HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices

Heart failure and telemedicine: where are we and where are we going? Opportunities and critical issues

Heart failure (HF) is one of the main causes of morbidity in the world and is responsible for an enormous amount of health costs, mostly due to hospitalizations. The remote control techniques of vital signs and health status have the potential to help prevent factors leading to HF instability by stimulating early therapeutic interventions. The goal of telemedicine is to change the intervention strategy from a 'reactive' type, in which therapy is optimized in response to the worsening of symptoms, to a 'pro-active' type, in which therapeutic changes are undertaken based on changes in the monitored parameters during the sub-clinical phase. This article is aimed at exploring the major results obtained by telemedicine application in HF patients with and without cardiac electronic devices or in those with haemodynamic sensors and to analyse the critical issues and the opportunities of its use.

HeartInsight: from SELENE HF to implementation in clinical practice

There is strong evidence that remote monitoring in cardiac implantable electronic devices can detect device malfunctions earlier than conventional monitoring and that it can be useful for detecting cardiac arrhythmias, while little data are available for an improved management of heart failure (HF). HeartInsight is a new remote monitoring algorithm developed and validated in the SELENE HF study that combines information from a diverse set of sensors integrated into one alert to detect worsening HF with promising accuracy. However, the shift from detecting technical issues or arrhythmia episodes to early predicting clinical events underscores the need to understand how to properly integrate these tools into the clinical workflow by defining an organizational model and shared guidelines for the management of HF alerts. Here, we critically discuss issues that will be raised by the implementation of this 'enhanced' remote monitoring approach to HF care in daily clinical practice.

Remote Patient Monitoring: What Have We Learned and Where Are We Going?

Purpose of Review

Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is an important part of patient follow-up. The increasing number of patients with CIEDs and the recent pandemic pose several challenges for already limited device clinic resources. This review focuses on recent evolutions in RM and identifies future needs to improve RM.

Recent Findings

RM has been associated with multiple clinical benefits, including improved survival, early detection of actionable events, reduction in inappropriate shocks, longer battery lives, and more efficient healthcare utilization. The survival benefit was driven by studies using alert-based continuous RM with daily transmissions and fast reaction times. Patients report a high satisfaction rate without significant differences in quality of life between RM and in-office follow-up.The increasing workload, due to the increasing number of CIEDs implanted with daily remote transmissions, results in several challenges for the future of RM. RM requires appropriate reimbursement for RM device clinics to optimize patient/staff ratios, including sufficient non-clinical and administrative support. Universal alert programming and data processing may minimize inter-manufacturer differences, improve the signal-to-noise ratio, and allow the development of standard operating protocols and workflows. In the future, programming by remote control and true remote programming may further improve remote CIED management, patient quality of life, and device clinic workflows.

Summary

RM should be considered standard of care in management of patients with CIEDs. The clinical benefits of RM can be maximized by an alert-based continuous RM model. Adapted healthcare policies are required to keep RM manageable for the future.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Reduction in long-term mortality using remote device monitoring in a large real-world population of patients with implantable defibrillators

AIMS

Remote monitoring (RM) for implantable cardioverter-defibrillators (ICDs) is advocated for the potential of early detection of disease progression and device dysfunction. While studies have examined the effect of RM on clinical outcomes in carefully selected populations of heart failure patients implanted with ICDs from a single vendor, there is a paucity of data in real-world patients. We aimed to assess the long-term effect of RM in a representative ICD population using real-world data.

METHODS AND RESULTS

This is an observational retrospective longitudinal study of 1004 patients implanted with an ICD or cardiac resynchronization therapy device (CRT-D) from all device vendors between 2010 and 2021. Patients started on RM (N = 403) within 90 days following de novo device implantation and yearly in-office visits were compared with patients with only bi-yearly in-office follow-up (non-RM, N = 601). In a propensity score matched cohort of 430 patients (mean age 61.4 ± 14.3 years, 26.7% female), all-cause mortality at 4-year was 12.6% in the RM and 27.7% in the non-RM group [hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.32-0.82; P = 0.005]. No difference in inappropriate ICD-therapy (HR 1.90, 95% CI 0.86-4.21; P = 0.122) was observed. The risk of appropriate ICD-therapy (HR 1.71, 95% CI 1.07-2.74; P = 0.026) was higher in the RM group.

CONCLUSION

Remote monitoring was associated with a reduction in long-term all-cause and cardiac mortality compared with traditional office visits in a real-world ICD population.

Implantable Cardioverter-Defibrillators in Poland Compared with other European Countries from the Patient's Perspective: Insights from the EHRA Patient Survey

BACKGROUND

The aim of this study was to compare differences between Polish ICD recipients and ICD recipients from other European countries in terms of quality of life, information provision before ICD implantation, and end-of-life issues.

METHODS

This is a sub-analysis of the "Living with an ICD" patient survey (25-item questionnaire) organized by the European Heart Rhythm Association between 12 April 2021 and 5 July 2021 in ten European countries.

RESULTS

There were 410 (22.7%) patients from Poland and 1399 (77.3%) from other European countries. A total of 51.0% of Polish patients reported improvement in their quality of life compared with 44.3% in other countries (p = 0.041). Remote monitoring was three times more often utilized in other countries than in Poland (66.8% vs. 21.0%, p < 0.001). While 78.1% of Poles felt well informed before ICD implantation compared with 69.6% of subjects from other countries (p = 0.001), they were less familiar with the ICD deactivation process than others (38.9% vs. 52.5%, p < 0.001).

CONCLUSIONS

Despite the less frequent use of remote monitoring and gaps in end-of-life issues, Polish ICD recipients reported more favorable quality of life and a higher level of information received before device placement than patients in other European countries.

The patient perspective on remote monitoring of implantable cardiac devices

Aims

Remote monitoring for patients with cardiac implantable electronic devices (CIEDs) is well established in clinical routine and recommended by current guidelines. Nevertheless, data regarding patients' perceptions are limited. Therefore, this study aims to analyze the patient perspectives on the remote monitoring of cardiac devices in Germany.

Methods and results

Patients with CIEDs and remote monitoring of all current manufacturers from three German centers were asked to participate. The questionnaire consisted of 37 questions regarding the patients' individual use and perspectives on remote monitoring. Survey participation was anonymous and on a voluntary basis. A total of 617 patients (71.6% men) participated. Most patients reported feeling well informed (69.3%) and reported having unchanged or improved coping (98.8%) since the start of remote monitoring. At least 39.7% of patients experienced technical problems regarding the transmitter, whereas most patients (60.3%) reported that they never noted technical issues. Older patients had significantly less interest than younger patients in using their own smartphones for data transfer (p < 0.001).

Conclusion

Patients with remote follow-up of CIED reported that they felt well informed about the remote monitoring approach. Remote monitoring can support coping with their disease. With remote monitoring, patients experienced a prolongation of intervals of in-person follow-up visits, and especially younger patients would appreciate smartphone-based data transfer of their CIEDs.

Alert-driven vs scheduled remote monitoring of implantable cardiac defibrillators: A cost-consequence analysis from the TRUST trial

BACKGROUND

Alert-driven remote patient monitoring (RPM) or fully virtual care without routine evaluations may reduce clinic workload and promote more efficient resource allocation, principally by diminishing nonactionable patient encounters.

OBJECTIVE

The purpose of this study was to conduct a cost-consequence analysis to compare 3 postimplant implantable cardioverter-defibrillator (ICD) follow-up strategies: (1) in-person evaluation (IPE) only; (2) RPM-conventional (hybrid of IPE and RPM); and (3) RPM-alert (alert-based ICD follow-up).

METHODS

We constructed a decision-analytic Markov model to estimate the costs and benefits of the 3 strategies over a 2-year time horizon from the perspective of the US Medicare payer. Aggregate and patient-level data from the TRUST (Lumos-T Safely RedUceS RouTine Office Device Follow-up) randomized clinical trial informed clinical effectiveness model inputs. TRUST randomized 1339 patients 2:1 to conventional RPM or IPE alone, and found that RPM was safe and reduced the number of nonactionable encounters. Cost data were obtained from the published literature. The primary outcome was incremental cost.

RESULTS

Mean cumulative follow-up costs per patient were $12,688 in the IPE group, $12,001 in the RPM-conventional group, and $11,011 in the RPM-alert group. Compared to the IPE group, both the RPM-conventional and RPM-alert groups were associated with lower incremental costs of -$687 (95% confidence interval [CI] -$2138 to +$638) and -$1,677 (95% CI -$3134 to -$304), respectively. Therefore, the RPM-alert strategy was most cost-effective, with an estimated cost-savings in 99% of simulations.

CONCLUSIONS

Alert-driven RPM was economically attractive and, if patient outcomes and safety are comparable to those of conventional RPM, may be the preferred strategy for ICD follow-up.

Recommendations for the Quality Management of Patient-Generated Health Data in Remote Patient Monitoring: Mixed Methods Study

BACKGROUND

Patient-generated health data (PGHD) collected from innovative wearables are enabling health care to shift to outside clinical settings through remote patient monitoring (RPM) initiatives. However, PGHD are collected continuously under the patient's responsibility in rapidly changing circumstances during the patient's daily life. This poses risks to the quality of PGHD and, in turn, reduces their trustworthiness and fitness for use in clinical practice.

OBJECTIVE

Using a sociotechnical health informatics lens, we developed a data quality management (DQM) guideline for PGHD captured from wearable devices used in RPM with the objective of investigating how DQM principles can be applied to ensure that PGHD can reliably inform clinical decision-making in RPM.

METHODS

First, clinicians, health information specialists, and MedTech industry representatives with experience in RPM were interviewed to identify DQM challenges. Second, these stakeholder groups were joined by patient representatives in a workshop to co-design potential solutions to meet the expectations of all the stakeholders. Third, the findings, along with the literature and policy review results, were interpreted to construct a guideline. Finally, we validated the guideline through a Delphi survey of international health informatics and health information management experts.

RESULTS

The guideline constructed in this study comprised 19 recommendations across 7 aspects of DQM. It explicitly addressed the needs of patients and clinicians but implied that there must be collaboration among all stakeholders to meet these needs.

CONCLUSIONS

The increasing proliferation of PGHD from wearables in RPM requires a systematic approach to DQM so that these data can be reliably used in clinical care. The developed guideline is an important next step toward safe RPM.

Failure of Guidelines and Consensus Statements to Recommend Follow-up for Chronic Cardiovascular Conditions

BACKGROUND

Many cardiac conditions require long-term clinical follow-up to monitor progression of disease and tolerance and adherence to therapies. Providers are often unsure as to the frequency of clinical follow-up and who should provide the follow-up. In the absence of formal guidance, patients may be seen more frequently than necessary - thereby limiting clinic space for other patients, or not frequently enough, potentially leading to undetected progression of disease.

OBJECTIVES

To determine the extent to which guidelines (GL)/consensus statements (CS) provide guidance about appropriate follow-up for common cardiovascular conditions.

METHODS

We identified 31 chronic cardiovascular disease conditions for which long-term (beyond 1 year) follow-up is indicated and used PubMed and professional society websites to identify all relevant GL/CS (n = 33) regarding these chronic cardiac conditions.

RESULTS

Of the 31 cardiac conditions reviewed, GL/CS contained no recommendation or vague recommendation for long-term follow-up for 7 of the conditions. Of the 24 conditions with recommendations for follow-up, 3 had recommendations for imaging follow-up only without mention of clinical follow-up. Of the 33 GL/CS reviewed, 17 made any recommendations about long-term follow-up. When recommendations were made regarding follow-up, they were often vague, using terminology such as "as needed".

CONCLUSIONS

Half of GL/CS fail to provide recommendations for clinical follow-up of common cardiovascular conditions. Writing groups for GL/CS should adopt a standard of routinely including recommendations for follow-up including specific advice about level of expertise needed (eg, primary care physician, cardiologist), need for imaging or testing, and frequency of follow-up.

Real-World Disparities in Remote Follow-Up of Cardiac Implantable Electronic Devices and Impact of the COVID-19 Pandemic: A Single-Center Experience

Background Remote monitoring (RM) of cardiac implantable electronic devices has been shown to improve cardiovascular morbidity and mortality. To date, no studies have investigated disparities in use and delivery of RM. This study was performed to investigate if racial and socioeconomic disparities are present in cardiac implantable electronic device RM. Methods and Results This was a retrospective observational cohort study at a single tertiary care center in the United States. Patients who received a newly implanted cardiac implantable electronic device or device upgrade between January 2017 and December 2020 were included. Patients were classified as RM positive (RM+) when they underwent at least ≥2 remote interrogations per year during follow-up. Of all eligible patients, 2520 patients were included, and 34% were women. The mean follow-up was 25 months. Mean age was 71±14 years. Pacemakers constituted 66% of implanted devices, whereas 26% were implantable cardioverter-defibrillators, and 8% were cardiac resynchronization therapy with implantable cardioverter-defibrillators. Most patients (83%) were of European American ancestry. During follow-up, 66% of patients were classified as RM+. Patients who were younger, European American, college-educated, lived in a county with higher median household income, and were active on the hospital's patient portals were more frequently RM+. In an adjusted regression model, RM+ remained associated with the use of the online patient portal (odds ratio [OR], 2.889 [95% CI, 2.387-3.497]), presence of an implantable cardioverter-defibrillator (OR, 1.489 [95% CI, 1.207-1.835]), advanced college degree (OR, 1.244 [95% CI, 1.014-1.527]), and lastly with European American ancestry (P<0.05). During the years of the COVID-19 pandemic, the number of RM+ patients increased, whereas the association with ancestry and ethnicity decreased. Conclusions Despite being offered to all patients at implantation, significant disparities were present in cardiovascular implantable electronic device RM in this cohort. Disparities were partly reversed during COVID-19. Further studies are needed to examine health center- and patient-specific factors to overcome these barriers, and to facilitate equal opportunities to participate in RM.

Early Smartphone App-Based Remote Diagnosis of Silent Atrial Fibrillation and Ventricular Fibrillation in a Patient with Cardiac Resynchronization Therapy Defibrillator

Due to distressing statistics concerning cardiovascular diseases, remote monitoring of cardiac implantable electronic devices (CIED) has received a priority recommendation in daily patient care. However, most bedside systems available so far are not optimal due to limited patient adherence. We report that smartphone app technology communicating with CIED improved the patient's engagement and adherence, as well as the accuracy of atrial and ventricular arrhythmias diagnosis, thus offering more efficient treatment and, consequently, better patient clinical outcomes. Our findings are in concordance with previously published results for implantable loop recorders and pacemakers, and provide new insight for heart failure patients with an implanted cardiac resynchronization therapy defibrillator.

The Feasibility, Effectiveness and Acceptance of Virtual Visits as Compared to In-Person Visits among Clinical Electrophysiology Patients during the COVID-19 Pandemic

The feasibility and effectiveness of virtual visits (VVs) for cardiac electrophysiology patients are still unknown. We aimed to assess the feasibility and effectiveness of VVs as compared to in-person visits, and to describe patient experience with virtual care in clinical electrophysiology. We prospectively enrolled patients scheduled to receive a clinical electrophysiology evaluation, dividing them in two groups: a VV group and an in-person visit group. Outcomes of interest were: (1) improvement in symptoms after the index visit, (2) disappearance of remote monitoring (RM) alerts at follow-up, (3) necessity of urgent hospitalization and (4) patient satisfaction measured by the Patient Satisfaction Questionnaire-18 (PSQ-18). This study included 162 patients in the VV group and 185 in the in-office visit group. As compared to in-person visits, VVs resulted in a similar reduction in RM alerts (51.5% vs. 43.2%, p-value 0.527) and in symptomatic patient rates (73.6% vs. 56.9%, p-value 0.073) at follow-up, without differences in urgent hospitalization rates (p-value 0.849). Patient satisfaction with VVs was higher than with in-person evaluation (p-value < 0.012). VVs proved to be as feasible and as effective as in-person visits, with high patient satisfaction. A hybrid model of care including VVs and in-person visits may become the new standard of care after the COVID-19 pandemic is over.

Remote monitoring of pacemakers and defibrillators: Effective and safe in Brazil?

Background

The remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) has become a common method of in-home monitoring and follow-up in high-income countries given its effectiveness, safety, convenience, and the possibility of early intervention. However, in Brazil, RM is still underutilized.

Objectives

This observational study aims to demonstrate our experience of using RM in Brazil and the predictive factors of RM of CIED follow-up in Brazil.

Methods

This was a prospective cohort study of patients with a CIED. Event rates are reported and clinical responses to those findings and outcomes based on the detection of RM. A logistic regression model was performed to identify predictors of more events, with P < .05 for statistical significance.

Results

This study evaluated consecutive 119 patients: 30.2% with pacemakers, 42.8% with implantable cardioverter-defibrillator, 22.7% with cardiac resynchronization therapy (CRT) with defibrillator, and 3.3% with CRT with pacemaker. Events were detected in 63.9% of the cases in 29.5 ± 23 months of follow-up. The outcomes found were that 44.5% needed elective evaluation in medical treatment and 23.5% needed immediate evaluation in therapy. Logistic regression analysis showed that the groups with CRT or CRT with defibrillator (75.0%), reduced ejection fraction (76.5%), and New York Heart Association functional class ≥II (75.0%) had the highest RM event rates.

Conclusions

RM proved to be effective and safe in the follow-up of patients with CIEDs in Brazil, allowing early interventions and facilitating therapeutic management.

Remote interrogation and reprogramming of cardiac implantable electronic devices using a custom multivendor solution

BACKGROUND

Until recently, remote interrogation and reprogramming of therapeutic cardiac implantable electronic devices (CIEDs) have been virtually nonexistent owing to technical challenges and safety concerns. It could be extremely useful, in particular in case of emergencies, when patients live far from CIED professionals or during enforced physical distancing.

OBJECTIVE

We investigated the feasibility and safety of a custom solution for remote interrogation and reprogramming of CIEDs from various manufacturers in various clinically relevant situations.

METHODS

Our solution consists of remote controlling CIED programmers through screen capture and remote cursor control. In this multicenter feasibility study, the primary outcome was technical feasibility (% of success) and safety (absence of complication) of interrogation and reprogramming when indicated in clinically driven encounters.

RESULTS

A total of 115 remote interrogations were performed in 110 patients: within the hospital (n = 73), medium range (50-100 km; n = 22), and long range (>5000 km; n = 20). Implanted devices were pacemakers (n = 85) and implantable cardioverter-defibrillators (n = 25) from Abbott (N=13), Biotronik (n = 65), and MicroPort (n = 32). Patients were located in the outpatient clinic, cardiology department, radiology department (magnetic resonance imaging), operating room (per implantation), and intensive care unit. Teleworking was performed in 39 cases. Complete CIED interrogations succeeded in all patients with reprogramming in 56 of 115 sessions (49%). No clinical or technical complications occurred. The time lag for screen interaction was below 1 second.

CONCLUSION

Remote interrogation and reprogramming of CIEDs are feasible and safe across disparate clinical contexts and distances. This strategy may enhance health care access and facilitate medical training, tele-expertise, and telework worldwide.

Racial and ethnic differences in implantable cardioverter-defibrillator patient selection, management, and outcomes

Racial and ethnic differences in treatment-cardiovascular and otherwise-have been documented in many aspects of the American health care system and can be seen in implantable cardioverter-defibrillator (ICD) patient selection, counseling, and management. ICDs have been demonstrated to be a powerful tool in the prevention of sudden cardiac death, yet uptake across all eligible patients has been modest. Although patients who do not identify as White are disproportionately eligible for ICDs in the United States, they are less likely to see specialists, be counseled on ICDs, and ultimately have an ICD implanted. This review explores racial and ethnic differences demonstrated in ICD patient selection, outcomes including shock effectiveness, and postimplantation monitoring for both primary and secondary prevention devices. It also highlights barriers for uptake at the health system, physician, and patient levels and suggests areas of further research needed to clarify the differences, illuminate the driving forces of these differences, and investigate strategies to address them.

Remote versus in-office monitoring for implantable cardioverter defibrillators: Results from a randomized pragmatic controlled study in Portugal

INTRODUCTION

Remote monitoring (RM) is a safe and effective alternative to in-office conventional follow-up.

OBJECTIVE

We aimed to evaluate patient satisfaction with RM and its impact on healthcare resources in a population with cardiac implantable electronic devices.

METHODS

Randomized, pragmatic, open-label controlled trial, with adult wearers of implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with ICD (CRT-D), eligible for the CareLink® system. Patients newly implanted or with previous conventional follow-up were randomized to RM or conventional follow-up (control), and followed for 12 months, according to the centers' practice. The number of in-office visits and adverse events were compared between groups. Patient and healthcare professionals' satisfaction with RM were described.

RESULTS

Of the 134 randomized patients (69 RM; 65 control, aged 60±13 years), 80% were male, 23% employed, 72% ICD wearers and 54% newly implanted. Most patients (70%) reported travel costs less than 15€/visit, and 46% daily routine interference with in-office visits. Median physician/technician time with patient was 15 min/15 min, per in-office visit. Excluding baseline and final visits, control patients had more in-office visits in total: median 1 vs. 0, p<0.001. In 81% of the in-office visits, no clinical measures were taken. There were 10 adverse events, with no differences between groups. At the final visit, 95% of RM patients considered RM easy/very easy to use, and would all prefer to maintain RM and recommend it to others. All professionals found the CareLink website easy/very easy to use and were satisfied with transmission data.

CONCLUSIONS

In a Portuguese population with ICD and CRT-D, RM safely reduced the burden of in-office visits, with high levels of satisfaction among patients and healthcare professionals.

Remote monitoring in patients with heart failure with cardiac implantable electronic devices: a systematic review and meta-analysis

BACKGROUND

Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is now the standard of care, but whether the demonstrated benefits of RM translate into improvements in heart failure (HF) management is controversial. This systematic review addresses the role of RM in patients with HF with a CIED.

METHODS AND RESULTS

A systematic search of the literature for randomised clinical trials in patients with HF and a CIED assessing efficacy/effectiveness of RM was performed using MEDLINE, PubMed and Embase. Meta-analysis was performed on the effects of RM of CIEDs in patients with HF on mortality and readmissions. Effects on implantable cardiac defibrillator (ICD) therapy, healthcare costs and clinic presentations were also assessed.607 articles were identified and refined to 10 studies with a total of 6579 patients. Implementation of RM was not uniform with substantial variation in methodology across the studies. There was no reduction in mortality or hospital readmission rates, while ICD therapy findings were inconsistent. There was a reduction in patient-associated healthcare costs and reduction in healthcare presentations.

CONCLUSION

RM for patients with CIEDs and HF was not uniformly performed. As currently implemented, RM does not provide a benefit on overall mortality or the key metric of HF readmission. It does provide a reduction in healthcare costs and healthcare presentations.

PROSPERO REGISTRATION NUMBER

CRD42019129270.

Smartphone-based cardiac implantable electronic device remote monitoring: improved compliance and connectivity

Aims

Remote monitoring (RM) is the standard of care for follow up of patients with cardiac implantable electronic devices. The aim of this study was to compare smartphone-based RM (SM-RM) using patient applications (myMerlinPulse™ app) with traditional bedside monitor RM (BM-RM).

Methods and results

The retrospective study included de-identified US patients who received either SM-RM or BM-RM capable of implantable cardioverter defibrillators or cardiac resynchronization therapy defibrillators (Abbott, USA). Patients in SM-RM and BM-RM groups were propensity-score matched on age and gender, device type, implant year, and month. Compliance with RM was quantified as the proportion of patients enrolling in the RM system (Merlin.net™) and transmitting data at least once. Connectivity was measured by the median number of days between consecutive transmissions per patient. Of the initial 9714 patients with SM-RM and 26 679 patients with BM-RM, 9397 patients from each group were matched. Remote monitoring compliance was higher in SM-RM; significantly more patients with SM-RM were enrolled in RM compared with BM-RM (94.4 vs. 85.0%, P < 0.001), similar number of patients in the SM-RM group paired their device (95.1 vs. 95.0%, P = 0.77), but more SM-RM patients transmitted at least once (98.1 vs. 94.3%, P < 0.001). Connectivity was significantly higher in the SM-RM, with patients transmitting data every 1.2 (1.1, 1.7) vs. every 1.7 (1.5, 2.0) days with BM-RM (P < 0.001) and remained better over time. Significantly more SM-RM patients utilized patient-initiated transmissions compared with BM-RM (55.6 vs. 28.1%, P < 0.001).

Conclusion

In this large real-world study, patients with SM-RM demonstrated improved compliance and connectivity compared with BM-RM.

Clinical utility of remote monitoring for patients with cardiac implantable electrical devices

Background

Remote monitoring of cardiac implantable electronic devices (CIEDs) offers practical and clinical benefits juxtaposed against burdens associated with high transmission volume.

Methods

We identified patients receiving de novo pacemakers (PPMs) and implantable cardiac defibrillators (ICDs) at a single academic medical center (January 2016–December 2019) with at least 1 year of follow-up device care. We collected patient- and device-specific data at time of implant and assessed all remote and in-person interrogation reports for clinically actionable findings based on pre-specified criteria.

Results

Among 963 patients (mean age of 71 (± 14) years, 37% female), 655 (68%) underwent PPM, and 308 (32%) underwent ICD implant. Median follow-up was 874 (627–1221) days, during which time patients underwent a mean of 13 (10–16) total interrogations; remote interrogations comprised 53% of all device evaluations; and of these, 96% were scheduled transmissions. Overall, 22% of all CIED interrogations yielded significant findings with a slightly higher rate in the PPM than in the ICD group (23% vs. 20%, p < 0.01). Only 8% of remote interrogations produced clinically meaningful results, compared with 38% of in-person ones. In adjusted models, routine, remote transmissions were least likely to be useful for both PPM and ICD patients (p < 0.001), whereas time from initial device implant was inversely associated with probability of obtaining a useful interrogation (p < 0.001).

Conclusions

Routine remote interrogations constitute the majority of device evaluations performed, but uncommonly identify clinically actionable findings.

ESC Working Group on e-Cardiology Position Paper: accuracy and reliability of electrocardiogram monitoring in the detection of atrial fibrillation in cryptogenic stroke patients : In collaboration with the Council on Stroke, the European Heart Rhythm Association, and the Digital Health Committee

The role of subclinical atrial fibrillation as a cause of cryptogenic stroke is unambiguously established. Long-term electrocardiogram (ECG) monitoring remains the sole method for determining its presence following a negative initial workup. This position paper of the European Society of Cardiology Working Group on e-Cardiology first presents the definition, epidemiology, and clinical impact of cryptogenic ischaemic stroke, as well as its aetiopathogenic association with occult atrial fibrillation. Then, classification methods for ischaemic stroke will be discussed, along with their value in providing meaningful guidance for further diagnostic efforts, given disappointing findings of studies based on the embolic stroke of unknown significance construct. Patient selection criteria for long-term ECG monitoring, crucial for determining pre-test probability of subclinical atrial fibrillation, will also be discussed. Subsequently, the two major classes of long-term ECG monitoring tools (non-invasive and invasive) will be presented, with a discussion of each method's pitfalls and related algorithms to improve diagnostic yield and accuracy. Although novel mobile health (mHealth) devices, including smartphones and smartwatches, have dramatically increased atrial fibrillation detection post ischaemic stroke, the latest evidence appears to favour implantable cardiac monitors as the modality of choice; however, the answer to whether they should constitute the initial diagnostic choice for all cryptogenic stroke patients remains elusive. Finally, institutional and organizational issues, such as reimbursement, responsibility for patient management, data ownership, and handling will be briefly touched upon, despite the fact that guidance remains scarce and widespread clinical application and experience are the most likely sources for definite answers.

Factors associated with remote monitoring adherence for cardiovascular implantable electronic devices

BACKGROUND

Professional societies strongly recommend remote monitoring (RM) of all cardiac implantable electronic devices, and higher RM adherence is associated with improved patient outcomes. However, adherence with RM is suboptimal.

OBJECTIVE

The purpose of this study was to better understand factors associated with RM adherence.

METHODS

We linked RM data from the Veterans Affairs National Cardiac Device Surveillance Program to clinical data for patients monitored between October 25, 2018, and October 24, 2020. RM adherence was defined as the percentage of days covered by an RM transmission during the study period. Patients were classified into 3 categories: complete (100% of days covered by an RM transmission), intermediate (above median in patients with <100% adherence), and low (below median in patients with <100% adherence) adherence. We used multivariable logistic regression to examine patient, device, and facility characteristics associated with adherence.

RESULTS

In 52,574 patients, average RM adherence was 71.9%. Only 30.9% (16,224) of patients had complete RM adherence. Black or African American patients had a lower odds of complete RM adherence than white patients (odds ratio 0.88; 95% confidence interval 0.82-0.94), and Hispanic or Latino patients had a lower odds of complete RM adherence (odds ratio 0.79; 95% confidence interval 0.70-0.89) than non-Hispanic or Latino patients. Dementia, depression, and posttraumatic stress disorder were associated with a lower odds of RM adherence.

CONCLUSION

There are significant disparities in RM adherence by race, ethnicity, and neuropsychiatric comorbidities. These findings can inform strategies to improve health equity and ensure that all patients with cardiac implantable electronic devices receive the evidence-based clinical benefits of RM.

Physical Activity in Cardiac Implantable Electronic Device Recipients During the COVID-19 Pandemic

OBJECTIVE

To characterize the physical activity (PA) level in patients with a cardiac implantable electronic device (CIED) during the coronavirus disease 2019 (COVID-19) pandemic and compare PA level during the pandemic in 2020 with the year 2019.

METHODS

We performed a retrospective analysis of PA activity in individuals implanted with a CIED enrolled in the BIOTRONIK CERTITUDE Registry. Mean daily and weekly PA from January to August 2020 was compared with 2019.

RESULTS

A total of 21,660 individuals met eligibility criteria, with mean age of 72.6±11.6 years, and 12,411 (57.3)% were males. A significant decline in daily PA was noted following the pandemic declaration in 2020, with a maximum mean reduction of -24.5±36.3 minutes (P<.0001) observed in April 2020 compared with 2019. PA in 2020 increased from April to May (120.6±67.4 to 129.2±70.9 min/d). PA was lower for all months in 2020 compared with 2019. The decrease in PA was observed in all prespecified groups based on age, sex, type of device, and region of the country.

CONCLUSION

After the declaration of the coronavirus disease 2019 pandemic, a significant decline in daily PA was observed in individuals with a CIED. Future investigation to establish the impact of this reduction on short and long-term cardiovascular outcomes is required.

Current status of reimbursement practices for remote monitoring of cardiac implantable electrical devices across Europe

Remote monitoring (RM) of cardiac implantable electrical devices (CIEDs) is currently proposed as a standard of care for CIEDs follow-up, as recommended by major cardiology societies worldwide. By detecting a series of relevant device and patient-related parameters, RM is a valuable option for early detection of CIEDs' technical issues, as well as changes in parameters related to cardio-respiratory functions. Moreover, RM may allow longer spacing between in-office follow-ups and better organization of in-hospital resources. Despite these potential advantages, resulting in improved patient safety, we are still far from a widespread diffusion of RM across Europe. Reimbursement policies across Europe still show an important heterogeneity and have been considered as an important barrier to full implementation of RM as a standard for the follow-up of all the patients with pacemakers, defibrillators, devices for cardiac resynchronization, or implantable loop recorders. Indeed, in many countries, there are still inertia and unresponsiveness to the request for widespread implementation of RM for CIEDs, although an improvement was found in some countries as compared to years ago, related to the provision of some form of reimbursement. As a matter of fact, the COVID-19 pandemic has promoted an increased use of digital health for connecting physicians to patients, even if digital literacy may be a limit for the widespread implementation of telemedicine. CIEDs have the advantage of making possible RM with an already defined organization and reliable systems for data transmissions that can be easily implemented as a standard of care for present and future cardiology practice.

Forensic cardiac device analysis at the Los Angeles County Department of the Coroner: A 20-year experience

Cardiac implantable electronic devices (CIEDs) store information continuously; however, the log of these devices is rarely analyzed in forensic practice. We retrospectively reviewed all cases referred for CIED interrogation by the Los Angeles County Department of Medical Examiner-Coroner between 2001 and 2020. According to the Department's practice, CIED interrogation may be requested for decedents in which details or cause of death are not clear from autopsy and clinical history. The CIED analysis was considered informative for the coroner's investigation either if it detected an arrhythmia or malfunction likely related to decedent's terminal event or if it was essential to determine time of death or identity of decedent. A total of 57 CIEDs were evaluated during the 20-year period. In almost half of cases (26/57: 45.6%), device analysis was informative for coroner's investigation. Arrhythmias likely related to terminal event were commonly detected (21/57: 36.8%). Device malfunction was identified as the likely cause of death in almost 10% of decedents (5/57: 8.8%), including three cases of battery depletion (3/57: 5.3%), one case of misclassification of ventricular tachycardia as supraventricular tachycardia with failure to deliver therapy (1/57: 1.7%), and one case of lead failure due to a broken pacing wire (1/57: 1.7%). Not infrequently, CIED interrogation was essential for determination of time of death (9/57: 15.8%), and there was one case (1/57: 1.7%) in which interrogation was essential for identifying the decedent. Our study shows that postmortem CIED interrogation can provide unique information regarding mechanism and time of death, and decedent's identity.

Wearables in Sports Cardiology

The expanding array and adoption of consumer health wearables is creating a new dynamic to the patient-health-care provider relationship. Providers are increasingly tasked with integrating the biometric data collected from their patients into clinical care. Further, a growing body of evidence is supporting the provider-driven utility of wearables in the screening, diagnosis, and monitoring of cardiovascular disease. Here we highlight existing and emerging wearable health technologies and the potential applications for use within sports cardiology. We additionally highlight how wearables can advance the remote cardiovascular care of patients within the context of the COVID-19 pandemic. Finally, despite these promising advances, we acknowledge some of the significant challenges that remain before wearables can be routinely incorporated into clinical care.

Cardiac Society of Australia and New Zealand (CSANZ) Position Statement on the Follow-Up of Cardiovascular Implantable Electronic Devices 2022

Recognising the need for a national approach for the recommended best practice for the follow-up of implanted cardiac rhythm devices to ensure patient safety, this document has been produced by the Cardiac Society of Australia and New Zealand (CSANZ). It draws on accepted practice standards and guidelines of international electrophysiology bodies. It lays out methodology, frequency, and content of follow-up, including remote monitoring; personnel, including physician, allied health, nursing and industry; paediatric and adult congenital heart patients; and special considerations including magnetic resonance imaging scanning, perioperative management, and hazard alerts.

The Gallant™ system heart rhythm management device: making a connection

Implantable cardiac defibrillators have revolutionized the way we prevent sudden cardiac death via arrhythmias. The addition of cardiac resynchronization pacing to defibrillators has broadened that treatment to include patients with heart failure and reduced ejection fraction. As with all technology, new devices and platforms expand the capabilities and interface with patients across the world. This review discusses the evolution from the initial modalities and methods of communication of implantable devices up to the most recent advances in implantable defibrillators and their integration into patient lives and clinical practice. This review is focused on the integration of Bluetooth communication into modern healthcare with the Gallant™ family of devices, the first branded launch by Abbott Laboratories.

Effects of COVID-19 lockdown on arrhythmias in patients with implantable cardioverter-defibrillators in southern Italy

BACKGROUND

The effects of lockdown on non-COVID patients are varied and unexpected. The aim is to evaluate the burden of cardiac arrhythmias during a lockdown period because of COVID-19 pandemics in a population implanted with cardiac defibrillators and followed by remote monitoring.

METHODS

In this retrospective, multicentre cohort study, we included 574 remotely monitored implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy-defibrillator (CRT-D) recipients implanted before January 1, 2019, at seven hospitals in the Campania region, comparing the burden of arrhythmias occurred during the lockdown period because of COVID-19 epidemics (from March 9 to May 1, 2020) with the arrhythmias burden of the corresponding period in 2019 (reference period). Data collection was performed through remote monitoring.

RESULTS

During the lockdown period, we observed ventricular tachyarrhythmias (ventricular tachycardia or fibrillation) in 25 (4.8%) patients while in seasonal reference period we documented ventricular tachyarrhythmias in 12 (2.3%) patients; the comparison between the periods is statistically significant (P < .04). Atrial arrhythmias were detected in 38 (8.2%) subjects during the lockdown period and in 24 (5.2%) during the reference period (P < .004).

CONCLUSION

In seven hospitals in the Campania region, during the pandemic lockdown period, we observed a higher burden of arrhythmic events in ICD/CRT-D patients through device remote monitoring.

A mobile app for improving the compliance with remote management of patients with cardiac implantable devices: a multicenter evaluation in clinical practice

BACKGROUND

The remote device management (RM) is recommended for patients with cardiac implantable electronic devices (CIEDs). RM underutilization is frequently driven by the lack of correct system activation. The MyLATITUDE Patient App (Boston Scientific) has been developed to encourage patient compliance with RM by providing information on communicator setup, troubleshooting, and connection status of the communicator.

METHODS

At 14 centers, patients with CIEDs were invited to download and install the App on a mobile device. After 3 months, patients were asked to complete an ad hoc questionnaire to evaluate their experience.

RESULTS

The App was proposed to 242 consecutive patients: 81 before RM activation, and 161 during follow-up. The App was successfully installed by 177 (73%) patients. The time required for activation of the communicator and the need for additional support were similar between patients who followed the indications provided by the App and those who underwent standard in-clinic training. During follow-up, notifications of lack of connection were received by 20 (11%) patients and missed transmission by 22 (12%). The median time from notification to resolution was 2 days. After 3 months, 175 (99%) communicators of the 177 patients who installed the App were in "Monitored" status versus 113 (94%) of 120 patients without the App installed (p=0.033). The use of the app made 84% of patients feel reassured.

CONCLUSIONS

The App was well accepted by CIED patients and offered support for communicator management and installation. Its use enabled patients to remain connected with greater continuity during follow-up.

Wearables, telemedicine, and artificial intelligence in arrhythmias and heart failure: Proceedings of the European Society of Cardiology: Cardiovascular Round Table

Digital technology is now an integral part of medicine. Tools for detecting, screening, diagnosis, and monitoring health-related parameters have improved patient care and enabled individuals to identify issues leading to better management of their own health. Wearable technologies have integrated sensors and can measure physical activity, heart rate and rhythm, and glucose and electrolytes. For individuals at risk, wearables or other devices may be useful for early detection of atrial fibrillation or sub-clinical states of cardiovascular disease, disease management of cardiovascular diseases such as hypertension and heart failure, and lifestyle modification. Health data are available from a multitude of sources, namely clinical, laboratory and imaging data, genetic profiles, wearables, implantable devices, patient-generated measurements, and social and environmental data. Artificial intelligence is needed to efficiently extract value from this constantly increasing volume and variety of data and to help in its interpretation. Indeed, it is not the acquisition of digital information, but rather the smart handling and analysis that is challenging. There are multiple stakeholder groups involved in the development and effective implementation of digital tools. While the needs of these groups may vary, they also have many commonalities, including the following: a desire for data privacy and security; the need for understandable, trustworthy, and transparent systems; standardized processes for regulatory and reimbursement assessments; and better ways of rapidly assessing value.

Realtime Remote Programming in Patients Carrying Cardiac Implantable Electronic Devices Requiring Emergent Reprogramming

To protect cardiac implantable electronic device (CIED) patients with arrhythmia or possible device malfunction, it is important for health care professionals to provide emergent device evaluation and reprogramming. This case series illustrated the clinical application of realtime remote programming in CIED patients requiring emergent in-person evaluation and reprogramming (ChiCTR2100046883 chictr.org). All remote sessions were performed safely and efficiently by remote electrophysiologists without being in the physical presence of a patient. The implementation of realtime remote programming not only largely reduces the response time to urgent events but also greatly helps to minimize personnel exposure to COVID-19 infection.

Cloud Follow-Up in Patients With Cardiovascular Implantable Electronic Devices: A Single-Region Study in China

Background

Due to seriously imbalanced distribution of follow-up clinics in China, routine in-office visits are erratically attended by many cardiovascular implantable electronic device (CIED) patients. Meanwhile, remote monitoring is significantly underutilized. Novel tools to address the current predicament of routine in-office visits in China is urgently needed.

Objectives

To assess the reliability and feasibility of cloud follow-up in CIED patients.

Methods

A total of 325 CIED patients from 13 hospitals in Sichuan Province, China, were enrolled. Information on patients’ sociodemographic and basic clinical characteristics was collected. All devices were tested and programmed with 5G-cloud follow-up platform in a real-time manner. All patients were surveyed about their acceptance of and preferences regarding cloud follow-up compared to routine in-office visits.

Results

Compliance with routine in-office visits in this region was 60.6%. None of the patients were enrolled in remote monitoring services. Clinically important predictors of non-compliance were elderly age (≥75 years old), odds ratio (OR) 2.392 (95% confidence interval, 1.111–5.150); needing notification from a follow-up clinic, OR 2.518 (1.179–5.376); and being beyond 15 months post-implantation, OR 5.440 (2.563–11.543). All cloud follow-up sessions were performed safely and efficiently, without any adverse events. 292 (89.8%) patients preferred cloud follow-up for future device management.

Conclusion

Compliance with routine in-office visits in this region has much room for improvement. Cloud follow-up addresses the limitations of an imbalanced distribution of follow-up clinics and geographic barriers for in-office CIED evaluation. Thus, cloud follow-up provides a potential solution to the current predicament of routine in-office visits in China.

Decongestive treatment adjustments in heart failure patients remotely monitored with a multiparametric implantable defibrillators algorithm

AIMS

HeartLogic algorithm combines data from multiple implantable defibrillators (ICD)-based sensors to predict impending heart failure (HF) decompensation. A treatment protocol to manage algorithm alerts is not yet known, although decongestive treatment adjustments are the most frequent alert-triggered actions reported in clinical practice. We describe the implementation of HeartLogic for remote monitoring of HF patients, and we evaluate the approach to diuretic dosing and timing of the intervention in patients with device alerts.

METHODS

The algorithm was activated in 229 ICD patients at eight centers. The median follow-up was 17 months (25th-75th percentile: 11-24). Remote data reviews and patient phone contacts were undertaken at the time of HeartLogic alerts, to assess the patient's status and to prevent HF worsening. We analyzed alert-triggered augmented HF treatments, consisting of isolated increases in diuretics dosage.

RESULTS

We reported 242 alerts (0.8 alerts/patient-year) in 123 patients, 137 (56%) alerts triggered clinical actions to treat HF. The HeartLogic index decreased after the 56 actions consisting of diuretics increase. Specifically, alerts resolved more quickly when the increases in dosing of diuretics were early rather than late: 28 days versus 62 days, p < .001. The need of hospitalization for further treatments to resolve the alert condition was associated with higher HeartLogic index values on the day of the diuretics increase (odds ratio: 1.11, 95% CI: 1.02-1.20, p = .013) and with late interventions (odds ratio: 5.11, 95% CI: 1.09-24.48, p = .041). No complications were reported after drug adjustments.

CONCLUSIONS

Decongestive treatment adjustments triggered by alerts seem safe and effective. The early use of decongestive treatment and the use of high doses of diuretics seem to be associated with more favorable outcomes.

Pro-Con Debate: Are Patients With a Cardiovascular Implantable Electronic Device Suitable to Receive Care in a Free-Standing Ambulatory Surgery Center?

Migration of surgical and other procedures that require anesthesia care from a hospital to a free-standing ambulatory surgery center (ASC) continues to grow. Patients with cardiac implantable electronic devices (CIED) might benefit from receiving their care in a free-standing ASC setting. However, these patients have cardiovascular comorbidities that can elevate the risk of major adverse cardiovascular events. CIEDs are also complex devices and perioperative management varies between devices marketed by various manufacturers and require consultation and ancillary services, which may not be available in a free-standing ASC. Thus, perioperative care of these patients can be challenging. Therefore, the suitability of this patient population in a free-standing ASC remains highly controversial. Although applicable advisories exist, considerable discussion continues with surgeons and other proceduralists about the concerns of anesthesiologists. In this Pro-Con commentary article, we discuss the arguments for and against scheduling a patient with a CIED in a free-standing ASC.

Should We Check It? Assessing Interrogation of Cardiac Implantable Electronic Devices in the Emergency Department-The CHECK-ED Study: Implications for Service Planning and Care Delivery

BACKGROUND

Requests from the emergency department (ED) for cardiac implantable electronic device (CIED) checks constitute a large workload for cardiac electrophysiology services. We sought to determine the yield of, and clinical characteristics associated with, clinically relevant (remarkable) issues from ED CIED checks.

METHODS

Consecutive CIED checks from our ED over a 12-month period were studied. A remarkable issue (RI) was defined as arrhythmia relating to the presentation or device/lead issue requiring reprogramming or intervention. The association between the presenting complaint and an RI was assessed using regression analysis. Multivariable regression model was used to identify pre-specified patient-level characteristics that were predictive of a RI.

RESULTS

A RI was found in 28% (n=98) of 354 ED CIED checks for 306 patients (76±16 yrs 59% male). Most patients had no RI (n=224 73%). One third of checks occurred after-hours and these had a higher yield of RIs than those during routine clinic hours (35% vs 23% p=0.018). Presenting with a perceived ICD shock was predictive of a RI (odds ratio [OR] 6.0 95% CI=1.8-20.0). Syncope/presyncope was five-fold less likely to be predictive of a RI (OR 0.19 95% CI=0.13-0.28) despite being the most common indication for CIED check (51% n=180 checks). Only history of AF was predictive of RI while advancing age was predictive of not finding a RI.

CONCLUSION

Almost three-quarters of ED CIED checks did not yield any RI. Patient-reported ICD shock and history of AF were predictive of RI, while syncope/presyncope was not. New models of care especially during after-hours, may help to reduce the burden on cardiac electrophysiology services and health care costs.

Heart failure clinical trial enrollment at a rural satellite hospital

INTRODUCTION

Heart failure is a clinical condition that notably affects the lives of patients in rural areas. Partnering of a rural satellite hospital with an urban academic medical center may provide geographically underrepresented populations with heart failure an opportunity to access to controlled clinical trials (CCTs).

METHODS

We report our experience in screening, consenting and enrolling subjects at the VCU Health Community Memorial Hospital (VCU-CMH) in rural South Hill, Virginia, that is part of the larger VCU Health network, with the lead institution being VCU Health Medical College of Virginia Hospitals (VCU-MCV), Richmond, VA. Subjects were enrolled in a clinical trial sponsored by the National Institutes of Health and assigned to treatment with an anti-inflammatory drug for heart failure or placebo. We used the electronic health record and remote guidance and oversight from the VCU-MCV resources using a close-loop communication network to work with local resources at the facility to perform screening, consenting and enrollment.

RESULTS

One hundred subjects with recently decompensated heart failure were screened between January 2019 and August 2021, of these 61 are enrolled to date: 52 (85%) at VCU-MCV and 9 (15%) at VCU-CMH. Of the subjects enrolled at VCU-CMH, 33% were female, 77% Black, with a mean age of 52 ± 10 years.

CONCLUSION

The use of a combination of virtual/remote monitoring and guidance of local resources in this trial provides an opportunity for decentralization and access of CCTs for potential novel treatment of heart failure to underrepresented individuals from rural areas.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03797001.

Assessing the safety of interrogating cardiac-implantable electronic devices with brand-mismatched remote interrogators: a pilot study

Objective

Remote cardiac implantable electronic device (CIED) interrogators, originally developed for home use, have been proven to be efficacious in clinical settings, especially emergency departments. Concern exists that attempting to interrogate a CIED with the remote interrogator of a different brand, i.e., a brand-mismatched interrogator, may cause device malfunction. The aim of this study was to determine if intentionally attempting to interrogate a CIED with a brand-mismatched remote interrogator resulted in device malfunction.

Methods

A total of 75 ex vivo CIEDs manufactured by various companies underwent attempted interrogation by a brand-mismatched remote interrogator. CIED settings were compared before and after attempted mismatch interrogation. A total of 30 in vivo CIEDs were then randomized for an attempted 2-minute mismatched remote interrogation by one of the two possible mismatched remote interrogators. CIED settings were compared before and after attempted mismatch interrogation.

Results

Of 150 ex vivo brand-mismatched interrogations, no device setting changes or malfunctions occurred; no remote interrogators connected to a mismatched CIED, and no devices were turned off. In the 30 patients undergoing brand-mismatched interrogations, the mean (standard deviation) age was 71.6 ( ± 14.7) years, 16 (53%) were male, with 24 pacemakers (80%), four pacemaker/implantable cardioverter defibrillators (13%), and two implantable cardioverter defibrillators (7%). Of the 30 mismatched interrogations performed, no device setting changes or malfunctions occurred; no remote interrogators connected to a mismatched CIED, and no devices turned off.

Conclusion

In a total 180 attempted brand-mismatched CIED interrogations, no CIED malfunctions occurred. This suggests that the use of remote CIED interrogators when device manufacturer is unknown is unlikely to result in adverse CIED-related events.

Remote Programming of Cardiac Implantable Electronic Devices: A Novel Approach to Program Cardiac Devices for Magnetic Resonance Imaging

BACKGROUND

Magnetic Resonance imaging (MRI) in patients with MRI-conditional cardiovascular implantable electronic devices (CIED) remain a logistical issue for device programming during the scan. In current practice, a trained person needs to be present on-site to program CIED for MRI scan. This can cause delay in patient care, rescheduling of tests and increase healthcare costs. A novel remote programming (RP) strategy can be utilized to reprogram the CIED remotely. We sought to explore the feasibility and safety of RP of CIEDs in patients undergoing MRI scan.

METHODS

We implemented the Medtronic CIED RP software at our institution after ensuring HIPAA compliance. The MRI technician started the session by contacting an off-site remote operator and placing a programmer wand from the 2090 Medtronic programmer over the CIED. The remote operator logged into a remote access software and provided a unique access code to the MRI technician. After entering the access code into the programmer, the remote operator was able to program the device as needed. We conducted a periodic audit of the first 209 patients who underwent RP of CIEDs for MRI. Outcomes analyzed were successful completion of RP sessions and time saved per scan.

RESULTS

Of the 209 MRI scans, 51 scans were performed urgently. There were no connectivity and programming problems or need for MRI rescheduling. In-person reprogramming was not required for any patient. All scans were completed safely in a timely manner, and there were no reports of CIED malfunction. Time saved per scan was estimated to be 28 +/-10 minutes.

CONCLUSIONS

Remote programming of CIEDs for MRI scans is a safe and effective strategy. This article is protected by copyright. All rights reserved.