Home Monitoring technology and integrated follow-up care of ICD patients.

OBJECTIVE: Increasing utilization rates of implantable cardioverter-defibrillators (ICDs) tend to overburden follow-up resources at the implanting electrophysiological centres (ECs). Remote monitoring technology allows physicians from different institutions to simultaneously review ICD data of shared patients. We studied if an integrated follow-up care involving ECs and general cardiologists (GCs) may reduce the frequency of in-office follow-ups at ECs by using remote monitoring data to identify routine checks that may be conducted at GCs. METHODS AND RESULTS: The analysis included 109 patients (aged 63 +/- 11 years, 84.4% male) followed for a cumulative study duration of 155 patient-years. The patients underwent 436 in-office controls after hospital discharge: 143 (33%) at two ECs and 293 (67%) at two GCs (each cooperating with one EC). The mean duration of in-office follow-up sessions was 13.7 min (EC) and 10.3 min (GC). The average distance between patients' homes and follow-up sites was 31.6 km (EC) vs. 16.2 km (GC). Investigators considered a follow-up to be of'high or medium'importance in 78% (EC) vs. 45% (GC) of all in-office follow-ups. At one EC, the integrated follow-up care concept appeared highly successful, with 97% of follow-ups transferred to the corresponding GC and, on average, 103.8 km shorter patient trips per follow-up. CONCLUSIONS: Integrated follow-up care guided by remote monitoring allows to direct the more significant follow-ups towards ECs and routine follow-ups towards GCs.This concept may contribute to the needed adaptations of the health-care system to the rising numbers of patients with implanted devices.

Conversion of recent-onset atrial fibrillation or flutter with ibutilide after amiodarone has failed.

OBJECTIVE: To evaluate whether ibutilide can convert atrial fibrillation or flutter in patients in whom amiodarone has failed. DESIGN AND SETTING: Clinical study in a university hospital intensive care unit (ICU). PATIENTS: Twenty-six patients were studied, in whom atrial fibrillation or flutter persisted for a maximum of 6 h at maximum. Patients were monitored continuously during the arrhythmia. Medical conversion was necessary due to symptomatic or hemodynamic causes. INTERVENTIONS: All patients initially received amiodarone (150 mg i.v.) and after 2 h of persistent arrhythmia ibutilide (1 mg or, without success and body weight > 70 kg, 2 mg i.v.). Before the administration of ibutilide 1 g magnesium was administered, and high normal levels of potassium serum levels were achieved (4.5-5.0 mmol/l). RESULTS. After amiodarone atrial flutter persisted in 73% and atrial fibrillation in 27% of patients. After ibutilide the QT interval was prolonged from 327 +/- 61 to 387 +/- 62 ms. The QTc interval increased from 456 +/-32 to 461 +/- 66 ms. Conversion to normal sinus rhythm was achieved in 22 of 27 of cases. Nonsustained torsade de pointes tachycardia was seen in three patients (11%). No patient showed sustained ventricular tachycardia. Patients with proarrhythmic effects were characterized by a decreased left ventricular function. CONCLUSIONS: In ICU patients ibutilide led to conversion to sinus rhythm in 81.5% of patients in whom amiodarone was unsuccessful. Nonsustained tachycardias were seen in 11%; sustained ventricular tachycardia was not seen. Ibutilide seems to be well suitable for conversion of recent onset atrial fibrillation or flutter and had no severe side effects in this study population.

Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment.

OBJECTIVES: We sought to determine the incidence of arteriovenous fistulas (AVF), identify risk factors for AVF, and follow up the clinical outcome of femoral AVF. BACKGROUND: Arteriovenous fistulas are a potential harmful complication of cardiac catheterization. Incidence and clinical outcome of iatrogenic AVF are unknown so far, although important for risk stratification and treatment. METHODS: A total of 10,271 consecutive patients undergoing cardiac catheterization were followed up prospectively over a period of three years. Diagnosis of AVF was performed by duplex sonography. RESULTS: The incidence of AVF was 0.86% (n = 88). The following significant and independent risk factors for AVF were identified: high heparin dosage (odds ratio [OR]) = 2.88), coumadin therapy (OR = 2.34), puncture of the left groin (OR = 2.21), arterial hypertension (OR = 1.86), and female gender (OR = 1.84). Within 12 months 38% of all AVF closed spontaneously. No signs of cardiac volume overload or limb damage were observed in patients with persisting AVF. None of the risk factors for AVF influenced the incidence or the rate of AVF closure. Only intensified anticoagulation showed a tendency to extend AVF persistence. CONCLUSIONS: Almost 1% of patients undergoing cardiac catheterization acquire femoral AVF, for which patient- and procedure-related risk factors could be identified. One-third of iatrogenic AVF close spontaneously within one year. Cardiac volume overload and limb damage are highly unlikely with AVF persistence. Thus, a conservative management for at least one year seems to be justified.