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Dr. John Rickard joins Dr. Eric Roselli to discuss the cardiac resynchronization therapy – heart failure optimization clinic and key takeaways from a recent Tall Rounds® session.

Enjoy the full Tall Rounds® & earn free CME

  • Introduction by Moderator: John Rickard, MD,MPH
  • Case Presentation: Adam Grimaldi, MD
  • Multidisciplinary Care - The CRT CHF Clinic: John Rickard MD,MPH
  • Medical Optimization for CRT: W.H. Wilson Tang, MD
  • Reasons for Poor Response to CRT: Chony Albert, MD
  • Imaging Modalities for the Non-responder: Richard Grimm, DO
  • Ablation of Atrial Arrhythmias in Heart Failure: Tyler Taigen, MD

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Talking Tall Rounds®: Multidisciplinary Care for the CRT Patient

Podcast Transcript

Announcer:
Welcome to the Talking Tall Rounds Series, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic.

Dr. Eric Roselli:
Hello, everyone. Welcome to Cleveland Clinic Heart, Vascular, & Thoracic Institute, Talking Tall Rounds. I'm Eric Roselli, and I'm here with Jack Rickard, who is the founder of our CRT Clinic, multidisciplinary heart failure clinic, which is really in line with our multidisciplinary and collaborative care that we provide at the Cleveland Clinic. We went to an institute model many years ago, a little different from the traditional department of medicine and department of surgery design, because we knew that we needed to focus more on patient-centered care.

Dr. Eric Roselli:
And within our Heart, Vascular, & Thoracic Institute, we also wanted to create opportunities for people that are focused on specific problems to work better together, more optimally. And so we also have many centers within our organization of the Cleveland Clinic, and in addition to centers, we have even more specifically focused clinics. And that's the topic of today's talk, and I'm really excited to talk with Jack about this. In keeping with our Tall Rounds format, the Tall Rounds Event begins with a case presentation. Jack, you want to tell us about this?

Dr. Jack Rickard:
Yeah. Thanks, Eric. Appreciate you having me, and it's really exciting to be able to talk to you today. So the case that we presented at Tall Rounds was really an interesting case, and one that we've seen a couple at this point. It was a gentleman who was in his 50s, who had a big left bundle branch block, non-ischemic cardiomyopathy, a really good candidate for CRT, Eric. He met all of the criteria. Big wide left bundle, very symptomatic.

Dr. Jack Rickard:
One of our colleagues tried to take him to the lab to put a CRT device in, and just because of an anatomical problem, wasn't able to get a CRT device implanted, ended up going to surgery for a surgically placed epicardial lead, got the lead, and did poorly after that, potentially even worse. Ended up in our multidisciplinary clinic where we really needed to put our heads together to figure out what to do for this guy, who was a formerly functional guy in his 50s with a family.

Dr. Jack Rickard:
We put him through this multidisciplinary approach with input from heart failure, from imaging, from CT surgery, and obviously, electrophysiology, and came up with a plan. Oddly, the problem in the case was that the surgical lead was placed not in a great position. It wasn't really the surgeon's fault. The guy is obese, and wasn't really a ... It was really challenging to get the lead laterally. It was more anteriorly placed.

Dr. Jack Rickard:
After much debate, we decided that the heart failure meds were all optimized. There wasn't much we could do with that. We talked to CT surgery. They didn't want to take the patient back because it was tough the first time. So we decided to try to go back into the lab and try to give this another shot, doing it percutaneously. And fortunately, we were able to get by some of the anatomical problems that the first implanter couldn't get around, and we delivered an LV lead and the ejection fraction improved dramatically. His NYHA class became II, and he basically turned around quite a bit.

Dr. Jack Rickard:
Ultimately, he also required therapies for atrial fibrillation and flutter, and he received an ablation. And the end result was that he was back to work with the ejection fractions in the 45% range, and doing great. But he was headed down a pretty dark road, potentially looking towards advanced heart failure therapies because he was that sick, and it was a really nice turnaround that required input from imaging, CT surgery, heart failure, and electrophysiology to figure out what to do for him.

Dr. Eric Roselli:
That's an awesome success story, especially a very young guy. He's around my age, and to get them from an ejection fraction of 10 or 15% up to 45 range and functional, truly functional, that's got to be exciting. It really did require a whole bunch of people to come together around him. You led off the discussion in the Tall Rounds about how you built that team. Can you give us some of the highlights or maybe even tell us some of the difficulties you ran into, if any, or suggestions for folks who want to do this elsewhere?

Dr. Jack Rickard:
Yeah. The first thing was identifying the problem, and when you look at the guidelines for CRT therapy, the North American guidelines, European guidelines, Asian guidelines, they do a really good job of recapitulating the clinical trials, multiple clinical trials on CRT, but they did an awful job of telling us what we should do after the device has been implanted. And that's very important because CRT care around the country is fragmented. People don't get the best care after CRT is put in.

Dr. Jack Rickard:
So we attempted to remedy this issue with the goal of not just starting a small little clinic at the Cleveland Clinic, but to try to create an algorithm that could be used nationally or internationally, where we could try to address this problem, the ultimate goal of changing guidelines. What we did was we teamed up with ... It was an electrophysiologist, myself, and colleagues in heart failure, decided that we would start this clinic, such that every patient who got CRT would be seen in our clinic at six months after the device was implanted.

Dr. Jack Rickard:
The patients are seen in the same room at the same time with both doctors, simultaneously, doing some different things. And then they would get individualized plan going forward. If they were doing great, they'd get a pat on the back. If they were doing horribly, they could get referrals for LVAD, and everything in between those two extremes. The purpose of this was to break down the silos of care that were inevitably involved in not just cardiology, but lots of different specialties to try to target what we believe are some of the sickest patients in cardiology, the CRT recipient, and try to get to them earlier, before it's too late.

Dr. Jack Rickard:
And to your question about the challenges, yeah, there were some challenges along the road developing this. We've been at this for over three years now, and we've given lots of talks around the country with this, and we now have a bunch of sister sites that have adopted the same algorithm. And secondly, the scheduling is complex, right? You're scheduling out six months with an echocardiogram in the morning. So the actual scheduling bit of it was challenging, but after some trial and error, we were able to overcome those obstacles.

Dr. Eric Roselli:
And so on. That's fantastic. It's nice to hear about it after you've had some experience, right? You guys have been doing this for a couple of years. We do the same sort of thing when we treat some of these other complex problems that we run into, like advanced stage bowel disease, and certainly in aortic disease. Really, congrats to you to build this team.

Dr. Eric Roselli:
A couple of the heart failure colleagues are folks we hear from next in this talk, in this event, this Tall Rounds event, Wilson Tang, who has been a heart failure cardiologist here at the Cleveland Clinic for probably 20 years, or getting close to it. A very prominent researcher in the field talks to us about medical optimization for CRT. I thought it was interesting he brought up the point about how CRT is probably under-utilized and a couple of other important points about medical therapy.

Dr. Jack Rickard:
Yeah. Wilson gave a really nice talk, really nice summary of where we're at, that oftentimes, that patients come to us and one person's ideal idea of optimal medical therapy really is not usually what a heart failure doctor's idea of optimal medical therapy is. So a lot of times we see these patients, and they're on what he would call a child doses of Coreg or lisinopril, small doses of lisinopril. So oftentimes there's lots of opportunities to up-titrate medications.

Dr. Jack Rickard:
He also brought up a point that was really interesting, and this was a really interesting study that was presented at the Heart Failure Society of America last year, where it looked at patients who had normalized their ejection fraction post CRT, the super responder. Usually, they're female, non-ischemic left bundle, who just has this enormous response, and then saw, "Okay, did we fix the myopathy?" So in half the patients, they withdrew the beta blocker and the ACE inhibitor, and they went on to see how they would do compared to super responders who continue medical therapy.

Dr. Jack Rickard:
What they found was that the super responders who had the medical therapy withdrawn did worse. So it really gets to the point where we're not fixing the problem, we're mediating it. Mitigating it, I should say. So it's almost like we're suppressing it. It didn't fix it. It suppressed it. So that was a really interesting point, a really paper he brought up.

Dr. Eric Roselli:
Yeah, it's what these complex problems need, are these multi-component complimentary therapies that one person can't deliver alone. I couldn't imagine what it would be like to be an EP doc who's handling all the complex rhythm issues that you guys deal with and then be also asked to handle the complexities of managing heart failure medicines, which seems like we have a new one every six to 12 months and a new study that comes out that describes different ways to use those medicines. If you want those physicians that are on the leading edge of all those detailed therapies, you really need, I think, a team to take care of these patients. Our next speaker is Chonyang Albert.

Dr. Jack Rickard:
Yeah.

Dr. Eric Roselli:
Another heart failure specialist. Special kind of people that decide to be heart failure specialists, and a lot of persistence. She gives a great talk. We'll actually hear her talk at the end of this discussion because I thought she gave a really nice conversation and discussion review and summary of a problem that everybody is going to run into, are the patients that fail CRT.

Dr. Jack Rickard:
Yeah. Chonyang really did give a nice summary of where we're at. One of the things that I think is really interesting about Chonyang's talk, and one of the things that most people don't realize is there have been over 13,000 papers written on CRT, and most of them refer to a CRT responder or non-responder. You get the CRT device at three, six months later, whatever, you check an echo and the ejection fraction gets better. And all those who didn't get better were labeled non-responders right?

Dr. Jack Rickard:
In 2021, we're starting to throw that on its head a little bit because that dichotomous phenotype doesn't really take into account the natural history of disease. So we're starting to think there may be actually five phenotypes with CRT outcomes, meaning that you've got the super responder, that pure electrical myopathy that gets better. You've got the responder, who could be an ischemic male patient with a left bundle whose ejection fraction improves, but doesn't get all the way better.

Dr. Jack Rickard:
But then what's interesting is this has now crept into the European guidelines, this idea of a stabilizer, meaning that someone whose ejection fraction may not get better, but didn't get worse. And you seem to have blunted the natural history of disease. And for years, those patients would have been tossed into the non-responder category, but that's not really true because if you hadn't given them CRT, they would have gotten a lot worse.

Dr. Jack Rickard:
And then the true non-responders, the person who doesn't get better, who doesn't get worse, they stay the same, and then the negative responder. And that's another thing to my heart failure colleagues, they don't recognize that there's a small percentage of patients whose ejection fraction and symptoms actually get worse with CRT, and that could be the patient had a bad lead position coupled with a bad electrical substrate to start with. So Chonyang really talked a little bit about a lot of different aspects of CRT, but I really keyed in on the phenotype she described because that's novel, and a lot of people don't think of it that way.

Dr. Eric Roselli:
Yeah, I think that really makes a lot of sense. Gives you some sort of structure about how to manage folks, or at least give people out there that are taking care of these patients a better sense of when to refer people to a specialist as well. But a lot of these decisions, these fine decisions about where to go next are guided by the imaging that we do. And we hear from Rick Grimm, who runs our echocardiography lab and also has vast experience in seeing all kinds of complex patients and has been through the whole evolution, a lot of different imaging modalities as well. Gives us a nice review of that next.

Dr. Jack Rickard:
Yeah, I think Rick is one of the experts at AV optimization. He really did a nice talk. In a way, imaging with CRT could take a big back step when the PROSPECT trial was published about, I think it was eight years ago now, which looked at various measures of mechanical dyssynchrony and find and predict CRT outcome. The trial failed, and as a result, we in the EP and heart failure community haven't really given a lot of attention to imaging and CRT, but I think that's a disservice to our patients, and I actually believe that imaging does really play a key role in some of these CRT patients.

Dr. Jack Rickard:
For example, in our case, Eric, we actually put the patient through an echocardiogram looking at strain imaging on and off and we've determined that the patient was actually doing worse with that surgical epicardial lead than he was with the device off. And that was important because it gave us more backing to take the patient back to the lab to do an invasive procedure, knowing that this really wasn't working, and the imaging really did play a key role in helping us make that decision.

Dr. Jack Rickard:
So I don't think the imaging matters in every patient, but certainly the CRT non-responders, for example, the left bundle branch block non-responders, imaging may play a key role. What we do at the Cleveland Clinic with that is that we turn the device off, we do longitudinal strain imaging to identify the latest activated mechanical segment in the LV, and then we try to figure out whether our LV lead is in that segment, near it or just way off. And if it's way off, that gives us fodder to take the patient back to the lab, to either put the LV lead in a different spot or try LBB pacing or His bundle pacing. In certain patients, we believe that the imaging does play a role, and Rick did a nice summary of it.

Dr. Eric Roselli:
That's great. One thing I've noticed, there's all this discussion about precision medical care, and a lot of the focus about this discussion and medicine is focused on the genetic basis of things, but I'll tell you, as our imaging technologies get more and more complex, then we see imaging where we can physiology with structure, that concept of providing precision care to patients guided by their imaging, I think, is an important one we need to focus on. And that's exactly what you described, the ability to be more precise for any particular patient with that imaging guidance.

Dr. Eric Roselli:
And then of course, we got a nice little wrap-up from Adam. I liked the way he broke the case up into the pre and post discussion. Then, as you already told us, the patient had had a great response to the therapies. And then there is some other important therapy, though, along the electrophysiology lines, based on specific problems that you run into. And our final speaker was Tyler Taigen, who's an electrophysiologist who both trained here and now works with us and discussed what he does in the lab in some of these complex patients with focused issues that require the ablation, is that right?

Dr. Jack Rickard:
Yeah. So in the last couple of years, there's been a renewed interest in looking at A-fib, specifically PVI in patients with heart failure. The CASTLE-AF trial was a trial in the New England Journal of Medicine showing a mortality outcome in patients treated with PVI who have a depressed ejection fraction. And so Tyler did a nice job summarizing why we may choose to be aggressive in terms of rhythm control in patients with the depressed EF.

Dr. Jack Rickard:
The other issue, this really pertains well to the CRT patient because, remember, AF interrupts BiV pacing. The irregularity in the CRT makes CRT not as effective. In fact, in some cases, not effective at all. Oftentimes, in a persistent AF patient, when you read the percent BiV pacing, they'll say 95%. But in reality, if you've got a Holter, a lot of those paced waveforms are fused and not really effective CRT.

Dr. Eric Roselli:
Not effective, right?

Dr. Jack Rickard:
Right. So we, in our clinic, we're very aggressive treating A-fib in patients who have CRT devices for that very reason. And this patient had flutter and A-fib, but ultimately, without an ablation to get rid of the flutter, all the efforts we made to get this patient adequate CRT would have been for naught. So I think that was the point, that just stopping at getting the CRT implant wasn't enough. We then had to address the rhythm disturbance.

Dr. Eric Roselli:
Yeah. Great. And then you guys were spot on with the plan to save a few minutes for discussion, which was also really great. And I think you guys really delivered an excellent Tall Rounds event. Thank you for that. Thanks for leading that. I look forward to working with you on many more.

Dr. Eric Roselli:
For the members of our audience that are interested in viewing the entire Tall Rounds event that's focused on the CRT heart failure clinic model and a discussion of it, you can see this online, and we offer complimentary CME from those events and many others. Please feel free to join us online. It's a free service to get a front seat of the academic and educational events that happen at the world-class Cleveland Clinic. Jack, I really enjoyed talking with you today.

Dr. Jack Rickard:
Thanks so much, Eric. This was great. I'd like to introduce Dr. Chonyang Albert, whose talk is reasons for poor CRT response, 2020. Chonyang is a heart failure physician in our section of heart failure and works closely with me in the CRT HF clinic.

Dr. Chonyang Albert:
My name is Chonyang Albert, and I'm from the section of heart failure, and it's my pleasure to discuss the causes of CRT non-response. As we know, there are five categories of post CRT outcomes. You can have super responders, responders, non-progressors, non-responders, and negative responders. And the definition of CRT non-response has been varied in the literature, ranging from hard clinical outcomes, such as death or heart failure, morbidity mortality, remodeling measures as defined by left ventricular geometry and dimension volumes, for example, functional measurements and clinical composite measures.

Dr. Chonyang Albert:
No matter how you look at the data, in general, about 30 to 40% of patients who receive a CRT are ultimately considered non-responders. And the reasons for CRT non-response can be multifactorial. In these papers from Wilfred Mullins, Wilson Tang, et al., looked at insights into why patients may not be CRT responders. And broadly speaking, we can break it down into three major categories: Medical optimization, EP management, and disease severity.

Dr. Chonyang Albert:
For the purposes of my talk, I've, again, structured it into heart failure causes of non-response, imaging considerations, and EP causes of non-response. Because I'm a heart failure physician, I'm going to start with the heart failure causes of non-response. It's important to consider the etiology of heart failure. In patients with extensive cardiac scarring, such as those with ischemic cardiomyopathy or potentially undefined or underdiagnosed valvular heart disease, or infiltrative heart disease, those patients may not respond as well to CRT treatment. Additionally, regardless of the etiology of heart failure, patients with extensive LV dilatation may not respond as well.

Dr. Chonyang Albert:
In this previous paper by Dr. Rickard, et al., looked at the point of no return, so to speak. And the inflection point appears to be around 6.5 centimeters in terms of the left ventricular and diastolic dimension, beyond which, if the left ventricle is severely remodeled, we may not expect a good CRT response.

Dr. Chonyang Albert:
Additionally, as Dr. Wilson Tang just discussed, we should always strive to optimize guideline directed medical therapy, not only the appropriate medications, but at maximally tolerated doses for all of our heart failure with reduced EF patients. But particularly in patients who have shown non-response to CRT, this gives us an opportunity to really dive deep on their medications and optimize them as best as we can. And because this is a moving field with the introduction of ARNIs and SGLT2 inhibitors, it's important for us to fully optimize patients medically.

Dr. Chonyang Albert:
Lastly, we should consider heart failure severity and staging. We know that frailty is a predictor of poor CRT response. So it's possible that patients have not responded to CRT because, simply, they're too frail. But also, we know that some patients have potentially progressed to stage D or end-stage heart failure. I like this pneumonic previously published in 2017 to help us parse out the red flags, which might indicate somebody is truly at advanced heart failure staging.

Dr. Chonyang Albert:
And of course, we know that patients who are requiring inotropes, previously required inotropes, that's a high risk feature. But we should also be reminded of patients with severe functional limitations and organ dysfunction, very depressed ejection fraction, frequent defibrillator shocks, hospitalizations, worsening edema, lower blood pressure, and poor tolerance to guideline-directed medical therapy. These are red flags as well. And in the CRT multi-disciplinary clinic, the heart failure physician can detect these patients and make a timely referral for advanced heart failure therapies, such as ventricular assist devices or heart transplantations when appropriate.

Dr. Chonyang Albert:
In terms of imaging predictors of non-response, you'll hear more from Dr. Grimm later, but we know that advanced imaging modalities, such as cardiac MRI can better define scar burden. We know that they are tools in terms of looking at left ventricular geometry and to improve synchrony. Lastly, we arrive at the electoral physiologic causes of non-response, and I think there are three main categories to consider here: The electrical substrate, the lead placement, and percentage of biventricular pacing.

Dr. Chonyang Albert:
We know that patients who have a true left bundle branch block cardiomyopathy with a Straussian left bundle branch block respond the best to CRT treatment by definition of their underlying cause of dyssynchrony. In patients who have a right bundle branch block or a mixed picture with an intraventricular conduction delay, we do not expect as robust of a response to CRT pacing.

Dr. Chonyang Albert:
Lead placement is also of paramount importance, and in this AP view on the left of the chest x-ray, you can see that the heart has been parsed out into basil, mid, and atypical sections. And on the lateral view on the right, the heart is parsed out into anterior, lateral, and posterior sections. Previous work has shown that the left ventricular lead placement in anterolateral and posterolateral placements tend to respond more favorably than lead positions in the anterior or posterior positions. Additionally, we know that patients with non-apical LV lead position do better than those with atypical leads.

Dr. Chonyang Albert:
Lastly, we should pay attention to optimize the percentage of biventricular pacing. This paper shows that when assessed by quartiles, patients with biventricular pacing percentage above 99.6% experienced a 24% reduction in mortality compared with other quartile groups. Thus, attention must be made to fully optimize the percentage of biventricular pacing, paying special attention to the occurrence of PVCs and atrial arrhythmias.

Dr. Chonyang Albert:
In summary, there are multiple reasons why a patient may not have a good CRT response. We should consider the heart failure and imaging reasons, such as the etiology of heart failure, frailty of the patient, the severity of heart failure, and this gives the heart failure physicians an opportunity to re-examine patients, guideline-directed medical therapy, and refer for advanced therapies when appropriate. In terms of the EP reasons for poor CRT response, we must consider the electrical substrate, attempt to optimize lead placement, and to improve the percentage of biventricular pacing. Thank you.

Announcer:
Thank you for listening. We hope you enjoyed the podcast. Like what you heard? Visit Tallroundsonline@clevelandclinic.org/tallrounds and subscribe for free access to more education on the go.

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