Remote Monitoring of Patients with Implanted Cardiac Devices – A Review

Bosede A Afolabi, Fred M Kusumoto
European Cardiology, 2012;8(2):88–93
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Abstract

There has been a rapid growth in the number of patients with cardiovascular implantable electronic devices (CIEDs), due to the consistent good results from large randomised trials and changing worldwide demographics with progressive ageing in all developed countries. Early generations of CIEDs provided only basic operations and stored only rudimentary data, but the evolution of all types of CIEDs (pacemakers, defibrillators, cardiac resynchronisation devices, implantable monitors) has led to their increased complexity and the development of a myriad of specialised features. As an outgrowth of this increased sophistication, once implanted, CIEDs can provide significant amounts of important clinical information, allowing to identify the presence of significant arrhythmias, assess drug efficacy, evaluate heart failure status and continuously monitor device function. With the advent of new methods of remote monitoring, the information recorded by these devices can be accessible in real time and thus lead to more timely clinical decision-making. This article summarises the impact of remote monitoring on clinical practice today and how the use of remote monitoring may evolve to affect the practice of medicine in the future.
Keywords
Cardiovascular implantable electronic devices, remote monitoring, transtelephonic monitoring, heart failure monitoring, pacemaker follow-up, lead recall
Disclosure The authors have no conflicts of interest to declare.
Received: March 05, 2012 | Accepted April 08, 2012 | Citation European Cardiology, 2012;8(2):88–93
Correspondence: Fred M Kusumoto, Electrophysiology and Pacing Service, Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, 4500 San Pablo Ave, Jacksonville, FL 32224, US. E: Kusumoto.fred@mayo.edu

Since the first implantable pacemaker was introduced in 1958, electronic devices designed to treat cardiac problems have experienced technological leaps. A rapidly expanding number of patients depend on this technology.1 Cardiovascular implantable electronic devices (CIEDs) now include implantable cardioverter defibrillators (ICDs), pacemakers (PMs), cardiac resynchronisation therapy (CRT) devices, implantable loop recorders (ILRs) and implantable haemodynamic monitors (IHMs).2 The indications for CIED implantation have also broadened, and CIEDs are now important therapeutic options for selected patients with bradycardia, tachycardia or heart failure as well as a diagnostic option for patients with syncope.

Regardless of type, once a device has been implanted, its continued monitoring is necessary for evaluating the effects of therapy and has become part of a complete cardiac evaluation, much like an electrocardiogram, echocardiogram or stress test. Data from the device may alert the physician and/or the patient to important events, such as device malfunction, arrhythmia, changes in haemodynamic status or inadvertent changes in programmed parameters. The goals of CIED monitoring include optimising device function, improving patient quality of life, and identifying and correcting device malfunction in a timely fashion.

This article will focus primarily on the remote monitoring of ICDs, PMs and CRT devices (which can be subdivided into devices with additional defibrillator capabilities [CRT-D] or without defibrillator capabilities [CRT-P]). An extensive discussion of ILRs and IHMs is beyond the scope of this article, but these devices will be briefly described in the last section.

The 2008 collaborative Heart Rhythm Society(HRS)/European Heart Rhythm Association (EHRA) expert consensus statement on the monitoring of CIEDs serves as a useful reference point for physicians caring for patients with CIEDs.3 Monitoring of a CIED can be done by scheduled or unscheduled clinic visits (in-person monitoring), by data transmission to the physician initiated by the device or the patient (remote monitoring), or using a combination of both modalities. The recommended frequency for both in-person and remote monitoring is based on patient-specific factors – such as left ventricular function or the possible presence of atrial arrhythmias – and device-specific factors – such as device type (e.g., PM or ICD) and possible hardware issues (e.g., the lead under advisory due to higher than expected failure rates). The data collected at follow-up should be tailored to fit the individual clinical scenario, but often include battery voltage and impedance, magnet rate, sensing and pacing thresholds, review of programmed parameters, pacing requirements, device therapies and detected arrhythmias, haemodynamic measurements, and lead parameters and impedances – plus, for defibrillators, charge time and shock impedance.3

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