Rationale and Design of the Left Atrial Pressure Monitoring to Optimize Heart Failure Therapy Study (LAPTOP-HF)

Benefits of remote hemodynamic monitoring in heart failure

Despite treatment advancements, HF mortality remains high, prompting interest in reducing HF-related hospitalizations through remote monitoring. These advances are necessary considering the rapidly rising prevalence and incidence of HF worldwide, presenting a burden on hospital resources. While traditional approaches have failed in predicting impending HF-related hospitalizations, remote hemodynamic monitoring can detect changes in intracardiac filling pressure weeks prior to HF-related hospitalizations which makes timely pharmacological interventions possible. To ensure successful implementation, structural integration, optimal patient selection, and efficient data management are essential. This review aims to provide an overview of the rationale, the available devices, current evidence, and the implementation of remote hemodynamic monitoring.

Physician-directed patient self-management in heart failure using left atrial pressure: Interim insights from the VECTOR-HF I and IIa studies

AIMS

Haemodynamic monitoring using implantable pressure sensors reduces the risk of heart failure (HF) hospitalizations. Patient self-management (PSM) of haemodynamics in HF has the potential to personalize treatment, increase adherence, and reduce the risk of worsening HF, while lowering clinicians' burden.

METHODS AND RESULTS

The VECTOR-HF I and IIa studies are prospective, single-arm, open-label clinical trials assessing safety, usability and performance of left atrial pressure (LAP)-guided HF management using PSM in New York Heart Association class II and III HF patients. Physician-prescribed LAP thresholds trigger patient self-adjustment of diuretics. Primary endpoints include the ability to perform LAP measurements and transmit data to the healthcare provider (HCP) interface and the patient guidance application, and safety outcomes. This is an interim analysis of 13 patients using the PSM approach. Over 12 months, no procedure- or device-related major adverse cardiovascular or neurological events were observed, and there were no failures to obtain measurements from the sensor and transmit the data to the HCP interface and the patient guidance application. Patient adherence was 91.4%. Using PSM, annualized HF hospitalization rate significantly decreased compared to a similar period prior to PSM utilization (0 admissions vs. 0.69 admissions over 11.84 months, p = 0.004). At 6 months, 6-min walk test distance and the Kansas City Cardiomyopathy Questionnaire overall summary score demonstrated significant improvement.

CONCLUSIONS

Interim findings suggest that PSM using a LAP monitoring system is feasible and safe. PSM is associated with high patient adherence, potentially improving HF patients' functional status, quality of life, and limiting HF hospitalizations.

Data Interoperability for Ambulatory Monitoring of Cardiovascular Disease: A Scientific Statement From the American Heart Association

Wearable devices are increasingly used by a growing portion of the population to track health and illnesses. The data emerging from these devices can potentially transform health care. This requires an interoperability framework that enables the deployment of platforms, sensors, devices, and software applications within diverse health systems, aiming to facilitate innovation in preventing and treating cardiovascular disease. However, the current data ecosystem includes several noninteroperable systems that inhibit such objectives. The design of clinically meaningful systems for accessing and incorporating these data into clinical workflows requires strategies to ensure the quality of data and clinical content and patient and caregiver accessibility. This scientific statement aims to address the best practices, gaps, and challenges pertaining to data interoperability in this area, with considerations for (1) data integration and the scope of measures, (2) application of these data into clinical approaches/strategies, and (3) regulatory/ethical/legal issues.

Implantable Hemodynamic Monitors Improve Survival in Patients With Heart Failure and Reduced Ejection Fraction

BACKGROUND

Trials evaluating implantable hemodynamic monitors to manage patients with heart failure (HF) have shown reductions in HF hospitalizations but not mortality. Prior meta-analyses assessing mortality have been limited in construct because of an absence of patient-level data, short-term follow-up duration, and evaluation across the combined spectrum of ejection fractions.

OBJECTIVES

The purpose of this meta-analysis was to determine whether management with implantable hemodynamic monitors reduces mortality in patients with heart failure and reduced ejection fraction (HFrEF) and to confirm the effect of hemodynamic-monitoring guided management on HF hospitalization reduction reported in previous studies.

METHODS

The patient-level pooled meta-analysis used 3 randomized studies (GUIDE-HF [Hemodynamic-Guided Management of Heart Failure], CHAMPION [CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients], and LAPTOP-HF [Left Atrial Pressure Monitoring to Optimize Heart Failure Therapy]) of implantable hemodynamic monitors (2 measuring pulmonary artery pressures and 1 measuring left atrial pressure) to assess the effect on all-cause mortality and HF hospitalizations.

RESULTS

A total of 1,350 patients with HFrEF were included. Hemodynamic-monitoring guided management significantly reduced overall mortality with an HR of 0.75 (95% CI: 0.57-0.99); P = 0.043. HF hospitalizations were significantly reduced with an HR of 0.64 (95% CI: 0.55-0.76); P < 0.0001.

CONCLUSIONS

Management of patients with HFrEF using an implantable hemodynamic monitor significantly reduces both mortality and HF hospitalizations. The reduction in HF hospitalizations is seen early in the first year of monitoring and mortality benefits occur after the first year.

Remote Monitoring Devices and Heart Failure

Remote patient monitoring (RPM) in patients with heart failure (HF) involves transmitting physiological data from devices to a health-care provider via a wireless connection with targeted interventions when values exceed the preset threshold. Devices used in telemonitoring range from weighing scales, blood pressure cuffs, and pulse oximeters to devices used to measure cardiac filling pressure and intrathoracic impedance using cardiac implantable electronic devices and wearables. Accordingly, RPM devices can potentially engage patients in their cardiovascular care and reduce the burden of HF in society.

Implantable Triboelectric Nanogenerators for Self-Powered Cardiovascular Healthcare

Triboelectric nanogenerators (TENGs) have gained significant traction in recent years in the bioengineering community. With the potential for expansive applications for biomedical use, many individuals and research groups have furthered their studies on the topic, in order to gain an understanding of how TENGs can contribute to healthcare. More specifically, there have been a number of recent studies focusing on implantable triboelectric nanogenerators (I-TENGs) toward self-powered cardiac systems healthcare. In this review, the progression of implantable TENGs for self-powered cardiovascular healthcare, including self-powered cardiac monitoring devices, self-powered therapeutic devices, and power sources for cardiac pacemakers, will be systematically reviewed. Long-term expectations of these implantable TENG devices through their biocompatibility and other utilization strategies will also be discussed.

Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure

BACKGROUND

Central Illustration : Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure Transcatheter devices for monitoring and treating advanced chronic heart failure patients. PA: pulmonary artery; LA: left atrium; AFR: atrial flow regulator; TASS: Transcatheter Atrial Shunt System; VNS: vagus nerve stimulation; BAT: baroreceptor activation therapy; RDN: renal sympathetic denervation; F: approval by the American regulatory agency (FDA); E: approval by the European regulatory agency (CE Mark).

BACKGROUND

Innovations in devices during the last decade contributed to enhanced diagnosis and treatment of patients with cardiac insufficiency. These tools progressively adapted to minimally invasive strategies with rapid, widespread use. The present article focuses on actual and future directions of device-related diagnosis and treatment of chronic heart failure.

Current state of the art and future directions for implantable sensors in medical technology: Clinical needs and engineering challenges

Implantable sensors have revolutionized the way we monitor biophysical and biochemical parameters by enabling real-time closed-loop intervention or therapy. These technologies align with the new era of healthcare known as healthcare 5.0, which encompasses smart disease control and detection, virtual care, intelligent health management, smart monitoring, and decision-making. This review explores the diverse biomedical applications of implantable temperature, mechanical, electrophysiological, optical, and electrochemical sensors. We delve into the engineering principles that serve as the foundation for their development. We also address the challenges faced by researchers and designers in bridging the gap between implantable sensor research and their clinical adoption by emphasizing the importance of careful consideration of clinical requirements and engineering challenges. We highlight the need for future research to explore issues such as long-term performance, biocompatibility, and power sources, as well as the potential for implantable sensors to transform healthcare across multiple disciplines. It is evident that implantable sensors have immense potential in the field of medical technology. However, the gap between research and clinical adoption remains wide, and there are still major obstacles to overcome before they can become a widely adopted part of medical practice.

Implantable Cardiovascular Devices: Current and Emerging Technologies for Remote Heart Failure Monitoring

Heart failure remains a substantial socioeconomic burden to our health care system. With the aging of the population, the incidence is expected to rise in the ensuing years. Standard heart failure management strategies have failed to reduce hospitalizations and mortality. In patients with heart failure, remote hemodynamic monitoring with implantable devices provides essential data, which can be used in unison with standard patient management to reduce heart failure hospitalizations. This review will chronicle the important clinical trials of various implantable devices and describe the emerging technologies in remote heart failure management. Cardiovascular implantable electronic devices, namely implanted cardioverter-defibrillator and cardiac resynchronization therapy devices with defibrillator, have evolved beyond sole resynchronization and currently can deliver real-time cardiac hemodynamics. Clinical data regarding hemodynamic monitoring with implanted cardioverter-defibrillator and cardiac resynchronization therapy devices with defibrillator have not consistently demonstrated a reduction in heart failure or mortality benefit. However, there is promise in the future with the application of multiparameter diagnostic algorithms with these devices. The most efficacious implantable device has been the pulmonary artery pressure sensor, CardioMEMS. This device has been proven to be safe and shown to reduce heart failure hospitalizations. Moreover, multiple newly developed devices are currently under investigation after successful first-in-man studies.

Clinical Pathways Guided by Remotely Monitoring Cardiac Device Data: The Future of Device Heart Failure Management?

Research examining the utility of cardiac device data to manage patients with heart failure (HF) is rapidly evolving. COVID-19 has reignited interest in remote monitoring, with manufacturers each developing and testing new ways to detect acute HF episodes, risk stratify patients and support self-care. As standalone diagnostic tools, individual physiological metrics and algorithm-based systems have demonstrated utility in predicting future events, but the integration of remote monitoring data with existing clinical care pathways for device HF patients is not well described. This narrative review provides an overview of device-based HF diagnostics available to care providers in the UK, and describes the current state of play with regard to how these systems fit in with current HF management.

Novel approaches for left atrial pressure relief: Device-based monitoring and management in heart failure

The importance of the left atrium (LA) has been emphasized in recent years as the features of heart failure (HF), especially with regard to variability in patient and pathology phenotypes, continue to be uncovered. Of note, among the population with HF with preserved ejection fraction (HFpEF), pressure or size of the LA have become a target for advanced monitoring and a therapeutic approach. In the case of diastolic dysfunction or pulmonary hypertension, which are often observed in patients with HFpEF, a conventional approach with clinical symptoms and physical signs of decompensation turned out to have a poor correlation with LA pressure. Therefore, to optimize HF treatment for these populations, several devices that are applied directly to the LA have been developed. First, two LA pressure (LAP) sensors (Heart POD and V-LAP Device) were developed and may enable patient self-management remotely with LAP-guided and physician-directed style. Second, there are device-based approaches that aim to decompress the LA directly. These include: (1) interatrial shunt devices; (2) left ventricular assist devices with LA cannulation; and (3) the left atrial assist device. While these novel device-based therapies are not yet commercially available, there is expected to be a rise in the proposition and adoption of a wider range of choices for monitoring or treating LA using device-based options, based on LA dimensional reduction and optimization of the clinically significant pressure relief. Further development and evaluation are necessary to establish a more favorable management strategy for HF.

The V-LAP System for Remote Left Atrial Pressure Monitoring of Patients with Heart Failure: Remote Left Atrial Pressure Monitoring

OBJECTIVE

Patients with heart failure (HF) are at an increased risk of hospital admissions. The aim of this report is to describe the feasibility, safety and accuracy of a novel wireless left atrial pressure (LAP) monitoring system in HF patients.

METHODS

The V-LAP Left Atrium Monitoring systEm for Patients With Chronic sysTOlic & Diastolic Congestive heart Failure (VECTOR-HF) study is a prospective, multicenter, single-arm, open-label, first-in human clinical trial to assess the safety, performance and usability of the V-LAP system (Vectorious Medical Technologies, Ltd) in NYHA Class III HF patients. The device was implanted in the inter-atrial septum via a percutaneous, trans-septal approach, guided by fluoroscopy and echocardiography. Primary endpoints included the successful deployment of the implant, ability to perform initial pressure measurements and safety outcomes.

RESULTS

To date, 24 patients were implanted with the LAP monitoring device. No device-related complications have occurred. LAP was reported accurately, agreeing well with wedge pressure at 3 months (Lin's CCC=0.850). After 6 months, NYHA class improved in 40% of the patients (95% CI =16.4%-63.5%), while 6-minute walk test distance had not changed significantly (313.9 ± 144.9 vs. 232.5 ± 129.9 meters, p=0.076).

CONCLUSION

The V-LAP left atrium monitoring system appears to be safe and accurate.

Implantable devices for heart failure monitoring

Heart failure (HF) is associated with considerable morbidity and mortality. The increasing prevalence of HF and inpatient HF hospitalization has a considerable burden on healthcare cost and utilization. The recognition that hemodynamic changes in pulmonary artery pressure (PAP) and left atrial pressure precede the signs and symptoms of HF has led to interest in hemodynamic guided HF therapy as an approach to allow earlier intervention during a heart failure decompensation. Remote patient monitoring (RPM) utilizing telecommunication, cardiac implantable electronic device parameters and implantable hemodynamic monitors (IHM) have largely failed to demonstrate favorable outcomes in multicenter trials. However, one positive randomized clinical trial testing the CardioMEMS device (followed by Food and Drug Administration approval) has generated renewed interest in PAP monitoring in the HF population to decrease hospitalization and improve quality of life. The COVID-19 pandemic has also stirred a resurgence in the utilization of telehealth to which RPM using IHM may be complementary. The cost effectiveness of these monitors continues to be a matter of debate. Future iterations of devices aim to be smaller, less burdensome for the patient, less dependent on patient compliance, and less cumbersome for health care providers with the integration of artificial intelligence coupled with sophisticated data management and interpretation tools. Currently, use of IHM may be considered in advanced heart failure patients with the support of structured programs.

In Search of Clinical Impact: Advanced Monitoring Technologies in Daily Heart Failure Care

Despite significant advances in the management of heart failure (HF), further improvement in the outcome of this chronic and progressive disease is still considered a major unmet need. Recurrent hospitalizations due to decompensated HF frequently occur, resulting in increased morbidity and mortality rates. Past attempts at early detection of clinical deterioration were mainly based on monitoring of signs and symptoms of HF exacerbation, which have mostly given disappointing results. Extensive research of the pathophysiology of HF decompensation has indicated that hemodynamic alterations start days prior to clinical manifestation. Novel technologies aim to monitor these minute hemodynamic changes, allowing time for therapeutic interventions to prevent hemodynamic derangement and HF exacerbation. The latest noticeable advancements include assessment of lung fluid volume, wearable devices with integrated sensors, and microelectromechanical systems-based implantable devices for continuous measurement of cardiac filling pressures. This manuscript will review the rationale for monitoring HF patients and discuss previous and ongoing attempts to develop clinically meaningful monitoring devices to improve daily HF health care, with particular emphasis on the recent advances and clinical trials relevant to this evolving field.

Remote monitoring for heart failure using implantable devices: a systematic review, meta-analysis, and meta-regression of randomized controlled trials

In heart failure (HF) patients, remote monitoring using implantable devices may be used to predict and reduce HF exacerbations and mortality. Data from randomized controlled trials (RCTs) was assessed to determine the effectiveness of implantable remote monitoring on the improvement of outcomes in HF patients. A systematic review and meta-analysis of RCTs testing remote monitoring versus standard of care for management of HF patients was performed. Primary endpoints were all-cause mortality and a composite of cardiovascular (CV) and HF hospitalizations. Rate ratios (RRs) and 95% confidence intervals (CI) were calculated. A secondary analysis tested for heterogeneity of treatment effect (HTE) comparing right ventricular/pulmonary pressure monitoring versus impedance-based monitoring on hospitalization. A regression analysis was performed using the mean follow-up time as the moderator on each primary endpoint. Eleven RCTs (n = 6196) were identified with a mean follow-up of 21.9 months. The mean age and reported ejection fraction were 64.1 years and 27.7%, respectively. Remote monitoring did not reduce mortality (RR 0.89 [95% CI 0.77, 1.03]) or the composite of CV and HF hospitalizations (RR 0.98 [0.81, 1.19]). Subgroup analysis found significant HTE for hospitalizations between those studies that used right ventricular/pulmonary pressure monitoring versus impedance-based monitoring (I² = 87.1%, chi² = 7.75, p = 0.005). Regression analysis found no relationship between the log rate ratio of remote monitoring’s effect on mortality, CV hospitalization or HF hospitalization, and mean follow-up time. Compared to standard of care, remote monitoring using implantable devices did not reduce mortality, CV, or HF hospitalizations. However, right ventricular/pulmonary pressure monitoring may reduce HF hospitalizations, which will need to be explored in future studies.

MONITORIA: The start of a new era of ambulatory heart failure monitoring? Part I - Theoretical Rationale

Heart failure (HF) is a multifactorial chronic syndrome with progressive increasing incidence causing a huge financial burden worldwide. Remote monitoring should, in theory, improve HF management, but given increasing morbidity and mortality, a question remains: are we monitoring it properly? Device-based home monitoring enables objective and continuous measurement of vital variables and non-invasive devices should be first choice for elderly patients. There is no shortage of literature on the subject, however, most studies were designed to monitor a single variable or class of variables that were not properly assembled and, to the best of our knowledge, there are no large randomized studies about their impact on HF patient management. To overcome this problem, we carefully selected the most critical possible HF decompensating factors to design MONITORIA, a non-invasive device for comprehensive HF home monitoring. MONITORIA stands for MOnitoring Non-Invasively To Overcome mortality Rates of heart Insufficiency on Ambulatory, and in this paper, which is part I of a series of three articles, we discuss the theoretical basis for its design. MONITORIA and its inherent follow-up strategy will optimize HF patient care as it is a promising device, which will essentially adapt innovation not to the disease but rather to the patients.

Invasive Devices and Sensors for Remote Care of Heart Failure Patients

The large and growing burden of chronic heart failure (CHF) on healthcare systems and economies is mainly caused by a high hospital admission rate for acute decompensated heart failure (HF). Several remote monitoring techniques have been developed for early detection of worsening disease, potentially limiting the number of hospitalizations. Over the last years, the scope has been shifting towards the relatively novel invasive sensors capable of measuring intracardiac filling pressures, because it is believed that hemodynamic congestion precedes clinical congestion. Monitoring intracardiac pressures may therefore enable clinicians to intervene and avert hospitalizations in a pre-symptomatic phase. Several techniques have been discussed in this review, and thus far, remote monitoring of pulmonary artery pressures (PAP) by the CardioMEMS (CardioMicroelectromechanical system) HF System is the only technique with proven safety as well as efficacy with regard to the prevention of HF-related hospital admissions. Efforts are currently aimed to further develop existing techniques and new sensors capable of measuring left atrial pressures (LAP). With the growing body of evidence and need for remote care, it is expected that remote monitoring by invasive sensors will play a larger role in HF care in the near future.

MONITORIA: The start of a new era of ambulatory heart failure monitoring? Part I - Theoretical Rationale

Heart failure (HF) is a multifactorial chronic syndrome with progressive increasing incidence causing a huge financial burden worldwide. Remote monitoring should, in theory, improve HF management, but given increasing morbidity and mortality, a question remains: are we monitoring it properly? Device-based home monitoring enables objective and continuous measurement of vital variables and non-invasive devices should be first choice for elderly patients. There is no shortage of literature on the subject, however, most studies were designed to monitor a single variable or class of variables that were not properly assembled and, to the best of our knowledge, there are no large randomized studies about their impact on HF patient management. To overcome this problem, we carefully selected the most critical possible HF decompensating factors to design MONITORIA, a non-invasive device for comprehensive HF home monitoring. MONITORIA stands for MOnitoring Non-Invasively To Overcome mortality Rates of heart Insufficiency on Ambulatory, and in this paper, which is part I of a series of three articles, we discuss the theoretical basis for its design. MONITORIA and its inherent follow-up strategy will optimize HF patient care as it is a promising device, which will essentially adapt innovation not to the disease but rather to the patients.

Remote Patient Monitoring in Heart Failure: Factors for Clinical Efficacy

Despite clinical advances in its treatment, heart failure (HF) is associated with significant adverse clinical outcomes and is among the greatest drivers of healthcare utilization. Outpatient management of HF remains suboptimal, with gaps in the provision of evidence-based therapies, and difficulties in predicting and managing clinical decompensation. Remote patient monitoring (RPM) has the potential to address these issues, and thus has been of increasing interest to HF clinicians and health systems. Economic incentives, including increasing RPM reimbursement and HF readmission penalties, are also spurring increased interest in RPM. This review establishes a framework for evaluating RPM based on its various components: 1) patient data collection, 2) data transmission, analysis, and presentation, and 3) care team review and clinical action. The existing evidence regarding RPM in HF management is also reviewed. Based on the data, we identify RPM features associated with clinical efficacy and describe emerging digital tools that have the promise of addressing current needs.

Cardiac Implantable Electronic Miniaturized and Micro Devices

Advancement in the miniaturization of high-density power sources, electronic circuits, and communication technologies enabled the construction of miniaturized electronic devices, implanted directly in the heart. These include pacing devices to prevent low heart rates or terminate heart rhythm abnormalities ('arrhythmias'), long-term rhythm monitoring devices for arrhythmia detection in unexplained syncope cases, and heart failure (HF) hemodynamic monitoring devices, enabling the real-time monitoring of cardiac pressures to detect and alert for early fluid overload. These devices were shown to prevent HF hospitalizations and improve HF patients' life quality. Pacing devices include permanent pacemakers (PPM) that maintain normal heart rates, defibrillators that are capable of fast detection and the termination of life-threatening arrhythmias, and cardiac re-synchronization devices that improve cardiac function and the survival of HF patients. Traditionally, these devices are implanted via the venous system ('endovascular') using conductors ('endovascular leads/electrodes') that connect the subcutaneous device battery to the appropriate cardiac chamber. These leads are a potential source of multiple problems, including lead-failure and systemic infection resulting from the lifelong exposure of these leads to bacteria within the venous system. One of the important cardiac innovations in the last decade was the development of a leadless PPM functioning without venous leads, thus circumventing most endovascular PPM-related problems. Leadless PPM's consist of a single device, including a miniaturized power source, electronic chips, and fixating mechanism, directly implanted into the cardiac muscle. Only rare device-related problems and almost no systemic infections occur with these devices. Current leadless PPM's sense and pace only the ventricle. However, a novel leadless device that is capable of sensing both atrium and ventricle was recently FDA approved and miniaturized devices that are designed to synchronize right and left ventricles, using novel intra-body inner-device communication technologies, are under final experiments. This review will cover these novel implantable miniaturized cardiac devices and the basic algorithms and technologies that underlie their development. Advancement in the miniaturization of high-density power sources, electronic circuits, and communication technologies enabled the construction of miniaturized electronic devices, implanted directly in the heart. These include pacing devices to prevent low heart rates or terminate heart rhythm abnormalities ('arrhythmias'), long-term rhythm monitoring devices for arrhythmia detection in unexplained syncope cases, and heart failure (HF) hemodynamic monitoring devices, enabling the real-time monitoring of cardiac pressures to detect and alert early fluid overload. These devices were shown to prevent HF hospitalizations and improve HF patients' life quality. Pacing devices include permanent pacemakers (PPM) that maintain normal heart rates, defibrillators that are capable of fast detection and termination of life-threatening arrhythmias, and cardiac re-synchronization devices that improve cardiac function and survival of HF patients. Traditionally, these devices are implanted via the venous system ('endovascular') using conductors ('endovascular leads/electrodes') that connect the subcutaneous device battery to the appropriate cardiac chamber. These leads are a potential source of multiple problems, including lead-failure and systemic infection that result from the lifelong exposure of these leads to bacteria within the venous system. The development of a leadless PPM functioning without venous leads was one of the important cardiac innovations in the last decade, thus circumventing most endovascular PPM-related problems. Leadless PPM's consist of a single device, including a miniaturized power source, electronic chips, and fixating mechanism, implanted directly into the cardiac muscle. Only rare device-related problems and almost no systemic infections occur with these devices. Current leadless PPM's sense and pace only the ventricle. However, a novel leadless device that is capable of sensing both atrium and ventricle was recently FDA approved and miniaturized devices designed to synchronize right and left ventricles, using novel intra-body inner-device communication technologies, are under final experiments. This review will cover these novel implantable miniaturized cardiac devices and the basic algorithms and technologies that underlie their development.

Telemonitoring for the Management of Patients with Heart Failure

Advances in technology now make it possible to manage heart failure (HF) from a remote to a telemonitoring approach using either noninvasive solutions or implantable devices. Nowadays, it is possible to monitor at-home parameters that can be recorded, stored and remotely transmitted to physicians, allowing them to make decisions for therapeutic modification, hospitalization or access to the emergency room. Standalone systems are available that are equipped with self-intelligence and are able to acquire and elaborate data that can inform the remote physician of impending decompensation before it results in additional complications. The development of miniature implantable devices, which could measure haemodynamic variables and transmit them to a monitor outside the body, offers the possibility for the physician to obtain more frequent evaluations of HF patients and the opportunity to take these data into account in management decisions. At present, several telemonitoring devices are available, but the only Food and Drug Administration-approved system is the cardio-microelectromechanical system, which is an implantable pulmonary arterial pressure (PAP) monitoring device that allows a direct monitoring of the PAP via a sensor implanted in the pulmonary artery. This information is then uploaded to a web-based interface from which healthcare providers can track the results and manage patients. At present, the challenge point for telemedicine management of HF is to find the more relevant biological parameter to monitor the clinical status.

HVAD Flow Waveform Estimates Left Ventricular Filling Pressure

BACKGROUND

HVAD left ventricular assist device flow waveforms provides graphical real-time information linking device performance with invasive hemodynamics. Previous studies have demonstrated a good correlation between the slopes of the ventricular filling phase slope (VFPS) and directly measured pulmonary capillary wedge pressure (PCWP). We aimed to validate the utility of VFPS to estimate PCWP and predict clinical outcomes.

METHODS

In this prospective blinded study, screenshots from the HVAD monitor and simultaneous invasive hemodynamic measurements were obtained. Each screenshot was digitized and the VFPS was calculated by 2 independent reviewers who were blinded to the hemodynamic results. The equation PCWP = 7.053 +1.365 × (VFPS) was derived from a previously published dataset and the estimated PCWP was correlated to the actually measured PCWP.

RESULTS

One hundred thirty-one sets of simultaneous measurements (VFPS and PCWP) were obtained from 27 HVAD patients (mean age 55 years, 47% male). A previously proposed cutoff of VFPS ≥5.8 L/min/s predicted PCWP ≥ 18 mmHg with 91.5% sensitivity and 95.2% specificity with the area under curve of 0.987. The estimated PCWP significantly correlated with measured PCWP (R² = 0.65, P < .001) and showed acceptable agreement with measured PCWP. Patients with VFPS ≥ 5.8 L/min/s experienced significantly higher heart failure readmission rates than those without (0.24 vs 0.05 events/y, P < .001).

CONCLUSIONS

VFPS of the HVAD flow waveform is a novel noninvasive parameter that can estimate PCWP.

A novel noninvasive method for remote heart failure monitoring: the EuleriAn video Magnification apPLications In heart Failure studY (AMPLIFY)

Current remote monitoring devices for heart failure have been shown to reduce hospitalizations but are invasive and costly; accurate non-invasive options remain limited. The EuleriAn Video Magnification ApPLications In Heart Failure StudY (AMPLIFY) pilot aimed to evaluate the accuracy of a novel noninvasive method that uses Eulerian video magnification. Video recordings were performed on the neck veins of 50 patients who were scheduled for right heart catheterization at the Palo Alto VA Medical Center. The recorded jugular venous pulsations were then enhanced by applying Eulerian phase-based motion magnification. Assessment of jugular venous pressure was compared across three categories: (1) physicians who performed bedside exams, (2) physicians who reviewed both the amplified and unamplified videos, and (3) direct invasive measurement of right atrial pressure from right heart catheterization. Motion magnification reduced inaccuracy of the clinician assessment of central venous pressure compared to the gold standard of right heart catheterization (mean discrepancy of −0.80 cm H₂O; 95% CI −2.189 to 0.612, p = 0.27) when compared to both unamplified video (−1.84 cm H₂O; 95% CI −3.22 to −0.46, p = 0.0096) and the bedside exam (−2.90 cm H₂O; 95% CI −4.33 to 1.40, p = 0.0002). Major categorical disagreements with right heart catheterization were significantly reduced with motion magnification (12%) when compared to unamplified video (25%) or the bedside exam (27%). This novel method of assessing jugular venous pressure improves the accuracy of the clinical exam and may enable accurate remote monitoring of heart failure patients with minimal patient risk.

Setting Up a Heart Failure Program in 2018: Moving Towards New Paradigm(s)

PURPOSE OF REVIEW

Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting.

RECENT FINDINGS

Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients' care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined. HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.

Device monitoring in heart failure management: outcomes based on a systematic review and meta-analysis

Implantable devices have been developed for continuous monitoring of heart failure. We investigated the effect of fluids and hemodynamic monitoring, using these devices, on heart failure clinical outcomes. Literature search was performed January 2000 through May 2017 of studies comparing device monitored patients with control group. Random-effects meta-analysis was used to pool outcomes across the studies. A total of 5,454 patients were included from 14 studies. There was no difference in heart failure (HF)-related admissions rate [odds ratio (OR) 1.25, 95% CI: 0.92-1.69, P=0.15], all-cause mortality (OR 1.21, 95% CI: 0.91-1.61, P=0.20) or combined admission rate and all-cause mortality (OR 1.21, 95% CI: 0.89-1.64, P=0.22) between the device monitored and the control group. In a subgroup analysis including only pressure sensors devices, there was no difference in all-cause mortality (OR 1.04, 95% CI: 0.62-1.74, P=0.89), however, there was a lower admissions rate (OR 1.63, 95% CI: 1.10-2.41, P=0.02). In a subgroup of only impedance monitoring devices, there was no difference in all-cause mortality or admissions rate. Pressure monitoring was associated with lower HF admissions rate. No improvement in these outcomes was noted with impedance monitoring.

A Systems-Based Analysis of the CardioMEMS HF Sensor for Chronic Heart Failure Management

Background

Hemodynamic-guided therapy using the CardioMEMS™ system has been shown to reduce heart failure hospitalization (HFH) in both clinical trials and real-world settings. However, the CardioMEMS system requires input from multiple independent elements to achieve its effect, and no studies have been done to investigate those elements. Consistent patient participation and health care provider participation are two of those key elements, and this study sought to assess how they affect HFHs.

Methods

This was a single-center, retrospective cohort study of patients with the CardioMEMS sensor. The primary outcome was the number of HFH days patients experienced in the 1 year following CardioMEMS sensor implant. The primary independent variables were the average number of days between patient transmissions of data and the average number of days between health care provider reviews of those data. Covariates included patient demographics, medical comorbidities, history of HFHs, and initial pressure response to hemodynamic-guided therapy at 28 days after implant. Data were fit to a zero-inflated negative binomial regression.

Results

Seventy-eight patients were included in the study. The mean age was 64 ± 15 years, 52 (67%) were male, and 58 (76%) had heart failure with reduced ejection fraction. During the study period, there were 538 cumulative HFH patient-days. Based on the regression model, there was an exponential relationship between HFH days and the mean number of days between patient transmissions (IRR = 1.74, 95% CI: 1.09–2.75, p=0.019). There was also an exponential relationship between HFH days and the mean number of days between health care provider reviews (IRR = 1.03, 95% CI: 1.01–1.05, p=0.013).

Conclusions

This single-center study suggests that more frequent patient transmissions and health care provider reviews of the CardioMEMS system are associated with a decreased number of HFH days, but larger multicentered studies are required. Further systems-based analyses of the CardioMEMS system may be a useful approach to guiding effective use of the CardioMEMS device.

Clinical and Socioeconomic Predictors of Heart Failure Readmissions: A Review of Contemporary Literature

Heart failure represents a clinical syndrome that results from a constellation of disease processes affecting myocardial function. Although recent studies have suggested a declining or stable incidence of heart failure, patients with heart failure continue to have high hospitalization and readmission rates, resulting in a substantial economic and public health burden. We searched PubMed and Google Scholar to identify published literature from 1998 through 2018 using the following keywords: heart failure, readmissions, predictors, prediction models, and interventions. Cited references were also used to identify relevant literature. Developments in the diagnosis and management of patients with heart failure have improved hospitalization and readmission rates in the past few decades. However, heart failure remains the most common cause of hospitalization in persons older than 65 years. As a result, given the enormous clinical and financial burden associated with heart failure readmissions on health care, there has been growing interest in the investigation of mechanisms aimed at improving outcomes and curtailing associated costs of care. Herein, we review the current literature on clinical and socioeconomic predictors of heart failure readmissions, briefly discussing limitations of existing strategies and providing an overview of current technology aimed at reducing hospitalizations.

Remote Management of Heart Failure: An Overview of Telemonitoring Technologies

Technological advances have enabled increasingly sophisticated attempts to remotely monitor heart failure. This should allow earlier identification of decompensation, better adherence to lifestyle changes and medication and interventions (such as diuretic dosage changes) that reduce the need for hospitalisation. This review discusses telemonitoring approaches in heart failure, and the evidence for their impact. It is not difficult to collect data remotely, but converting more data into better decision-making that improves the outcome of care is challenging. Policy-makers and technology companies are enthusiastic about the potential of digital technologies to transform healthcare and bring expertise to the patient, rather than the other way round, but guideline writers are not yet convinced, due to the lack of consistent findings in randomised trials.

Remote Monitoring of Patients With Heart Failure: A White Paper From the Heart Failure Society of America Scientific Statements Committee

BACKGROUND

After several neutral telehealth trials, the positive findings and subsequent Food and Drug Administration approval of an implantable pulmonary arterial pressure monitor (PAPM) led to renewed interest in remote patient monitoring (RPM). Here we seek to provide contemporary guidance on the appropriate use of RPM technology.

RESULTS

Although early trials of external RPM devices suggested benefit, subsequent multicenter trials failed to demonstrate improved outcomes. Monitoring features of cardiac implantable electronic devices (CIEDs) also did not deliver improved HF outcomes, newer, multisensor algorithms may be better. Earlier technologies using direct pressure measurement via implanted devices failed to show benefit owing to complications or failure. Recently, 1 PAPM showed benefit in a randomized controlled trial. Although not showing cost reduction, cost-benefit analysis of that device suggests that it may meet acceptable standards. Additional research is warranted and is in progress. Consumer-owned electronic devices are becoming more pervasive and hold hope for future benefit in HF management. Practical aspects around RPM technology include targeting of risk populations, having mechanisms to ensure patient adherence to monitoring, and health care team structures that act on the data.

CONCLUSIONS

Based on available evidence, routine use of external RPM devices is not recommended. Implanted devices that monitor pulmonary arterial pressure and/or other parameters may be beneficial in selected patients or when used in structured programs, but the value of these devices in routine care requires further study. Future research is also warranted to better understand the cost-effectiveness of these devices.

Implantable devices to monitor patients with heart failure

Reducing heart failure hospitalizations represents a major challenge for modern clinicians. Early detection of congestion plays a key role in disease management strategy. Apart from traditional methods (patient reporting symptoms, body weight monitoring), novel home-care strategies allow guided adjustments in medical therapy through telemonitoring embedded in cardiac electronic implantable devices or through stand-alone diagnostic devices for hemodynamic monitoring. Wireless pulmonary artery pressure monitoring seems to reduce re-admission risk and is currently approved for this purpose in patients with heart failure. Multiparameter monitoring is also appealing and could be a valuable tool in managing these patients. However, invasive techniques face several safety concerns and cost-effectiveness issues. Therefore, quest for future research and emerging technologies is necessary.

Interventional Heart Failure and Hemodynamic Monitoring

Convergence of the fields of heart failure (HF) and interventional cardiology has led to the formation of a discipline referred to as interventional HF. Although the term may be applied to essentially any invasive procedure performed in patients with HF (eg, coronary angiography, percutaneous coronary intervention, invasive assessment of hemodynamics), it is more commonly reserved for the application of invasive diagnostic or therapeutic procedures to improve the clinical decision-making, functional status, and outcomes of HF patients. This article reviews developing modalities.

Chronic heart failure management and remote haemodynamic monitoring

Heart failure (HF) has a large societal and economic burden and is expected to increase in magnitude and complexity over the ensuing years. A number of telemonitoring strategies exploring remote monitoring and management of clinical signs and symptoms of congestion in HF have had equivocal results. Early studies of remote haemodynamic monitoring showed promise, but issues with device integrity and implantation-associated adverse events hindered progress. Nonetheless, these early studies established that haemodynamic congestion precedes clinical congestion by several weeks and that remote monitoring of intracardiac pressures may be a viable and practical management strategy. Recently, the safety and efficacy of remote pulmonary artery pressure-guided HF management was established in a prospective, single-blind trial where randomisation to active pressure-guided HF management reduced future HF hospitalisations. Subsequent commercial use studies reinforced the utility of this technology and post hoc analyses suggest that tight haemodynamic management of patients with HF may be an additional pillar of therapy alongside established guideline-directed medical and device therapy. Currently, there is active exploration into utilisation of this technology and management paradigm for the timing of implantation of durable left ventricular assist devices (LVAD) and even optimisation of LVAD therapy. Several ongoing clinical trials will help clarify the extent and utility of this strategy along the spectrum of patient with HF from individuals with chronic, stable HF to those with more advanced disease requiring heart replacement therapy.

Implantable Hemodynamic Monitoring for Heart Failure Patients

Rates of heart failure hospitalization remain unacceptably high. Such hospitalizations are associated with substantial patient, caregiver, and economic costs. Randomized controlled trials of noninvasive telemedical systems have failed to demonstrate reduced rates of hospitalization. The failure of these technologies may be due to the limitations of the signals measured. Intracardiac and pulmonary artery pressure-guided management has become a focus of hospitalization reduction in heart failure. Early studies using implantable hemodynamic monitors demonstrated the potential of pressure-based heart failure management, whereas subsequent studies confirmed the clinical utility of this approach. One large pivotal trial proved the safety and efficacy of pulmonary artery pressure-guided heart failure management, showing a marked reduction in heart failure hospitalizations in patients randomized to active pressure-guided management. "Next-generation" implantable hemodynamic monitors are in development, and novel approaches for the use of this data promise to expand the use of pressure-guided heart failure management.

Intracardiac Pressures Measured Using an Implantable Hemodynamic Monitor: Relationship to Mortality in Patients With Chronic Heart Failure

BACKGROUND

The purpose of this analysis was to examine whether implantable hemodynamic monitor-derived baseline estimated pulmonary artery diastolic pressure (ePAD) and change from baseline ePAD were independent predictors of all-cause mortality in patients with chronic heart failure.

METHODS AND RESULTS

Retrospective analysis used data from 3 studies (n=790 patients; 216 deaths). Baseline ePAD was related to mortality using a multivariable model including baseline and demographic data. Changes in ePAD defined as change from baseline to 6 months and from baseline to 14 days before death or exit from study were related to subsequent mortality, and analysis was adjusted for baseline ePAD. Area under the pressure versus time curve during 180 days before death or exit from study was related to mortality. Baseline ePAD, independent of other covariates, was a significant predictor of mortality (hazard ratio=1.07; 95% confidence interval=1.05-1.09; P<0.0001). Change in ePAD was an independent predictor of mortality (hazard ratio=1.07; 95% confidence interval=1.05-1.100; P=0.0008). Increased ePAD of 3, 4, or 5 mm Hg from baseline to 6 months was associated with increased mortality risk of 23.8%, 32.9%, or 42.8%. Change in ePAD from baseline to 14 days before death or exit from study was higher in patients who died (3.0±8 versus 1.7±10 mm Hg; P=0.003). Area under the pressure versus time curve in the final 180 days before death or exit from study was higher in patients who died versus those alive at end of study (185±668 versus 17±482 mm Hg.days; P=0.006).

CONCLUSIONS

Implantable hemodynamic monitor-derived baseline ePAD and change from baseline ePAD were independent predictors of mortality in chronic heart failure patients.

Invasive Hemodynamic Assessment of Patients with Heart Failure and Pulmonary Hypertension

OPINION STATEMENT

Right heart catheterization (RHC) with a pulmonary artery (PA) catheter is a minimally invasive method of obtaining hemodynamic data (e.g., right atrial and pulmonary pressures, cardiac output, pulmonary vascular resistance), which are used to diagnose and manage patients with advanced heart failure (HF), HF with preserved ejection fraction, and pulmonary hypertension (PH). Invasive hemodynamic data obtained from RHC can aid in the prognostication of HF and PH patients and are important in guiding decisions of implanting mechanical circulatory support devices and listing patients for heart and/or lung transplantation. The basis of RHC has also paved the way for implantable hemodynamic devices to monitor pulmonary artery pressures in the outpatient setting, which can reduce rates of HF-related hospitalizations. We will discuss the utility of PA catheters in the diagnosis and management of the aforementioned disease states, the role of implantable hemodynamic monitors, and the complications associated with RHC procedures.

Ambulatory Heart Failure Monitoring: A Systemic Review

Heart failure (HF) is one of the leading causes of morbidity and mortality and has a large effect on the country's economy. Although there have been major advances in HF monitoring, including more advanced pharmacological management and device-based therapy, HF-related mortality remains high. It is important to monitor HF so that HF-related hospitalization and mortality can be prevented. Due to the lower sensitivity of clinical features and biochemical markers, as well as the failure of telemonitoring in early detection of HF, more advanced techniques have been sought to more accurately predict impending HF, in order to address timely pharmacological management and prevent heart failure hospitalization (HFH). Device-based therapy has passed through various stages and culminated in the recently introduced CardioMEMSTM (St. Jude Medical, Inc., Saint Paul, Minnesota). CardioMEMSTM is a wireless pulmonary artery pressure (PAP) monitoring device, which continuously monitors PAP and transmits data to a healthcare provider. It rapidly identifies changes in intracardiac pressure and allows timely pharmacological management. CardioMEMSTM showed a higher reduction of HFH compared to any other devices.

Current and Future Percutaneous Strategies for the Treatment of Acute and Chronic Heart Failure

The prevalence of heart failure (HF) has risen in parallel with improved survival in patients after a myocardial infarction and an aging population worldwide. In recent years, new percutaneous therapies have been developed to complement current established treatments for acute/decompensated and chronic HF and minimize risks. In acute presentations, the failure of medical treatment is no longer the end of the road in refractory circulatory shock; the use of mechanical circulatory support devices may be the next milestone in well-resourced health settings. Although evidence in this area is difficult to generate, research networks can facilitate the volume and quality of data needed to further augment the clinician's knowledge. Pulsatile (intra-aortic balloon pump), axial continuous (Impella), or centrifugal continuous pumps (TandemHeart; HeartMate PHP) together with percutaneously implanted extracorporeal membrane oxygenation are radically changing the prognosis of acute HF. Newer percutaneous therapies for chronic HF are based on attractive hypotheses, including left atrial decompression with shunting devices, left ventricle restoration through partitioning devices, or pressure-guided implantable therapies that may help to promptly treat decompensations. To date, only the last has been proved effective in a randomized study. Therefore, thorough research is still needed in this dynamic and promising field.

Ambulatory pulmonary artery pressure monitoring in advanced heart failure patients

Heart failure (HF) is an emerging epidemic associate with significant morbidity, mortality, and health care expenditure. Although there were major advances in pharmacologic and device based therapies for the management of HF, mortality of this condition remains high. Accurate monitoring of HF patients for exacerbations is very important to reduce recurrent hospitalizations and its associated complications. With the failure of clinical signs, tele-monitoring, and laboratory bio-markers to function as early markers of HF exacerbations, more sophisticated techniques were sought to accurately predict the circulatory status in HF patients in order to execute timely pharmacological intervention to reduce frequent hospitalizations. CardioMEMS^TM (St. Jude Medical, Inc., Saint Paul, Minnesota) is an implantable, wireless pulmonary arterial pressure (PAP) monitoring system which transmits the patient’s continuous PAPs to the treating health care provider in the ambulatory setting. PAP-guided medical therapy modification has been shown to significantly reduce HF-related hospitalization and overall mortality. In advanced stages of HF, wireless access to hemodynamic information correlated with earlier left ventricular assist device implantation and shorter time to heart transplantation.

Pulmonary Pressure Monitoring for Patients With Heart Failure

Heart failure (HF) affects over 5.8 million patients in the United States, and can be very costly due to the number of hospitalizations and rehospitalizations during the final years of life. Due to the large number of hospitalizations for HF exacerbations, effective methods for preventing these occurrences are necessary. Improvements in the outpatient treatment of HF, aided by noninvasive and invasive home monitoring methods, can reduce the number of hospitalizations. Pulmonary pressure monitoring through the CardioMEMS system provides one method of hemodynamic assessment of patients. The efficacy of the CardioMEMS system in reducing the number of HF exacerbations has been explored in the CHAMPION trial (CardioMEMS Heart Sensor Allows Monitoring of Pressures to Improve Outcomes in NYHA Functional Class III Heart Failure Patients), which demonstrated a reduction in hospitalizations for HF exacerbations in patients whose medical management was guided by adjusting medications based on pulmonary pressures compared with clinical signs and symptoms. Retrospective analyses suggest that HF patients of certain subgroups, including those with left heart dysfunction and those with preserved left ventricular ejection fraction, could benefit from pulmonary pressure monitoring in controlling their HF. Larger studies are needed to determine whether mortality can be reduced with pulmonary pressure monitoring.