The future of electrophysiology

Introduction

One of the areas of cardiology that has improved dramatically in quality and quantity of the procedures performed is electrophysiology. Technical improvements, new, extremely sophisticated tools, and scientific information have introduced a number of new procedures aimed at solving complex cardiological problems. Many of these were either unrecognised (i.e., asynchronism in the ventricles as a source of left ventricular disfunction), or were too difficult to be treated (i.e., transmural circuits in ventricular tachycardia or left atrial flutter). Continuous academic research and collaboration between investigators and industry has allowed the development of new concepts, new targets and new forms of treatment which were unavailable a few decades ago. Today, almost every arrhythmia can be effectively treated in the electrophysiological lab with no limit in terms of the complexity or difficulty of access to the site of origin. However, even in the problems and challenges that seemed to be solved, such as pacing for bradycardia, scientific research continues to find new elements, such as physiological His or bundle branch pacing, to improve treatment for our patients.

What can we expect in the near future for electrophysiology?

Certainly, ageing of the population is one of the most relevant elements in relation to how the need for electrophysiological procedures will evolve. The most prevalent conditions needing sophisticated therapy are age-related. Atrial fibrillation, heart failure, ventricular arrhythmias post-myocardial infarction or cardiac pacing for bradycardic problems are the most important ones. In all these issues, the increasing need for invasive procedures and device implants will challenge our capabilities to give and answer to the real needs of our patients. These capabilities are clearly underpowered at present. In Europe, we are unable to offer adequate, high-quality therapy to all the patients who need it. In many countries, waiting lists for an atrial fibrillation ablation are desperately long. In many areas of Europe, the high-tech capacity to perform a complex arrhythmia substrate ablation is lacking. The biggest challenge in the immediate future is probably just this: treating as many patients as required in a reasonable time frame. To do so, increasing resources is crucial, but the simplification of techniques could also be one way to treat many more patients. Very sophisticated techniques that can be used only by a minority to treat very few patients might be scientifically very interesting but are socially irrelevant. We need available techniques that can be performed by the majority of centres and expand the tools and the training of physicians so that, finally, the therapies can be offered to the very large number of patients who require them. The combination of sophistication and simplicity will be the main challenge for us to develop in the coming years and this is where scientific knowledge and ease-of-use high-tech tools should be focused.

What new developments can we expect in the next few years?  

In the field of ablation, we will probably have automated, single-shot techniques to treat complex cardiac arrythmias. New 3-D mapping techniques combined with automated identification of the target area are on the way. The electrophysiologist will tackle the area of interest with the help of technology. Robot-guided catheters will be directed towards the point to be eliminated. Instant electrical mapping combined with anatomical descriptions will identify the area that will to be eliminated by a single shot, using a safe and highly effective type of energy. The next generation will probably combine all these techniques without the need of catheters, identifying the site of interest and delivering the energy non-invasively.

In the field of bradycardia, leadless pacemakers already exist, so the next developments will probably be seen in chip (and not device) implants, auto-rechargeable, and easy to deliver to different areas of the heart.  Farther into the future, catheter-deliverable automatic cells and conductive cells will probably be implanted in the areas where automaticity or conduction has to be resumed. Leads, devices and batteries will disappear from our lives.

In sudden cardiac death prevention, devices will progressively become less and less invasive, and smaller. Leadless techniques will evolve towards chip-related implants and new energy sources, different and less aggressive than DC shock, will be available.

External defibrillators will become available worldwide, probably as part of the smartphone, in the car, at home as another home appliance, and obviously in all public places, in situ or delivered by drones.

We will better understand the genetics of cardiac arrhythmias, and these will open the door to genetic therapies: not only embryonic selection but also therapies that correct genetic defects using the tools that will allow for editing genes and correcting anomalies.

Many of these advances will be seen very soon - in our generation - others will require longer periods of time, and some of them will require ethical, political and social debates because they go further than simply treating patients and might change human nature itself.

Conclusion

Looking back 40 years ago, no one could imagine that electrophysiology would evolve in the way it has. Those, like myself, who were so lucky as to be a part of these developments, look at the future thinking that the best is still to come; that scientific knowledge, technical developments and therapeutical tools will even be better, easier to use and safer than the current ones. This will probably create a truly global, socially relevant field of cardiac electrophysiology, where we will be able to treat patients in need everywhere around the world.

Take-home messages

• Treating as many patients as required in a reasonable time frame is our major challenge. For this, increasing resources is crucial, but simplification of techniques could also be one way to treat many more patients.
• New developments, such as automation and robotics, will become available and eliminate the factor of human error in the procedures.
• Genetics will definitively modify our understanding of cardiac arrhythmias.