A 45-year-old man with a medical history significant for nonischemic cardiomyopathy, heart failure (HF) with reduced ejection fraction, positive titin (TTN) genetic variant, hypertension, and type 1 diabetes mellitus (hemoglobin A1c concentration 7.2%) presents to establish care in the HF clinic. He has had two hospitalizations over the past 4 years because of decompensated HF. He is maintained on reasonable doses of guideline-directed medical therapy (GDMT), including sacubitril/valsartan, carvedilol, spironolactone, and empagliflozin. He endorses New York Heart Association (NYHA) class III HF symptoms including fatigue and dyspnea with mild-moderate exertion. He has a single-chamber internal cardiac defibrillator in place.
His vital signs include blood pressure 100/60 mm Hg, heart rate 75 bpm, and oxygen saturation 98% on room air.
Recent laboratory study results included sodium level 137 mEq/L, potassium level 4.2 mEq/L, creatinine level 1.3 mg/dL, glomerular filtration rate 60 mL/min/m2, and N-terminal pro–B-type natriuretic peptide (NT-proBNP) level 1900 pg/mL. An echocardiogram has findings of left ventricular ejection fraction (LVEF) 35%, mild mitral regurgitation, and mildly reduced right ventricular (RV) systolic function. An electrocardiogram has findings of normal sinus rhythm with QRS 110 msec and no evidence of significant conduction delay. Recent right heart catheterization (RHC) had findings of right atrial pressure 5 mm Hg, pulmonary capillary wedge pressure 10 mm Hg, and cardiac index 2.2 L/min/m2.
The correct answer is: A. Cardiac contractility modulation (CCM).
This patient met the criteria for CCM. Ultimately, team-based collaboration allows identification of device strategies tailored to individual physiology and disease stage, optimizing timing and selection across the device therapy continuum.1
He had NYHA class III HF symptoms, LVEF 35%, and QRS 120 msec with no conduction delay; therefore, he did not meet the criteria for CRT.2 The Class 1 indication for CRT includes LVEF ≤35%, sinus rhythm, left bundle branch block morphology, QRS ≥150 msec, and NYHA class II-IV HF symptoms despite GDMT. Furthermore, despite having NYHA class III HF symptoms, he had been hospitalized twice over the last 4 years, was tolerating reasonable doses of GDMT, and had RHC findings of normal hemodynamic values, demonstrating that he was not quite ready for advanced HF therapy evaluation. He remained ambulatory and hemodynamically stable enough for device optimization before consideration of LVAD/transplant.
Remembering the indications and criteria for CCM and BAT is important. CCM delivers high-voltage, long-duration electric signals to the RV septal wall during the absolute myocardial refractory period, which is associated with augmentation of left ventricular contraction.3 CCM is approved by the Food and Drug Administration (FDA) for patients with NYHA class III HF symptoms and LVEF 25-45% who are not candidates for CRT.4 BAT offers electrical stimulation of carotid baroreceptors, which in turn promotes activation of the baroreflex system, causing an increase in parasympathetic activity and decrease in sympathetic activity.5 BAT is FDA approved for patients with NYHA class III HF symptoms, LVEF ≤35%, and NT-proBNP level <1600 pg/mL who are not CRT candidates.
This patient case quiz is part of the Beyond the Pill: Advancing Heart Failure Care With Monitoring and Device Therapy initiative. Educational Grant Support Provided By: CVRx, Edwards Lifesciences, Abbott.
References
- Truby LK, Rogers JG. Advanced heart failure: epidemiology, diagnosis, and therapeutic approaches. JACC Heart Fail. 2020;8(7):523-536. doi:10.1016/j.jchf.2020.01.014
- Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(17):e263-e421. doi:10.1016/j.jacc.2021.12.012
- Fudim M, Abraham WT, von Bardeleben RS, et al. Device therapy in chronic heart failure: JACC state-of-the-art review. J Am Coll Cardiol. 2021;78(9):931-956. doi:10.1016/j.jacc.2021.06.040
- Pipilas DC, Hanley A, Singh JP, Mela T. Cardiac contractility modulation for heart failure: current and future directions. J Soc Cardiovasc Angiogr Interv. 2023;2(6Part B):101176. Published 2023 Dec 4. doi:10.1016/j.jscai.2023.101176
- Kaufmann H, Norcliffe-Kaufmann L, Palma JA. Baroreflex dysfunction. N Engl J Med. 2020;382(2):163-178. doi:10.1056/NEJMra1509723
Log in to MyACC
