Michał Chudzik

ISHNE/EHRA expert consensus on remote monitoring of cardiovascular implantable electronic devices (CIEDs)

We are in the midst of a rapidly evolving era of technology-assisted medicine. The field of telemedicine provides the opportunity for highly individualized medical management in a way that has never been possible before. Evolving medical technologies using cardiac implantable devices (CIEDs) with capabilities for remote monitoring permit evaluation of multiple parameters of cardiovascular physiology and risk, including cardiac rhythm, device function, blood pressure values, the presence of myocardial ischaemia, and the degree of compensation of congestive heart failure. Cardiac risk, device status, and response to therapies can now be assessed with these electronic systems of detection and reporting. This document reflects the extensive experience from investigators and innovators around the world who are shaping the evolution of this rapidly expanding field, focusing in particular on implantable pacemakers (IPGs), implantable cardioverter-defibrillators (ICDs), devices for cardiac resynchronization therapy (CRT) (both, with and without defibrillation properties), loop recorders, and haemodynamic monitoring devices. This document covers the basic methodologies, guidelines for their use, experience with existing applications, and the legal and reimbursement aspects associated with their use. To adequately cover this important emerging topic, the International Society for Holter and Noninvasive Electrocardiology (ISHNE) and the European Heart Rhythm Association (EHRA) combined their expertise in this field. We hope that the development of this field can contribute to improve care of our cardiovascular patients.

ISHNE/EHRA Expert Consensus on Remote Monitoring of Cardiovascular Implantable Electronic Devices (CIEDs)

We are in the midst of a rapidly evolving era of technology‐assisted medicine. The field of telemedicine provides the opportunity for highly individualized medical management in a way that has never been possible before. Evolving medical technologies using cardiac implantable devices with capabilities for remote monitoring permit evaluation of multiple parameters of cardiovascular physiology and risk, including cardiac rhythm, device function, blood pressure values, the presence of myocardial ischaemia, and the degree of compensation of congestive heart failure. Cardiac risk, device status, and response to therapies can now be assessed with these electronic systems of detection and reporting. This document reflects the extensive experience from investigators and innovators around the world who are shaping the evolution of this rapidly expanding field, focusing in particular on implantable pacemakers, implantable cardioverter defibrillators, devices for cardiac resynchronization therapy (both with and without defibrillation properties), loop recorders, and hemodynamic monitoring devices. This document covers the basic methodologies, guidelines for their use, experience with existing applications, and the legal and reimbursement aspects associated with their use. To adequately cover this important emerging topic, the International Society for Holter and Noninvasive Electrocardiology and the European Heart Rhythm Association combined their expertise in this field. We hope that the development of this field can contribute to improve care of our cardiovascular patients.

Endocardial Lead Extraction in the Polish Registry - clinical practice versus current Heart Rhythm Society consensus.

Introduction Over the last 10 years, there has been an increasing number of patients with pacemaker (PM) and cardioverter-defibrillator (ICD). This study is a retrospective analysis of indications for endocardial pacemaker and ICD lead extractions between 2003 and 2009 based on the experience of three Polish Referral Lead Extraction Centers. Material and methods Since 2003, the authors have consecutively retrospectively collected all cases and entered the information in the database. All patients which had indication for lead extraction according to Heart Rhythm Society Guidelines were included to final analyze. Between 2003 and 2005, the data were analyzed together. Since 2006, data have been collected and analyzed annually. Results In each year, a significant increase in lead extraction was observed. The main indications for LE were infections in 52.4% of patients. Nonfunctioning lead extraction constituted the second group of indications for LE in 29.7% of patients. During the registry period, the percentage of class I indications decreased from 80% in 2006 to only 47% in 2009. On the other hand, increasingly more leads were removed because of class 2, especially class 2b. In 2009, 40% of leads were extracted due to class 2b. Conclusions Polish Registry of Endocardial Lead Extraction 2003-2009, shows an increasing frequency of lead extraction. The main indication for LE is infection: systemic and pocket. An increase in class 2, especially 2b, LE indication in every center during the study period was found.

Pacing and sensing disturbances in patients with DDD pacemakers in the early period after implantation.

Objectives — We sought to determine the usefulness of ambulatory 24-hour Holter monitoring in detecting asymptomatic pacemaker (PM) malfunction episodes in patients with dual-chamber pacemakers whose pacing and sensing parameters were proper, as seen in routine post-implantation follow-ups.This aspect has not been widely discussed so far. Methods and results — Ambulatory 24-hour Holter recordings [HM] were performed in 100 patients with DDD pacemakers one day after the implantation. Only asymptomatic patients with proper pacing and sensing parameters (assessed on PM telemetry on the first day post-implantation) were enrolled in the study.The following parameters were assessed: failure to pace, failure to sense (both oversensing and undersensing episodes) as well as the percentage of all PM disturbances. Despite proper sensing and pacing parameters, HM revealed PM disturbances in 23% of the patients. Atrial undersensing episodes were found in 12 patients and failure to capture in 1 patient. T wave oversensing was the most common ventricular channel disorder (9 patients). Malfunction episodes occurred sporadically, leading to pauses of up to 1.6 s or temporary bradycardia, which were, nevertheless, not accompanied by clinical symptoms. No ventricular pacing disturbances were found. Conclusion — Asymptomatic pacemaker dysfunction may be observed in nearly 25% of patients with proper DDD parameters after implantation.Thus, ambulatory HM during the early post-implantation period may be a useful tool to detect the need to reprogramme PM parameters.

Short-term ECG recordings for heart rate assessment in patients with chronic atrial fibrillation

Introduction There is no consensus on the length of ECG tracing that should be recorded to represent adequate rate control in patients with atrial fibrillation (AFib). The purpose of the study was to examine whether heart rate measurements based on short-term ECGs recorded at different periods of the day may correspond to the mean heart rate and rate irregularity analyzed from standard 24-hour Holter monitoring. Material and methods The study enrolled 50 consecutive patients with chronic AFib who underwent 24-hour Holter monitoring. Mean heart rate (mHR) and the coefficient of irregularity (CI) were assessed from 5- and 60-minute intervals of Holter recordings in different periods of the day. Results The highest correlation in mean heart rate interval within 24 h was found during a 6-hour sample and in the periods 11.00 AM–12.00 PM, 12 PM–1.00 PM, and 1.00 PM–2.00 PM. With respect to irregularity, only the CI measurements based on a 6-hour interval (7.00 AM–1.00 AM) show a correlation > 0.08 compared to data from the 24-hour recording. Conclusions Only long-term (6-hour) recordings provide a high correlation within 24 h in mean heart rate interval and coefficient of irregularity. It seems that the mean heart rate interval in 1-hour periods between 11 AM and 2 PM might be predictive for 24-hour data. Short time recordings of the coefficient of irregularity of heart rate in AFib patients at this moment are not useful in clinical practice for long-term prognosis of ventricular irregularity.

Ambulatory Holter monitoring in asymptomatic patients with DDD pacemakers - do we need ACC/AHA Guidelines revision?

Introduction We sought to determine the usefulness of ambulatory 24-hour Holter monitoring in detecting asymptomatic pacemaker (PM) malfunction episodes in patients with dual-chamber pacemakers whose pacing and sensing parameters were proper, as seen in routine post-implantation follow-ups. Material and methods Ambulatory 24-hour Holter recordings (HM) were performed in 100 patients with DDD pacemakers 1 day after the implantation. Only asymptomatic patients with proper pacing and sensing parameters (assessed on PM telemetry on the first day post-implantation) were enrolled in the study. The following parameters were assessed: failure to pace, failure to sense (both oversensing and undersensing episodes) as well as the percentage of all PM disturbances. Results Despite proper sensing and pacing parameters, HM revealed PM disturbances in 23 patients out of 100 (23%). Atrial undersensing episodes were found in 12 patients (p < 0.005) with totally 963 episodes and failure to capture in 1 patient (1%). T wave oversensing was the most common ventricular channel disorder (1316 episodes in 9 patients, p < 0.0005). Malfunction episodes occurred sporadically, leading to pauses of up to 1.6 s or temporary bradycardia, which were, nevertheless, not accompanied by clinical symptoms. No ventricular pacing disturbances were found. Conclusions Asymptomatic pacemaker dysfunction may be observed in nearly 25% of patients with proper DDD parameters after implantation. Thus, ambulatory HM during the early post-implantation period may be a useful tool to detect the need to reprogram PM parameters.

Optimization of atrio-ventricular delay in patients with dual-chamber pacemaker

Development and advances in heart pacing over the last nearly half a century allowed to save numerous lives by providing pacing support in bradycardia and complete heart block. Nevertheless, long-term follow up of patients with implanted pacemaker showed unfavorable remodeling of the heart, both from hemodynamic as well as electrical standpoint. The optimal programmed pacemaker setting, apart from the optimal place for ventricular stimulation, is essential to obtain the best hemodynamic and the clinical after-effects of the stimulation of the heart and to minimize potential unfavorable effects. In patients with dual-chamber pacemaker (DDD) the correct function of the left ventricle of the heart depends mainly on the electric delays between the stimulated chambers. Atrio-ventricular delay (AVD) during dual-chamber pacing influences left ventricle contraction function through preload modulation. Improperly programmed AVD in the DDD pacemaker can have unfavorable hemodynamic results. Various methods have been developed during last few decades (right heart catheterization, ventriculography, peak endocardial acceleration, echocardiography, and impedance cardiography), however only echocardiography and reocardiography are currently in general use. There should be noticed too, that also the application of special algorithms present in modern pacemakers allowing for dynamic changes of the time of the delay represents certain alternative to individual AVD optimization.

Pacemaker Memory Data Compared to Twenty-Four-Hour Holter Monitoring in Patients with VVI Pacemakers and Chronic Atrial Fibrillation

Background: In light of the results from the AFFIRM trial, the “rate control” strategy has become an accepted treatment modality for patients with atrial fibrillation (AF). Establishing effective rate control requires long‐term monitoring of the heart rate. The aim of the study was to compare the heart rate and rhythm monitoring capabilities of the pacemaker memory data (PMD) algorithm and traditional twenty‐four‐hour Holter monitoring.

Risk score to assess mortality risk in patients undergoing transvenous lead extraction: OSZCZYGIEŁ et al .

The main aim of this study was to assess 1‐year mortality and its predictors in a cohort of patients who underwent transvenous lead extraction (TLE) procedure.

Potential benefit of optimizing atrioventricular & interventricular delays in patients with cardiac resynchronization therapy

Background & objectives: The clinical benefit of optimization (OPT) of atrioventricular delay (AVD) and interventricular delay (VVD) in cardiac resynchronization therapy (CRT) remains debatable. This study was aimed to determine the influence of AVD and VVD OPT on selected parameters in patients early after CRT implantation and at mid-term follow up (FU). Methods: Fifty two patients (61±10 yr, 23 males) with left bundle branch block, left ventricular ejection fraction (LVEF) ≤35 per cent and heart failure were selected for CRT implantation. Early on the second day (2DFU) after CRT implantation, the patients were assigned to the OPT or the factory setting (FS) group. Haemodynamic and electrical parameters were evaluated at baseline, on 2DFU after CRT and mid-term FU [three-month FU (3MFU)]. Echocardiographic measures were assessed before implantation and at 3MFU. The AVD/VVD was deemed optimal for the highest cardiac output (CO) with impedance cardiography (ICG) monitoring. Results: On 2DFU, the AVD was shorter in the OPT group, LV was paced earlier than in FS group and CO was insignificantly higher in OPT group. At 3MFU, improvement of CO was observed only in OPT patients, but the intergroup difference was not significant. At 3MFU in OPT group, reduction of LV in terms of LV end-diastolic diameter (LVeDD), LV end-systolic diameter, LV end-diastolic and systolic volume with the improvement in LVEF was observed. In FS group, only a reduction in LVeDD was present. In OPT group, the paced QRS duration was shorter than in FS group patients. Interpretation & conclusions: CRT OPT of AVD and VVD with ICG was associated with a higher CO and better reverse LV remodelling. CO monitoring with ICG is a simple, non-invasive tool to optimize CRT devices.