in the right 330
These speculations display the domain of cellular, molecular and genetic cardiology. In my view two other important research lines need full attention. As I mentioned earlier in the 2003 Wenckebach Lecture, it is a challenge to identify proarrhythmia from antiarrhythmic drugs with genetic molecular studies in patients who are dependent on antiarrhythmic drugs. Application of a small and cheap genetic probe for testing of the vulnerable channels will become an attractive method to assess the proarrhythmia risk in the individual patient. In the pharmacology department of the St Antonius Hospital, Dr Vera Deneer has paved the way for genetic studies with flecainide in cooperation with Professor Arthur Wilde and his coworkers. Secondly, genetic prediction of fatal ventricular tachyarrhythmias is now an important target but the journey to success will be long, as elucidated by Arthur Wilde in this conference. However, it now appears to be becoming the most successful direction for community-oriented prevention of sudden arrhythmic death and ventricular arrhythmia. Health perep Finally, one should not forget that cardiac arrhythmias affect all parts of the human body and depend upon the influence of the human brain and the autonomic nervous system, whereas the 'burden' of arrhythmias is strongly determined by our emotions and mental perception. Recently it was demonstrated that paroxysmal atrial fibrillation occurs in 50 to 70% of patients without symptoms and many have symptomatic as well as asymptomatic attacks. On the other hand, a single premature ventricular beat can trouble the individual patient in such way that a visit to the emergency departnent is unavoidable. The modulating influence of the autonomic nervous system can now be investigated very precisely, for example by changes of the electrocardiographic repolarisation under various conditions, as presented by Dr Cees Swenne (Leiden). The outcome ofthese studies creates opportunities for prediction of a high risk for fatal arrhythmias in various populations. Netherlands Heart Journal, Volume 13, Number 9, Scptember 2005 fiC
FAREWELL LECTURE
The treatment of the fast or slow heart beat cannot be done without assessment of the perception of quality of life This aspect also determines our decision on whether or not to start a therapeutic intervention. I greatly appreciated the discovery tour with Professor Rick Grobbee and Dr Monique Stofhieel in the land of assessment of quality of life. One of the amazing findings was the observation that 'Ifyou feel well, it is very difficult to feel better'. This statement has serious consequences for many new developments in cardiology in the near future. I would like to finish by thanking the organisers of this conference, and specifically the unrestricted support
of many sponsors. For three decades I had a sincere cooperation with many ofthem. I also wish all the best to Dr Eric Wever, Dr Lucas Boersma and the coworkers of the invasive arrhythmia department, and the other staffmembers ofthe cardiology department of the St Antonius Hospital. Finally, I apologise that I was not able to mention the names ofall people who have contributed visually or not, to my professional development. m ProfessorNorbert M van Hemel Utrecht University Medical Centre Department of Cardiolo,gy, StAntonius Hospital, E-mail: n.m.vanhemel @hetnet.nl
INFORMATION FOR AUTHORS Genral remarks Prepare your manuscript text using a word processing package. Texts in PDF-files are not accepted. Manuscripts should be double-spaced, each page and line should be numbered. The text should be submitted exclusively in English. Texts in other languages will not be accepted. The Netherlands Heart Journal adopts British English (as in the Collins or Oxford dictionaries). Please ensure that anything you submit conforms to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, issued by the International Committee for Medical Journal Editors that can be found at www.icmje.org/. By submitting manuscripts, the author dedares that: - He/she assigns copyright; - The manuscript has not been submitted before or is not currently submitted to another journal; - He/she agrees that the manuscriptwill be evaluated by the editorial staff; - The persons who contributed to this article and are identified by name agree to having their names published; - He/she has authorisation to publish material that has been published before.
Article categores Original articles An original article should comprise about 2500 words, excluding abstract and references. A structured abstract not exceeding 200 words should be provided, induding the headings Background/Objectives, Methods, Results, Condusion. Aim for 30 references. An original article should contain a maximum of five figures and three tables. Please provide three to six key words. Review articles The article should not exceed 2750 words, exduding summay and references. A review article should contain a summary not exceeding 200 words. No more than six illustrations should be induded. Aim fbr a maximum of50 references. Please provide three to six keywords.
Case reports A case report should contain a summary of no more than 150 words, followed by a discussion and a conclusion. No morc than five authors should be mentioned. The article should not exceed 1500 words, exduding summary and references. A case report should contain a maximum of three illustrations and 15 references.
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Imaging A submission to this section may be one page or two pages. A onepage submission should not exceed 250 words and have a maximum
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Nctherlands Hcart Journal, Volumc 13, Number 9, September 2005
of two figures and five references. For two pages, no more than 500 words with a maximum of fbur figures and ten references is required. Rhythm puzzle A rhythm puzzle comprises one page (200 words) for the question and one page (250 words) for the answer. A maximum oftwo figures and five references are allowed.
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