RESUMO
Remote control (RC) of cardiac implantable electronic devices (CIEDs) has been tested as safe and effective in the magnetic resonance imaging space. We sought to evaluate RC applications of patients at home. RC of cardiac devices in patients' homes is feasible, safe, and effective, with consistent patient satisfaction. Patients with CIEDs using the CareLink™ network (Medtronic, Minneapolis, MN, USA) participated in a pair of home RC sessions. A technician visited the patient's house and set up a telehealth tablet and a programmer, which included inputting a session key enabling programmer access via a third-party host. The investigator video-conferenced with the patient and remotely controlled the programmer for device testing and data assessment, using a cellular hotspot for Internet connection. Reprogramming was performed as necessary. In all cases, an RC session legend was programmed in the device information field as a control. The patients then completed an experience questionnaire. One hundred fifty patients (99 pacemakers and 51 implantable cardioverter-defibrillators) completed 2 RC sessions, for 300 RC sessions in total. There were no complications or communication interruptions once the system communication proved stable after the first minute. In 26 sessions, initial communication was interrupted upon device interrogation, requiring communication to be re-established (which sometimes necessitated switching to an alternative carrier). Clinically driven parameter reprogramming was performed in 58 RC sessions (39%). Programming of notations concerning RC sessions was performed in all 300 sessions. The average duration of the RC sessions was 11 min. Patients' satisfaction scored 4.5 out of 5 points. In conclusion, RC management of cardiac devices at patients' homes is safe, effective, convenient, and associated with high patient satisfaction. This technology may prove very useful in a changing health care delivery system, especially amid the coronavirus disease 2019 pandemic.
RESUMO
Atrial fibrillation (AF) is a known risk factor of ischemic stroke with a reported fivefold increase in incidence. However, it is not well established whether treatment with oral anticoagulation (OAC) in cryptogenic stroke patients with AF, detected by insertable cardiac monitors (ICMs), reduces the risk of recurrent stroke. We aimed to compare recurrent stroke rates between cryptogenic stroke patients who have AF detected by ICMs and thus started on OAC treatment and those without detected AF. We performed a combined retrospective and prospective analysis of consecutive patients who received an ICM indicated for cryptogenic stroke and were followed up with between July 2015 and November 2019. Patients with a prior documented history of AF were excluded. All patients were required to have a home remote monitoring system. We calculated the rates of AF detection and OAC initiation, then compared recurrent annualized stroke rates (ASRs) between patients with and without AF detected. A total of 298 patients with ICMs were included in the study [mean ± standard deviation age: 77 ± 11.7 years; female/male: 147/151; virtual CHA2DS2-VASc score: 4.96 ± 1.28 points]. AF was discovered in 91 patients (~30%) over a mean 19.3 months follow-up. Of those, 65 (71.4%) were started on OAC, 12 (13.2%) were already on OAC, and 10 (11%) remained non-anticoagulated. In four (4.4%) patients, OAC was started after recurrent stroke when AF was diagnosed. A total of 24 of 298 patients developed recurrent strokes (ASR: 5.0%). Among the 24 patients with recurrent strokes, four had new AF and were on OAC (ASR: 3.23%), six had new AF and were not anticoagulated (ASR: 26.62%), and 14 had no AF detected and no OAC (ASR: 4.20%). Our study found new AF detected by ICMs in almost one-third (30%) of cryptogenic stroke patients (consistent with previous studies), and the majority of them (89%) received OACs. There was no significant difference in the recurrent stroke rate among patients without AF detected and those with AF detected and on OAC. Rigorous arrhythmia monitoring using ICMs can increase new AF detection rates in cryptogenic stroke patients, thereby allowing early initiation of OACs, ultimately reducing the risk of recurrent stroke to background levels.
RESUMO
BACKGROUND: The beginning of ventricular overdrive pacing (VOP) during supraventricular tachycardia (SVT) accurately distinguishes orthodromic reentrant tachycardia (ORT) from atrioventricular nodal reentrant tachycardia (AVNRT) even when pacing terminates tachycardia. Tachycardia resetting most often occurs during this transition zone (TZ) of QRS fusion in ORT and after this TZ in AVNRT. The end of the TZ is marked by the first beat with a stable QRS morphology but is a subjective assessment. Disagreement concerning this beat may change tachycardia diagnosis. OBJECTIVE: The purpose of this study was to assess interobserver agreement for identifying the TZ and whether disagreement affected diagnosis. METHODS: Seventy-nine consecutive patients with inducible ORT and AVNRT were included. Resetting of tachycardia was evaluated by (1) atrial timing perturbation and (2) fixed stimulation-atrial activation timing (SA). Two blinded observers identified the end of the TZ and used the two resetting criteria to establish a diagnosis. Diagnostic results were compared with standard criteria for SVT diagnosis. The diagnosis was considered correct if both electrophysiologists' TZ assessment resulted in a correct diagnosis. RESULTS: Agreement on the TZ occurred in 80% (148/186) of VOP trains. In ORT patients, tachycardia resetting occurred during the TZ and correctly diagnosed ORT based on atrial timing perturbation and fixed SA in 91% and 98% of VOP trains, respectively. In AVNRT patients, tachycardia resetting occurred after the TZ and correctly diagnosed AVNRT based on atrial timing perturbation and fixed SA in 93% and 94% of VOP trains, respectively. CONCLUSION: Resetting criteria used during the VOP TZ accurately differentiate between ORT and AVNRT despite interobserver disagreement concerning identification of the TZ.
