Author Archives: Mac Milano

In this article, we present two cases utilizing a collaborative approach and advanced technologies to treat patients with heart failure (HF) at the University of New Mexico Sandoval Regional Medical Center.

NEW HF TOOL

We recently began utilizing the new HeartLogic Heart Failure Diagnostic Service (Boston Scientific) tool, which has significantly improved our ability to manage and monitor our HF patients, utilizing Heart Sounds, Thoracic Impedance, Respiration, Heart Rate, and Activity. This platform was chosen specifically to help optimize the management of our patients with an implantable pacemaker or defibrillator system, allowing early detection of HF decompensation, which may prevent hospitalization or other catastrophic events.

Our patients are closely monitored and our team works with local primary care physicians and cardiologists as well. When a patient’s left ventricular ejection fraction decreases over time to a level <35%, they are referred for an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) device when necessary and applicable. After receiving a CRT device, the patient’s degree of monitoring becomes more sophisticated; there are sensors in the implanted leads, and these devices have Bluetooth-like technology. Patients can simply keep the remote transmitters at their bedside, and we can monitor the parameters evaluated by HeartLogic’s platform:

• Heart Sounds: reveal signs of elevated filling pressures;
• Thoracic Impedance: measures fluid accumulation and possible impending pulmonary edema. Many times, the intrathoracic impedance will trend in a worrying fashion even before there are overt clinical manifestations;
• Respiration: monitors rapid shallow breathing pattern associated with shortness of breath;
• Heart Rate: indicates cardiac status and arrhythmias. Patients can develop arrhythmias such as atrial fibrillation or ventricular tachycardia which may be nonsustained at first and can be intervened upon before they become sustained arrhythmias or full-blown heart failure develops, and;
• Patient Activity: shows overall patient status and fatigue; we are alerted when there is a downward trend in their daily activities, which further informs us about the patient’s well-being.

A 50-year-old male presented with a long history of coronary artery disease, multiple previous myocardial infarctions, and ischemic cardiomyopathy. He had a dual-chamber defibrillator implanted several years ago and had been doing well, but he was gradually declining in his exercise capacity — suffering from shortness of breath after walking only 10-20 feet. He works as an electrician and is the sole financial provider in his home. As his clinical course gradually declined, his ECG began to show evidence of intraventricular conduction delay and left bundle branch block. When his QRS duration exceeded 135 milliseconds, despite maximum appropriate medical therapy for years, he was referred for an upgrade to a Resonate X4 CRT-D (Boston Scientific) by cardiologist Dr. Fundador Adajar.

The procedure went very smoothly, lasting approximately 40 minutes. His left ventricular pace/sense lead was placed in an ideal posterolateral position, which fortunately did not cause significant phrenic nerve stimulation and had excellent thresholds. His paced QRS duration narrowed from 135 milliseconds to 114 milliseconds, which typically predicts a good clinical response to cardiac resynchronization therapy. He demonstrated an almost immediate clinical response, with significant improvement of his systolic blood pressure from the 80s to about 110 while still in surgery. He was discharged the same day of the procedure, and all follow-up was performed by his cardiologist. Postoperatively, his exercise capacity improved dramatically. He was able to walk further without resting, and his fatigue almost completely resolved. During follow-up, the patient later developed dizziness due to over-diuresis, for which therapy was tailored down. We are currently awaiting a follow-up echocardiogram for this patient.

A 78-year-old male presented with a long history of coronary artery disease and multiple previous myocardial infarctions; the patient has also had complete heart block since 1998. He has had multiple dual-chamber pacemaker systems and when he developed cardiac arrest, his pacemaker was upgraded to an ICD. His clinical course had been declining rapidly; he experienced shortness of breath at rest, and required constant oxygen supplementation therapy. Over the past year, he was hospitalized frequently for episodes of acute decompensated congestive heart failure, and when he was referred to me by Dr. Yazan Alkhouri, his cardiologist, he was in cardiogenic shock with cardiorenal syndrome, where his kidney function had deteriorated significantly due to congestive heart failure. He was admitted the same day to the hospital, where he underwent diuresis and required inotropic support with dobutamine for four days. When he was able to lie flat for his procedure, he underwent an upgrade to a Resonate X4 CRT-D. An ideal posterolateral position was obtained, with accompanying narrow paced QRS duration decreasing from 186 ms to 136 ms with biventricular pacing. Postoperatively, he was able to rapidly wean off dobutamine. Two days later, when we were able to transition him to oral diuretic therapy after reaching his dry weight, he was discharged. His exercise capacity has improved significantly since then, and his renal function continues to improve. He no longer requires supplemental oxygen therapy. His primary cardiologist is performing all follow-ups post discharge.

We rely heavily on cardiologists, primary care physicians, and ER physicians to detect and diagnose early HF before these patients are then referred to us for the next level of care. Physicians such as Dr. Adajar and Dr. Alkhouri are crucial members of a patient’s healthcare team. Working with an electrophysiologist like me, they are able to give access to higher technology therapies for their patients. I routinely partner with Drs. Adajar and Alkhouri to remotely monitor their patients’ implanted devices. Our EP team works closely with these offices so that we can collaborate quickly and efficiently in response to patient alerts, to execute further and appropriate care for patients.

The takeaway message from these two cases is for physicians to be vigilant and persistent about treating patients with heart failure, and providing them with access to more advanced technologies. Cardiac resynchronization therapy is well-proven as an effective therapy for the treatment of patients with advanced heart failure, left bundle branch block, or in patients who have been ventricularly paced for a significant amount of time.

In addition, it is important to note that many rural clinics may not have an incentive or the resources to provide an upgrade to a biventricular device. Remote monitoring, especially in the rural setting, allows for earlier detection and intervention on an outpatient basis, thereby decreasing hospitalization and  improving outcomes for patients. There is better interaction between the clinic and patient, resulting in overall higher patient satisfaction and compliance.

UPCOMING HF INITIATIVE

I often travel throughout New Mexico to give presentations about the current guidelines on optimal care to the local physician community. Dr. Bart Cox, Dr. Leonardo Macias, and Dr. Alexander Schevchuck and I also recently joined together to form the Southwest Heart Failure Society. Our mission is to educate the community in order to improve delivery of care to not only meet national standards, but also exceed them. The community, consisting of medical providers and other partners, is key in the delivery of care for patients. Together, we hope to improve the standard of medical care provided to the people of New Mexico.

Acknowledgement. Dr. Khoo wishes to thank Redline Technical Editing, LLC for their assistance with this article.

Disclosure: The author has no conflicts of interest to report regarding the content herein.

References

1. Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007;297(1):61-70.
2. Fonarow GC, Abraham WT, Albert NM, et al. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF. Arch Intern Med. 2008;168(8):847-854.
3. O’Connor CM, Abraham WT, Albert NM, et al. Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Am Heart J. 2008;156(4):662-673.
4. Hatlestad J, Mehta S, Whelan-Schwartz J, Shanker R, Boehmer JP. Night-time elevation angles in MultiSENSE study are related to symptoms of orthopnea & paroxysmal nocturnal dyspnea. J Card Fail. 2012;18(8):S8.