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

Is There a Future for Remote Cardiac Implantable Electronic Device Management?

In the era of communication technology, remote monitoring has been a paradigm shift in the way patients with cardiac implantable electronic devices are managed. It has been endorsed by scientific societies and is being increasingly adopted in the clinical setting. Despite the various advantages associated with this strategy, data on improved clinical outcome are still sparse. The recently published study on the remote management of heart failure using implanted devices and formalised follow-up procedures, which turned out to be negative, has cast doubt on whether remote monitoring should still be used. This article provides a critical appraisal of the study, and discusses the issue of remote data management.

The Significance of Shocks in Implantable Cardioverter Defibrillator Recipients

Large-scale implantable cardioverter defibrillator (ICD) trials have unequivocally shown a reduction in mortality in appropriately selected patients with heart failure and depressed left ventricular function. However, there is a strong association between shocks and increased mortality in ICD recipients. It is unclear if shocks are merely a marker of a more severe cardiovascular disease or directly contribute to the increase in mortality. The aim of this review is to examine the relationship between ICD shocks and mortality, and explore possible mechanisms. Data examining the effect of shocks in the absence of spontaneous arrhythmias as well as studies of non-shock therapy and strategies to reduce shocks are analysed to try and disentangle the shocks versus substrate debate.

Mobile health in cardiology: a review of currently available medical apps and equipment for remote monitoring

INTRODUCTION

Recent developments in implantable cardioverter-defibrillators (ICDs) and smartphone technology have increased the possibilities for remote monitoring. It is the purpose of this review to give an overview of these new possibilities.

AREAS COVERED

Remote monitoring in ICD allows for early detection of lead fractures and remote follow-up of patients. Possible limitations are the lack of standardization and the possible unsafety of the data stored on the ICD. Secondly, remote monitoring of health parameters using smartphone compatible wearables and smartphone medical apps is addressed. Possible limitations include the fact that the majority of smartphone apps are unregulated by the regulatory authorities and privacy issues such as selling of app-generated data to third parties. Lastly, clinical studies with smartphone apps are discussed. Expert commentary: New technologies in ICDs and smartphones have the potential to be used for remote monitoring. However, unreliability of smartphone technology, inadequate legislation and lack of reimbursement impede implementation.

Implantable Cardiac Defibrillator Lead Failure and Management

The implantable-cardioverter defibrillator (ICD) lead is the most vulnerable component of the ICD system. Despite advanced engineering design, sophisticated manufacturing techniques, and extensive bench, pre-clinical, and clinical testing, lead failure (LF) remains the Achilles' heel of the ICD system. ICD LF has a broad range of adverse outcomes, ranging from intermittent inappropriate pacing to proarrhythmia leading to patient mortality. ICD LF is often considered in the context of design or construction defects, but is more appropriately considered in the context of the finite service life of a mechanical component placed in chemically stressful environment and subjected to continuous mechanical stresses. This clinical review summarizes LF mechanisms, assessment, and differential diagnosis of LF, including lead diagnostics, recent prominent lead recalls, and management of LF and functioning, but recalled leads. Despite recent advances in lead technology, physicians will likely continue to need to understand how to manage patients with transvenous ICD leads.

Innovative pacing: Recent advances, emerging technologies, and future directions in cardiac pacing

The field of cardiovascular medicine is rapidly evolving as advancements in technology and engineering provide clinicians new and exciting ways to care for an aging population. Cardiac pacing, in particular, has seen a series of game-changing technologies emerge in the past several years spurred by low-power electronics, high density batteries, improved catheter delivery systems and innovative software design. We look at several of these emerging pacemaker technologies, discussing the rationale, current state and future directions of these pioneering developments in electrophysiology.

Safety threshold of R-wave amplitudes in patients with implantable cardioverter defibrillator

OBJECTIVE

A safety threshold for baseline rhythm R-wave amplitudes during follow-up of implantable cardioverter defibrillators (ICD) has not been established. We aimed to analyse the amplitude distribution and undersensing rate during spontaneous episodes of ventricular fibrillation (VF), and define a safety amplitude threshold for baseline R-waves.

METHODS

Data were obtained from an observational multicentre registry conducted at 48 centres in Spain. Baseline R-wave amplitudes and VF events were prospectively registered by remote monitoring. Signal processing algorithms were used to compare amplitudes of baseline R-waves with VF R-waves. All undersensed R-waves after the blanking period (120 ms) were manually marked.

RESULTS

We studied 2507 patients from August 2011 to September 2014, which yielded 229 VF episodes (cycle length 189.6±29.1 ms) from 83 patients that were suitable for R-wave comparisons (follow-up 2.7±2.6 years). The majority (77.6%) of VF R-waves (n=13953) showed lower amplitudes than the reference baseline R-wave. The decrease in VF amplitude was progressively attenuated among subgroups of baseline R-wave amplitude (≥17; ≥12 to <17; ≥7 to <12; ≥2.2 to <7 mV) from the highest to the lowest: median deviations -51.2% to +22.4%, respectively (p=0.027). There were no significant differences in undersensing rates of VF R-waves among subgroups. Both the normalised histogram distribution and the undersensing risk function obtained from the ≥2.2 to <7 mV subgroup enabled the prediction that baseline R-wave amplitudes ≤2.5 mV (interquartile range: 2.3-2.8 mV) may lead to ≥25% of undersensed VF R-waves.

CONCLUSIONS

Baseline R-wave amplitudes ≤2.5 mV during follow-up of patients with ICDs may lead to high risk of delayed detection of VF.

TRIAL REGISTRATION NUMBER

NCT01561144; results.

Remote monitoring of cardiac implantable electronic devices (CIED)

With increasing indications and access to cardiac implantable electronic devices (CIEDs) worldwide, the number of patients needing CIED follow-up continues to rise. In parallel, the technology available for managing these devices has advanced considerably. In this setting, remote monitoring (RM) has emerged as a complement to routine in-office care. Rigorous studies, randomized and otherwise, have demonstrated advantages to patient with CIED management systems, which incorporates RM resulting in authoritative guidelines from relevant professional societies recommending RM for all eligible patients. In addition to clinical benefits, CIED management programs that include RM have been shown to be cost effective and associated with high patient satisfaction. Finally, RM programs hold promise for the future of CIED research in light of the massive data collected through RM databases converging with unprecedented computational capability. This review outlines the available data associated with clinical outcomes in patients managed with RM with an emphasis on randomized trials; the impact of RM on patient satisfaction, cost-effectiveness, and healthcare utilization; and possible future directions for the use of RM in clinical practice and research.

Measuring quality in electrophysiology

The evolving healthcare environment demands optimally measured quality of care. Performance measures are increasingly being used for quality improvement, public reporting, and reimbursement determinations. The National Quality Forum has created rigorous criteria for the evaluation of potential performance measures across medical fields. The Heart Rhythm Society has championed the development of four separate electrophysiology (EP)-specific performance measures: implantable cardioverter defibrillator complication rate, cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation, infection within 180 days of a cardiac implantable electronic device implantation, replacement, or revision, and in-person evaluation following a cardiac implantable electronic device implantation. National registries serve a key role in developing performance measures and facilitating quality improvement, particularly as they provide improved granularity and accuracy of data compared with administrative claims data. All performance measures demand continued reassessment as technology and performance gaps change and as unintended consequences may arise.

Improved survival in patients enrolled promptly into remote monitoring following cardiac implantable electronic device implantation

Purpose

Guidelines advocate remote monitoring (RM) in patients with a cardiac implantable electronic device (CIED). However, it is not known when RM should be initiated. We hypothesized that prompt initiation of RM (within 91 days of implant) is associated with improved survival compared to delayed initiation.

Methods

This retrospective, national, observational cohort study evaluated patients receiving new implants of market-released St. Jude Medical™ pacemakers (PM), implantable cardioverter defibrillators (ICD), and cardiac resynchronization therapy (CRT) devices. Patients were assigned to one of two groups: an “RM Prompt” group, in which RM was initiated within 91 days of implant; and an “RM Delayed” group, in which RM was initiated >91 days but ≤365 days of implant. The primary endpoint was all-cause mortality.

Results

The cohort included 106,027 patients followed for a mean of 2.6 ± 0.9 years. Overall, 47,014 (44 %) patients had a PM, 31,889 (30 %) patients had an ICD, 24,005 (23 %) patients had a CRT-D, and 3119 (3 %) patients had a CRT-P. Remote monitoring was initiated promptly (median 4 weeks [IQR 2, 8 weeks]) in 66,070 (62 %) patients; in the other 39,957 (38 %) patients, RM initiation was delayed (median 24 weeks [IQR 18, 34 weeks]). In comparison to delayed initiation, prompt initiation of RM was associated with a lower mortality rate (4023 vs. 4679 per 100,000 patient-years, p < 0.001) and greater adjusted survival (HR 1.18 [95 % CI 1.13–1.22], p < 0.001).

Conclusions

Our data, for the first time, show improved survival in patients enrolled promptly into RM following CIED implantation. This advantage was observed across all CIED device types.

Performance of a remote interrogation system for the in-hospital evaluation of cardiac implantable electronic devices

Purpose

Patients with a cardiac implantable electronic device (CIED) often need device interrogation in an in-hospital environment. A diagnosis-only, remote interrogation device and process for CIED interrogation was developed to address this situation. Here, we describe our initial clinical experience with this system.

Methods

The LATITUDE Consult Communicator is a stand-alone interrogation-only device used to read the patient’s implanted CIED. Once retrieved, the data are securely transmitted via an analog phone line to a central server. The clinician can request a review of the transmitted data at any time. Following FDA approval, we determined the usage and performance of the system.

Results

Communicators (n = 53) were installed in 42 hospital facilities. The most common location was in the emergency department (n = 32, 60 %). There were 509 discreet transmissions, which were categorized as follows: no arrhythmia episodes in the past 72 h and no out of range measurements (n = 174, 34 %); arrhythmia episodes in past 72 h but no out of range measurements (n = 170, 33 %); and further review recommended (n = 130, 26 %). (In 35 [7 %] instances, interrogation without analysis was requested.) The further review interrogations were then sub-divided into those of a non-urgent and urgent nature. Overall, only 53 (10 %) of the 509 transmissions were classified as urgent. Clinicians had access to full technical consultation in ≤15 min in 89 % of instances.

Conclusion

Our data demonstrate the feasibility of a new diagnosis-only, remote interrogation device and remote evaluation process for the interrogation of CIEDs in an in-hospital environment.

Electronic supplementary material

The online version of this article (doi:10.1007/s10840-015-0091-4) contains supplementary material, which is available to authorized users.

[Device therapy of chronic heart failure: Update 2015]

Cardiac pacemakers, implantable cardioverter defibrillators (ICD) and systems for cardiac resynchronization therapy (CRT) represent an important component of heart failure therapy. Pacemakers only play a role in bradycardia-associated heart failure and require optimal programming to prevent ventricular desynchronization. Primary prophylactic ICD implantation is indicated in patients with a left ventricular ejection fraction of ≤ 35 %, clinical stages NYHA II-III and a life expectancy > 1 year. The CRT is indicated in patients with a left bundle branch block but only in individual cases for other QRS morphologies of < 150 ms duration. The combination of CRT with a pacemaker or defibrillator must be decided on an individual basis. Device therapy in heart failure should always include remote monitoring to detect events early and to implement treatment accordingly. New developments include quadripolar left ventricular leads and pacing from multiple sites simultaneously thus enabling better resynchronization. Stimulation for modulation of cardiac contractility and the autonomous nervous system are currently being clinically tested. The optimal utilization of device therapy improves the course of heart failure and prevents cardiac decompensation and fatalities.

Home Monitoring for Cardiovascular Implantable Electronic Devices

Recent technological advances in the management of patients with cardiovascular implantable electronic devices (CIEDs) have expanded clinicians’ ability to remotely monitor patients with CIEDs. Remote monitoring, in addition to periodic in-person device evaluation, provides many advantages to patients and clinicians. Aside from the therapeutic and diagnostic benefits of pacemakers, implantable cardioverter-defibrillators, cardiac resynchronization therapy devices, and implantable loop recorders, improvement in clinical outcomes, clinical efficiencies, and patient experience can be realized with the adoption of remote CIED monitoring. These advantages create significant value to both patients and CIED follow-up centers.