271 - Using Heart Rate Data From Ambulatory Hemodynamic Monitoring System in Heart Failure Management

Abstract

Introduction: Standard use of ambulatory hemodynamic monitoring in heart failure (HF) management primarily involves adjustment of diuretics and vasodilator therapy. The CHAMPION Trial demonstrated the benefit of hemodynamic-guided management in symptomatic HF patients, which is highlighted in this case. Case: An 81-year-old white woman with ischemic cardiomyopathy, LVEF 27% and refractory NYHA III symptoms had paroxysmal AF (s/p 2 prior successful cardioversions and intolerant to antiarrhythmics) and biventricular pacemaker-defibrillator placement. She was on optimal evidence-based medical therapy and had been hospitalized 4 times in the past year for HF decompensation. We deemed her eligible for ambulatory hemodynamic monitoring to reduce HF hospitalizations and improve quality of life, and successfully implanted the CardioMEMS HF System. Post implant, hemodynamic data revealed elevated pulmonary artery pressures (PAPs) and heart rate (HR) and, based on evidence-based interventions, we continued intermittent adjustment of her medical regimen (Fig. 1). PAPs, HR and symptoms remained refractory despite this. Further evaluation unmasked uncontrolled paroxysmal AF. After an electrophysiology consult, she underwent successful atrioventricular node ablation using conventional catheter mapping techniques. Her hemodynamics and symptoms improved. Diuretics were down-titrated, with improvement in renal function and no rebound PAPs; she has not been admitted to the hospital for a HF decompensation event since. Discussion: This case illustrates the complicated nature of the syndrome of HF, and the adverse hemodynamic and clinical effects of AF. In “real world” experience, not every patient's hemodynamic pressures improve with a diuretic- or vasodilator-based strategy alone. We suspect that persisting with this restrained strategy may lead to adverse events, e.g., hypotension and renal dysfunction. This case highlights the use of HR, which is accessible data in the CardioMEMS HF System, as part of HF management strategy. This may help diagnose various mechanisms of HF decompensation. Interventions should also be expanded to include consideration of HR modulation strategies (eg, antiarrhythmics, ivabradine, optimal use of pacemakers and catheter-based ablation) when indicated. These proposed interventions, though individually proven to favorably impact HF management, need further investigation to be established as an adjunct to the current evidence-based strategy with ambulatory hemodynamic monitoring.