What Do Devices Tell Us? Laura Quinn

Highly Specialist Cardiac Physiologist Northern General Hospital

∗ CRT ∗ What does it do? ∗ Who should get one? ∗ General Device Diagnostics ∗ Heart Failure Diagnostics ∗ CRT Optimisation Clinic

Overview

∗ With each subsequent HF related admission – patient leaves hospital with a further decrease in cardiac function

Worsening Heart Failure

Cardiac Resynchronisation Therapy (CRT) – Biventricular pacing

∗ Treating heart failure with an implantable device

∗ Improves heart ability to pump and promotes synchronized ventricular contraction

∗ Like a pacemaker but with an additional lead placed in coronary sinus that stimulates the left ventricle

∗ Single Therapy – CRT P ∗ Combined systems – Plus a

defibrillator – CRT D

What does CRT do?

Ventricular Dyssynchrony Cardiac Resynchronisation

Right and left ventricles contract uniformly

∗ Improves pump efficiency ∗ Stroke volume increases ∗ Mitral regurgitation decreases ∗ HF symptoms ease and QOL improves ∗ Proven to reduce heart failure admissions ∗ Mechanical remodelling of LV

What does CRT do?

∗ Ventricular dyssynchrony – LBBB, Prolonged QRS duration >130ms

∗ NYHA class II, III or IV heart failure symptoms despite optimal medical therapy

∗ Low ejection fraction <35% ∗ Block HF – trial that found patients with AV block

(require high % of ventricular pacing) and had LV dysfunction benefitted from BiV pacing vs RV pacing

Who is a good candidate?

∗ Maintaining continuous BiV pacing (target 100%) is crucial and will increase likelihood of response.

∗ Seen in device clinic for routine follows up to ensure ongoing function of device

∗ Optimising CRT pacing parameters can help to increase cardiac output and ventricular filling.

CRT therapy

∗ Can be prescheduled or automatic alerts ∗ Home monitor box sits by patients bedside ∗ Every night device awakes to communicate with box ∗ If abnormalities have been occurring – information

gets downloaded to their box and sent via secure server to websites

∗ Physiologists check these websites daily

Remote monitoring

General Device Data

Arrhythima’s

∗ Presented in two different ways

∗ EGM’s (intracardiac signals) if meets criteria programmed by device

∗ Duration of episode, heart rate

∗ What device thinks arrhythmia is

Arrhythmias

∗ Counter/trend data ∗ Arrhythmia burden over

time between sessions and from the overall history of device.

Rate Histograms and Percentages

∗ Provides data about conduction status

∗ Pacing and sensing percentages

∗ BiV pacing ∗ Heart rate distributions ∗ Chronotropic response ∗ Rate control during AF ∗ Changes between sessions

Heart Failure Diagnostics

Diagnostics in Heart Failure

∗ Can provide an early warning of congestion

∗ Can provide additional insight to try and reduce re-hospitalisation rate

∗ Can follow response to treatment

Patterns to Decompensation

Hospitalisation

Cardiac Output

Left Atrial Pressure Sympathetic Nervous Activity

Pulmonary Fluid

Weight

Symptoms Activity

Sensor on devices Heart Rate Variability Thoracic Impedance Activity

∗ CRT devices display some data together in trend graphs so that you can see multiple sensor measurements together to help in diagnostic process

∗ Increases in Night heart rate and decrease in heart rate variability

∗ Thoracic Impedance – can be indicator of increase in fluid retention

∗ Decrease in patients activity levels – accelerometer inside devices can track patients activity daily which correlates to patient symptoms.

∗ Algorithms can use all this data to alert us to a potential event.

Trend data

Thoracic Impedance

• Thoracic impedance is based on the principle that water is a relatively good conductor of electrical current. Thus, electrical conductance through body tissues varies according to the water content of the tissue.

• If fluid retention goes up, impedance goes down and if fluid retention goes down, impedance goes up.

• There are many factors that can cause an

impedance increase or decrease. Therefore, a threshold crossing is not always an indicator of a heart failure decompensation

Triage Heart Failure

∗ We have implemented these diagnostics into our remote follow up service

∗ Currently with Sheffield and Chesterfield with hopes to expand

∗ Patient alerts as high risk of a heart failure event from remote follow up

∗ Email the appropriate Specialist Heart Failure Nurse

∗ Specialist Heart Failure Nurses have access to the heart failure risk report

∗ Assess patients status and treatment

∗ Aim: Proactively eliminate common causes of CRT non-response ∗ Multi disciplinary clinic ∗ Patients with newly implanted CRT devices ∗ Pre implant - Echo, 6 minute walk test and a QOL assessment

questionnaire. ∗ Six weeks - Seen by Specialist Cardiac Physiologists and

Specialist Heart failure nurses ∗ Device is fully optimised and tailored to patient ∗ Remote monitor is given ∗ Medication is reviewed and up- titrated if necessary

CRT Optimisation Clinic

∗ 5 months – Repeat Echo to look for remodelling ∗ 6months – Patient comes back to CRT Opt. Clinic ∗ Ensure device is fully optimised, reviewed again by Specialist

Heart Failure Nurses ∗ Repeat QOL questionnaire and repeat 6minute walk ∗ All indices are compared at 6months to pre implant to assess the

response to therapy ∗ Functional response, mechanical response and symptomatic

response ∗ 2 out of 3 have improved – classed as a responder to CRT ∗ If classed as a non responder – responsible consultant is

informed to assess if anything further can be done.

CRT Optimisation Clinic

CRT Optimisation Clinic

∗ Ensures that all CRT patients are receiving the best possible chance to respond to this therapy in a very streamlined and timely way

∗ Standardised approach

∗ Adamson PB. Pathophysiology of the transition from chronic compensated and acute decompensated heart failure: new insights from continuous monitoring

devices. Curr Heart Fail Rep. 2009;6:287–292.

∗ Adamson PB, Smith AL, Abraham WT, et al.: Continuous autonomic assessment in patients with symptomatic heart failure: prognostic value of heart rate

variability measured by an implanted cardiac resynchronization device. Circulation 2004, 110:2389–2394.

∗ Adamson PB, Kleckner KJ, VanHout WL, et al.: Cardiac resynchronization therapy improves heart rate variability inpatient with symptomatic heart failure.

Circulation 2003, 108:266–269.

∗ Yu CM, Wang L, Chau E, et al.: Intrathoracic impedance monitoring in patients with heart failure: correlation with fluid status and feasibility of early warning

preceding hospitalization. Circulation 2005, 112:841–848.

∗ Small R, Wickemeyer W, Germany R, et al.: Changes in intrathoracic impedance are associated with subsequent risk of hospitalizations for acute decompensated heart failure: clinical utility of implanted device monitoring without a patient alert. J Card Fail 2009, 15:475–481.

∗ McAllister F, et al. Ann Intern Med. 2009; 150:784-794

∗ Swedberg K, et al. J Am Coll Cardiol 2012; 59:1938-45

∗ Cullington D, et al. Eur J Heart Fail (2012) 14 (7): 737-747

∗ McAllister F, et al. Ann Intern Med. 2009; 150:784-794

∗ Swedberg K, et al. J Am Coll Cardiol 2012; 59:1938-45

∗ Cullington D, et al. Eur J Heart Fail (2012) 14 (7): 737-747

∗ Uçar FM, Yilmaztepe MA, Taylan G, Aktoz M. Non-Sustained Ventricular Tachycardia Episodes Predict Future Hospitalization in ICD Recipients with Heart Failure.

Arq Bras Cardiol. 2017 Oct;109(4):284-289. doi: 10.5935/abc.20170141.

∗ Steven A. Lubitz, Jagmeet P. Singh; Biventricular pacing: more is better!, European Heart Journal, Volume 36, Issue 7, 14 February 2015, Pages 407–409,

∗ Lechat P, Hulot JS, Escolano S, Mallet A, Leizorovicz A, Werhlen-Grandjean M, Pochmalicki G, Dargie H. Heart rate and cardiac rhythm relationships with bisoprolol

benefit in chronic heart failure in CIBIS II Trial. Circulation. 2001 Mar 13;103(10):1428-33. ∗ Swedberg, Karl et al. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study The Lancet , Volume 376 , Issue 9744 , 875 -

885

References