C. C. de Cock

Remote monitoring and follow-up of cardiovascular implantable electronic devices in the Netherlands: An expert consensus report of the netherlands society of cardiology

Remote monitoring of cardiac implanted electronic devices (CIED: pacemaker, cardiac resynchronisation therapy device and implantable cardioverter defibrillator) has been developed for technical control and follow-up using transtelephonic data transmission. In addition, automatic or patient-triggered alerts are sent to the cardiologist or allied professional who can respond if necessary with various interventions. The advantage of remote monitoring appears obvious in impending CIED failures and suspected symptoms but is less likely in routine follow-up of CIED. For this follow-up the indications, quality of care, cost-effectiveneness and patient satisfaction have to be determined before remote CIED monitoring can be applied in daily practice. Nevertheless remote CIED monitoring is expanding rapidly in the Netherlands without professional agreements about methodology, responsibilities of all the parties involved and that of the device patient, and reimbursement. The purpose of this consensus document on remote CIED monitoring and follow-up is to lay the base for a nationwide, uniform implementation in the Netherlands. This report describes the technical communication, current indications, benefits and limitations of remote CIED monitoring and follow-up, the role of the patient and device manufacturer, and costs and reimbursement. The view of cardiology experts and of other disciplines in conjunction with literature was incorporated in a preliminary series of recommendations. In addition, an overview of the questions related to remote CIED monitoring that need to be answered is given. This consensus document can be used for future guidelines for the Dutch profession.

Utility and Safety of Prolonged Temporary Transvenous Pacing Using an Active-Fixation Lead:

Transvenous temporary pacing is associated with a substantial dislocation rate reported to range from 10 to 37%. The aim of the study was to assess the safety and utility of a recently introduced 3.5 Fr temporary pacing lead using active fixation in a consecutive series of 36 patients with prolonged (≥48 hours) transvenous temporary pacing (validation group). A group of 36 patients with prolonged transvenous pacing managed with a passive‐fixation lead just prior to the introduction of the active‐fixation lead served as a control group (reference group). Pacing related adverse events included dislocation, inappropriate pacing (i.e., two‐fold or greater increase of initial pacing threshold), local infection, and thrombosis. There were no significant differences in patient characteristics or duration of pacing ( 5.84 ± 2.4 days in the reference group vs 5.94 ± 2.6 days in the validation group). Acute pacing threshold was significantly higher in the validation group as compared to the reference group ( 1.38 ± 0.67 V vs. 0.7 ± 0.21 V, P < 0.01 ). The dislocation rate was significantly lower in the validation group as compared to the reference group (5.5 vs 33.3%, P < 0.001 ). There were 11 (31%) pacing related adverse events in the validation group versus 21 (58%) in the reference group (P < 0.01) . The vast majority of patients in the validation group (75%) had ambulatory temporary pacing. Thus, transvenous temporary pacing using active fixation is safe and is associated with a low dislocation rate and a reduction in pacing related adverse events. (PACE 2003; 26:1245–1248)

patients with coronary stenosis and a fractional flow reserve of ≥ 0.75 measured in daily practice at the VU University Medical center

Objectives. The aim of this study was to analyse the rate of major adverse clinical events in patients with coronary artery disease and a fractional flow reserve (FFR) of ≥0.75 and deferred for coronary intervention in daily practice. Methods. From 1 January to 31 December 2006, FFR measurement was initiated in 122 patients (5%) out of 2444 patients referred for coronary angiography. In two patients FFR measurement failed and in one patient the FFR value could no longer be traced in the documents. Thus, 119 patients (84 men, 64 years, range 41-85) were included in the evaluation (145 lesions). Major adverse clinical events (death, myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG)) and the presence of angina were evaluated at follow-up. Furthermore a cost-effectiveness analysis was performed.Results. In 93 patients (76%) the FFR value was ≥0.75. Seventy of these 93 patients (76%) were treated with medication alone or underwent PCI for a different lesion (medical treatment group). Average duration of follow-up of all 119 patients was 22 months (range 4 days to 30 months). In the medical treatment group seven patients (10%) experienced a major adverse clinical event related to the FFR-evaluated lesion during follow-up. In this study population, the use of FFR measurement is cost-reducing provided that at least 65% of the patients in the medical treatment group has had a PCI with stent implantation when the use of FFR measurement is impossible. In this case, the decision to use PCI with stent implantation is purely based on the angiogram. Conclusions. In patients with a coronary stenosis based on visual assessment and an FFR of ≥0.75 deferral of PCI or CABG is safe in daily clinical practice and saves money. (Neth Heart J 2010;18:402-7.)

Fifty years of cardiac pacing: the dark side of the moon?

Fifty years after its introduction, cardiac pacing has evolved from an experimental medical treatment to an expanding field in todays cardiology. Only recently there is accumulating evidence that prolonged stimulation of the right ventricular apex is associated with clinically significant adverse effects. In this commentary, the potential adverse effects are summarised and potential modifications in contemporary pacing are discussed. (Neth Heart J 2008;16(suppl 1):S12-S14.)

Parallel import and pacemakers: who pays the ferryman?

Fifty years after its introduction in clinical cardiology, artificial pacing for patients with bradyarrhythmias has made a huge leap forward.1 The development from bulky, simple fixed-rate pacemakers to small, complex, multi-programmable devices paralleled the vast technological achievements of the second half of the 20th century. In the late 1990s hope emerged even for patients with severe heart failure, with the introduction of biventricular pacing which resulted in an additional class I indication according to the recent guideline of the European Society of Cardiology.2 Consequently, the number of implantations has steadily increased, resulting in more than 10,000 implantations (both first implants and replacements) in the Netherlands in 2007.

703 Abnormal left ventricular rotational direction predicts acute response to cardiac resynchronization therapy

Background: Left ventricular (LV) torsion is an essential component of cardiac contraction in normal heart function, but is impaired in patients with dilated cardiomyopathy. The aim of this study is to determine the predictive value of impaired torsion for the acute response to cardiac resynchronization therapy (CRT) in these patients. Methods: In 35 CRT candidates and 12 controls, basal and apical LV rotations were calculated using MRI tagging. Impaired torsion was quantified by the correlation between both rotations, where a negative value indicates normal torsion and a positive value indicates a torsion disorder: basal and apical rotations follow the same path. This value was called ‘Torcor’. In patients, LV pressure was measured under atrial-sensed ventricular stimulation, using different pacing combinations. Acute response to CRT was defined by >10% increase in invasively measured dP/dtmax from the best pacing configuration relative to baseline. Torcor was compared between responders, non-responders and controls, and ROC-analysis was performed. Results: Torcor was significantly higher in responders (n=18) than in non-responders (n=17) and controls (0.60±0.55, -0.45±0.55 and 0.68±0.22, resp., p<0.001), but was not significantly different between the non-responder and the control group (p=0.71). ROC analysis resulted in an area under the curve of 0.88, p<0.001, 95% CI: 0.76 to 1.00. The sensitivity and specificity for prediction of response were 83% at a cutoff-value of 0.11.

Cardiac resynchronization therapy: assessment of dyssynchrony and effects on metabolism

In recent years cardiac resynchronization therapy has emerged as a promising new treatment strategy in a subgroup of patients with congestive heart failure and an asynchronous contraction pattern. By simultaneously pacing both right ventricular apex and lateral side of the left ventricle, ventricular synchrony can be partially restored and beneficial effects on cardiac performance can be observed. This review discusses the principles of ventricular dyssynchrony, and the acute and chronic effects of cardiac resynchronization therapy on systolic function, cardiac metabolism, and clinical parameters. Furthermore, the issue of identifying patients who do not respond to this therapy is addressed.