Welcome, and thank you for taking the time to review the February case scenario for the EP device implant registry focused on metric 27 and the AUC. This 58-year-old female is admitted for a CRTD implant secondary to heart failure, which has been unresponsive to guideline-directed medical therapy, despite multiple attempts over the last six months to adjust her medications. She has a history of non-ischemic cardiomyopathy, which was diagnosed two years ago. Her most recent LVEF was 38% with an NYHA class 3. The ECG revealed sinus rhythm with a right bundle branch block and a QRS duration of 168. She has recently had syncope secondary to a sustained VT event. Is the patient included in the numerator of metric 27? Number one, no, or number two, yes. Please take a moment to review the documentation in question before determining the best answer. The answer is number one, no. Reviewing the Executive Summary Measure and Metrics Companion Guide will assist in determining why the patient did not meet the numerator of metric 27. When we review the class 2A recommendation for a CRTD, we find that our patient has NICM, non-ischemic cardiomyopathy. However, when the ICD indication is secondary prevention, we skip to the second section of the algorithm. Immediately, we determine the reason the patient did not meet the numerator criteria. An LVEF of less than or equal to 35% is required. Our patient had an LVEF of 38%. A bonus question. Is this patient included in the numerator of metric 25? Number one, no, or number two, yes. Please take a moment to review the documentation in question before determining the best answer. The answer is number two, yes. When a patient meets criteria in metric 25 due to secondary prevention, this patient has unstable sustained monomorphic VT. The patient will be displayed as a yes in the numerator for metric 25 as a defibrillator ICD is indicated. Remember, metric 25 will evaluate patients regardless of the device implanted. This patient meets a class one recommendation for an ICD, however, does not meet the requirements for the CRT portion of the device. Therefore, the patient is included in the numerator of metric 25, however, is not included in the numerator of metric 27. To review, this 58-year-old female is admitted for a CRTD secondary to heart failure, which has been unresponsive to guideline-directed medical therapy. Despite multiple attempts over the last six months to adjust her medications, she has a history of non-ischemic cardiomyopathy, which was diagnosed two years ago. Her most recent LVEF was 38% with an NYHA class of three. The ECG revealed sinus rhythm with a right bundle branch block and a QRS duration of 168. She has recently had syncope secondary to a sustained VT event. So our question is, is this patient included in the numerator of metrics 105, 106, 107 or 108? Number one, metric 105, CRTD procedures not classifiable for AUC. Number two, metric 106, CRTD procedures classified as appropriate. Number three, metric 107, CRTD procedures classified as appropriate. Number three, metric 107, CRTD procedures classified as maybe appropriate. Or number four, metric 108, CRTD procedures classified as rarely appropriate. Please take a few moments to review the documentation and question before determining the best answer. The answer is number three, metric 107, CRTD procedures classified as maybe appropriate. Let us review the steps to successfully navigate the 2013 AUC document located under Resources, Documents, Quality Tools and Reference Documents. It's easiest to navigate the AUC using a systematic three-step process. The first step is to determine the applicable section. Section 1 evaluates secondary prevention ICDs. Section 2 evaluates primary prevention ICDs. Section 3 evaluates comorbidities. Section 4 evaluates ICD generator replacement at elective replacement indicator, ERI. Section 5 evaluates dual chamber ICD as opposed to single chamber ICD. And Section 6 evaluates CRT with no prior implant. The second step is to determine which patient factors have been coded versus what has been documented in the medical record. And the third step is to identify the appropriate indication. The patient had an initial CRTD implant. Therefore, begin by looking at Section 6, CRT, no prior implant. A non-left bundle branch block is defined as right bundle branch block or nonspecific intraventricular conduction block, not transient or rate-related. The patient has an LVEF of 38% and a secondary indication for a defibrillator which meets the first two requirements of Table 6.3.1. The QRS duration is greater than 150 at 168 milliseconds. The patient has a right bundle branch block or non-left bundle branch block and is in sinus rhythm. And the NYHA class is 3, completing all the criteria required for indication 219, which has a rating of 4 of may be appropriate. Thank you for viewing the February case scenario of 2023, focused on metric 27 and AUC.

heart failure

non-ischemic cardiomyopathy

CRTD implant

LVEF

sustained VT event