A Multistep Approach to Deal With Advanced Heart Failure: A Case Report on the Positive Effect of Cardiac Contractility Modulation Therapy on Pulmonary Pressure Measured by CardioMEMS

Abstract

During the last years, the management of heart failure (HF) made substantial progress, focusing on device-based therapies to meet the demands of this complex syndrome. In this case report, we present a multistep approach to deal with HF. Specifically, we report the first patient subjected to the implantation of both Optimizer Smart^® (Impulse Dynamics Inc., Marlton, NJ, USA) and CardioMEMS devices. A 72-year-old male patient with HF and reduced ejection fraction (HFrEF) was admitted to our cardiology department in January 2021, following a progressive shortening of the time between hospitalizations for levosimendan infusions. Specifically, the patient was monitored daily by CardioMEMS, and a strategy of levosimendan infusions guided by the device had been adopted. He was also a carrier of MitraClips and cardiac resynchronization therapy defibrillator (CRT-D) and had optimized HF medical therapy. In January 2021, the patient implanted Optimizer Smart^® device for cardiac contractility modulation (CCM) therapy because of poor response to therapy and elevated pulmonary artery pressure (PAP). CCM significantly reduced PAP values following discharge (systolic PAP 33.67 ± 2.92 vs. 40.6 ± 3.37 mmHg, diastolic PAP 14.5 ± 2.01 vs. 22.5 ± 2.53 mmHg, mean PAP 22.87 ± 2.20 vs. 30.9 ± 2.99 mmHg, HR 60.93 ± 1.53 vs. 80.83 ± 3.66 bpm; p < 0.0001), with persisting effect at 9 months. The usefulness of CCM is objectively demonstrated for the first time by continuous invasive monitoring of PAP by CardioMEMS, which can suggest the correct timing for CCM implantation.

Keywords: CardioMEMS; Optimizer Smart®; cardiac contractility modulation; case report; heart failure; levosimendan; medical devices; telemonitoring.

Figure 1

Optimizer Smart^® system. (A) The Optimizer Smart^® Implantable Pulse Generator (IPG) unit. (B) Optimizer Smart Charger System. Patients can recharge the IPG unit using a portable, home-based charger system, without supervision. Charging the device on a weekly basis assures it has enough energy to provide the prescribed dose of CCM therapy.

Figure 2

Chest X-ray of the patient. (A) The figure shows two CCM leads, three CRT-D leads, CardioMEMS, and MitraClips. (B) The figure shows CCM device on the right and CRT-D on the left. CRT-D, cardiac resynchronization therapy – defibrillator device; CCM 1, lead 1 CCM; CCM 2, lead 2 CCM; RV, right ventricular lead for CRT-D; LV, left ventricular lead for CRT-D; RA, right atrial lead for CRT-D.

Figure 3

A 12-lead ECG with visible spikes of high-energy impulses from CCM therapy.

Figure 4

Pulmonary artery pressure tracing detected by CardioMEMS. Starting from September 2020, there was a progressive shortening of the time between hospitalizations (pink squares) for levosimendan infusions. Pulmonary artery pressure tracing showing a mean diastolic PA drop after Optimizer Smart^® implantation (January 2021). M and/or purple lines, remote therapy modifications; H, hospitalization.