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.

John Rickard, MD:

Hello, I'm Jack Rickard and welcome to Tall Rounds. The title of our talk today is Multidisciplinary Care for the CRT Patient. We're going to be running through a case of a patient we saw that received CRT and using this case to highlight a multidisciplinary clinic we have here at Cleveland Clinic called the CRT CHF Clinic. So with that, we'll get started and Dr. Adam Grimaldi will present our case.

Adam Grimaldi, MD:

So our case starts with a 48 year old male, had CRT-D implanted, presents to our clinic for multidisciplinary evaluation for CRT non-response. Past medical history is significant for a non-ischemic cardiomyopathy. He has NYHA class III symptoms with an ejection fraction of 15%. He also has a left bundle branch block of 170 milliseconds, diabetes, gout and OSA. A percutaneous LV lead was attempted at an outside facility and failed.

Adam Grimaldi, MD:

He subsequently underwent a surgical LV lead. The patient unfortunately had ongoing heart failure symptoms and an echo showed no change in his EF. Here's his baseline ECG prior to surgical LV lead placement, showing a left bundle branch block of 170 milliseconds, and here's his ECG after CRT-D implant, showing QRS of 154 milliseconds. The device was checked. The leads showed appropriate capture sensing and thresholds and he was BiV pacing 99.8% of the time.

John Rickard, MD:

So around three years ago, a section of heart failure and electrophysiology to Cleveland Clinic set off to try to fix a big problem we've seen in the care of CRT patients. So you look around the country and at the Cleveland Clinic, CRT patients don't typically get the best care and the reason that is, is that there's a silo effect between heart failure, electrophysiology and imaging. CRT patients have heart failure. They have an electrical problem and they often require various imaging modalities and the problem is the sections don't typically talk to the degree necessary for optimal care of these patients. So we decided to try to fix this by having heart failure and electrophysiology in the same room at the same time after implant to break down the silos.

John Rickard, MD:

So what do CRT guidelines have in common? They do a very good job of telling us who we should put CRT devices in. They largely recapitulate the findings from the major clinical trials. What they don't do, however, is they don't tell us what to do after CRT is implanted. So if you look around the country and you look at Niraj Varma's Advanced CRT Registry, care after CRT is extremely fragmented. In fact, electrophysiologists are typically the ones managing these very sick patients and typically electrophysiologists are not adept at managing sick heart failure patients. They're not good at up-titrating medications. They're not good at starting sacubitril/valsartan. They're not good at knowing when to refer for advanced heart failure staging and so there's a lot of things missing from the care.

John Rickard, MD:

So we set off to try to remedy this problem. So why do we care how patients do after CRT? Now, if I told you, you have stage III renal cell carcinoma in the UK, that probably would get your alarm bells ringing. If I told you, you were a, quote, unquote, non-responder defined by no improvement in ejection fraction post CRT, you may not feel that that's as big of a deal. However, the two populations actually have the same survival. So measuring an echo six months after CRT is vitally important because it gives us tremendous prognostic information as to where that patient's headed.

John Rickard, MD:

When we see a patient in the CRT Clinic, we try to put them into three buckets, so to speak. I think this is a really good conceptual framework for all CRT patients. So on the left hand side, you have patients with a pure LV electrical conduction delay. That's your female non-ischemic wide Strauss left bundle. That's the patient who the electrical problem is the primary driver of the myopathy. On the right hand side, you've got patients who have a widened QRS, but that widened QRS is not necessarily traditional electrical dyssynchrony. What it really is indicative of is a very sick heart, lots of scar, huge LV mass. That could be your male patient, ischemic, IVCD of 140, 150 milliseconds, where the LVEDD is 7.5cm.

John Rickard, MD:

It's not really dyssynchrony. It's a measure of sickness. So in those patients, CRT is not overly helpful and potentially harmful and they need a heart failure trajectory. On the left hand side, resynchronization. We are not the first to have a CRT clinic. The first clinic was in 2010 here at Cleveland Clinic with Dr. Tang, Dr. Grimm, Dr. Starling and others, where it was a referral pathway where, if your patient wasn't doing well, they could be referred in for CRT. It's a really nice approach, in some ways, that it doesn't require a ton of resources but it does one, miss a lot of patients and number two, it oftentimes gets patients too far along in the process where you could have helped them.

John Rickard, MD:

2012, the Stark Clinic at MGH formed and that was an endeavor to start a care pathway approach, where they saw every patient after CRT implants and we adopted this kind of strategy in our clinic with a couple of tweaks. So how does this clinic work? So patients get their CRT device and at six months, they're scheduled for an echocardiogram and a clinic visit. The patients get the echocardiogram in the morning so that we can compare it to their pre-CRT echo. When the patients show up to clinic, they're seen by our nurse who completes a neurocognitive evaluation, which is a clock draw, some neurocognitive questions. The patients are asked to remember three words. They get a patient's self-assessment. "How are you doing on a scale of zero to 100?" An EQ-5D, which gets at how the patient's functionally doing. Basically, we're trying to get at their neurocognitive status and whether they're frail. If you can't remember a couple words, how are you going to remember to take all these complex medications at all these different times during the day. Frailty, as you're going to hear later, is also an important predictor of poor response to CRT.

John Rickard, MD:

So while that's going on, Heart Failure and Electrophysiology are huddling together, reviewing all the patient's background details, as well as the coronary sinus venogram, the details from the CRT implant, as well why the patient got CRT. Then we go into the room. Heart failure starts off with a history and physical while electrophysiology is interrogating the device, doing all the typical things, but also recording something called QLV, looking at PVC burden, AFib burden, checking for something called anodal stimulation, looking at all the different other pacing vectors that would be possible. So it's a device check with more added to it.

John Rickard, MD:

After that, heart failure, our nursing staff and EP huddle. We figure out how the patient's doing and then we come up with an individualized plan. That can be anywhere from, "Congratulations, you're a super responder," to, "You need to be referred for a potential LVAD implant," and everything in between. Oftentimes, the most important thing is medication up-titration and optimization. We do do device optimization with an EKG, trying to narrow down the QRS. There's a wide range of things we do. After that, the patient's referred back to their doctor for further management.

John Rickard, MD:

Does this matter? Well, this is data from MGH showing that multidisciplinary care post CRT can improve heart failure free survival. So that's why we feel this is such an important tool.

Announcer:

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