Cardiac Resynchronization Therapy by Best Cardiologist Doctor In Delhi: So your clinical practice, what is the percentage of patients you monitor remotely as far as the heart devices are concerned? So institutionally, between heart failure physicians and the electrophysiologist, I would say it’s about 90% 90 to 95%, are monitored. The challenge across most institutions in the United States is actually trying to determine who’s actually going to follow the data, right. And so there are actually some. So there are some quirks to the billing associated with interrogation of these devices. And so whether we interrogate devices remotely for electrophysiologic parameters, versus hurt failure parameters, those can actually build differently, I see. And they can be actually billed on a monthly basis. And so if one is looking for heart failure parameters that can be billed more frequently, which can be challenging in a healthcare environment, like in the United States, where there are challenges to costs. And I’d imagine more so here, where patients are going to be, you know, I don’t know if their charges are for remote interrogation or how that works domestically.
So It’s a bit complicated here. I would completely agree with you on that. And my question, which I think is very dear to implanting physicians who implant CRT is to reduce the burden of non-responders. So I want to hear from you about three implants post-implant, what is your strategy to reduce the percentage of non-responders, I think the most important thing with regards to non-response with CRT is to pick the right patients. And so truly following the guidelines for patients with optimal guideline-directed therapy for three months, with class two heart failure symptoms, at least, if they have a left bundle and a QRS duration of greater than 150. Those people I usually can say, with some confidence, you’re likely to have a good response to this therapy. For patients whose QRS duration is still with a left bundle is between 120 and 150. I usually will counsel those patients that you may not have a greater response. And particularly with right bundles, I say to them, you know, this is really a decision that you would need to make and we should make that together. So if I can stop you here for continuation in your practice.
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What is the percentage who should have a QRS of more than 150? With IBBB? What is the other?
Yeah, that’s so the ideal patient for CRT implant is a diamond in the rough these days, if they’re very hard to find, typically, most of our patients will end up falling in the 120 to 150 range. And those are, those are difficult conversations to have. Typically, when we talk about CRT implants, we’re hoping most patients are not. They’re interested in extending their lives, but most of what they want is an improvement in quality of life. And so to counsel people on how much benefit they’ll derive from CRT therapy can be quite challenging. And those patients end up being the bulk of our patients. So, we discuss pre-implant Yeah, so pre-implantation, we will discuss with the patient you know, look, this may not be the perfect EKG, you may have some response you may not. And how to assess that response can be challenging as well. Patients. So I’ve had one patient who had several prior attempts at Lv lead implantation, all of which failed, had recurrent hospital heart failure hospitalizations, and was referred for another attempt. So we were able to find a position and when I saw that patient’s back post-implant, he said, You know, I don’t really feel better. But I told you you haven’t been in the hospital in three years. Right. And so how do we temper that perception of what response is right. And so he actually had quite a successful response to, to ob pacing, but didn’t perceive it that way. And so I think part of what we also need to do in speaking with patients has to lead them to expect and what to expect, you know if we start off telling people, you’re going to, you know, three-quarters of the time, you’re going to feel better. That isn’t always, you know, people expect, oh, I’m going to be able to get up and run around, when in fact, that’s not likely to be the case, we may improve somebody from 100, you know, heart failure, class three to two, well, we’re certainly not going to take somebody from three to one. So, and explaining that to patients, having them understand that gain some insight prior to the implant, I think can be very, very helpful. Again, particularly here, where patients are going to be guided by, you know, I have to pay for this device, potentially, knowing which device might benefit them more, and what they’re seeking, in terms of quality of life versus quantity of life, can be potentially very helpful, right? So, in your post-implant.
What is your Practice in Programming The device? Do You Have The RV Pacing on? Or Do You Like To Do It With Pacing off
I’d like your input on that. So typically, particularly with the current generation Medtronic devices, which will do adaptive pacing, in people who have a normal PR interval, and a prolonged QRS, those devices can be very, very effective in avoiding RV pacing, which as we know, can be deleterious to heart function, and precipitate as much heart failure as, as not pacing or as not, not by V pacing. And so typically, in those devices, I’m very happy to see how much Lv pacing or lb only pacing they’re having, we won’t typically turn off RV pacing. We’ll keep it on for the adaptive element of that. But in other device companies, we tend to have more fusion pacing, more RV and Lv pacing combined. So I think there are some distinct advantages to that, you know, based upon the studies that we’ve seen, there does appear to be a distinct benefit to avoiding RV pacing, but I don’t typically turn off RV pacing in those. So in St. Jude devices or habit devices, they’ll actually sense Lv and sense RV, so one could program those devices, but they don’t have the predictive nature that the adaptive CRT does to track the AV delay and appropriately pace said there’s a fusion between intrinsic RV activation and then the Lv fusion. So that ends up being quite limited to just one device manufacturer, at least for us. Another question, which I’d like to ask you is for the responder rate to increase, would you do an echo-guided optimization for every patient that you implant? Or is it something that is reserved for the subset which does not respond?
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So typically, we reserve echo optimization to non-responders. The data on echo optimization is the challenge is just the dynamic nature of people, right? We’re up and moving about. We do eco optimization while people are recumbent. And so it can be quite challenging, but those are usually reserved in our institution for people who will not respond. We are, you know, we’re a research institution where we’re doing pre-procedural MRIs in order to determine both optimal, it helps us determine both the venous anatomy pre-implantation, as well as areas of scar in areas of delayed activation in order to determine what the best size of implant may be. So perhaps that leads to some better responder rates than perhaps otherwise. But in general, we still reserve echo optimization to the non-responder.
Is there any rule of coming back to his bundle? Do you ever think there is a rule of seeing the QRS duration when you do your pacing? Because of what we began to do in our centers, few of us are supposed to be given the dual chamber and we are giving his bundle. Would you like to consider the thickness of the QRS duration at various sites? And then go ahead and do the PC? Yeah,
so the data on that still, there really just isn’t enough data to suggest that pacing in multiple sites is going to be helpful in terms of long-term outcomes. The challenge ends up being that just in terms of doing eco optimization for CRT, you can also do QRS optimization for CRT. And there really isn’t good data for one versus the other and in the same way There isn’t necessarily good data for shorter QRS duration based on pacing, right? So I think the one exception to that ends up being direct is per kanji pacing, right. So if we get into the conduction system when we pace, then that may have long term, long-term benefits. But beyond that, you know, having the QRS look more narrow doesn’t mean that there’s not going to be dyssynchrony. And so I think that ends up being one of the challenges. The other issue ends up being that just because the QRS is narrow, doesn’t mean that depolarization of the ventricle is done in a more synchronous, synchronous fashion, as though it was going through his Purkinje system, there’s lots of evidence to suggest that fibrosis within the ventricle can lead to disparate conduction and disparate and dyssynchrony. And so just because the QRS looks narrow doesn’t mean that lvd polarization or RV depolarization is synchronous. And so I think that makes us feel better. But there’s no evidence to suggest that there’s a long-term benefit to that.
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In the post danish era, how has your practice changed? The reality ends up being I think, for most of us, we still are practicing, you know, in a pre-Danish area. I do for most of my patients, we talk about the advantages of CRT P versus CRT D. And so particularly now the in about February of this year, the US Medicare changed its guidelines, and actually mandated that we have documented shared decision making now or my practice has always been to do a degree of shared decision making with my patients talking about the risks of implant and post, post-implant management of the device and risks of complications. But now we talk a lot more about the benefits of crop versus CRT D and the time differential in terms of longevity between those two, on average, instead of these being just months. Right. So I see.
So I think you would like to speak on AF ablation a bit? We’ll just touch on one subject. One question. Yeah, I think
earlier in the CRT discussion that we had had, there was a lot of we talked specifically about AF ablation in the setting of heart failure. And I think, you know, with the recent publication of castle AF and how that impacts how we manage heart failure in the setting of atrial fibrillation, you know, the challenges with AF ablation in an environment where we’re where we are doing a lot of it. The success rates are not always what we perceive them to be or what we’d hoped they would be. And in particular, in patients with heart failure, those results can be more can be poor. And so I think we still have to approach those patients as long as they have an understanding that I’m going to get a procedure to manage heart failure, and to help me symptomatically that may fail after some period of time, as long as they understand that and are have eyes wide open about that. I think that’s a very reasonable approach. And I’ll be seeing a 30-year-old man with heart failure, he’s developing an F to talk about ablation, in, I think, on Tuesday when I get back to the clinic. And so they’re very, patients are very aware of the fact that the outcomes of ablation are not always perfect. But when you take a young patient who develops a fib and if they’ve been induced cardiomyopathy, for example, those patients would much prefer to manage afib with an invasive approach, rather than putting in a long-term device. And so I think a lot of that depends, so the patient I’ll be seeing next week already has a device implanted device. I’m thinking of another patient who is in his 50s woke up one morning with severe heart failure, was hospitalized for two weeks, and was cardioverted to maintain sinus rhythm, but then his AF was all attacking induced cardiomyopathy. And so he underwent ablation and has been doing quite well. But now anytime his heart rate doesn’t feel quite right to him, he’s quite anxious about the potential for recurrence, particularly of heart failure.
So I think my last question to you would be about left atrial appendage closure devices. So understand that in your clinical practice, how often do you find a patient who cannot offer an old C, and deserves to undergo a left atrial appendage closure.
So the challenges with that are actually quite deep. So just last week in the hospital, I was taking care of a patient that I’d done an appendage closure on two weeks prior that patient had had a bilateral lung transplant, developed atrial fibrillation post lung transplant, which one would think would be quite uncommon, but it happens a fair amount. We implanted the device knowing that she’d had prior bleeding episodes. And we discussed you may bleed after we put this device in because we put people on anticoagulation. And so I was seeing her in the hospital because she’d bled quite a bit. And we talked about what to do. She had an upper examination, a lower examination with no source identified, and she left the hospital on aspirin alone, not ideal anticoagulation. But these patients are not a perfect population. We don’t have good answers for them with anticoagulants with regards to anticoagulation, because almost all of the patients that I’m implanting these devices in have bled already. Yes. And so I discussed with all of them, you know, how are we going to approach anticoagulation post-implantation? And what you know, what do we do if there is recurrent bleeding? So they all understand that there are limitations, there is no perfect, there is no perfect patient for this device. The studies all show that often, patients had more issues with bleeding post-implantation than they may have beforehand until they get off of the anticoagulation. and manage that risk in the long term. determining how best to regulate people, I think is going to be a big problem until we’re doing so ASAP. To is a study that’s being done to evaluate the safety of anticoagulation and what approach should be taken. So we’re that that’s a very important trial, but it’s very, very difficult to enroll patients in the randomization to either continue therapy with current anticoagulation, whatever strategy that may be, or device implantation. Most patients aren’t willing to be randomized to no end or no intervention. They’re not willing to enroll in that study. So the company has had a very difficult time enrolling patients. So but again, I think part of the way to manage that is to have patients understand what is going to happen to them afterward, and what the risks are. So as long as they understand that, you know, as long as we have a therapeutic relationship, I think that it ends up being helpful to them.
So I’d like to thank you very much, Dr. Roy, for being here with us. And look at the book, look forward to meeting you. The next upcoming CSI is in the coming years. Thank you very much, very much.
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