L. Van Erven

Risk factors and time delay associated with cardiac device infections: Leiden device registry

Aims: A nested case-control study of 75 patients with cardiac device infections (CDI) and 75 matched controls was conducted to evaluate time course, risk factors, culture results and frequency of CDI. Methods and results: CDI occurred in 75/3410 (2.2%) device implantation and revision procedures, performed between 2000 and 2007. The time delay between device procedure and infection ranged from 0 to 64 months (mean 14 (SD 16)), 21 patients (28%) had an early infection (<1 month), 26 (35%) a late infection (1–12 months) and 28 (37%) a delayed infection (>12 months). Of interest, 18 (24%) patients presented with an infection >24 months after the device-related procedure. Time delay until infection was significantly shorter when cultures were positive for micro-organisms compared to negative cultures (8 (12) vs 18 (18) months, p = 0.03). Pocket cultures in delayed infections remained more often negative (61% vs 23%, p = 0.01). Independent CDI risk factors were: device revision (odds ratio (OR) 3.67; 95% confidence interval (CI), 1.51 to 8.96), renal dysfunction defined as glomerular filtration rate <60 ml/min (OR 4.64; CI, 1.48 to 14.62) and oral anticoagulation use (OR 2.83; CI 1.20 to 6.68). Conclusion: CDI occurred in 2.2% of device procedures, with 24% occurring more than two years after the device-related procedure. Renal dysfunction, device revisions and oral anticoagulation are potent risk factors for CDI.

Cardiac resynchronisation therapy in chronic atrial fibrillation: impact on left atrial size and reversal to sinus rhythm

Objective: To evaluate the impact of long term cardiac resynchronisation therapy (CRT) on left atrial and left ventricular (LV) reverse remodelling and reversal to sinus rhythm (SR) in patients with heart failure with atrial fibrillation (AF). Patients: 74 consecutive patients (age 68 (8) years; 67 men) with advanced heart failure and AF (20 persistent and 54 permanent) were implanted with a CRT device. Main outcome measures: Patients were evaluated clinically (New York Heart Association (NYHA) class, quality of life, six minute walk test) and echocardiographically (LV ejection fraction, LV diameters, and left atrial diameters) before and after six months of CRT. Additionally, restoration of SR was evaluated after six months of CRT. Results: NYHA class, quality of life score, six minute walk test, and LV ejection fraction had improved significantly after six months of CRT. In addition, left atrial and LV end diastolic and end systolic diameters had decreased from 59 (9) to 55 (9) mm, from 72 (10) to 67 (10) mm, and from 61 (11) to 56 (11) mm, respectively (all p < 0.01). During implantation 18 of 20 (90%) patients with persistent AF were cardioverted to SR. At follow up 13 of 18 (72%) patients had returned to AF and none had spontaneously reverted to SR; thus, only 5 of 74 (7%) were in SR. Conclusion: Six months of CRT resulted in significant clinical benefit with significant left atrial and LV reverse remodelling. Despite these beneficial effects, 93% of patients had not reverted to SR.

The dialysis procedure as a trigger for atrial fibrillation: new insights in the development of atrial fibrillation in dialysis patients

Aims Atrial fibrillation (AF) is common in dialysis patients and is associated with increased morbidity and mortality. The pathophysiology may be related to common risk factors for both AF and renal disease or to dialysis-specific factors. The purpose of this study was to determine whether and how AF onset relates to the dialysis procedure itself. Methods All dialysis patients enrolled in the implantable cardioverter defibrillator-2 (ICD-2) trial until January 2012, who were implanted with an ICD, were included in this study. Using the ICD remote monitoring function, the exact time of onset of all AF episodes was registered. Subsequently, this was linked to the timing of dialysis procedures. Results For the current study, a total of 40 patients were included, follow-up was 28±16 months, 80% male, 70±8 years old. A total of 428 episodes of AF were monitored in 14 patients. AF onset was more frequent on the days of haemodialysis (HD) (p<0.001) and specifically increased during the dialysis procedure itself (p=0.04). Patients with AF had a larger left atrium (p<0.001) and a higher systolic blood pressure before and after HD (p<0.001). Conclusion This study provides insight in the exact timing of AF onset in relation to the dialysis procedure itself. In HD patients, AF occurred significantly more often on a dialysis day and especially during HD. These findings might help to elucidate some aspects of the pathophysiology of AF in dialysis patients and could facilitate early detection of AF in these high-risk patients.

Atrial and brain natriuretic peptides as markers of response to resynchronisation therapy

Cardiac resynchronisation therapy (CRT) has recently been introduced to treat patients with drug refractory heart failure.1,2 Studies have demonstrated immediate haemodynamic improvement after CRT, followed by improvement in symptoms, quality of life, and exercise capacity.1,2 Although the majority of patients respond well to CRT, in 20% of patients symptoms do not improve. The main problem is the lack of objective parameters to measure the effect of CRT. Natriuretic peptides are now used in studies involving patients with heart failure.3 The value of these markers to objectively assess response to CRT was evaluated in this study. Based on traditional selection criteria (New York Heart Association (NYHA) functional class III–IV, left ventricular ejection fraction (LVEF) 120 ms, and left bundle branch block configuration), 30 consecutive patients, of whom 23 were men (mean (SD) age 65 (12) years), underwent biventricular pacemaker implantation; 13 had ischaemic and 17 had idiopathic dilated cardiomyopathy. Medication consisted of diuretics, angiotensin converting enzyme inhibitors, spironolactone, β blockers, and/or amiodarone, and remained unchanged during the entire study. The day before implantation, echocardiography was performed in combination with tissue Doppler imaging (TDI) (to assess left ventricular dyssynchrony). Clinical evaluation included assessment of NYHA class, ECG (QRS duration, morphology), quality of life, and six minute walking distance. Blood samples were obtained for the analysis of atrial natriuretic peptide (ANP) …

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.

Integration of data from remote monitoring systems and programmers into the hospital electronic health record system based on international standards

Remote follow-up of implanted ICDs may offer a solution to the problem of overcrowded outpatient clinics. All major device companies have developed a remote follow-up solution. Data obtained from the remote follow-up systems are stored in a central database system, operated and owned by the device company and accessible for the physician or technician. However, the problem now arises that part of the patient’s clinical information is stored in the local electronic health record (EHR) system in the hospital, while another part is only available in the remote monitoring database. This may potentially result in patient safety issues. Ideally all information should become available in the EHR system. IHE (Integrating the Healthcare Enterprise) is an initiative to improve the way computer systems in healthcare share information. To address the requirement of integrating remote monitoring data in the local EHR, the IHE Implantable Device Cardiac Observation (IDCO) profile has been developed. In our hospital, we have implemented the IHE IDCO profile to import data from the remote databases from two device vendors into the departmental Cardiology Information System. Data are exchanged via an HL7/XML communication protocol, as defined in the IHE IDCO profile.

Evaluation of resynchronization of contractile function following biventricular pacing using colour tissue Doppler imaging

Biventdcular (BV) pacing is evaluated as an alternative treatment for patients with dilated cardiomyppathy (both ischemic and non-ischemic) and end-stage heart failure. Colour tissue Doppler imaging using echocardiography allows noninvasive, quantitative assessment of radial motion in the long-axis with measurement of peak systolic velocity timing. The aim of the present study was to evaluate quantitatively, the systolic performance of the left ventricle and the resynchrenization of contraction (before vs after implantation). Patients and methods: 25 patients with dilated cardiomyopathy (11 ischemic), NYHA class III or IV, QRS duration >120 ms received a biventricular pacemaker. Routine 2D echo and colour tissue Doppler imaging were performed before and within 1 week following implantation. LVEF was assessed using the biplane Sampsons method.Peak systolic velocity (PSV) and time to PSV (TPV) were assessed in 4 regions (basal anterior, inferior, lateral and septal). By averaging the TPV from all 4 regions, a synchronization index was dedved from these measurements. Reaults: LVEF improved by 9±9% following pacing; 17 patients improved LVEF 5% or more. The change in PSV in the septal and lateral regions related significantly to the change in LVEF (r=0.74, r=0.62).The change in synchronization index before vs after pacing (as a measurement of REsynchronization) was related to the change in LVEF (y=120x+5.6, r=0.79, P<0,01). Using a change in synchronization of 40, a sensitivity of 76% and a specificity of 100% were obtained to predict improvement of LVEE Conclusion: Colour tissue Doppler imaging allows assessment of resynchronization of contraction following BV pacing and may be used to predict change in LVEE

Fusion of electrophysiology mapping data and angiographic images to facilitate radiofrequency ablation

Localization of target sites for radiofrequency catheter ablation (RFCA) is facilitated by the identification of abnormal electrograms at specific endocardial sites. With new 3-D electro-anatomical mapping systems such as the CARTO/sup TM/ system and the Real-time Positioning Management System/sup TM/ (RPM) the 3-D position of EP catheters can be visualized and recorded Detailed information about anatomical structures can only be obtained by standard imaging modalities, such as ventricular angiography. Combination of information obtained from the 3-D mapping systems with angiographic image information would therefore greatly enhance the applicability of these systems. In patients referred for ventricular tachycardia, the XYZ-coordinates of the ablation catheter positions, were obtained with the RPM system, and visualized in 3-D space. In addition, biplane angiographic images were obtained in these patients to confirm the geometric findings of the mapping system, and to display the ablation locations superimposed on the angiographic images. Analysis of the mapping and angiography data revealed that it is not feasible to create an accurate 3-D representation of a heart chamber based on two angiographic projections. Therefore, fusion of mapping data and angiographic images was not possible as planned. However, new ideas are presented that may make this fusion possible in the near future.

Eligibility for biventricular pacing in patients with an implantable cardioverter defibrillator

Implantable cardioverter defibrillator (ICD)‐therapy prevents sudden death in patients at high risk, but incidence of death due to heart failure remains unaltered. Recent data suggest that biventricular (BV) pacing is useful in patients with heart failure. It is unclear, how many patients with an ICD indication may have an indication for BV pacing. Therefore all patients who received an ICD were analyzed for eligibility of BV pacing using the following criteria: NYHA class III or IV, QRS duration >120 ms, depressed LVEF. Three hundred and ninety consecutive patients received an ICD from June 1996 to March 2001. Underlying disease was ischemic heart disease in 66%. In the 390 patients the mean LVEF was 36±17%, 20% were in NYHA class III–IV and 16% were in NYHA class II with an LVEF <30%. Of these 140 patients, 79 had a QRS duration >120 ms. Thus, 79 (20%) patients were eligible for BV pacing in addition to ICD‐therapy. Patients who received a BV pacemaker in addition to ICD‐therapy had a superior survival, improved in NYHA class and showed a significantly lower hospitalization rate as compared to patients who received an ICD only. Screening for eligibility of BV pacing may be considered in patients with CHF scheduled for ICD implantation.

Wireless LV endocardial stimulation for cardiac resynchronisation: 12 month experience of clinical efficacy and clinical events

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