Wearable cardioverter-defibrillator for prevention of sudden cardiac death after infected implantable cardioverter-defibrillator removal: A cost-effectiveness evaluation

Wearable Cardioverter Defibrillator Shortens the Lengths of Stay in Patients with Left Ventricular Dysfunction after Myocardial Infarction: A Single-Centre Real-World Experience

The wearable cardioverter defibrillator (WCD) has been proven to be effective in preventing sudden cardiac death (SCD) in patients soon after acute myocardial infarction (AMI) and left ventricular ejection fraction (LVEF) ≤35%. The aim of this study was to assess whether a WCD may shorten the length of an initial hospital stay (total length, days in the intensive care unit (ICU) and in the acute cardiac care unit (ACCU)) among these patients. This was a single-centre, retrospective observational study of patients referred for the management of SCD risk post-AMI and LVEF ≤35%, in a tertiary care hospital. The clinical characteristics and length of index hospitalization of the group of patients discharged, with or without WCD, were compared. A propensity score analysis was performed, then weighted regression models were conducted. A total of 101 patients in the WCD group and 29 in the control group were enrolled in the analysis. In the weighted regression models, WCD significantly reduced the days spent in ACCU (p < 0.001). WCD patients had significantly fewer days spent in ACCU (5.5 ± 2.6 vs. 8.4 ± 12.8 days, p < 0.001) and shorter hospitalizations (10.2 ± 5.7 vs. 13.4 ± 17.6 days, p = 0.005), compared with the control group. It was concluded that the WCD appears to reduce the total length of hospitalization and lengths of stay in ACCU for patients post-AMI and with left ventricular dysfunction.

Wearable cardioverter defibrillator for preventing sudden cardiac death in patients at risk: An updated systematic review of comparative effectiveness and safety

Objectives

To synthesise the available evidence of wearable cardioverter defibrillator (WCD) therapy as an add-on measure to optimal medical therapy (OMT) or as a replacement of hospital stay.

Methods

An update systematic review (SR) of comparative effectiveness and safety of WCD therapy was conducted. We included randomised controlled trials (RCT), prospective comparative studies and prospective uncontrolled studies with at least 100 patients. A narrative synthesis of the evidence was conducted.

Results

One RCT (n = 2348) and further eleven observational studies (n = 5345) fulfilled our inclusion criteria. In the only available RCT, the use of the WCD was not statistically associated with a clinical benefit on arrhythmic mortality in post-myocardial infarction (MI) patients with an ejection fraction of ≤35%. The compliance with WCD therapy was low in the RCT and high in observational studies, with ten observational studies reporting on a daily wear time between 20 and 23.5 h. The range of percentage of patients receiving at least one appropriate shock was 1-4.8% and the rate of first shock success was reported to be 100% in three studies. Serious adverse events (SAEs) such as inappropriate shocks occurred rarely, with between 0% and 2% of patients being inappropriately shocked within ten observational studies. In one of the observational studies, two patients (2%) were allergic to nickel developing skin rash and false alarms occurred in 58 patients (57%) in this study. Another registry study (n = 448) reported milder AEs, such as dermatitis and pressure marks, occurring in 0.9% and 0.2% of enrolled patients, respectively.

Conclusion

The only available RCT failed to show superiority of add-on use of WCD in post MI patients. Observational evidence shows that the compliance with WCD is good, but the evidence is afflicted with selection bias and the inclusion of diverse mixed patient populations diluting the ability to draw indication-specific conclusions on the utility of the device. More comparative data is needed to justify continuing or expanding use of WCD therapy.

Sudden cardiac death while waiting: do we need the wearable cardioverter-defibrillator?

Sudden cardiac death (SCD) is the most frequent cause of cardiovascular death in industrialized nations. Patients with cardiomyopathy are at increased risk for SCD and may benefit from an implantable cardioverter-defibrillator (ICD). The risk of SCD is highest in the first months after myocardial infarction or first diagnosis of severe non-ischemic cardiomyopathy. On the other hand, left ventricular function may improve in a subset of patients to such an extent that an ICD might no longer be needed. To offer protection from a transient risk of SCD, the wearable cardioverter-defibrillator (WCD) is available. Results of the first randomized clinical trial investigating the role of the WCD after myocardial infarction were recently published. This review is intended to provide insight into data from the VEST trial, and to put these into perspective with studies and clinical experience. As a non-invasive, temporary therapy, the WCD may offer advantages over early ICD implantation. However, recent data demonstrate that patient compliance and education play a crucial role in this new concept of preventing SCD.

Repostioning of Telemedicine in Cardiovascular World Post-COVID-19 Pandemic

Background

During the COVID-19 pandemic, telemedicine is a quickest expanding service solution to provide improved access to sophisticated healthcare that is efficient, cost-effective, and time-consuming.

Methods

This analysis is evaluated on the basis of several studies that look at the history, benefits, various techniques, challenges, uses, and impact of telemedicine in the treatment of heart failure and cardiac rehabilitation as during COVID-19 outbreak.

Results

Patients avoided or refused medical treatment during COVID-19 pandemic despite the risk of illness and the threat of infections spreading. Telemedicine has become a non-traditional form of care delivery due to better access and high-end technologies such as virtual consultations, face-to-face video, smartphone visits, two-way text communication, distant patient history, and distal characteristic assessment. Remote monitoring can help manage cardiovascular disease risk factors and increase patient participation in blood pressure, heart failure data, and workout or other activity progress.

Conclusion

Based on the findings of past studies, we can infer that telemedicine is still an emerging subject in the treatment and management of cardiovascular disease. Telemedicine and similar technologies will also revolutionize healthcare services by expanding their reach and providing a big pool of database for better research and analysis.

Delayed Improvement of Left Ventricular Function in Newly Diagnosed Heart Failure Depends on Etiology—A PROLONG-II Substudy

In patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF), three months of optimal therapy are recommended before considering a primary preventive implantable cardioverter-defibrillator (ICD). It is unclear which patients benefit from a prolonged waiting period under protection of the wearable cardioverter-defibrillator (WCD) to avoid unnecessary ICD implantations. This study included all patients receiving a WCD for newly diagnosed HFrEF (n = 353) at our center between 2012 and 2017. Median follow-up was 2.7 years. From baseline until three months, LVEF improved in patients with all peripartum cardiomyopathy (PPCM), myocarditis, dilated cardiomyopathy (DCM), or ischemic cardiomyopathy (ICM). Beyond this time, LVEF improved in PPCM and DCM only (10 ± 8% and 10 ± 12%, respectively), whereas patients with ICM showed no further improvement. The patients with newly diagnosed HFrEF were compared to 29 patients with a distinct WCD indication, which is an explantation of an infected ICD. This latter group had a higher incidence of WCD shocks and poorer overall survival. All-cause mortality should be considered when deciding on WCD prescription. In patients with newly diagnosed HFrEF, the potential for delayed LVEF recovery should be considered when timing ICD implantation, especially in patients with PPCM and DCM.

Cost-minimization analysis of a wearable cardioverter defibrillator in adult patients undergoing ICD explant procedures: Clinical and economic implications

Aims

Patients with permanently increased risk of sudden cardiac death (SCD) can be protected by implantable cardioverter defibrillators (ICD). If an ICD must be removed due to infection, for example, immediate reimplantation might not be possible or indicated. The wearable cardioverter defibrillator (WCD) is an established, safe and effective solution to protect patients from SCD during this high‐risk bridging period. Very few economic evaluations on WCD use are currently available.

Methods

We conducted a systematic review to evaluate the available evidence of WCD in patients undergoing ICD explant/lead extraction. Additionally, a decision model was developed to compare use and costs of the WCD with standard therapy (in‐hospital stay). For this purpose, a cost‐minimization analysis was conducted, and complemented by a one‐way sensitivity analysis.

Results

In the base case scenario, the WCD was less expensive compared to standard therapy. The cost‐minimization analysis showed a cost reduction of €1782 per patient using the WCD. If costs of standard care were changed, cost savings associated with the WCD varied from €3500 to €0, assuming costs for standard care of €6800 to €3600.

Conclusion

After ICD explantation, patients can be safely and effectively protected from SCD after hospital discharge through WCD utilization. Furthermore, the use of a WCD for this patient group is cost saving when compared to standard therapy.

Keeping up to date: a current review of wearable cardioverter defibrillator use

The introduction of wearable cardioverter defibrillators (WCD) provides a novel means of protection in select patients at high risk for sudden cardiac death. The WCD can safely record and terminate life-threatening arrhythmias. In this review, we explore the data behind indications for WCD use and discuss its limitations. We searched PubMed, Google Scholar and Cochrane Central Register of controlled trials for relevant studies. The VEST trial, the first randomised controlled trial on WCD use, did not show statistical significance in utility of the WCD in post-myocardial infarction patients with low ejection fraction. While the use of WCD in this select patient population showed no benefit, the findings of the trial merit closer inspection. Various other indications of WCD use still exist and others require exploration. Select subsets of patients who stand to benefit for other indications include severely decreased left ventricular function post-revascularization with high arrhythmic burden, severe non-ischaemic cardiomyopathy, patients awaiting heart transplant and patients who have had their implantable cardioverter device temporarily removed. The role of the WCD is also being explored in children, peripartum cardiomyopathy, haemodialysis patients, and in syncope secondary to high-risk arrhythmias.

Comparison of the Outcome of Patients Protected by the Wearable Cardioverter Defibrillator (WCD) for <90 Wear Days versus ≥90 Wear Days

BACKGROUND/AIM

The wearable cardioverter/defibrillator (WCD) is recommended to prevent sudden cardiac death (SCD). Guidelines suggest a 90 days' period, but prolongation of WCD wear time until increasing the ejection fraction (≥35%) might be suggested.

PATIENTS AND METHODS

A cohort of 153 patients with prescribed WCD were divided into two groups: A <90 wear days' group (n=112) vs. ≥90 wear days' group (n=41) and followed.

RESULTS

In the first group, WCD shock occurred in 3.6% of patients, 47.3% improved in left ventricular ejection fraction (LVEF) after 3 months, and 37.5% had a cardiac implantable electronic device (CIED) implantation with appropriate implantable cardioverter defibrillator (ICD) shock events occurring in 6 patients. Two of these patients already received WCD shock therapy due to ventricular fibrillation. A 20.5% improved in LVEF after 6-12 months, but 73% were already implanted with ICD. In the second group, 4.9% received WCD shock, 34.1% improved in LVEF after 3 months, 48.8% were implanted with ICD, and 2 had ICD shocks during follow up time. LVEF improvement after 6-12 months occurred in 26.8%. ICD implantation was prevented in 7.3% of patients due to LVEF recovery.

CONCLUSION

Prolonging wearing days of WCD may reduce the number of inappropriate ICD implantation.

Wearable cardioverter-defibrillators in pediatric cardiomyopathy: A cost-utility analysis

BACKGROUND

Dilated cardiomyopathy (DCM) is the most common cardiomyopathy in children. Patients with severe cardiac dysfunction are thought to be at risk of sudden cardiac arrest (SCA). After diagnosis, a period of medical optimization is recommended before permanent implantable cardioverter-defibrillator (ICD) implantation. Wearable cardioverter-defibrillators (WCDs) provide an option for arrhythmia protection as an outpatient during this optimization.

OBJECTIVE

The purpose of this study was to determine the strategy that optimizes cost and survival during medical optimization of a patient with DCM before ICD placement.

METHODS

A Markov state transition model was constructed for the 3 clinical approaches to compare costs, clinical outcomes, and quality of life: (1) "Inpatient," (2) "Home-WCD," and (3) "Home-No WCD." Transitional probabilities, costs, and utility metrics were extracted from the existing literature. Cost-effectiveness was assessed comparing each paradigm's incremental cost-effectiveness ratio against a societal willingness-to-pay threshold of $50,000 per quality-adjusted life year.

RESULTS

The cost-utility analysis illustrated that Home-WCD met the willingness-to-pay threshold with an incremental cost-effectiveness ratio of $20,103 per quality-adjusted life year and 4 mortalities prevented per 100 patients as compared with Home-No WCD. One-way sensitivity analyses demonstrated that Home-No WCD became the most cost-effective solution when the probability of SCA fell below 0.2% per week, the probability of SCA survival with a WCD fell below 9.8%, or the probability of SCA survival with Home-No WCD quadrupled from base-case assumptions.

CONCLUSION

Based on the existing literature probabilities of SCA in pediatric patients with DCM undergoing medical optimization before ICD implantation, sending a patient home with a WCD may be a cost-effective strategy.

The Cost-Effectiveness of Digital Health Interventions on the Management of Cardiovascular Diseases: Systematic Review

BACKGROUND

With the advancement in information technology and mobile internet, digital health interventions (DHIs) are improving the care of cardiovascular diseases (CVDs). The impact of DHIs on cost-effective management of CVDs has been examined using the decision analytic model-based health technology assessment approach.

OBJECTIVE

The aim of this study was to perform a systematic review of the decision analytic model-based studies evaluating the cost-effectiveness of DHIs on the management of CVDs.

METHODS

A literature review was conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Scopus, Web of Science, Center for Review and Dissemination, and Institute for IEEE Xplore between 2001 and 2018. Studies were included if the following criteria were met: (1) English articles, (2) DHIs that promoted or delivered clinical interventions and had an impact on patients' cardiovascular conditions, (3) studies that were modeling works with health economic outcomes of DHIs for CVDs, (4) studies that had a comparative group for assessment, and (5) full economic evaluations including a cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis, and cost-consequence analysis. The primary outcome collected was the cost-effectiveness of the DHIs, presented by incremental cost per additional quality-adjusted life year (QALY). The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

A total of 14 studies met the defined criteria and were included in the review. Among the included studies, heart failure (7/14, 50%) and stroke (4/14, 29%) were two of the most frequent CVDs that were managed by DHIs. A total of 9 (64%) studies were published between 2015 and 2018 and 5 (36%) published between 2011 and 2014. The time horizon was ≤1 year in 3 studies (21%), >1 year in 10 studies (71%), and 1 study (7%) did not declare the time frame. The types of devices or technologies used to deliver the health interventions were short message service (1/14, 7%), telephone support (1/14, 7%), mobile app (1/14, 7%), video conferencing system (5/14, 36%), digital transmission of physiologic data (telemonitoring; 5/14, 36%), and wearable medical device (1/14, 7%). The DHIs gained higher QALYs with cost saving in 43% (6/14) of studies and gained QALYs at a higher cost at acceptable incremental cost-effectiveness ratio (ICER) in 57% (8/14) of studies. The studies were classified as excellent (0/14, 0%), good (9/14, 64%), moderate (4/14, 29%), and low (1/14, 7%) quality.

CONCLUSIONS

This study is the first systematic review of decision analytic model-based cost-effectiveness analyses of DHIs in the management of CVDs. Most of the identified studies were published recently, and the majority of the studies were good quality cost-effectiveness analyses with an adequate duration of time frame. All the included studies found the DHIs to be cost-effective.

The wearable cardioverter-defibrillator vest: Indications and ongoing questions

Multiple clinical trials have demonstrated the efficacy of implantable cardioverter-defibrillators (ICDs) for the prevention of sudden cardiac death (SCD) among specific high-risk populations. However, it remains unclear how to optimally treat those patients who are at elevated risk of cardiac arrest but are not among the presently identified groups proven to benefit from an ICD, are unable to tolerate surgical device implantation, or refuse invasive therapies. The wearable cardioverter-defibrillator (WCD) is an alternative antiarrhythmic device that provides continuous cardiac monitoring and defibrillation capabilities through a noninvasive, electrode-based system. The WCD has been shown to be highly effective at restoration of sinus rhythm in patients with a ventricular tachyarrhythmia, and one randomized trial using the WCD in patients with recent myocardial infarction at elevated risk for arrhythmic death reported a decrease in overall mortality despite no SCD mortality benefit. The current clinical indications for WCD use are varied and continue to evolve as experience with this technology increases.

[Wearable defibrillator : Current evidence]

The wearable cardioverter/defibrillator (WCD) is safe and effective in the prevention of sudden cardiac death, and has found its way into international guidelines and clinical practice. Nearly 40,000 patients with a WCD have been published in clinical registries and one randomized study has recently been presented. Especially patients with newly diagnosed cardiomyopathy with severely reduced left ventricular function show an increased risk for ventricular tachyarrhythmias and may benefit from a WCD. In these patients without an indication for an implantable cardioverter-defibrillator (ICD), the WCD offers protection from sudden cardiac death during initiation and optimization of heart failure medication. Critical patient selection and structured patient management is crucial for successful WCD prescription. This review gives an overview of the current data and recommendations on WCD.

[Patients with a wearable cardioverter-defibrillator (WCD) : Prescription, function and rehabilitation support]

Assessment of a permanent risk of life-threatening ventricular arrhythmia in patients with severely reduced left ventricular ejection fraction (LVEF <35%), e. g. after myocarditis, dilated cardiomyopathy, acute myocardial infarction, in patients with postpartum cardiomyopathy or implantable cardioverter-defibrillator (ICD) and cardiac resynchronization treatment plus defibrillator (CRT-D) infection with temporary explantation of the system is a medical challenge. This is time-consuming and unsafe because life-threatening ventricular arrhythmias may occur during the time of risk assessment. During this phase of risk stratification, a wearable cardioverter-defibrillator (WCD) is indicated. The WCD, which is usually worn by the patient for several months, combines continuous retrievable electrocardiogram (ECG) recordings with a reliable defibrillation capability. The prescription of a WCD guarantees safe rehabilitation procedures for patients following acute inpatient treatment. Rehabilitation measures in patients with a WCD are indicated because of the underlying systolic cardiac insufficiency due to severe myocardial disease. In almost half of the patients, who are potentially threatened by ventricular tachyarrhythmias or sudden cardiac death (SCD), the LVEF and heart failure symptoms improve under controlled medication within a few months. Thus, the risk of SCD is lowered so that in many cases a first line ICD implantation is no longer necessary. The purpose of this article is to provide recommendations for rehabilitation procedures of patients with a WCD. A review of the currently available data on WCD publications was carried out with special emphasis on the current national and international guidelines.

The wearable cardioverter defibrillator as a bridge to reimplantation in patients with ICD or CRT-D-related infections

Background

The approach to treat device infection in patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) is a challenging procedure. Optimal treatment is complete extraction of the infected device. To protect these patients from sudden cardiac arrest while waiting for reimplantation and to avoid recurrent infection, a wearable cardioverter defibrillator (WCD) seems to be a valuable solution.

Therefore, we investigated the management and outcome of patients with ICD or CRT-D infections using the WCD as a bridge to re-implantation after lead extraction procedures.

Methods

We conducted a retrospective study on consecutive patients who underwent ICD or CRT-D removal due to device-related local or systemic infections. All patients were prescribed a WCD at our center between 01/2012 and 10/2015. All patients returned to our outpatient clinic for regular ICD or CRT-D monitoring initially 1 and 3 months after reimplantation followed by 6-months intervals.

Results

Twenty-one patients (mean age 65.0 ± 8.0 years, male 76.2%) were included in the study. Complete lead extraction was achieved in all patients. While waiting for reimplantation one patient experienced a symptomatic episode of sustained ventricular tachycardia. This episode was converted successfully into sinus rhythm by a single 150 J shock.

Mean follow-up time 392 ± 206 days, showing survival rate of 100% and freedom from reinfection in all patients.

Conclusion

The WCD seems to be a valuable bridging option for patients with ICD or CRT-D infections, showing no recurrent device infection.

Experience With Wearable Cardioverter-Defibrillators at 2 Academic Medical Centers

OBJECTIVES

This study sought to characterize the experience in a cohort of patients prescribed a wearable cardioverter-defibrillator (WCD) over a 2-year interval at 2 academic medical centers.

BACKGROUND

The WCD is available for patients felt to be at high risk of sudden cardiac death. However, there is a lack of randomized data to guide its use and prescribing patterns vary.

METHODS

We retrospectively reviewed indications and therapies of all WCD prescriptions over a 2-year period from 2 large academic medical centers. Data on compliance and treatment events of patients wearing the WCD were reviewed.

RESULTS

Among the 147 patients prescribed a WCD, 80% were male with an age of 59 ± 14 years. The WCD was prescribed for the following reasons: primary prevention in the setting of a left ventricular ejection fraction ≤35% (53%), secondary prevention when an implantable cardioverter-defibrillator was not implanted (16%), implantable cardioverter-defibrillator explantation (23%), and other high-risk scenarios for arrhythmic sudden death (9%). The median wear duration was 50 days (interquartile range [IQR]: 25 to 85 days) with a median of 21.0 h of wear per day (IQR: 15.0 to 22.8 h). High-voltage treatment was delivered in 3 separate patients, 2 of whom died. The third patient received 3 WCD shocks without restoration of a perfusing rhythm and ultimately was resuscitated by emergency responders. No patients received inappropriate therapies.

CONCLUSIONS

Events requiring therapy were rare and no lives were directly saved by the WCD. Future efforts are needed to improve identification of patients most likely to benefit from a WCD.

The wearable cardioverter-defibrillator: current technology and evolving indications

The wearable cardioverter-defibrillator has been available for over a decade and now is frequently prescribed for patients deemed at high arrhythmic risk in whom the underlying pathology is potentially reversible or who are awaiting an implantable cardioverter-defibrillator. The use of the wearable cardioverter-defibrillator is included in the new 2015 ESC guidelines for the management of ventricular arrhythmias and prevention of sudden cardiac death. The present review provides insight into the current technology and an overview of this approach.

Wearable cardioverter defibrillator: Bridge or alternative to implantation?

The implantable cardioverter-defibrillator (ICD) is effective to prevent sudden cardiac death (SCD) in selected patients with heart disease known to be at high risk for ventricular arrhythmia. Nevertheless, this invasive and definitive therapy is not indicated in patients with potentially transient or reversible causes of sudden death, or in patients with temporary contra-indication for ICD placement. The wearable cardioverter defibrillator (WCD) is increasingly used for SCD prevention both in patients awaiting ICD implantation or with an estimated high risk of ventricular arrhythmia though to be transient. We conducted a review of current clinical uses and benefits of the WCD, and described its technical aspects, limitations and perspectives.

Low lateral thoracic site for cardiac implantable electronic device implantation: A viable alternative in patients with limited access options after infected device extraction

BACKGROUND

Device reimplantation after extraction because of cardiac implantable electronic device (CIED) infection in pacemaker-dependent patients can be challenging in individuals with limited access options.

OBJECTIVE

The purpose of this study was to describe a straightforward, low lateral thoracic implantation technique for patients with a patent axillary vein but unavailable bilateral pectoral sites.

METHODS

Nine pacemaker-dependent patients (mean age 70 ± 13 years, 7 male) who underwent CIED extraction and low lateral thoracic reimplantation in whom bilateral pectoral sites were unavailable were included in the study.

RESULTS

Extraction was performed a median of 10 (interquartile range [IQR] 8-13) days before CIED reimplantation (4 dual-chamber, 3 single-chamber, 2 cardiac resynchronization therapy). The new generator was implanted in the low lateral thoracic region ipsilateral to the extracted generator in 7 patients (78%) and contralateral in 2 patients (22%), via a subcutaneous pocket in 6 (67%) and submuscular pocket in 3 (33%). Median procedure duration was 85 (IQR 61-116) minutes, median fluoroscopy time was 7.2 (IQR 5.7-10.9), minutes and median fluoroscopy exposure was 26.0 (IQR 10.0-110.5) mGy. No acute complications occurred. Over median follow-up of 92 (IQR 31-131) days, 1 patient experienced right atrial lead dislodgment (122 days postimplantation) requiring lead revision. No patients experienced recurrent device infection.

CONCLUSION

In pacemaker-dependent patients with limited prepectoral and vascular access options, a low lateral thoracic implantation site is a viable alternative to surgical epicardial or femoral pacing systems. This simple implantation technique is a safe and effective option in selected patients who require a single-chamber, dual-chamber, or biventricular pacemaker or implantable cardioverter-defibrillator.

Risk for life-threatening arrhythmia in newly diagnosed peripartum cardiomyopathy with low ejection fraction: a German multi-centre analysis

Introduction

Peripartum cardiomyopathy (PPCM) is a rare cardiomyopathy characterized by an acute reduction in left ventricular ejection fraction (LVEF). Sudden deaths during the course of PPCM are reported to be elevated, the underlying mechanisms remains unknown. The aim of the present multi-centre study was to evaluate the arrhythmia burden in a multi-centre approach in patients with PPCM using a wearable cardioverter/defibrillator (WCD).

Methods and results

Forty-nine patients from 16 German centres with newly diagnosed PPCM and LVEF ≤35% receiving a WCD were included in this retrospective analysis. Mean follow-up was 15 ± 10 months. At diagnosis, mean age was 33 ± 5 years, parity was 2.1 ± 1.6, LVEF was 21 ± 7%, NYHA functional class was 3.4 ± 0.7. Mean wear time was 120 ± 106 days, mean wear time per day was 21.4 ± 3.3 h. Six (12%) patients presented eight ventricular tachyarrhythmias during WCD period: five episodes of VF, two sustained ventricular tachycardia (VT) and one non-sustained VT occurred.

Conclusion

This multicentre study underpins the elevated risk for ventricular tachyarrhythmias in patients with newly diagnosed PPCM and reduced LVEF. A WCD should be considered for 3–6 months in these patients to prevent sudden cardiac death from ventricular tachyarrhythmias.

Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association

The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.

Outpatient treatment with the wearable cardioverter defibrillator: clinical experience in two Dutch centres

Introduction

The latest European Society of Cardiology Guidelines recommend consideration of a wearable cardioverter-defibrillator (WCD) for patients with a poor left ventricular ejection fraction (LVEF) who are at risk of sudden arrhythmic death but are not eligible for an implantable defibrillator. For these patients a WCD can be an alternative to long-term hospitalisation.

Purpose

To evaluate the use of WCD therapy in these patient groups in two Dutch centres.

Methods

All consecutive patients treated with the WCD between 2009 and 2016 were included from two centres in the Netherlands. Data on events and compliance were collected retrospectively through home monitoring systems and adjudicated by the investigators.

Results

A total of 79 patients were treated with a WCD. Common indications were newly diagnosed cardiomyopathy without optimal medical treatment in 46 patients (58.2%) and bridge to implantable cardioverter-defibrillator (ICD) implant in 33 patients (41.8%). Bridge to implant indications consisted of contraindications for immediate implantation such as infections (e. g. previous device-related infections) and radiotherapy. Compliance was over 97% per day (median 23.3 h, 22.6–23.7), during a median of 79 days (50.0–109.8.0). Two patients (2.6%) received an appropriate shock (annual rate 13.6%), there was 1 (1.3%) inappropriate shock (annual rate 6.7%). In 24 patients (52.2%) without optimal medical treatment, the LVEF was sufficiently improved and ICD implant was avoided. Eight (10.1%) patients did not receive an ICD. In 45 patients an ICD was implanted (57.0%).

Conclusion

WCD therapy provides a safe and effective treatment in outpatient setting for patients at high risk for sudden cardiac death and reduces the number of ICDs implanted.

New horizon for infection prevention technology and implantable device

There has been a significant increase in the number of patients receiving cardiovascular implantable electronic devices (CIED) over the last two decades. CIED infection represents a serious complication after CIED implantation and is associated with significant morbidity and mortality. Recently, newly advanced technologies have offered attractive and suitable therapeutic alternatives. Notably, the leadless pacemaker and anti-bacterial envelope decrease the potential risk of CIED infection and the resulting mortality, when it does occur. A completely subcutaneous implantable cardioverter defibrillator is also an alternative to the transvenous implantable cardioverter defibrillator (ICD), as it does not require implantation of any transvenous or epicardial leads. Among the patients who require ICD removal and subsequent antibiotics secondary to infection, the wearable cardioverter defibrillator represents an alternative approach to inpatient monitoring for the prevention of sudden cardiac death. In this review paper, we aimed to introduce the advanced technologies and devices for prevention of CIED infection.

[The wearable cardioverter/defibrillator : Temporary protection from sudden cardiac death]

In the majority of cases sudden cardiac death (SCD) is caused by ventricular tachyarrhythmia. Implantable cardioverter-defibrillators (ICD) represent an evidence-based and established method for prevention of SCD. For patients who do not fulfill the criteria for guideline-conform implantation of an ICD but still have an increased, e.g. transient risk for SCD, a wearable cardioverter-defibrillator (WCD) vest was developed to temporarily prevent SCD. Numerous studies have shown the safety and efficacy of the WCD, although there is still a gap in evidence concerning a reduction in overall mortality and improvement in prognosis. This article gives an overview on the currently available literature on WCD, the indications, potential risks and complications.

Digital monitoring and care: Virtual medicine

Remote digital health monitoring technologies can be synergistically organized to create a virtual medical system providing more continuous care centered on the patient rather than the bricks and mortar medical complex. Utilization of the digitalized patient health monitoring can facilitate diagnosis, treatment plans, physician-patient interaction, and accelerate the progress of medical research, education, and training. The field of cardiac electrophysiology has been an early adopter of this shift in care and serves as a paradigm applicable to all areas of medicine. The overall impact of this remote virtual care model on the quality of medical care and patient experience requires greater study, as well as vigilance as to the differences between technology and care in order to preserve the intangible and immeasurable factors that bring humanity to the art and science of medicine.

The Wearable Cardioverter/Defibrillator - Toy Or Tool?

After the success story of implantable cardioverter/defibrillator systems, prevention of sudden cardiac death (SCD) remains one of the main duties in cardiology. For patients with unkown or transient risk profile for SCD, a wearable cardioverter/defibrillator (WCD) has been established for temporary and effective prevention of sudden arrhythmic death. Several studies have shown safety and efficacy of the WCD, even though randomized studies proving a mortality benefit are still lacking. This review provides an overview of actual WCD data and usage, special indications and possible risks and complications. WCD use is effective and adequate for temporary prevention of SCD in chosen populations. In particular, it provides secured time for sophisticated risk stratification to identify patients at persistent risk for SCD. Nevertheless, prospective randomized trials seem mandatory to prove a prognostic relevance and the economic value of this device.

Arrhythmia management after device removal

Arrhythmic management is needed after removal of cardiac implantable electronic devices (CIEDs). Patients completely dependent on CIEDs need temporary device back-up until new CIEDs are implanted. Various methods are available for device back-up, and the appropriate management varies among patients. The duration from CIED removal to implantation of a new CIED also differs among patients. Temporary pacing is needed for patients with bradycardia, a wearable cardioverter defibrillator (WCD) or catheter ablation is needed for patients with tachyarrhythmia, and sequential pacing is needed for patients dependent on cardiac resynchronization therapy. The present review focuses on arrhythmic management after CIED removal.