Understanding adherence to the CardioMEMS pulmonary artery pressure monitoring system for heart failure: A qualitative study

Bias-Free Cardiac Monitoring Capsule

Cardiovascular disease (CVD) remains the leading cause of death worldwide. Patients often fail to recognize the early signs of CVDs, which display irregularities in cardiac contractility and may ultimately lead to heart failure. Therefore, continuously monitoring the abnormal changes in cardiac contractility may represent a novel approach to long-term CVD surveillance. Here, a zero-power consumption and implantable bias-free cardiac monitoring capsule (BCMC) is introduced based on the triboelectric effect for cardiac contractility monitoring in situ. The output performance of BCMC is improved over 10 times with nanoparticle self-adsorption method. This device can be implanted into the right ventricle of swine using catheter intervention to detect the change of cardiac contractility and the corresponding CVDs. The physiological signals can be wirelessly transmitted to a mobile terminal for analysis through the acquisition and transmission module. This work contributes to a new option for precise monitoring and early diagnosis of CVDs.

Early Experience and Lessons Learned Using Implanted Hemodynamic Monitoring in Patients With Fontan Circulation

BACKGROUND

Data on the use of implanted hemodynamic monitoring (IHM) in patients with Fontan circulation are limited. This study reports our experience using the CardioMEMS HF system in adults with Fontan circulation.

METHODS AND RESULTS

This single-center, retrospective study evaluated heart failure hospitalizations, procedural complications, and device-related complications in patients with Fontan circulation referred for IHM placement (2015-2022). The association of pulmonary artery pressure (by most recent catheterization and median IHM pressure within 30 days of placement) with both death and follow-up Model for End-Stage Liver Disease Excluding International Normalized Ratio score were evaluated. Of 18 patients referred for IHM placement, 17 were successful (median age, 30 [range 21-48] years, 6 women). Procedural complications (access site hematomas, pulmonary artery staining) occurred in 3 patients, without device-related procedural complications. In follow-up (median, 35 [range, 6-83] months), 1 patient developed a pulmonary embolism (possibly device-related). Heart failure hospitalizations/year were similar before and after IHM (median, 1 [interquartile range, 0-1.0] versus 0.6 [0-2.3]; P=0.268), though only 46% of heart failure hospitalizations had associated IHM transmissions. IHM pressures were associated with Model for End-Stage Liver Disease Excluding International Normalized Ratio scores (R2=0.588, P<0.001), though catheterization pressures were not (R2=0.140, P=0.139). The long-term mortality rate was 53% in this cohort. On unadjusted survival analysis, IHM pressures ≥18 mm Hg were associated with mortality (log rank P=0.041), which was not reproduced with catheterization pressures (log rank P=0.764).

CONCLUSIONS

In patients with Fontan circulation, IHM did not reduce heart failure hospitalizations, though patient adherence to transmission was low. Device-related complications were low. IHM pressures may better represent real-life conditions compared with catheterization given associations with mortality and Model for End-Stage Liver Disease Excluding International Normalized Ratio score.

Remote Monitoring for Heart Failure Management at Home

Early telemonitoring of weights and symptoms did not decrease heart failure hospitalizations but helped identify steps toward effective monitoring programs. A signal that is accurate and actionable with response kinetics for early re-assessment is required for the treatment of patients at high risk, while signal specifications differ for surveillance of low-risk patients. Tracking of congestion with cardiac filling pressures or lung water content has shown most impact to decrease hospitalizations, while multiparameter scores from implanted rhythm devices have identified patients at increased risk. Algorithms require better personalization of signal thresholds and interventions. The COVID-19 epidemic accelerated transition to remote care away from clinics, preparing for new digital health care platforms to accommodate multiple technologies and empower patients. Addressing inequities will require bridging the digital divide and the deep gap in access to HF care teams, who will not be replaced by technology but by care teams who can embrace it.

Patients' Information Needs Related to a Monitoring Implant for Heart Failure: Co-designed Study Based on Affect Stories

BACKGROUND

RealWorld4Clinic is a European consortium that is currently developing an implantable monitoring device for acute heart failure prevention.

OBJECTIVE

This study aimed to identify the main issues and information needs related to this new cardiac implant from the patients' perspective.

METHODS

A total of 3 patient collaborators were recruited to help us design the study. During 4 remotely held meetings (each lasting for 2 hours), we defined the main questions and hypotheses together. Next, 26 additional interviews were conducted remotely to test these hypotheses. During both phases, we used affect stories, which are life narratives focusing on affect and the relationship between patients and the care ecosystem, to highlight the main social issues that should be addressed by the research according to the patients.

RESULTS

Context of diagnosis, age, and severity of illness strongly influence patient experience. However, these variables do not seem to influence the choice regarding being implanted, which relies mostly on the individual patient's trust in their physicians. It seems that the major cause of anxiety for the patient is not the implant but the disease itself, although some people may initially be concerned over the idea of becoming a cyborg. Remote monitoring of cardiac implants should draw on existing remote disease management programs focusing on a long-term relationship between the patient and their medical team.

CONCLUSIONS

Co-design with affect stories is a useful method for quickly identifying the main social issues related to information about a new health technology.

Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.

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.

Concurrent Assessment of the CardioMEMS™ HF System and HeartLogic™ HF Diagnostic: A Retrospective Case Series

BACKGROUND

Heart failure (HF) causes high morbidity and mortality despite advances in medical therapy. Remote patient monitoring (RPM) for HF allows for optimization of medical therapy and prevention of HF hospitalizations. This is the first study to assess pulmonary artery diastolic pressures (PADP) using the CardioMEMS™ HF System (CMEMS) and cardiac implantable electronic device (CIED)-based multisensor indexes (HeartLogic index [HLI]) using the HeartLogic™ HF Diagnostic (HL) in a small, retrospective cohort of patients with HF at a single center.

METHODS AND RESULTS

Any hospitalization (HSP), HF hospitalization (HFH), HF-related outpatient visit (OPV), and pulmonary artery pressure action (PACT) were recorded in 7 patients with concurrent CMEMS and HL measurements for at least 1-year. Median time before both platforms were implanted and present in the same participant was 3.12 months. Median study period was 1.44 years per participant. Data availability for HL was significantly higher at 99.6% compared to 64.1% adherence for CMEMS (P = 0.016). Overall, PADP was only weakly correlated to HLI (r = 0.098), but there was a 2.87 mm Hg (P = 0.014) estimated increase in PADP during HLI alert periods versus non-alert periods. Similarly, the estimated odds of being above a PADP goal was 4.7 times higher (95% CI: [3.0, 7.2], P < 0.001) in HLI alert vs non-alert periods.

CONCLUSIONS

Concurrent analysis of patients with CMEMS and HL showed an association between PADP and HLI, but the correlation was weak. However, there was a significant increase in PADP during HLI alert periods versus non-alert periods.

A qualitative study exploring the perceptions and motivations of patients with heart failure who transitioned from non-adherence to adherence

BACKGROUND

Management of heart failure (HF) involves complex self-care recommendations. Many patients have difficulty adhering to these recommendations, and mechanisms that support behavior change are poorly understood.

OBJECTIVE

The objective of this study was to explore the perceptions and motivations of individuals with HF who became adherent to HF treatment recommendations after being non-adherent.

METHODS

This was a qualitative descriptive study. Participants were recruited from cardiology clinics and completed a semi-structured interview on their experiences and motivations for self-care behavior change. Data was analyzed using thematic analysis. The sample size (n = 8) was sufficient to achieve saturation.

RESULTS

Five themes were identified: experiencing mortality, optimism and hope, making connections between behavior and health, self-efficacy, and the role of the clinician. The temporal chronological sequence of these themes across participants varied.

CONCLUSIONS

This study adds to our current understanding of HF self-care by suggesting mechanisms that may enhance existing self-care interventions, and demonstrating the important role of the clinician.