Transcription:
The Latest Treatments For Heart Failure

Bill Klaproth (Host): There is new technology available that wirelessly measures and monitors certain heart functions. It's an FDA-approved device called the “CardioMEMS Heart Failure System” and here to tell us more about it is Dr. Scott Feitell of Rochester Regional Health. Dr. Feitell, thanks for your time. Can you tell us more about the CardioMEMS device and exactly what it does?

Dr. Scott Feitell (Guest): Sure. Thanks for having me on the show. So, the CardioMEMS Device is a relatively new device. It's a really neat technology. Basically, what it allows us to do is it allows us to measure the pressures inside the heart and lungs for people with heart failure. The reason that's important is that the pressures inside someone's lungs and their heart when they heart failure, correlates very much so with their volume status. So, the biggest problem people face with heart failure is they get short of breath very easily and they always have edema in their legs and that's usually a sign of volume overload. But, a lot of times, by the time we actually see that, i.e., you know the patient is experiencing a lot of shortness of breath when they walk, their ankles are swollen much more, and they can't fit in their shoes, these changes in their body have been going on for quite some time. So, the idea behind the CardioMEMS is what if we could see the signs of pressure going up long before the patient actually manifests with overt signs of swelling, either in the ER or in the doctor's office. So, that was kind of the idea behind doing this. A lot of studies have looked at pulmonary pressures, which is what this device measures, the pressures inside the lungs. We found that the pressures actually go up on average, three weeks to a month before someone actually has signs of clinical heart failure, meaning they get short of breath or they have the swelling. So, we can intervene on those pressure changes a month earlier, we can keep people out of the hospital, make them feel better, have better quality of life. We don't have data to suggest that they will live longer, but I'm hopeful that in near future we will have that data to prove that it improves mortality, as well.

Bill: That is fascinating. So, who is a good candidate for this, then? At what time do you decide, “Okay, maybe this person is right for a CardioMEMS system”?

Dr. Feitell: Sure. So, the FDA has it approved for people that have what we call “New York Heart Association Class III” symptoms. So, that's someone who gets short of breath with doing a lot of their general activities. You know, going to the local supermarket, or trying to walk down their driveway to get mail, and they're getting short of breath. That's usually a good sign that your heart failure is not optimally controlled just yet and that we need to do something more to make you feel better. And then, it also has to have someone who's been in the hospital in the last 12 months with heart failure. So, if you meet those criteria, most insurances nowadays will cover this procedure and that's usually a good indication that you may benefit from this. So, if we're not doing a good job with the traditional medicines that we're using, you're still getting very short of breath as you try and do your daily routine, and you have keep ending up in the ER with heart failure symptoms, then something else really needs to be done and those are the patients I'm really screening and honing in on and saying "Hey, I think this may benefit you. By being able to monitor your pressures from home, I can be a lot more aggressive with your medications; I can know of trouble before it arises and, hopefully, we can try and keep you out of the hospital and feeling better."

Bill: How often do you check the output of the machine, or is there a warning light, or do you get a notification if something is wrong? How does that work?

Dr. Feitell: So, the actual implant is very tiny. It's no longer than a pill and it actually goes inside the pulmonary artery and it stays there forever. It doesn't travel, it doesn't move, it has no moving parts to it. The patient gets sent home with a very fancy pillow that has a lot of electrical wiring in it and, basically, every time the patient lays down on that pillow for about 20 seconds a day, it transmits the data from that little CardioMEMS implant and then along to my email inbox, actually. So, I see their pulmonary pressure tracings, and I can see what their pressures are for that day. So, we get those reports. We ask the patient to do it once a day for 20 seconds. That's all it takes form their end. Then, usually, what we do is, instead of making a decision based off of one reading, we'll follow the trends over the course of every three days to a week, depending on how sick they are or how well they're doing. If they're very stable and they've had the implant for a while and we have them at a good steady state, usually we don't make too many adjustments--maybe once every week or two, or every month, even. But, initially, after they get implanted, the numbers are usually pretty high and we have to work to bring them down and so we'll make adjustments much more frequently. Then, the system is set up with these little red flags, so if we have someone that's made a big jump in their numbers, it will automatically alert me "Hey, Mr. Smith's had a jump in his pulmonary pressures over the last day. Do you want to address this," and then we can certainly intervene.

Bill: So, when you say make adjustments, are you talking about in the person's medication?

Dr. Feitell: Correct. Yes. So, one of the things we've learned from the trial data from the CardioMEMS, if you look at the initial trial that this was done in, is that clinicians, as good as we like to think we are, we're actually not really good at assessing patient’s volume status and figuring out how much fluid they're carrying. So, the initial trial was done at a rather large, academic university setting and even with the best and brightest brains on the cases, a lot of times, doctors misjudged the patient's volume status and the CardioMEMS proved it to us. So, if you look at the patients that got treated based on the CardioMEMS numbers, they actually got much more aggressive titration of their diuretics, those are the water pills that get the fluid off them, and a lot of the heart failure medicine that we use as standard practice. The doctors were able to be much more aggressive with the meds that they use in these patients in terms of increasing the dosages of them, or increasing the frequency of the medications. That combination of increasing the water pill in addition to increasing the heart failure medicines got the patients feeling a lot better and actually reduced hospital admissions by over a third in the initial trials, which is pretty dramatic. There aren't too many things that we have that can do something like that.

Bill: Yes, that is. So, if you see a jump in the volume status, do you call the patient and say "Mr. Smith, we see that your volume is up. I'm changing your prescription, please go to your local pharmacy and pick up this new medication"?

Dr. Feitell: Yep, absolutely. So, I work with a nurse practitioner very closely and we monitor these things every day. So, what will happen in the morning, the patients usually take most of the readings in the mornings. Sometimes we have the ones from the night before if they do it at nighttime, and that's okay. Basically, we look at the recordings and if we see that jump, we'll get on the phone right away and talk to Mr. Smith or whoever it may be and say, "How are you feeling? Have you noticed any differences in the . . .”? Again, the interesting thing is that these pressure recordings happen well before someone knows something's wrong. So, it's always a funny phone call at first when the patients are like "Hey, why are you calling me? I actually feel pretty good." "I know you do, but we're worried about what's going to happen three weeks from now, so if we intervene now, we take this extra dose of something, I'm optimistic that three weeks from now, you'll still be feeling fine, whereas prior to this device, in three weeks you would have ended up in the ER." A lot of times it's almost a light bulb moment for the patient and he's like, "You know, you're right. I feel good for two or three weeks and all of a sudden I ended up in the ER out of the blue and I never know what's wrong," and this really has given us some insight as to why that is and how we can really better manage these patients.

Bill: When you call, do you ask if they're having shortness of breath? When you say “edema” in the legs, that's swelling? When is edema bad? When there's major swelling? Like a person can't get their shoe on?

Dr. Feitell: Correct, yes. So, those usually are two screening questions. Sometimes we'll ask case specific questions, but usually we'll ask, “How's your breathing? Were you able to do your usual errands yesterday you usually do? Were you able to work, or did you take a day off as a sick day?” We'll usually ask them leading questions like that. And then, most patients that are living with heart failure usually have a pretty good indication when their ankles are getting a little puffy, a little swollen, and usually we'll ask them, we ask patients to weigh themselves every day in addition to this so that we can keep track of their weights and make sure that they're not holding onto fluid that they're not aware of. The CardioMEMS is much more sensitive and much more accurate at the recordings than weights. Weights are notoriously inaccurate sometimes for different reasons. But, we'll certainly ask the patient if they noticed anything and certainly some patients will always have a little bit of swelling in their legs and they may say "Oh, you know, yesterday I noticed it was a little bit worse than it has been." We'll be a little bit more aggressive. But, again, the CardioMEMS allows us to make the decision to prevent those things from happening. That's really the name of the game. That's the goal --to hopefully keep them from ever getting edema, or to really get them very short of breath. We can intervene before those things happen.

Bill: Right. This is just fascinating. So, how long does the procedure take to implant the CardioMEMS device?

Dr. Feitell: Good question. So, it's actually a same-day procedure. Usually, we'll have the patient come in in the morning. We ask that they don't eat breakfast the night before. For the most part, they can take most of the medicines. Occasionally, we'll hold one or two pills for various reasons, but they stay on all their regular medicines. They come in in the morning, they get checked in. Once we get them into the cath lab, the procedure's actually relatively quick. I can usually do the procedure in under an hour. After that, they'll stay in the recovery room. We'll usually get them a small meal, a lunch or a breakfast, depending on the timing of it, and they'll stay on bed rest for about two hours, and if they're feeling good and they're vital signs look good, and they're comfortable, we'll give them the education on the pillow, how they get their measurements from home. It's very user friendly. They basically lay down on the pillow and push a button, we walk them through the first readings so they can do it on their own, and then they're free to go, and that's it. And the, usually because I have this device, I actually don't even need to see them in the office because I already know what their heart is doing at home. So, usually it actually cuts back on the number of office visits they need to make, as well, which is nice.

Bill: This can save time and money, as well. And what is the long-term outlook? You said the CardioMEMS device can stay implanted for years and no troubles?

Dr. Feitell: Correct. So, they've been being implanted in people since around 2010 from the initial trials. So, we have some good data now, going on six or seven years, that these devices are actually very safe and very, very low risk for complications, and they really stay put once you put them in the right spot. So, if they get implanted properly, which I'd like to think I'm pretty good at doing, the patient can live out their days with it and they'll never know it's in there, really, except when they lay on the pillow, they may remember that they have it, but other than that, they really would have no knowledge that it's in them. They don't feel it, it doesn't cause any pain or discomfort. It literally just sits inside that pulmonary artery for the rest of their life and really doesn't cause any trouble.

Bill: That's wonderful. Dr. Feitell, thank you so much for talking to us about the CardioMEMS Heart Failure System, and could you wrap it up for us? Why should someone choose Rochester Regional for their heart health needs?

Dr. Feitell: Sure. So I think Rochester Regional Health does a lot of good things. It's a growing program. We've expanded to not only include structural heart, we do very high-risk intervention procedures. We have top-tier surgeons that can get from the sickest of the sick patients through cardiothoracic surgery and with my presence here managing heart failure, we really are a one-stop shop for all your heart care. All of our doctors are very compassionate. I work really well with all the nurses here and I think they do an outstanding job of staying on top of the patients and providing the extra level of support that they may need. I think there's really nothing that we fall short on. They really get everything they could want out of their doctors and nurses taking care of them, which is important.

Bill: Well, Dr. Feitell, thank you so much again for your time. You're listening to Rock Your Health Radio with Rochester Regional Health. For more information, you can go to www.rochesterregional.org. That's www.rochesterregional.org. I'm Bill Klaproth. Thanks for listening.