Clinical and economic impact of remote monitoring on the follow-up of patients with implantable electronic cardiovascular devices: an observational study.

Traditional follow-up of patients with cardiovascular devices is still an activity that, in addition to serving an increasing population, requires a considerable amount of time and specialized human and technical resources. Our aim was to evaluate the applicability of the CareLink(®) (Medtronic, Minneapolis, MN) remote monitoring system as a complementary option to the follow-up of patients with implanted devices, between in-office visits. Evaluated outcomes included both clinical (event detection and time to diagnosis) and nonclinical (patient's satisfaction and economic costs) aspects. An observational, longitudinal, prospective study was conducted with patients from a Portuguese central hospital sampled by convenience during 1 week (43 patients). Data were collected in four moments: two in-office visits and two remote evaluations, reproducing 1 year of clinical follow-up. Data sources included health records, implant reports, initial demographic data collection, follow-up printouts, and a questionnaire. After selection criteria were verified, 15 patients (11 men [73%]) were included, 63.4±10.8 years old, representing 14.0±6.3 implant months. Clinically, 15 events were detected (9 by remote monitoring and 6 by patient-initiated activation), of which only 9 were symptomatic. We verified that remote monitoring could detect both symptomatic and asymptomatic events, whereas patient-initiated activation only detected symptomatic ones (p=0.028). Moreover, the mean diagnosis anticipation in patients with events was approximately 58 days (p<0.001). In nonclinical terms, we observed high or very high satisfaction (67% and 33%, respectively) with using remote monitoring technology, but still 8 patients (53%) stated they preferred in-office visits. Finally, the introduction of remote monitoring technology has the ability to reduce total follow-up costs for patients by 25%. We conclude that the use of this system constitutes a viable complementary option to the follow-up of patients with implantable devices, between in-office visits.

Myxoma in the right ventricular outlow tract.

We present a patient with dyspnea, cyanosis and presyncope during exercise related to intermittent obstruction of the right outflow tract by a myxoma of the right ventricle attached to the membranous interventricular septum by its pedicle. We also review the specific medical and surgical features of such tumors. Right ventricular myxomas are rare benign tumors and clinical manifestations depend mainly on size and site of attachment. They can cause obstructive events, and embolism is also possible. Both forms of clinical presentation are potentially fatal and surgical removal should be urgently scheduled. This is usually curative, although recurrences have been reported, generally when these tumors are part of the Carney complex. The best surgical approach is individualized, and transesophageal echocardiography is an important tool in the decision. In our case right atriotomy was considered the best option.

Isolated pulmonary valve endocarditis due to Pseudomonas aeruginosa.

Isolated endocarditis of the native pulmonary valve is a rare clinical condition. It usually appears in association with certain predisposing factors, particularly intravenous drug abuse, alcohol abuse, sepsis, endovascular infections or congenital heart disease. The authors describe the case of isolated pulmonary valve endocarditis due to Pseudomonas aeruginosa of possible nosocomial origin in the absence of the predisposing factors mentioned above. Native pulmonary valve infection due to Pseudomnzonas aeruginosa in the absence of predisposing factors has not been described in the literature. The authors stress the importance of diagnosing this entity as early as possible as it is associated with high mortality and is on the increase due to the growing number of invasive procedures applied to patients in the hospital environment.

Familial apical hypertrophic cardiomyopathy with aneurysmal evolution--an unusual form.

The authors present the case of a 76-year-old patient with multiple vascular risk factors, admitted with acute coronary syndrome. The initial electrocardiogram was compatible with evolving anterior wall myocardial infarction and the echocardiogram showed an image interpreted in this context as left apical pseudoaneurysm. Complementary echocardiographic findings of atypical apical hypertrophy and echocardiographic screening performed on close relatives suggested apical hypertrophic cardiomyopathy as the most likely diagnosis, later confirmed by genetic study. This unusual presentation with evolution to ventricular aneurysm is probably due to progressive left ventricular apical remodeling and an echocardiographic image similar to that described points to the diagnosis of this entity. We emphasize the rarity of this phenotypic expression of apical hypertrophic cardiomyopathy, in particular with familial association.