Discussion About Cardiac Resynchronization Therapy-Dr Aparna Jaswal and Dr. Rohit Malhotra Top Cardiologist in Delhi and United States:-I would like to introduce to you our doctor here. And that’s Dr. Boyd Malhotra. Dr. Boyd Malhotra comes from the University of Virginia, Charlottesville, United States. Dr. Malhotra is one of the leading electrophysiologists with a keen interest in ablations of atrial fibrillation, left atrial appendage closures, and as well as CRTs. So the question that we are going to have to ask him will cover most aspects of electrophysiology.
So, welcome, Dr. Rohit, thank you very much for having me, it’s been a pleasure. So I’d like to start off with the latest guidelines that have just been published on pacing a couple of weeks ago. And they have expanded the utility of Cardiac Resynchronization Therapy implantation in patients who have a CH B, with an ejection fraction between 36 and 50%. And we expect we are pacing more than 40%. So I would like to know about your practices in the United States, and how you were looking at them.
So obviously, that data is all based on the block hf trial, which was published now about three, four years ago, that trial actually took quite a long time to enroll, the full number of patients actually never met the number that was expected to enroll. I think part of that ends up being that our institution like many in the United States, including those that participated in blocage F. You know, if we take a simple dual-chamber, pacemaker implant, that usually takes roughly an hour if we put in a CRT device that can take anywhere from one to two or three hours. And so I think that’s part of the challenge of that.
However, based upon the results of that trial, when we have patients who come to the hospital with complete heart block or are pre dispositioned, putting in crtp devices now is much higher. One of the other things that have become more commonly used in the last year or so as well, in the United States, there’s been more of his bundle-oriented pacing. Now, the challenge with that ends up being that we don’t really have any truly randomized trials to look at long-term outcomes.
Our experience has been across the United States that lead placement may have higher thresholds in his position.
And those thresholds tend to rise over time. And so we don’t know whether so in someone who has complete heart block, whether we’re able to actually implant and paste into his position. So if we plan for his position, pacing, and then have to change to crop, that can be cumbersome, changing the plan for the day with the lab, or vice versa, saying we’re going to proceed with hitting with card placement. But then there can be challenging CS anatomy. Or if the patient is, you know, we’ve gotten, it takes longer to get a lead in and we’re uncomfortable with how long they have heard and Walker, how we’re placing them in the interim.
So in each of these cases, I think we take it on a case-by-case basis. So for younger patients, we’re more likely to implant either CRT or have been the lead. For older patients, they’re often other comorbidities that come with a complete heart block. And so that’ll impact our approach and planning for the procedure.
I think I would like to add about the block hf in the biopic trial when you review the data. If I understand that correctly, block hf gives very good results. You give CRT, while biopics is said differently in patients with nearly preserved ejection fractions, and it said that probably you could go in for a dual-chamber. Yeah, so I’d like to know from you for a country like India, where CRT would be available largely in metros.
And would you consider telling us that maybe if you were to give a dual chamber for an ejection fraction of 40%, it’s a good idea to go sector?
Or do you think that you’re still practicing a pike?
so typically for us, you know, at the heart rhythm society meeting in the United States, I think every year there’s a debate, pro, and con of septal versus atypical pacing. And I think I’ve been to one of those sessions and had the one speaker say if you are implanting in the apex, you are doing the wrong thing. So I typically actually still implant in the apex for a number of different reasons.
One is lead dislodgement, maybe lower. In older patients. That’s one of the considerations for an older woman. I might consider placing more on that. More septal location rather than an atypical implant. But our patients on the whole in the United States tend to be larger than they are in most of the rest of the world. We’re winning in that regard. And so we tend, I tend to worry a little bit less about perforation in those cases. And so far, the data for septal versus atypical implant really has not demonstrated significant benefits. And so, now, x, the exception to that is likely to be his bundle pacing. The challenge with his bundle pacing is that there is a substantial learning curve both in terms of the implanting physician, but also post-implant management. You know, most of our, for us personally in our institution, our post-implant, post device implant patients are usually seen by technicians, nurses, most implantation. And so there isn’t really a clear way for us to delineate to our support staff that this is his bundle lead, and then they need to look at it and understand Okay, what,
how am I supposed to program this device?
Am I supposed to program it with the lowest output for the longest longevity, when in fact, we implanted it knowing that it would have a higher threshold in order to capture this bundle? And then in follow-up, you know, how do we maintain that higher output in order to maintain capture in the hits, particularly if there can be climbing thresholds or time. And so that experience, I think we still don’t, we still don’t have enough of that experience, and no clinical trial data to really support that. So if, in fact, we reduce the most supporting data for complete Herblock, really Crpt should be the approach that we take that has the most data behind it. So taking
the question for as far as his bundle if you have significant experience and excitement about his bundle pacing, would you recommend for the newer implanters? It’s a good idea to attempt six sinus patients? Or would you think that AV block,
what do you think we should go ahead and give two leads one in the RV epic girl and one in his bundle?
So I think generally if one is eager to learn how to do his bundle pacing then the six sinus patients are the ideal patients to learn on. Because without needing to do full-time RV pacing, right, you know, then at least we’re putting in a lead into a position that may not have long-term consequences for the patient. If we know, the steerable sheets that we use to implant those very flimsy leads, do allow for non his lead, hot non his position pacing. And so if we can’t find an optimal fundal position, we can still be implanted safely in the RV. And so learning from patients who have fairly standard anatomy is probably the best way to start. That’s not often how we start, but it probably is the best way to start, particularly if one is going to move in that direction.
So going back to CRT and heart failure, I’d like to ask you, how do you do monitoring of your patients on their follow-ups?
Yeah, you do remote monitoring, or what kind of policies do you all have?
So in general, at our institution, we follow the guidelines, which basically delineate three months supposed to implant. We see patients within two weeks, that’s typical with a device nurse, rather than with a physician necessarily. Following that, I usually will see patients at the three-month post-implant mark. And then after that, they’ll follow three months remotely, and six months in office. So in a year, there’ll be two in-office visits and two remote interrogations. In general, those data come to us directly into our medical records. And so we review that data. Typically, most of our heart failure patients are often followed by heart failure physicians as well. And if they’re not, then we manage their heart failure therapies as well, as well as examining unit volume status, which can be interpreted or indicated by device-based measurements, depending on the device, either the St. Jude Abbott core view monitoring or the Medtronic optimal system. There are some nuances to those systems, though, in terms of knowing what they mean and whether they’re important or not. I have certain patients who seem to have certain trends, where we see that the optimal measurements will go up in a period of time without any accompanying heart failure symptoms. And we’ve actually looked back at certain patients and in a year, we can see that every year they have a replicable pattern of optimal changes, which I can’t explain right. We can, we can actually see this pattern, often without accompanying heart failure symptoms, but often with as well. And so our device nurses, when they see a change in the optimum, will actually contact the patients and find out if they’ve had a weight gain, or if they have any symptoms of heart failure. And if they do that, they will note that indirect those patients to us, if not, then they note in their interrogation note to us, you’ve contacted the patient there, they’re asymptomatic at this time, that the lead time between changes in thoracic impedance and heart failure symptoms can be disparate, though. And so the patients are at least informed of the fact that there’s been a change, sometimes that leads to a change in their behavior and sometimes not.
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