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Implantation for a device that changed the life of a patient with severe heart failure in Al-Ahli Hospital

By Dr. Abdul Razzaq Al-Juhani, Head of the Heart Center at Al-Ahli Hospital - Doha / Qatar

There has been tremendous amount of research and improvement in the treatment of heart failure, over the last 20 years. Some important drugs have been introduced and tested which made a big difference to the life of patients of heart failure. However, there are many patients who continue to suffer from symptoms of heart failure, despite maximum medications. These patients often need repeated admissions, from time to time, to control their heart failure by giving medications via injections. In some, heart failure is so severe that they may need to be intubated and put on ventilator (artificial respiration via a tube introduced through the mouth into the air-pipe). For such patients, there has been an extremely important discovery of implantable devices called CRTD-ICD, and which made a huge difference to their life. 

We hereby report one such patient who had severe heart failure who saw his life turn around after the implantation of a special heart device.

Mr. DD is a middle-aged British gentleman who works as an engineer. He had suffered from increasing fatigue and breathlessness which he thought because of activity at work, but his symptoms got much worse that he could not climb stairs at all, and sometimes finds walking or even going to the toilet a difficult task. He attended the Cardiology Clinic of Dr. Gehani (Consultant Cardiologist and Chairman of Ahli Heart Center) in March 2018. He complained of severe breathlessness both on walking and at rest. Some nights he had to sit up, because lying down made him feel chocked. He said that sometimes he felt he was going to die. Dr. Gehani, said that the patient also had evidence of fluid in the lungs and swelling of both legs, which are highly suggestive of Heart Failure. He was immediately admitted and investigations confirmed severe weakness of heart muscle. The Echocardiogram revealed the pumping efficiency of the heart muscle was only 27% (Normally 55-65%). During admission, he was given medications by intravenous drip to reduce the fluid overload on the lungs and the body. Coronary angiogram was carried out to exclude blockage of the coronary arteries that supply the heart muscle, which is one of the most important causes of heart failure. This is done by passing a fine catheter from the arm or the groin and injecting small amount od dye directly in the coronary arteries, which can uncover any narrowing or blockage of the coronary arteries. There was no blockage and therefore cardiac MRI (Magnatic Resonance Imaginging) was carried out to study the structure of the heart muscle in details. This confirmed that there was extensive scarring of the heart muscle leading to its weakness. This is called Cardio-myopathy. 

The patient had good response to the medications when given in the hospital by intravenous drip, but he was given tablets to take at home, he became worse again and needed another admission to give the medications by drip. It has become clear that he needs more assistance than just medications. One modern option which has shown a great promise in such cases is a device called Cardiac Re-Synchronization Therapy Device (CRTD). This is implanted under the skin and has wires which are passed through the veins under the collarbone to the heart. These devices look like pacemakers, but are much more complicated. Traditional pacemakers only deal with slow heart rate (Bradycardia) which can cause dizziness or loss of consciousness. Under these circumstances the pacemaker gives extra beats to prevent loss of consciousness, but they cannot treat abnormal fast heart rate which can also cause sudden cardiac death. 

In each admission, Mr. DD showed good response when medications were given by drip, but whenever this was replaced by tablets to allow him to go home, he had some recurrence of symptoms and therefore oral medications were not able to completely control his symptoms. 

It was clear that he needs more than just oral medications and therefore, we had a long discussion with Mr. DD about the option of implanting one of the modern devices that has been shown to add to the improvement achieved by medications. Such devices can also prevent sudden cardiac death which is known to be a real threat in patients with heart failure. 

After studying the ECG (Electrocardiogram) and Echocardiogram (Ultrasound scan) of the heart, it became obvious that CRTD-ICD is the device of choice in this case. CRTD-ICD devices can, in addition to treating slow heart rate, also improve the function of the heart muscle by improving the coordination between the left and right ventricles of the heart. This coordination is lost in many patients with heart failure which makes heart failure much worse. This is the important function of the CRTD part of the device. The other part of the device is called ICD (Implantable Cardioverter Defibrillator) which has another very important function, that is the prevention of Sudden Cardiac Death which is common in patients of Heart failure. The ICD Technology continuously monitors the heart rate of the patient and if this becomes abnormal and threatens sudden arrest of the heart, the ICD deals with this by giving an electric shock that can bring the heart rhythm back to normal and prevent cardiac arrest. 

The implantation procedure for CRTD-ICD devices is done in the Cardiac Catheterization rooms and takes between 1-2 hours on average. They can be done under sedation and local anesthesia, but in patients who could not tolerate lying flat still (which is often the case in patients with heart failure), general anesthesia is often necessary and advisable. The implantation procedure was done by Prof. Gehani, and the anesthesia was administered by Dr. Iman Daoud, Consultant Cardiac Anesthetist. The procedure was straightforward without complications and three wires were passed from the CRTD-ICD device to the following chambers of the heart: One to the Right Atrium, one to the Right Ventricle and the third was passed to a special venous channel in the back of the heart, called coronary sinus, because it is close to the third chamber that we wanted to pace, the left ventricle said Prof. Gehani. 

The patient was discharged on the third day. He was seen for follow-up for nearly 2 years before he travelled back to his country. He experienced a huge improvement of daily life after the implantation of the CRTD-ICD device. He is now able to climb up to 3 flights of stairs without stopping and can sleep almost flat without waking up with a cough and breathlessness. The device was programed from time to time to optimize its function and the patients response was excellent every time, and we were able to reduce the number and quantity of medications, said Prof. Gehani.

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