ACC's 2014: What's Out There That's New?

I will be attending the ACC 2014 Scientific Sessions this year in Washington, DC.  Theheart.org has a nice post covering some of the early highlights of the conference (sorry, registration required).

But I'm going to try something a bit different this year.  Call it self-indulgence.  I'm going to try all my might to pull my head out of the corporate weeds for a while and look to my colleagues and start-up  friends to see where the innovation in health care is going, not where we've been.  After all, MADIT CRT, TAVR (Corevalve included), renal denervation (SYMPLICITY-3), colchicine in pericarditis (CORP 2 Trial), and 3-year results of bariatric surgery are, well, not exactly cutting edge.

I need to get back to my roots more.  While I'm a doctor, I'm also a biomedical engineer, a social media nerd, and a guy who loves innovation and creativity in medicine.  I want to discover new ideas, new people.  I want to discover those who want to attack the colossal challenges patients will have in health care delivery in the years ahead with new and innovative strategies for cardiovascular disease or cardiac arrhythmia management.  I want to connect with those who want to upend the status quo.   I want to wander around in the swamp of creativity instead of being led lock-step toward more marketing spin.

Am I crazy? Does such a venue exist at this years' ACC Scientific Sessions?

We'll see.

-Wes

(If you'd like to connect or have something that's really cool that might be interesting to discuss over breakfast or lunch one day, shoot me an e-mail at wes - at - medtees dot com or message me via Twitter at @doctorwes .  Please, no marketing pitches.)

Developing a Hybrid Pacemaker

Much like a hybrid car recaptures energy lost with braking, so too are technologies being developed to recapture the heart's motion to power a pacemaker using piezoelectric crystals and magnets:

The researchers haven’t built a prototype yet, but they’ve made detailed blueprints and run simulations demonstrating that the concept would work. As reported in the journal Applied Physics Letters, a hundredth-of-an-inch thin slice of a special “piezoelectric” ceramic material would essentially catch heartbeat vibrations and briefly expand in response. Piezoelectric materials’ claim to fame is that they can convert mechanical stress (which causes them to expand) into an electric voltage.



Karami and his colleague Daniel Inman, chair of aerospace engineering at U-M, have precisely engineered the ceramic layer to a shape that can harvest vibrations across a broad range of frequencies. They also incorporated magnets, whose additional force field can drastically boost the electric signal that results from the vibrations.

The new device could generate 10 microwatts of power, which is about eight times the amount a pacemaker needs to operate, Karami says. It always generates more energy than the pacemaker requires, and it performs at heart rates from 7 to 700 beats per minute. That’s well below and above the normal range.

-Wes

Chowing Down On Microchips

Imagine a "smart pill" containing a microchip that tells a computer when you've taken your medication.

Reality? You bet:

UK-based retail pharmacy chain Lloydspharmacy has inked an exclusive deal with Proteus Biomedical to launch Proteus’ first commercial product, Helius, an offering that includes sensor-enabled pills, a peel-and-stick sensor patch worn on the body, and a mobile health app. The patch records when a pill is ingested, tracks sleep patterns, and records physical activity levels.

Will it affect medication complicance?

I'm not so sure.

But the idea of a smart phone reminding folks they've skipped their medication might be pretty useful for some, provided they don't eventually suffer from a second potentially more severe malady: alarm fatigue.

-Wes

Interactive Pill Bottle Caps

Just saw this advertised for patients taking Multaq (dronedarone): interactive pill bottle caps called "GlowCaps:"

GlowCaps^TM is a bottle with built-in wireless communication... When you receive your GlowCap^TM, you program it with your schedule. It will then remind you when it's time to take Multaq by lighting up, playing a melody, or calling your home phone. If you and your physician choose, your GlowCap^TM can also send weekly reminder e-mail to you and a caregiver, send reports to your doctor, and refills can be initiated with the push of a button, if you provide a phone number when registering.

Okay. That's pretty cool.

How It Works

Glowcap^TM, manufactured by Vitality, Inc, has an embedded computer chip that communicates via low frequency RF with a cellular connected nightlight. The nighlight sends information to Vitality via a GE864-QUAD chip, over the AT&T GSM/GPRS network. Hence you must be in an AT&T wireless network area.

But I do worry about alarm fatigue. And how much does this cost? Will patients just ignore their pills or even grow to hate their melodies? And what happens when everyone's pill bottles go off at the symphony? Or what about pill identification: "Doc, it's the one that sounds like a wind-chime." Finally, if I start getting e-mail reports (spam?) from patients regarding their Multaq pills, I really, really won't be happy.

Just because technology can do all these things, doesn't mean it always should.

Still, it shows where technology is taking us in a hurry.

-Wes

Pacing Without Wires

From Medgadget via The Medical Quack:

EBR Systems, a start-up out of Sunnyvale California, and Cambridge Consultants, the technology design and development firm, have developed a leadless pacemaker system for patients with advanced heart failure. The Wireless Cardiac Stimulation System (WiCS) comprises two units, an implantable electrode and an external control unit. The electrode incorporates an ultrasonic, wireless receiver and delivers an electrical stimulus to the heart based on triggering signals from the external control unit.

In its current iteration the WiCS system is designed to work with conventional pacemakers/defibrillators pacing the right ventricle of patients requiring biventricular pacing. The WiCS external control unit senses the pacing stimulus delivered to the right ventricle and initiates a burst of stimulus from the electrode implanted in the left ventricle. According to the company, the wireless left ventricular pacing approach removes the need for complex surgery and the complications often associated with the coronary sinus leads used to pace the left ventricle.

Nice.

But to suggest that a left heart catheterization to place their little device in the endocardium of the left ventricle "removes the need for complex surgery" is a stretch. Embolic complications, valvular complications and the potential for stroke complications (with the need for at least some anticoagulation) will quickly temper their enthusiastic press release. And what happens when a patient needs an ultrasound of their heart or has a capsule endoscopy? Could there be significant electromagnetic interference?

But we should not rain on these companies' parade too quickly, even if they are a bit late to the party. The implications of this technology as we move forward with more sophisticated pacing therapies are profound. One only needs to consider complex congenital heart cases with anomalous venous return, epicardial delivery of this technology, or its capability to paired with drug delivery systems in the future to see where things might go with such a novel means of pacing.

-Wes

Medicine's New Snow Shovel

Click image to enlarge

-Wes

Image credit: Single-website personal license purchased for this blog from PoliticalCartoons.com

Your Beatin' Heart....

... could someday be donated to someone warm, toasty, and beating in a box:

Public relations video here.

-Wes

Power By Induction?

From the University of Washington: The experimental setup has a large transmission coil, at the right, connected to the building's electricity. At the left is the receiving coil, and near it is a smaller coil connected to a commercial heart pump sitting in a jar of fluid.

Interesting concept: using inductive power to possibly power a left ventricular assist devices.

Hope it works some day.

-Wes

Could Your Car Detect a Heart Attack?

Should car companies be in the medical business? Well, Ford Motor Company seems to think so. First the bluetooth-enabled glucose meter and now the ECG-enabled bucket seat:

AACHEN, Germany, May 24, 2011 – Ford Motor Company's advanced research engineers have developed a prototype vehicle seat that can monitor a driver's heart activity and could one day reduce the number of accidents and fatalities that occur as a result of motorists having heart attacks behind the wheel.

Engineers from Ford's European Research Centre in Aachen, Germany, working closely with Rheinisch-Westfälische Technische Hochschule, Aachen University, embarked on the project to address an often overlooked traffic safety issue – accidents triggered by drivers who experience heart problems.

The prototype Ford seat employs ECG (electrocardiograph) technology that monitors the heart's electrical impulses and detects signs of irregularity that can provide an early warning that a driver should seek medical advice, because he might be impacted by a heart attack or other cardiovascular issues. Whereas a normal ECG machine in a doctor's office requires metal electrodes to be attached to the skin at various points on the body, the Ford ECG seat has six built-in sensors that can detect heart activity through the driver's clothing.

So I wonder what the car will actually do when it detects a heart attack? Will it pull off to the side of the road and stop? Maybe it'll activate the car's OnStar system? Or maybe a few more electrodes could be applied to the seat that could deliver a corrective defibrillation jolt? (One false positive arrhythmia detection and you can bet that car will never sell, though).

Sheesh.

Next week, look for the pulse-oximeter-enabled steering wheel that drops oxygen masks from the car's ceiling when driver's oxygen level drops too low.

-Wes

When Medical Devices Speak to You

Could your implanted medical device soon speak to you?

Perhaps.

Two unlikely corporate partners, Ford Motor Company and Medtronic, are partnering on an interesting new "application" using continuous glucose monitors: a car that "speaks" to you:

The two companies announced Wednesday that they have developed an in-car prototype system that connects Ford’s Sync technology to a Medtronic glucose-monitoring device via Bluetooth—which then displays the driver’s glucose level on the car’s dashboard display. If a driver’s glucose level become too low, an alert sounds or a signal appears on the dashboard display.

Low blood sugar can cause confusion, clumsiness, dizziness, difficulty speaking, and a variety of other side effects that are potentially dangerous to drivers. Those side effects can typically be treated by eating or drinking glucose-rich foods or beverages.

The partnership between the two companies is part of a larger health and wellness initiative that Ford launched that is aimed at helping people with chronic illnesses or medical disorders—including diabetes, asthma, and allergies—manage their condition while on the go.

Very clever! A GPS system for your blood sugar!

Think of the possibilities...

A diabetic patient, equipped with their bluetooth-enabled continuous glucose meter sits behind the wheel and drives for about three miles when, quietly and non-obtrustively, a sultry voice behind the dashboard states:

"Prepare to turn unconscious... in... 0.2 miles..."

Or if a similar technology is developed for patients with implantable cardiac defibrillators:

"Pardon me for disturbing your tranquil drive, but your defibrillator has detected a rhythm disturbance and will begin therapy in approximately 400 ft.... 200 ft ... 50 ft....

*ka-blam!*

Please proceed to your planned route..."

But best of all, once they perfect implantable drug delivery systems we might hear from the dashboard of our cars:

"If your erection lasts over four miles..."

-Wes

A Blood-Powered Hydroelectric Turbine?

From IEEE Spectrum:

"The heart produces around 1 or 1.5 watts of hydraulic power, and we want to take maybe one milliwatt," Pfenniger explains. "A pacemaker only needs around 10 microwatts." At the Microtechnologies in Medicine and Biology conference in Lucerne, Switzerland, earlier this month, Pfenniger presented results from a trial in which a tube is designed to mimic the internal thoracic artery, a millimeters-wide vessel that doctors sometimes cannibalize for surgery because it is redundant. The most efficient of the three off-the-shelf turbines he tested produced around 800 microwatts, which could run devices much more power hungry than today’s pacemakers.

Pretty interesting. But the body is a formidable hydroelectric plant; they still have to work out the clotting and hemolysis potential of these devices...

-Wes

Skynet is Here

I saw this and could help but wonder how similar technology might be applied to atrial fibrillation ablation some day:



From IEEE Spectrum:

Being able to do this is all about communication, as Professor Nathan Michael discussed today at the IEEE International Conference on Robotics and Automation (ICRA) in Shanghai. As he and fellow researchers Matthew Turpin and Vijay Kumar have discovered, the robots have to not just know exactly where they are, but they also have to broadcast that information to their neighbors to maintain the integrity of the formation. This processing is all done on each individual quadrotor, so there's no all-seeing computer watching everything and telling each robot where to go. The accuracy is impressive: 50 percent of the time the quadrotors are within a mere two centimeters of where they should be.

Well, these robots haven't been miniaturized nor tested in blood so they're not ready for atrial fibrillation ablation yet, but it's still fascinating to see what creative minds can develop.

"Thinking" robots.

Uh, oh.

Then again, maybe I'm just reminded of scrubbing bubbles.

-Wes

World's Smallest Medical Camera

From FastCompany.com:

The world's smallest medical camera was unveiled this week by Israel-based biotechnology firm Medigus. The camera is .99 millimeters wide and boasts a resolution of 45,000 pixels--not high resolution by any means, but a shocking degree of clarity from a camera of that size. Because the camera is disposable, it will significantly cuts down on prep time for surgeries and endoscopic procedures thanks to being pre-sterilized. Even more importantly, the camera will significantly lower the cost of endoscopic diagnostic procedures. Reusable medical cameras require highly specialized, expensive sterilization procedures whose cost is often figured into patients' and insurance providers' bills.

Cool.

-Wes

A Pacemaker on a Chip?

Almost:

So far, Medtronic has developed most of the components—a circuit board, an oscillator to generate current, a capacitor to store and rapidly dispense charge, memory to store data, and a telemetry system to wirelessly transfer that data. The company has used chip manufacturing technology to assemble these components onto a wafer. Oesterle estimates that 60 to 70 pacemakers can be made from a single six-inch wafer, which the company creates at its own wafer fabrication plant in Arizona.

"What we don't have that is fundamental to a pacemaker is a way to power the chip," says Oesterle. The company is working with startups that make thin-film batteries and other innovative power sources, though Oesterle declined to give further details.

Oh, and don't forget the need for a fixation mechanism. Otherwise, these things might embolize and serve as the next Viagra.

On second thought...

-Wes

Klout: How "Influential" Are You, Doctor?

I stumbled across Klout.com recently, thanks to an tweet by the well-respected web strategist and industry analyst at the Altimeter Group, Jeremiah Owyang. Needless to say, it's not a place doctors venture much.

But I found the site, and it's potential to characterize physician's on-line influence, interesting.

It works by giving people on Twitter and Facebook a "score", influenced by the lists that people are on, the number of original "tweets," number of times things are re-tweeted by others, and so on and then uses the metrics to classify the type and influence of the individual using social media. I suppose an analogy might be that its like looking at a bunch of personality tests to understand the type of person you're following.

So I looked into the scores and characteristics of a few physician bloggers. The results were interesting.

Yours truly gave a meager "Klout score" of 48 at the time of this writing and was classified as a "Specialist."

Kevin Pho, MD is a "Thought Leader" with a score of 69.

Grunt Doc, an ER doctor and long-time blogger is a "Thought Leader", too, but has a score of 38.

Doctor Anonymous is an "Explorer" with a Klout score of 50.

Ramona Bates, MD - a plastic surgeon - is a "Specialist" too with a score of 54.

Happy Hospitalist has a Klout Score of 24, but is considered a Thought Leader, too.

(You can check your "score" and inflence type with a twitter account and then enter it here.)

By the way, I have no commercial relationship with this website, but I found the concept intriguing for doctors as we enter the new internet age of social media. Certainly this is not the only site that purports to measure the influence of someone on social media (see Peerindex, for instance), but it was interesting to see it's accuracy in determining these few individual's influence on the internet based on their content tweeted.

While Mr. Owyang does a nice job explaining the limitations of these metric websites (especially as it relates to lack of a "Sentiment Index"), but I must say that from my cursory look at the few fellow physicians I queried, it classified some of these more prolific bloggers and twitter users that I know pretty well.

Looking forward, it would not be unrealistic to think that some day a new variant of the Klout website might just serve as another form of doctor rating website. If so, the benefit of developing an valued online social media "physician brand" now might pay professional dividends later.

-Wes

Another Busy Year of Cardiovascular Innovations

The FDA just posted a nice summary of recently approved cardiovascular innovations, just in time for Heart Month, of course.

-Wes

For The Doctor's Dinner Table

A heart-shaped porcelain salt shaker.

-Wes

From LikeCool.com via Holy Kaw.

The Cardiologists' Hole Punch

... heart-shaped, of course.

-Wes

Ablating Hypertension

Refractory hypertension might be approached with radiofrequency catheter ablation techniques in the future, provided it's found the cure is not worse than the disease.

This week, the first non-blinded, prospective, randomized industry-sponsored Symplicity HTN-2 Trial of drug-refractory hypertension using endovascular low-power radiofrequency ablation within the renal arteries in 52 patients was reported. It is thought that this form of catheter ablation denervates the perivascular sympathetic innervation of the kidneys decreasing renin production and, therefore, blood pressure. (The guys over at Medgadget have some cool industry-sponsored pictures and videos about this technology). The ablation therapy in this trial appeared to carry promise at better blood pressure lowering compared to conventional medical therapy:

106 (56%) of 190 patients screened for eligibility were randomly allocated to renal denervation (n=52) or control (n=54) groups between June 9, 2009, and Jan 15, 2010. 49 (94%) of 52 patients who underwent renal denervation and 51 (94%) of 54 controls were assessed for the primary endpoint at 6 months. Office-based blood pressure measurements in the renal denervation group reduced by 32/12 mm Hg (SD 23/11, baseline of 178/96 mm Hg, p < 0.0001), whereas they did not differ from baseline in the control group (change of 1/0 mm Hg [21/10], baseline of 178/97 mm Hg, p=0·77 systolic and p=0·83 diastolic). Between-group differences in blood pressure at 6 months were 33/11 mm Hg (p < 0.0001). At 6 months, 41 (84%) of 49 patients who underwent renal denervation had a reduction in systolic blood pressure of 10 mm Hg or more, compared with 18 (35%) of 51 controls (p < 0.0001). We noted no serious procedure-related or device-related complications and occurrence of adverse events did not differ between groups; one patient who had renal denervation had possible progression of an underlying atherosclerotic lesion, but required no treatment.

This is an interesting study, but the long-term effects of this therapy to the renal arteries remains to be seen. The effects of low energy (6-8 watts of energy)applied over 2 min for each lesion will likely have variable effects at the tissue level.

Electrophysiologists have had a long history of experience with radiofrequency energy to ablate things. We have learned over the years that catheter tip temperature bears little resemblance to the tissue temperatures achieved. We know that low, long power applications make for larger lesions, provided tip catheter contact is stable. The low power applications used in this technology may have significant effects on surrounding tissues.

But we've also learned about the challenges with this technology inside vascular structures. We have learned (the hard way) about the development on intimal hyperplasia and later stenosis of vessels with radiofrequency ablation (in our case - pulmonary vein stenosis). If bilateral renal artery stenosis were to occur, how might the patient's blood pressure behave? Similarly, we have learned that stents placed in arteries cause inflamation and restenosis as well. Are we to think, naively, that inflamation inside renal arteries that have burn lesions applied inside them are more resistant to inflamation and later stenosis?

Hard to know.

Some protective effect against burns probably exists within the lumen of arteries thanks to the cooling effect of the brisk blood flow there. This convective cooling effect of the blood flow might be why these patients fared as well as they did while sufficient effects of heating occured in the outer adventitial layers of the renal arteries.

But there's also the question: what if it works too well? There are very effective treatments for patients with orthostatic hypotension (blood pressure that falls excessively with standing). It is interesting that one such patient was described in the USA Today article that covered this trial, but no mention of this complication occured in the peer-reviewed journal article published in Lancet which said:

Minor periprocedural events requiring treatment and possibly related to the procedure consisted of one femoral artery pseudoaneurysm that was treated with manual compression, one post-procedural drop in blood pressure resulting in a reduction in antihypertensive drugs, one urinary tract infection, one extended hospital admission for assessment of paraesthesias, and one case of back pain that was treated with analgesics and resolved after 1 month. Seven (13%) of 52 patients who underwent renal denervation had transient intraprocedural bradycardia requiring atropine; none had any sequelae.

No doubt a much larger trial will be forthcoming to evaluate these concerns. Still, this innovation might offer an interesting option for drug-refractory hypertension in the future but the jury's still out on it's long-term safety profile.

-Wes

A New Leadless Pacemaker-Pill?

The weak link in any pacemaker system are the leads that attach to the heart. Now a new innovation under development by Medtronic is on the horizon that might combine the pacemaker and lead together on a pill-sized device installed in the heart percutaneously:

The company has been developing the pacemaker for about a year now. It looks a cross between a battery and a beetle, with bug-like antenna sweeping back from one end.

The technology has yet to be tested in animals -- never mind humans. It's about five years away from being ready for market, if it's approved by the Food and Drug Administration.

While this first device will offer only backup VVI pacing, using several such devices controlled wirelessly might offer even more potential for sequential or simultaeous multi-sight pacing some day.

Very cool.

-Wes