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

Updates in medical professional liability: a primer for electrophysiologists

Medical professional liability (MPL), traditionally known as medical malpractice, affects most electrophysiologists some point during their career, either directly through personal experience or indirectly by the experiences of colleagues. Despite this, most physicians struggle to accurately describe MPL in the context of clinical practice. Providers know little about the outcomes of malpractice claims as reporting of settled or litigated MPL cases is sparse in the medical literature. In the USA, individual patients can file a malpractice claim in a tort-based system, whereas in other parts of the world, no-fault malpractice systems are increasingly prevalent. Tort reform remains a topic of much debate as the economic costs of malpractice contribute to the ever-expanding costs of health care in the USA. This review provides a framework to define MPL, describes the tort and no-fault systems of malpractice, and details the economic impacts of MPL on health care and the practice of cardiology in the USA. Current policy trends towards MPL including tort reform are reviewed, and MPL as it relates to the practice of cardiac electrophysiology is detailed.

An interactive assistant for patients with cardiac implantable electronic devices: A study protocol of the LUCY trial

Patients with chronic heart failure (CHF) and reduced left ventricle ejection fraction benefit from cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator (ICD). However, increasing numbers of patient with CRT and ICD devices produce overload of cardiology centers where patients are admitted to ambulatory visits. This study aims to find multivariate model predicting the requirement for ambulatory follow-up of cardiac implantable electronic devices (CIEDs).The LUCY study is an observational, cohort, prospective, 2-stage trial. As equal number of patients (300) will be included in the first and the second part of the study, finally, 600 patients will be included in the study. The inclusion criteria will be: age between 18 and 90 years, CHF (New York Heart Association classes I-III) and implanted ICD or CRT at least 30 days before study inclusion. The exclusion criteria will be dementia and other conditions impeding cooperation during the study. All patients included in the study will undergo standard ambulatory visit. Primary endpoint will be defined as any ambulatory visit qualified as necessary due to patient's condition or device malfunction diagnose by the cardiologist: any change in pharmacotherapy related to patient's clinical status assessed during the visit, any change in tachyarrythmia counter or discriminator status, any change in tachyarrythmia threshold, presence of ventricular undersensing or oversensing, presence of atrial or ventricular ineffective pacing, or device's pocket infection. Secondary endpoint will be defined as any ambulatory visit qualified as necessary due to the alarm identified via Medtronic CareLink Express (MCLE): sustained or treated ventricular tachyarrythmia, any not previously diagnosed supraventricular tachyarrythmia, or elective replacement indicator.Our study is the first attempt of implementation of the machine learning and elements artificial intelligence in health care optimization of patients with CIED. The LUCY will be an open product, available for additional testing and improvement with supplementary functionalities: quality of life assessment, teleconsultation, video-streaming, automated imagine recognizing.

Success of pacemaker remote monitoring using app-based technology: Does patient age matter?

BACKGROUND

Remote monitoring (RM) improves patient outcomes. App-based RM is a novel technology that enables transmission of implantable device data using smart devices. Limited data exist on the impact of age and sex on the use of app-based RM.

OBJECTIVE

To examine the impact of age and sex on the proportion of pacemaker patients who activated app-based RM, time from order to activation, and patient follow-up transmission adherence per guidelines.

METHODS

A retrospective analysis was performed using deidentified data from U.S. pacemaker patients enrolled in the Medtronic CareLink database with an app-based monitor (MyCareLink Smart™). Activation was defined as first RM transmission and was considered early if it occurred < 90 days from order. Adherence analysis was limited to patients with ≥12 months' follow-up from activation and excluded transmissions < 90 days from activation.

RESULTS

Of 48,016 patients assigned app-based RM, 40,511 (84.4%) activated their device; of these, 31,640 (65.9%) activated their device early. Among 14,232 activated patients (with 12 months' follow-up), 12,743 (89.5%) were considered adherent to guidelines by transmitting at least once more within 3-12 months following their activation transmission. While there were statistical differences in activation, early activation, and adherence among age and sex groups due to large sample sizes, the differences were not clinically significant and the majority of older patients were able to successfully use app-based RM.

CONCLUSIONS

Most patients in this large and first-of-its kind reported cohort used smart devices to successfully activate app-based RM technology and remained adherent per guidelines irrespective of age or sex.

Remote monitoring of implantable cardiac devices: current state and future directions

PURPOSE OF REVIEW

Recent evidence has demonstrated substantial benefits associated with remote monitoring of cardiac implantable electronic devices (CIEDs), and treatment guidelines have endorsed the use of remote monitoring. Familiarity with the features of remote monitoring systems and the data supporting its use are vital for physicians' care for patients with CEIDs.

RECENT FINDINGS

Remote monitoring remains underutilized, but its use is expanding including in new practice settings including emergency departments. Patient experience and outcomes are positive, with earlier detection of clinical events such as atrial fibrillation, reductions in inappropriate implantable cardioverter-defibrillator (ICD) shocks and potentially a decrease in mortality with frequent remote monitoring utilizaiton. Rates of hospitalization are reduced among remote monitoring users, and the replacement of outpatient follow-up visits with remote monitoring transmissions has been shown to be well tolerated. In addition, health resource utilization is lower and remote monitoring has been associated with considerable cost savings. A dose relationship exists between use of remote monitoring and patient outcomes, and those with early and high transmission rates have superior outcomes.

SUMMARY

Remote monitoring provides clinicians with the ability to provide comprehensive follow-up care for patients with CIEDs. Patient outcomes are improved, and resource utilization is decreased with appropriate use of remote monitoring. Future efforts must focus on improving the utilization and efficiency of remote monitoring.

A single center experience on the clinical utility evaluation of an insertable cardiac monitor

BACKGROUND

The evaluation of insertable cardiac monitor (ICM) has been largely on the device performance and safety with only limited studies on the clinical utility. The aim of this study was to evaluate the clinical utility of ICM in patients with a variety of clinical presentations.

METHODS

A single-center retrospective study on the clinical utility, as measured by both expected and unexpected clinical useful ICM findings and the initiation of therapeutic interventions, was conducted.

RESULTS

Ninety-five consecutive patients (median age 68 years) received ICM Reveal LINQ™ for clinical indications of unexplained syncope (53), cryptogenic stroke (19), unexplained infrequent palpitations (14) and AF management (9). During a median follow-up of 414 days, the causes for unexplained syncope were arrhythmia-related (11.3%), arrhythmia-unrelated (32%) and undetermined (56.6%). Atrial fibrillation in patients with cryptogenic stroke was detected in 31.6% (6/19). The clinical utility occurrence was 48.4% with the expected and incidental (unexpected) clinical utility of 41% and 7.4% patients respectively. Of these, therapeutic interventions based on ICM diagnoses were initiated in 18.9% (18/95) of patients.

CONCLUSIONS

ICM (Reveal LINQ™) offers substantial expected and unexpected clinical utility in patients with a variety of clinical presentations. The causes of nearly one third of patients receiving ICM for unexplained syncope were unrelated to cardiac arrhythmia. Nearly one fifth of patients with newly diagnosed arrhythmia from ICM received therapeutic interventions.

Does the CHA2DS2-VASc score reliably predict atrial arrhythmias? Analysis of a nationwide database of remote monitoring data transmitted daily from cardiac implantable electronic devices

BACKGROUND

CHA2DS2-VASc is a validated score for predicting stroke in patients with atrial fibrillation (AF).

OBJECTIVE

The purpose of this study was to assess whether the CHA2DS2-VASc score can predict new-onset AF in a cohort of patients with a cardiac implantable electronic device (CIED) followed with remote monitoring.

METHODS

Using the database of the Home Monitoring Expert Alliance project, we selected 2410 patients with no documented AF who had received a CIED with diagnostics on atrial high rate episodes (AHREs). The primary endpoint was time to first day with cumulative AHRE burden ≥15 minutes, 5 hours, 24 hours, and ≥7 consecutive days.

RESULTS

During a median duration of 24.1(11.5-42.9) months, the incidence of AHRE increased with increasing CHA2DS2-VASc. At 6 years, occurrence of ≥15-minute AHRE was 80.2% (CHA2DS2-VASc ≤1) vs 93.7% (CHA2DS2-VASc ≥5), whereas ≥5-hour AHRE incidence was 68.4% (CHA2DS2-VASc ≤1) vs 92.5% (CHA2DS2-VASc ≥5). Occurrence of ≥24-hour and ≥7-day AHREs also increased with increasing CHA2DS2-VASc: 9.1% and 3.9% (CHA2DS2-VASc ≤1) vs 40.4% and 28.7% (CHA2DS2-VASc ≥5), respectively. Adjusted hazard ratio for unitary CHA2DS2-VASc increase ranged from 1.09 (confidence interval 1.04-1.14; P <.001) with AHRE burden ≥15 minutes to 1.26 (confidence interval 1.11-1.42; P <.001) with AHRE burden ≥7 days. At receiver operating curve analysis, CHA2DS2-VASc ≥2 was estimated to predict persistent forms of AHREs with 95.8% sensitivity but 11.7% specificity at 3 years. CHA2DS2-VASc ≥5 had 77.0% specificity but 34.6% sensitivity.

CONCLUSION

In a CIED population with no previous diagnosis of clinical AF, AHRE incidence increased with increasing CHA2DS2-VASc score. The association was stronger with longer AHREs, but the accuracy of CHA2DS2-VASc as AHRE predictor was moderate.

INvestigation on Routine Follow-up in CONgestive HearT FAilure Patients with Remotely Monitored Implanted Cardioverter Defibrillators SysTems (InContact)

Background

In heart failure (HF) patients with implantable cardioverter defibrillators (ICD) or cardiac resynchronisation therapy defibrillators (CRT-D), remote monitoring has been shown to result in at least non-inferior outcomes relative to in-clinic visits. We aimed to provide further evidence for this effect, and to assess whether adding telephone follow-ups to remote follow-ups influenced outcomes.

Methods

InContact was a prospective, randomised, multicentre study. Subjects receiving quarterly automated follow-up only (telemetry group) were compared to those receiving personal physician contact. Personal contact patients were further divided into those receiving automated follow-up plus a telephone call (remote+phone subgroup) or in-clinic visits only.

Results

Two hundred and ten patients underwent randomisation (telemetry n = 102; personal contact n = 108 [remote+phone: n = 53; visit: n = 55]). Baseline characteristics were comparable between groups and subgroups. Over 12 months, 34.8% of patients experienced deterioration of their Packer Clinical Composite Response, with no significant difference between the telemetry group and personal care (p > 0.999), remote+phone (p = 0.937) or visit (p = 0.940) patients; predefined non-inferiority criteria were met. Mortality rates (5.2% overall) were comparable between groups and subgroups (p = 0.832/p = 0.645), as were HF-hospitalisation rates (11.0% overall; p = 0.605/p = 0.851). The proportion of patients requiring ≥1 unscheduled follow-up was nominally higher in telemetry and remote+phone groups (42.2 and 45.3%) compared to the visit group (29.1%). Overall, ≥ 1 ICD therapy was delivered to 15.2% of patients.

Conclusion

In HF patients with ICDs/CRT-Ds, quarterly remote follow-up only over 12 months was non-inferior to regular personal contact. Addition of quarterly telephone follow-ups to remote monitoring does not appear to offer any clinical advantage.

Trial registration

clinicaltrials.gov: NCT01200381 (retrospectively registered on September 13th 2010).

Real-Time Fault-Tolerant mHealth System: Comprehensive Review of Healthcare Services, Opens Issues, Challenges and Methodological Aspects

The burden on healthcare services in the world has increased substantially in the past decades. The quality and quantity of care have to increase to meet surging demands, especially among patients with chronic heart diseases. The expansion of information and communication technologies has led to new models for the delivery healthcare services in telemedicine. Therefore, mHealth plays an imperative role in the sustainable delivery of healthcare services in telemedicine. This paper presents a comprehensive review of healthcare service provision. It highlights the open issues and challenges related to the use of the real-time fault-tolerant mHealth system in telemedicine. The methodological aspects of mHealth are examined, and three distinct and successive phases are presented. The first discusses the identification process for establishing a decision matrix based on a crossover of 'time of arrival of patient at the hospital/multi-services' and 'hospitals' within mHealth. The second phase discusses the development of a decision matrix for hospital selection based on the MAHP method. The third phase discusses the validation of the proposed system.

Towards eradication of inappropriate therapies for ICD lead failure by combining comprehensive remote monitoring and lead noise alerts

INTRODUCTION

Recognition of implantable cardioverter defibrillator (ICD) lead malfunction before occurrence of life threatening complications is crucial. We aimed to assess the effectiveness of remote monitoring associated or not with a lead noise alert for early detection of ICD lead failure.

METHODS

From October 2013 to April 2017, a median of 1,224 (578-1,958) ICD patients were remotely monitored with comprehensive analysis of all transmitted materials. ICD lead failure and subsequent device interventions were prospectively collected in patients with (RMLN) and without (RM) a lead noise alert (Abbott Secure Sense™ or Medtronic Lead Integrity Alert™) in their remote monitoring system.

RESULTS

During a follow-up of 4,457 patient years, 64 lead failures were diagnosed. Sixty-one (95%) of the diagnoses were made before any clinical complication occurred. Inappropriate shocks were delivered in only one patient of each group (3%), with an annual rate of 0.04%. All high voltage conductor failures were identified remotely by a dedicated impedance alert in 10 patients. Pace-sense component failures were correctly identified by a dedicated alert in 77% (17 of 22) of the RMLN group versus 25% (8 of 32) of the RM group (P = 0.002). The absence of a lead noise alert was associated with a 16-fold increase in the likelihood of initiating either a shock or ATP (OR: 16.0, 95% CI 1.8-143.3; P = 0.01).

CONCLUSION

ICD remote monitoring with systematic review of all transmitted data is associated with a very low rate of inappropriate shocks related to lead failure. Dedicated noise alerts further reduce inappropriate detection of ventricular arrhythmias.

Economic impact of remote monitoring after implantable defibrillators implantation in heart failure patients: an analysis from the EFFECT study

Aims

Heart failure (HF) patients with implantable cardioverter-defibrillators (ICD) require admissions for disease management and out-patient visits for disease management and assessment of device performance. These admissions place a significant burden on the National Health Service. Remote monitoring (RM) is an effective alternative to frequent hospital visits. The EFFECT study was a multicentre observational investigation aiming to evaluate the clinical effectiveness of RM compared with in-office visits standard management (SM). The present analysis is an economic evaluation of the results of the EFFECT trial.

Methods and results

The present analysis considered the direct consumption of healthcare resources over 12-month follow-up. Standard tariffs were applied to hospitalizations, in-office visits and remote device interrogations. Economic comparisons were also carried out by means of propensity score (PS) analysis to take into account the lack of randomization in the study design. The analysis involved 858 patients with ICD or CRT-D. Of these, 401 (47%) were followed up via an SM approach, while 457 (53%) were assigned to RM. The rate of hospitalizations was 0.27/year in the SM group and 0.16/year in the RM group (risk reduction =0.59; P = 0.0004). In the non-adjusted analysis, the annual cost for each patient was €817 in the SM group and €604 in the RM group (P = 0.014). Propensity score analysis, in which 292 RM patients were matched with 292 SM patients, confirmed the results of the non-adjusted analysis (€872 in the SM group vs. €757 in the RM group; P < 0.0001).

Conclusion

There is a reduction in direct healthcare costs of RM for HF patients with ICDs, particularly CRT-D, compared with standard monitoring.

Clinical Trial Registration

http://clinicaltrials.gov/Identifier, NCT01723865.

Protocol-driven remote monitoring of cardiac resynchronization therapy as part of a heart failure disease management strategy

BACKGROUND

Cardiac resynchronisation therapy (CRT) is an established treatment for heart failure (HF) with reduced ejection fraction. CRT devices are equipped with remote monitoring functions, which are pivotal in the detection of device problems, but may also facilitate disease management. The aim of this study was to provide a comprehensive overview of the clinical interventions taken based on remote monitoring.

METHODS

This is a single centre observational study of consecutive CRT patients (n = 192) participating in protocol-driven remote follow-up. Incoming technical- and disease-related alerts were analysed together with subsequently triggered interventions.

RESULTS

During 34 ± 13 months of follow-up, 1372 alert-containing notifications were received (2.53 per patient-year of follow-up), comprising 1696 unique alerts (3.12 per patient-year of follow-up). In 60%, notifications resulted in a phone contact. Technical alerts constituted 8% of incoming alerts (0.23 per patient-year of follow-up). Rhythm (1.43 per patient-year of follow-up) and bioimpedance alerts (0.98 per patient-year of follow-up) were the most frequent disease-related alerts. Notifications included a rhythm alert in 39%, which triggered referral to the emergency room (4%), outpatient cardiology clinic (36%) or general practitioner (7%), or resulted in medication changes (13%). Sole bioimpedance notifications resulted in a telephone contact in 91%, which triggered outpatient evaluation in 8% versus medication changes in 10%. Clinical outcome was excellent with 97% 1-year survival.

CONCLUSIONS

Remote CRT follow-up resulted in 0.23 technical- versus 2.64 disease-related alerts annually. Rhythm and bioimpedance notifications constituted the majority of incoming notifications which triggered an actual intervention in 22% and 15% of cases, respectively.

Avoiding non-responders to cardiac resynchronization therapy: a practical guide

Over two decades after the introduction of cardiac resynchronization therapy (CRT) into clinical practice, ∼30% of candidates continue to fail to respond to this highly effective treatment of drug-refractory heart failure (HF). Since the causes of this non-response (NR) are multifactorial, it will require multidisciplinary efforts to overcome. Progress has, thus far, been slowed by several factors, ranging from a lack of consensus regarding the definition of NR and technological limitations to the delivery of therapy. We critically review the various endpoints that have been used in landmark clinical trials of CRT, and the variability in response rates that has been observed as a result of these different investigational designs, different sample populations enrolled and different means of therapy delivered, including new means of multisite and left ventricular endocardial simulation. Precise recommendations are offered regarding the optimal device programming, use of telemonitoring and optimization of management of HF. Potentially reversible causes of NR to CRT are reviewed, with emphasis on loss of biventricular stimulation due to competing arrhythmias. The prevention of NR to CRT is essential to improve the overall performance of this treatment and lower its risk-benefit ratio. These objectives require collaborative efforts by the HF team, the electrophysiologists and the cardiac imaging experts.

Remote Monitoring for Chronic Disease Management: Atrial Fibrillation and Heart Failure

This review aims to cover the latest evidence of remote monitoring of cardiac implantable electronic devices for the management of atrial fibrillation and heart failure. Remote monitoring is useful for early detection for device-detected atrial fibrillation, which increases the risk of thromboembolic events. Early anticoagulation based on remote monitoring potentially reduces the risk of stroke, but optimal alert setting needs to be clarified. Multiparameter monitoring with automatic transmission is useful for heart failure management. Improved adherence to remote monitoring and an optimal algorithm for transmitted alerts and their management are warranted in the management of heart failure.

Based Real Time Remote Health Monitoring Systems: A Review on Patients Prioritization and Related "Big Data" Using Body Sensors information and Communication Technology

The growing worldwide population has increased the need for technologies, computerised software algorithms and smart devices that can monitor and assist patients anytime and anywhere and thus enable them to lead independent lives. The real-time remote monitoring of patients is an important issue in telemedicine. In the provision of healthcare services, patient prioritisation poses a significant challenge because of the complex decision-making process it involves when patients are considered 'big data'. To our knowledge, no study has highlighted the link between 'big data' characteristics and real-time remote healthcare monitoring in the patient prioritisation process, as well as the inherent challenges involved. Thus, we present comprehensive insights into the elements of big data characteristics according to the six 'Vs': volume, velocity, variety, veracity, value and variability. Each of these elements is presented and connected to a related part in the study of the connection between patient prioritisation and real-time remote healthcare monitoring systems. Then, we determine the weak points and recommend solutions as potential future work. This study makes the following contributions. (1) The link between big data characteristics and real-time remote healthcare monitoring in the patient prioritisation process is described. (2) The open issues and challenges for big data used in the patient prioritisation process are emphasised. (3) As a recommended solution, decision making using multiple criteria, such as vital signs and chief complaints, is utilised to prioritise the big data of patients with chronic diseases on the basis of the most urgent cases.

Diagnostic power and healthcare resource consumption of a dedicated workflow algorithm designed to manage thoracic impedance alerts in heart failure patients by remote monitoring

PURPOSE

Modern cardiac implantable devices provide diagnostic information on several physiological variables which are associated with worsening heart failure, creating an opportunity for early intervention to prevent heart failure symptoms and hospitalizations. We evaluated diagnostic accuracy and workload of a remote monitoring (RM) workflow algorithm which leverages intrathoracic impedance and other device diagnostics.

METHODS

In our RM workflow a team of expert nurses was responsible for continuity of care, direct relationship with patients and implementation of a specific protocol to evaluate RM alerts and to limit unnecessary resource consumption. Each patient was univocally assigned to a reference nurse. End points were diagnostic accuracy, healthcare utilization, defined as any hospital admission, and actionability of alerts, defined as medication change or other clinical action.

RESULTS

One-hundred twenty-six consecutive patients with implantable cardioverter defibrillator/cardiac resynchronization therapy defibrillator were followed for a median time of 23 months. Out of 2176 remote transmissions, 893 (41%) in 111 patients (88.1%) showed clinically relevant events triggered by 574 alerts [2.2 (95% confidence interval = 2.0-2.4) per patient per year]. Among 309 alerts with intrathoracic impedance crossing, heart failure deterioration was confirmed in 116 (37.5%). Clinical actions followed 76/116 (65.5%) true heart failure alerts and 17/193 (8.8%) false-positive alerts (P < 0.001). In particular, drug therapy change followed 72/116 (62.1%) true heart failure alerts and 15/193 (7.8%) false-positive alerts (P < 0.001). Healthcare utilization occurred in 65.5% true heart failure alerts and in 24.9% false-positive alerts (P < 0.001).

CONCLUSION

A dedicated workflow algorithm results in more focused clinical surveillance leading to prompt detection and treatment of acute heart failure events without wasting healthcare resource.

Addition of Blood Pressure and Weight Transmissions to Standard Remote Monitoring of Implantable Defibrillators and its Association with Mortality and Rehospitalization

BACKGROUND

Among patients with implantable defibrillators (ICD), use of remote patient monitoring (RPM) is associated with lower risk of death and rehospitalization. Standard ICD RPM can be supplemented with weight and blood pressure data. It is not known whether standard RPM plus routine weight and blood pressure transmission (RPM+) is associated with better outcomes.

METHODS AND RESULTS

RPM+ patients (n=4106) were compared with patients who only transmitted standard ICD RPM data (n=14 183). Logistic regression models identified patient, physician, and hospital characteristics associated with RPM+ utilization. Mortality and rehospitalization were examined using landmark analyses at 180 days after ICD implant in Medicare fee-for-service patients. In these analyses, we examined the independent association between RPM+ utilization and times to events up to 3 years after device implantation with Cox regression models. We further examined whether the association between RPM+ and outcomes varied by frequency or type of transmissions. Determinants of RPM+ utilization included impaired ejection fraction, cardiac resynchronization therapy, and institutional practice. The risk of mortality of RPM+ patients was similar to standard ICD RPM patients (hazard ratio, 1.06; 95% confidence interval, 0.94-1.19; P=0.34). RPM+ patients also had similar risks of all-cause hospitalization (subdistribution hazard ratio, 1.03; 95% confidence interval, 0.94-1.14; P=0.52), cardiovascular hospitalization (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.83-1.02; P=0.15), or heart failure hospitalizations (subdistribution hazard ratio, 0.90; 95% confidence interval, 0.78-1.05; P=0.18). RPM+ transmission frequency was not associated with outcomes.

CONCLUSIONS

In patients using standard ICD RPM, the added transmission of weight and blood pressure data was not associated with improved outcomes.

Outcomes of Telemedicine Video-Conferencing Clinic Versus In-Person Clinic Follow-Up for Implantable Cardioverter-Defibrillator Recipients

BACKGROUND

Implantable cardioverter-defibrillator (ICD) recipients require close follow-up that can be difficult for patients who have to travel long distances for clinic follow-up. We aimed to compare clinical outcomes between ICD patients followed-up in a telemedicine video-conferencing clinic (TMVC) and a conventional in-person clinic (CIC). We hypothesized that outcomes of patients followed in the TMVC are noninferior to the CIC.

METHODS AND RESULTS

This retrospective study compares time to first appropriate ICD therapy, time to first inappropriate ICD therapy, time to first shock, and overall survival in patients followed in TMVC compared with CIC between 2001 and 2016. Two hundred and eighty-seven patients were followed in the TMVC group and 236 patients in the CIC. The average age of the TMVC and CIC groups was 64.13±9.38 and 65.23±8.57 years, respectively (P=0.164). There was no difference in the modified Seattle heart failure model score between the 2 groups (-0.12±1.0 versus -0.21±0.99; P=0.287). The Charlson comorbidity index score was higher in the CIC group compared with the TMVC group (7.0 versus 6.0; P=0.01). Mean duration of follow-up was 4.8 years. Adjusted and unadjusted tests of noninferiority found TMVC was not inferior to in-person follow-up for the prespecified outcomes.

CONCLUSIONS

Video-conferencing ICD follow-up for patients in areas where electrophysiology subspecialty care is not available leads to outcomes that are noninferior to CIC follow-up.

Anesthetic Management of Laser Lead Extraction for Cardiovascular Implantable Electronic Devices

Cardiovascular implantable electronic devices (CIEDs) play a significant role in the modern management of cardiovascular disease. CIEDs include implantable pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. These devices improve the quality of life of their recipients and help reduce the incidence of sudden cardiac death. Traditionally, CIEDs have been reliant on the use of transvenous endocardial leads to directly connect with the heart. Over time, these endovascular leads may become endothelialized rendering removal extremely difficult. As the indications for CIEDs expands and with the continuing evolution of these devices, the number of patients requiring explantation for device recall, malfunction, and infection continues to increase. In this manuscript, we review the most common CIEDs, the indications and process of lead removal/device explantation, potential complications associated with the procedure and the anesthetic management of these patients.

[Active cardiac implantable electronic devices: What is possible in ambulatory health care in 2017?]

Telemonitoring (TM) features are implemented in nearly all cardiac implantable electronic devices (CIEDs) that have recently been released to the market. In combination with pacemakers, defibrillators and systems for cardiac resynchronization it is a safe and efficient method for routine technical aftercare of the devices as well as for monitoring heart failure and arrhythmias. Using TM has the potential to optimize patient care with regard to economic, clinical and safety aspects. Despite the good availability of existing data and clear recommendations of the responsible scientific societies, it is often seen as an isolated solution which is not fully integrated into standard care, although it has its own EBM number for implantable cardioverter-defibrillators and cardiac resynchronization therapy systems. The reasons are not only the unsatisfactory reimbursement of costs, different IT structures and the borders between clinics and medical practices, but also acceptance problems of physicians and legal aspects. The compensation of cardiac pacemakers and 'event recorders' is unsolved. TM provides the prospect for optimal and cross-sectoral patient care. Furthermore it has the potential to become the standard method for the care for patients with a CIED.

[Telemetric follow-up of implantable electronic cardiac devices : Optimisation of care in clinical practice]

Remote follow-up of patients with implantable electronic cardiac devices (IECD) is a scientifically well-evaluated and technically mature method. Advantages over conventional follow-up include rapid detection of clinically relevant events (i. e. arrhythmias) and of technical problems. Additionally, telemetric follow-up of IECDs has a high degree of acceptance among both patients as well as health care professionals and carries the potential to reduce health care costs. The implementation of a remote follow-up programme is associated with organisational, infrastructural and legal aspects, which are reviewed.

The Role of Implantable Cardiac Monitors in Atrial Fibrillation Management

Continuous heart rhythm monitoring using implantable cardiac monitors (ICMs) for atrial fibrillation (AF) management is steadily increasing in current clinical practice, even in the absence of an established indication provided by international guidelines. The increasing use of such devices is mainly associated with recent technological improvements including miniaturization, easier implant procedures, and remote monitoring, all of which make this strategy continuously more appealing and promising. For these and other reasons, ICMs have been proven to be a safe and highly effective tool for detecting AF episodes. However, ICMs are not the best option for every patient, as limitations exist. Therefore, it is imperative to weigh the possible benefits against the potential limitations of using these devices when deciding individualized patient care.

[Device-based remote monitoring : Current evidence]

Telemedicine is increasingly used in clinical cardiology. It offers early detection of arrhythmias, technical device follow-up and support of heart failure management. Regarding technical device follow-up, remote monitoring significantly reduces usage of the health care system. Furthermore, remote monitoring is associated with a significantly reduced time from device malfunction to physician's perception of the event. Using remote monitoring, inappropriate ICD (implantable cardioverter defibrillator) shocks can be significantly reduced compared to routine in-office follow-up. In retrospective studies and meta-analyses a prognostic benefit with respect to mortality has been shown. Device-based detection of atrial fibrillation and atrial high rate episodes is feasible. However, clinical relevance is currently studied in prospective randomized clinical trials. Heart failure management based on surrogate parameters has not been shown to significantly improve outcome. However, therapeutic management based on pulmonary artery pressure has been shown to significantly reduce morbidity and mortality. This review offers a comprehensive overview on the role of remote monitoring in heart failure management, technical device follow-up and detection of atrial fibrillation and atrial high rate episodes.

Clinical recognition of pacemaker battery depletion and automatic reprogramming

All contemporary pacemakers undergo automatic reprogramming upon reaching elective replacement indication due to battery depletion. The majority of such reprogramming will result in changes to both pacing mode and pacing rate. The exact software reprogramming varies considerably among pacemaker manufacturers and may even vary among models of the same manufacturer. Accordingly, it is essential for healthcare providers managing pacemaker patients to have a detailed understanding of the automatic reprogramming seen at elective replacement indication as well as their potential physiological and clinical consequences.

Advances and Future Directions in Cardiac Pacemakers: Part 2 of a 2-Part Series

In the second part of this 2-part series on pacemakers, we present recent advances in pacemakers and preview future developments. Cardiac resynchronization therapy (CRT) is a potent treatment for heart failure in the setting of ventricular dyssynchrony. Successful CRT using coronary venous pacing depends on appropriate patient selection, lead implantation, and device programming. Despite optimization of these factors, nonresponse to CRT may occur in one-third of patients, which has led to a search for alternative techniques such as multisite pacing, His bundle pacing, and endocardial left ventricular pacing. A paradigm shift in pacemaker technology has been the development of leadless pacemaker devices, and on the horizon is the development of batteryless devices. Remote monitoring has ushered in an era of greater safety and the ability to respond to device malfunction in a timely fashion, improving outcomes.

Cybersecurity and medical devices: A practical guide for cardiac electrophysiologists

Medical devices increasingly depend on software. While this expands the ability of devices to perform key therapeutic and diagnostic functions, reliance on software inevitably causes exposure to hazards of security vulnerabilities. This article uses a recent high‐profile case example to outline a proactive approach to security awareness that incorporates a scientific, risk‐based analysis of security concerns that supports ongoing discussions with patients about their medical devices.

ANMCO/SIT Consensus Document: telemedicine for cardiovascular emergency networks

Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyse the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education, and legal aspects.

The future of telemedicine for the management of heart failure patients: a Consensus Document of the Italian Association of Hospital Cardiologists (A.N.M.C.O), the Italian Society of Cardiology (S.I.C.) and the Italian Society for Telemedicine and eHealth (Digital S.I.T.)

Telemedicine applied to heart failure patients is a tool for recording and providing remote transmission, storage and interpretation of cardiovascular parameters and/or useful diagnostic images to allow for intensive home monitoring of patients with advanced heart failure, or during the vulnerable post-acute phase, to improve patient's prognosis and quality of life. Recently, several meta-analyses have shown that telemedicine-supported care pathways are not only effective but also economically advantageous. Benefits seem to be substantial, with a 30-35% reduction in mortality and 15-20% decrease in hospitalizations. Patients implanted with cardiac devices can also benefit from an integrated remote clinical management since all modern devices can transmit technical and diagnostic data. However, telemedicine may provide benefits to heart failure patients only as part of a shared and integrated multi-disciplinary and multi-professional 'chronic care model'. Moreover, the future development of remote telemonitoring programs in Italy will require the primary use of products certified as medical devices, validated organizational solutions as well as legislative and administrative adoption of new care methods and the widespread growth of clinical care competence to remotely manage the complexity of chronicity. Through this consensus document, Italian Cardiology reaffirms its willingness to contribute promoting a new phase of qualitative assessment, standardization of processes and testing of telemedicine-based care models in heart failure. By recognizing the relevance of telemedicine for the care of non-hospitalized patients with heart failure, its strategic importance for the design of innovative models of care, and the many challenges and opportunities it raises, ANMCO and SIC through this document report a consensus on the main directions for its widespread and sustainable clinical implementation.

Defibrillators: Selecting the Right Device for the Right Patient

Advances in the field of defibrillation have brought to practice different types of devices that include the transvenous implantable cardioverter-defibrillator (ICD) with or without cardiac resynchronization therapy, the subcutaneous ICD (S-ICD), and the wearable cardioverter-defibrillator. To ensure optimal use of these devices and to achieve best patient outcomes, clinicians need to understand how these devices work, learn the characteristics of patients who qualify them for one type of device versus another, and recognize the remaining gaps in knowledge surrounding these devices. The transvenous ICD has been shown in several randomized clinical trials to improve the survival of patients resuscitated from near-fatal ventricular fibrillation and those with sustained ventricular tachycardia with syncope or systolic heart failure as a result of ischemic or nonischemic cardiomyopathy despite receiving guideline-directed medical therapy. Important gaps in knowledge regarding the transvenous ICD involve the role of the ICD in patient subgroups not included, or not well represented, in clinical trials and the need to refine the selection criteria for the ICD in patients who are indicated for it. S-ICDs were recently introduced into the clinical arena as another option for many patients who have an approved indication for a transvenous ICD. The main advantage of the S-ICD is a lower risk of infection and lead-related complications; however, the S-ICD does not offer bradycardia or antitachycardia pacing. The S-ICD may be ideal for patients with limited vascular access, high infection risk, or some congenital heart diseases. However, more data are needed regarding the efficacy and effectiveness of the S-ICD in comparison to transvenous ICDs, the extent of defibrillation testing required, and the use of the S-ICD with other novel technologies, including leadless pacemakers. Cardiac resynchronization therapy-defibrillators are indicated in patients with a left ventricular ejection fraction ≤35%, QRS width ≥130 ms, and New York Heart Association class II, III, or ambulatory IV symptoms despite treatment with guideline-directed medical therapy. Multiple randomized controlled trials have shown that the cardiac resynchronization therapy-defibrillator improves survival, quality of life, and several echocardiographic measures. One main challenge related to cardiac resynchronization therapy-defibrillators is the 30% nonresponse rate. Many initiatives are underway to address this challenge including improved cardiac resynchronization therapy and imaging technologies and enhanced selection of patients and device programming.

Optimizing Implantable Cardioverter-Defibrillator Remote Monitoring: A Practical Guide

Remote monitoring (RM) receives a Class I: Level of Evidence: A recommendation for the follow-up of patients with implantable cardioverter-defibrillators, positioning the technology as standard of care. RM is often seen and sold as a plug-and-play technology, whereas fundamental differences exist in the philosophy and conception of the 5 main RM systems. The capabilities and limitations of the different RM systems need to be understood and taken into account when the decision is made to remotely manage an individual patient. The purpose of this review is to provide to the cardiologist practical information about RM systems' specificities with respect to the different technical and clinical alerts. Clinically based indications and programming suggestions are provided.

Remote monitoring to Improve long-term prognosis in heart failure patients with implantable cardioverter-defibrillators

INTRODUCTION

Strong evidence exists for the utility of remote monitoring in cardiac implantable electronic devices for early detection of arrhythmias and evaluation of system performance. The application of remote monitoring for the management of chronic disease such as heart failure has been an active area of research. Areas covered: This review aims to cover the latest evidence of remote monitoring of implantable cardiac defibrillators in terms of heart failure prognosis. This article also updates the current technology relating to the method and discusses key factors to be addressed in order to better use the approach. PubMed and internet searches were conducted to acquire most recent data and technology information. Expert commentary: Multiparameter monitoring with automatic transmission is useful for heart failure management. Improved adherence to remote monitoring and an optimal algorithm for transmitted alerts and their management are warranted in the management of heart failure.

The Current State and Future Potential of Pediatric and Congenital Electrophysiology

Pediatric electrophysiologists specialize in the diagnosis and treatment of rhythm abnormalities in pediatric, congenital heart disease, and inherited arrhythmia syndrome patients. The field originated out of the unique knowledge base that rhythm management in young patients required. In the 1970s, pediatric electrophysiology was recognized as a distinct cardiac subspecialty and it has evolved rapidly since that time. Despite the considerable growth in personnel, technology, and complexity that the field has undergone, further opportunities to progress pediatric electrophysiology exist. In this review, we highlight some of the clinical focus of pediatric and adult congenital electrophysiologists to date and identify areas within this specialty where the pediatric and congenital electrophysiology community could come together in order to drive improvements in rhythm management for patients.

Smartphone-Based Electrocardiographic and Cardiac Implantable Electronic Device Monitoring

The field of arrhythmia monitoring is changing rapidly. The rapid advent of technology in combination with marked improvements in cellular communication and an increased desire by patients to be actively engaged in their care has ushered in a new era of clinical care. Today, physicians need to think about their patients outside the traditional in-office setting. Two technologies that embody this changing landscape are smartphone-based electrocardiographic (ECG) monitors and remote monitoring of cardiac implantable electronic devices (CIEDs). Smartphone-based ECG monitors allow the patient to assume a greater stake in their own care. They purchase the monitor, couple it to their smartphone, own it forever, and can capture a representative ECG whenever they want to assess symptoms. The physician needs to accept that this approach is vastly different from the use of standard ambulatory external ECG monitors that have been used for years in clinical practice. A similar paradigm shift is underway with respect to the care of the CIED patient. Remote follow-up was once considered an acceptable alternative to in-office calendar-based follow-up of CIEDs. Today, guidelines recommend remote monitoring to be the preferred method for device follow-up. Remote monitoring is tailor-made for the current evolution to a value-based healthcare system, having been demonstrated to reduce scheduled office visits, hospital admissions, and mortality. It is now time to educate patients and physicians on the value of remote monitoring and to ensure that clinical practices develop the infrastructure needed to enroll, monitor, and manage their patients.

Heart Rhythm Society: expert consensus statements-part 1

One of the most important roles for professional societies in medicine is assembling multiple stakeholders and experts to develop documents that can help guide and define policies and strategies for best medical care. Each year the Heart Rhythm Society (HRS) develops several consensus documents that address critical clinical subjects that have been identified by input from HRS members and HRS committees. Over the past 5 years, HRS has produced documents with multiple professional societies from around the world, and although the topics chosen for exploration center around arrhythmia management, the reviews and recommendations made in the documents are important for clinical cardiologists and generalists who are not arrhythmia specialists. When an internist or other primary care provider identifies a patient who may be having symptoms from an arrhythmia, the referral first is made to the clinical cardiologist and only later, if necessary, does an arrhythmia specialist become involved. These expert consensus statements are developed for specific clinical questions regarding arrhythmia management where there is controversy or uncertainty, often with less data from randomized controlled trials to help guide recommendations, which must then be made by extrapolation of existing data, observational data, and expert opinion. In this 2-part review, the consensus statements developed by the HRS over the past 5 years that pertain to adults are discussed in part 1; part 2 focuses on consensus statements that HRS has developed in conjunction with the Pediatric and Congenital Electrophysiology Society that address arrhythmia issues in children and adults with congenital heart disease.

Significant Discrepancy Between Estimated and Actual Longevity in St. Jude Medical Implantable Cardioverter-Defibrillators

BACKGROUND

Real-time estimated longevity has been reported in pacemakers for several years, and was recently introduced in implantable cardioverter-defibrillators (ICDs).

OBJECTIVE

We sought to evaluate the accuracy of this longevity estimate in St. Jude Medical (SJM) ICDs, especially as the device battery approaches depletion.

METHODS

Among patients with SJM ICDs who underwent generator replacements due to reaching elective replacement indicator (ERI) at our institution, we identified those with devices that provided longevity estimates and reviewed their device interrogations in the 18 months prior to ERI. Significant discrepancy was defined as a difference of more than 12 months between estimated and actual longevity at any point during this period.

RESULTS

Forty-six patients with Current/Promote devices formed the study group (40 cardiac resynchronization therapy [CRT] and 6 single/dual chamber). Of these, 34 (74%) had significant discrepancy between estimated and actual longevity (28 CRT and all single/dual). Longevity was significantly overestimated by the device algorithm (mean maximum discrepancy of 18.8 months), more in single/dual than CRT devices (30.5 vs. 17.1 months). Marked discrepancy was seen at voltages ≥2.57 volts, with maximum discrepancy at 2.57 volts (23 months). The overall longevity was higher in the discrepant group of CRT devices than in the nondiscrepant group (67 vs. 61 months, log-rank P = 0.03).

CONCLUSIONS

There was significant overestimation of longevity in nearly three-fourths of Current/Promote SJM ICDs in the last 18 months prior to ERI. Longevity estimates of SJM ICDs may not be reliable for making clinical decisions on frequency of follow-up, as the battery approaches depletion.