Sumeet Mitter, MD, Advanced Heart Failure and Transplant Cardiology at Mount Sinai Hospital, New York talks about how cardio sensors are helping patients with heart disease stay out of the hospital.
Interview conducted by Ivanhoe Broadcast News in May 2019.
If someone hears cardio, what is it? What are you monitoring for?
MITTER: So, when patients have heart failure the heart either cannot relax well or it can’t squeeze well. And that leads to higher pressures within the chambers of the heart as well as the lungs. And as those pressures go up, patients often become more symptomatic – not being able to walk as far as they normally do or even lay down because the pressures are so high they can’t breathe well. What the cardio allows us to do is actually measure those pressures remotely rather than having someone come into the hospital. And so the sensor receives and checks the pressures changes. The patient can lay on the pillow at home, it gets uploaded to a web portal and I can pull it up even at my desk or my iPhone.
What happens with someone when they have heart failure?
MITTER: Heart failure can be two types either when the heart isn’t pumping well, meaning the ejection fraction, the squeezing function of the heart is low. Such that the heart can’t necessarily circulate blood volume to the rest of the body. And then pressures rise within the heart as well as the lungs itself. Another form of heart failure is heart failure with preserved ejection fraction meaning that the squeezing function of the heart is OK. But the heart can’t relax. So, it’s almost like a stiff balloon that can’t expand anymore, then pressures rise in the heart as well and the lungs.
What causes it?
MITTER: There’s multiple causes of heart failure with reduced ejection fraction. It could be due to a genetic abnormality in the heart muscle, high blood pressure or even a blockage in an artery. And so when there’s reduced blood flow to different territories of the heart, the heart muscle gets damaged and can’t squeeze anymore. With heart failure with preserved ejection fraction that leads to a stiffening of the heart. And often it’s due to increased inflammation within the body from a multitude of factors such as comorbid high blood pressure, hypertension, diabetes, obesity, chronic kidney disease. And that overall leads to a stiffening of the heart.
If it’s not treated, what does the patient run the risk of?
MITTER: Any patient who develops heart failure and becomes hospitalized has a high risk of death. And so, we try to institute therapies that can change the direction of someone’s clinical course.
Before you had this way to monitor them so quickly, what would happen with a patient with heart failure? Would this be someone who you would chronically see in the hospital who would need a lot of a lot of individual attention, monitoring?
MITTER: Absolutely. And so heart failure patients often get readmitted. It’s actually one of the leading causes of readmissions within the United States. Patients can become very symptomatic when the pressures rise. Often, we have to bring them into the clinical setting, try to estimate what the pressures are within the heart by our clinical exam and then change medications tailored to patient care. With the cardiogram sensor we have a more scientific approach to understanding the pressures within the heart. We can use the pressures to guide our therapeutic intervention meaning changes in diuretic to help reduce pressures within the heart or even other medical therapy for heart failure reduced ejection fraction. That has led to a reduction of hospitalizations overall for both heart failure with reduced ejection fraction and preserved ejection fraction.
Over the past five or six years, is there now evidence that this is making a difference
MITTER: I do think this is a game changer because what we’ve been able to do is actually trend when pressures are rising in someone’s heart and lungs and call them with real-time information and change therapy rather than waiting for a patient to get a clinic appointment, come into our clinic or get admitted to the hospital. It’s reduced hospitalizations in clinical trials around 30% for reduced ejection fraction, keeping patients at home so they have a better quality of life and can enjoy what they like to do.
Is this a long procedure to implant the monitor?
MITTER: It’s not actually a very long procedure. It is a minimally invasive procedure where we enter a vein in the right femoral vein in the leg that leads back up to the heart. What we first do is we measure pressures within the cardiac chambers. Then we take a wire and take it up to the left pulmonary artery which is one of the arteries coming off the right side of the heart. Place a wire into this artery and then deploy a sensor after selecting the artery and taking the wire out.
So it’s a little sensor that lives where in the patient?
MITTER: The pulmonary artery is the main artery coming off the right side of the heart. And that bifurcates into a right and left side. And then in the left side, there’s an upper and lower branch. And so, on the left lower pulmonary artery, we actually implant it there.
How long does it stay? Is this a permanent thing?
MITTER: It’s permanent.
Does it move? Is there any risk to the patient?
MITTER: No. There’s no risk to the patient. Often what we’ll do is we’ll deploy the sensor. We’ll make sure that it’s not moving at the time of implant but slowly over time, there is what we called epithelthelization or it binds to the wall of the artery and no longer moves.
How is it operated? Will it work for the rest of the patient’s life?
MITTER: Works for the rest of the patient’s life. There is actually no battery involved. There is basically a capacitor that moves along with pressure changes within the heart as the heart beats. And the sensor basically senses the change in the pressure between each heartbeat throughout the cardiac cycle and converts that from a frequency into what we can monitor as real time pressure data. And it gets transmitted to us and we can then call the patient.
I wanted to ask you again how does it get transmitted at night?
MITTER: So once they have the sensor and they go home with a console and includes essentially a pillow and they can lay on the pillow every single morning transmit the pressure, it then gets uploaded to a web portal that I can log in to in my office, at home or even my iPhone and then call my patient with what their pressure readings are and how we want to change their medications.
And how often do you to monitor patients?
MITTER: Well the success of our program working with our heart failure nurse practitioners is that we monitor our patients every single day. And we can actually set alert values that if our patient crosses a threshold we automatically get an email or notification saying hey, we’re worried about one of your patients.
Can you talk to me about Dorris’s case a little bit? How much of a difference has this made for her?
MITTER: I met Dorris back in the fall of 2017 and at around that time she was getting frequently admitted to the hospital. She had no sense of what was triggering an exacerbation of her heart failure. Whether it be taking her medications properly or what in her diet was triggering an exacerbation. And I was very concerned about her because she has a very dilated heart, very weak heart. And I would see her every two weeks in the hospital. So, in discussing with her what her wishes were, she didn’t want any aggressive measures in terms of managing her heart failure. But she still wanted to just use medications to manage if possible. So, we implanted the sensor. And since February 2018 after the implant, she’s not been admitted to the hospital once. Where previously, she was being admitted every two weeks.
How long has it been since she’s been here?
MITTER: It’s been over a year that she stayed out of the hospital once she’s gotten a cardiac implant.
And how she feeling?
MITTER: She feels good. Every patient has good days and bad days. But if she has a bad day I can actually log in and see hey, are the pressures going up or are changed heart rhythms causing the pressures to go up and then tailor the medications directly to her. Over time, I understand what works for her in terms of her diuretic needs. I can tailor her therapy or even the medical therapy for her heart failure. But over time she also learns about her heart failure syndrome. She’s learned what foods trigger her heart failure. She knows if she misses a dose if a diuretic that her pressures are going to up. And we can sense that. And so it’s improved our communication with her. She’s been able to change all her lifestyle behaviors. Such that she’s enjoying what she likes to do at home. She stayed out of the hospital. She started a jewelry business. She makes jewelry at home. And I think that’s great.
Is there anything I didn’t ask you Dr that you want people know?
MITTER: I think we really need to focus on cardio as a way of just improving patient’s quality of life. Reducing the number of hospitalizations is one of the most important things we need to do within medicine especially because it is so expensive. And if we can offer great medical therapy while also improving a patient’s quality of life and then they can do the things that they want to do – engage with their loved ones, their family, their friends, for me that’s a win.
And then I am going to have you take out that sensor. If you could just describe what I’m looking at.
MITTER: This is the actual sensor that detects pressure changes within the pulmonary artery. And these are two loops on the end of it that help stabilize and anchor over time the sensor within the pulmonary artery. The epithelization occurs here. And so it is a very small sensor that we can put into the pulmonary artery. And this checks the pressures.
Looks like you could lose it in the carpet if you dropped it. It’s really small.
MITTER: One person once described it to be, it’s kind of like a paperclip in the pulmonary artery. And I thought OK. Well, colloquially, yeah that’s good.
So how long is the trial?
MITTER: They’re trying to expand the trials. There is an expanded protocol guide HF to include more patients to improve the real world data. And also, they’re testing the cardio as a tool with patients with Alvaz which is an advanced heart pump.
Has there been much of a change to the design?
MITTER: No.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Ilana Nikravesh
646-605-5973
ilana.nikravesh@mountsinai.org
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