Cardiac Implantable Electric Devices Research Articles

Enhancing risk assessment in Chagas cardiomyopathy: Electrophysiology study stratified by Rassi score

BackgroundChagas cardiomyopathy (CCM) is increasingly prevalent in developed countries due to migration from endemic areas. Accurate risk stratification is crucial due to the variable clinical course of CCM. ObjectiveTo analyze the association between Rassi score progression and electrophysiology study (EPS) changes in CCM patients. MethodsThis prospective, observational cohort study involved CCM patients from two tertiary hospitals. Patients were classified as low, intermediate, or high risk based on the Rassi score. Data collected included demographics, clinical history, and diagnostic tests. EPS assessed AH, HH, and HV intervals, and inducibility of ventricular arrhythmias. Follow-ups were at 30 days and six-month intervals, with individualized discussions for cardiac implantable electric devices (CIED) based on EPS results. ResultsOf 67 screened CCM patients, 59 underwent EPS. The mean Rassi score was 8.7 ± 4.5 points, with 33.8 % low, 38.9 % intermediate, and 27.1 % high risk. EPS abnormalities were found in 57.6 % of patients, mainly VT/VF (52.5 %). Most induced ventricular arrhythmias were monomorphic VT (80.7 %). A significant association was found between Rassi score risk classification and EPS changes (OR = 1.88 95 %CI: 1.15–3.06 p = 0.02). Higher Rassi scores correlated with VT presence on EPS (p = 0.0036). Syncope/pre-syncope had an OR 2.45 95 %CI:1.21–4.94; p = 0.012, independent of Rassi risk. Decreased ejection fraction was linked to EPS changes (p = 0.04). ConclusionEPS changes among CCM was associated with progression of the Rassi score, indicating its utility as a stratification tool. Factors such as the presence of syncope/pre-syncope, decreased LVEF and wall motion abnormalities emerged as independent predictors within Rassi scores for changes in EPS.

Cardiovascular Disease Burden, Mortality, and Sudden Death Risk in Epilepsy: A UK Biobank Study

BackgroundSudden death is the leading cause of mortality in medically refractory epilepsy. Middle-aged persons with epilepsy (PWE) are under investigated regarding their mortality risk and burden of cardiovascular disease (CVD). MethodsUsing UK Biobank, we identified 7786 (1.6%) participants with diagnoses of epilepsy and 6,171,803 person-years of follow-up (mean 12.30 years, standard deviation 1.74); 566 patients with previous histories of stroke were excluded. The 7220 PWE comprised the study cohort with the remaining 494,676 without epilepsy as the comparator group. Prevalence of CVD was determined using validated diagnostic codes. Cox proportional hazards regression was used to assess all-cause mortality and sudden death risk. ResultsHypertension, coronary artery disease, heart failure, valvular heart disease, and congenital heart disease were more prevalent in PWE. Arrhythmias including atrial fibrillation/flutter (12.2% vs 6.9%; P < 0.01), bradyarrhythmias (7.7% vs 3.5%; P < 0.01), conduction defects (6.1% vs 2.6%; P < 0.01), and ventricular arrhythmias (2.3% vs 1.0%; P < 0.01), as well as cardiac implantable electric devices (4.6% vs 2.0%; P < 0.01) were more prevalent in PWE. PWE had higher adjusted all-cause mortality (hazard ratio [HR], 3.9; 95% confidence interval [CI], 3.01-3.39), and sudden death-specific mortality (HR, 6.65; 95% CI, 4.53-9.77); and were almost 2 years younger at death (68.1 vs 69.8; P < 0.001). ConclusionsMiddle-aged PWE have increased all-cause and sudden death-specific mortality and higher burden of CVD including arrhythmias and heart failure. Further work is required to elucidate mechanisms underlying all-cause mortality and sudden death risk in PWE of middle age, to identify prognostic biomarkers and develop preventative therapies in PWE.

Octogenarian patients and laser-assisted lead extraction: Should we put a limit?

Transvenous laser lead extraction (TLE) for cardiac implantable electric devices (CIED) is a challenging procedure especially if performed in octogenarians. In this study we evaluated the safety and efficacy of transvenous laser lead extraction in elderly patients. This is a retrospective study of octogenarian patients who underwent laser-assisted lead extraction (LLE) (GlideLight laser sheath, Philips, San Diego, USA). 270 Consecutive patients were included. Patients were divided into two groups. Octogenarian group and non-octogenarian group. The Data was gathered from patients treated between September 2013 and January 2020 and is retrospectively analyzed. Of 270 consecutive patients, 38 (14.0%) were 80 years old or more. The total number of the extracted leads was 556 among which 84(15.0%) from the Octogenarian group. From these leads were 155 single coil leads, 82 dual coil leads, 129 right ventricular pacing leads, 155 right atrial leads, and 35 left ventricular leads. In the Octogenarian group the number of removed leads was as follows: 13 single coil leads, 10 dual coil leads, 28 right ventricular pacing leads, 28 right atrial leads and 5 left ventricular leads. No mortality was recorded in the Octogenarian group. One patient in the YG suffered from a superior vena cava tear and one patient suffered from pulmonary embolism. In octogenarian laser assisted lead extraction patients is a safe and effective procedure. No increase in morbidity, mortality or perioperative complication could be recorded in this group. Age should not be a limiting factor to perform this procedure.

Cardiac implantable electric devices in forensic medicine : Overview from the forensic and cardiology perspective

In 2021, about 75,000persons in Germany died unnaturally or due to unexplained reasons. As aconsequence, there are difficulties in more precisely identifying the time, cause and circumstances of death. Nevertheless, clarification is crucial not only from the clinical perspective, but these data are of considerable importance in the context of investigative procedures as they can be used to answer numerous legally relevant questions. Cardiac implantable devices (CIED) are of vital importance in the treatment of cardiac arrhythmias. In 2020 about 100,000patients underwent CIED implantation in Germany. Therefore, CIED are present in arelevant proportion of the deceased mentioned above. The valuable source of information represented by postmortal CIED interrogation has been shown in numerous studies. Nevertheless, postmortal CIED interrogation is not routinely performed in the context of forensic medical examinations for reasons of practicability. This article summarizes benefits and limitations of postmortal CIED interrogation from the perspective of forensic medicine and cardiology and gives arecommendation for realization.

Pacemaker infection in fragile patients

Complications associated with cardiac implantable electric devices (CIED) are manifold. They include lead dislocation, twiddler's syndrome, device malfunction, haematoma formation and infection. Infections can be divided into acute, subacute and late infections. Both the time of onset and the route of infection play acrucial role. The consequences of aCIED infection are devastating. The most modern treatment methods include the removal of all implanted implants. If complete removal is not followed in the event of infection, there is ahigh rate of infection recurrence. Open thoracic surgery to remove infected CIED hardware has been replaced by percutaneous lead extraction procedures. Lead extraction requires specialised equipment and expertise and may not be readily available or feasible for some patients. Each extraction procedure is associated with asmall risk of potentially fatal complications (e.g. cardiac avulsion, vascular avulsion, haemothorax and cardiac tamponade). For these reasons, the performance of such procedures should be limited to centres with adequate equipment and experience. Successful salvage of CIED systems with in situ sterilisation of contaminated hardware has been reported. In our case, we report the successful salvage of an exposed generator in afrail patient treated more than 5years after the last generator replacement.

Performance of alert transmissions from cardiac implantable electronic devices to the CareLink network: A retrospective analysis

Remote monitoring of cardiac implantable electric devices improves patient outcomes and experiences. Alert-based systems notify physicians of clinical or device issues in near real-time, but their effectiveness is contingent upon device connectivity. To assess patient connectivity by analyzing alert transmission times from patient transceivers to the CareLink network. Alert transmissions were retrospectively gathered from a query of the United States de-identified Medtronic CareLink database. Alert transmission time was defined as the duration from alert occurrence to arrival at the CareLink network and was analyzed by device type, alert event, and alert type. Using data from previous studies, we computed the benefit of daily connectivity checks. The mean alert transmission time was 14.8 hours (median = 6 hours), with 90.9% of alert transmissions received within 24 hours. Implantable pulse generators (17.0 ± 40.2 hours) and cardiac resynchronization therapy-pacemakers (17.2 ± 42.5 hours) had longer alert transmission times than implantable cardioverter-defibrillators (13.7 ± 29.5 hours) and cardiac resynchronization therapy-defibrillators (13.5 ± 30.2 hours), but the median time was 6 hours for all 4 device types. There were differences in alert times between specific alert events. Based on our data and previous studies, daily connectivity checks could improve daily alert transmission success by 8.5% but would require up to nearly 800 additional hours of staff time on any given day. Alert transmission performance from Medtronic devices was satisfactory, with some delays likely underscored by patient connectivity issues. Daily connectivity checks could provide some improvement in transmission success at the expense of increased clinic burden.

Novel findings of an old algorithm: PVC response "Atrial Pace'' initiates atrial arrhythmias in Abbott ICD and CRT-D devices.

Many algorithms have been developed to ensure the safety and accuracy of cardiac implantable electric devices (CIED). A specific algorithm designed to prevent pacemaker induced tachycardia (PMT) after a premature ventricular complex (PVC response) is available in all Abbott (former St. Jude Medical) CIED. However, a few case reports suggest that this algorithm may be proarrhythmic when programmed to Atrial Pace (A-Pace on PVC). We analyzed the data of all (n=333) Abbot implantable cardioverter defibrillator (ICD) and cardiac resynchronization defibrillator (CRT-D) devices followed remote using the Merlin.net Patient Care Network in our institute in 2020. Status of the PVC response algorithm A-Pace on PVC or Off was collected, and all atrial mode switch (AMS) episodes longer than 30 s were thoroughly evaluated. Data on clinical characteristics of the patients was collect from the electronic patient records. A total of 173 patients had A-Pace on PVC and twenty-five of them (14%) had at least one atrial high rate episode (AHRE) >30 s (AHRE) triggered by the action of this algorithm. The median PVC count was higher in patients who had algorithm triggered AHRE than in those with no algorithm-triggered AHRE (1.7% [IQR 0-3.2] vs. 0% [IQR 0-1.1], p<.0001). The major clinical characteristics were comparable in the two groups. The A-Pace on PVC setting was frequently used in our patients. Our study shows that a considerable number of patients had at least one AHRE triggered by the algorithm. The use of this algorithm should be carefully reconsidered.

New York Heart Association class change on heart failure patients with implantable devices: does it matters?

Abstract Background Chronic heart failure (CHF) is a pathology with high prevalence and an important cause of morbidity and mortality. Benefits of implantable devices have been demonstrated in selected groups of patients with benefits on symptoms and heart failure hospitalization. Purpose To determine the clinical impact of New York Heart Association class change (NYHA) in patients with CHF and Cardiac Implantable Electric Devices (CIEDs). Methods We retrospectively enrolled 178 consecutive patients with CHF and CIEDs between November 2003 and January 2021, during a follow-up period of 51±43,9 months. Patients demographic characteristic and NYHA class change impact on occurrence of arrhythmic events, heart failure hospitalization (HFH) or long-term admission in an emergency department were assessed. Patients with NYHA class change were considered responders to therapy. Results Out of 178 patients enrolled in this study, sixty-seven (37,6%) had a reduction ≥1 in NYHA functional class and in this group, 61 patients (91,0%) had a cardiac resynchronization therapy (CRT) and 9% had an implantable cardioverter defibrillator. Mean age 68±11,3 years, 44 (65,7%) patients were male, 33 (49,2%) were in NYHA class II, 30 (44,8%) NYHA class III and 4 (6%) NYHA class IV. Mean QRS width 129,9±63,1 ms before CIEDs. Fifty-eight patients (86,6%) had an improvement in one NYHA functional class and 9 patients (13,4%) in two NYHA functional class. Fourty NYHA responders patients (59,7%) had paroxistic or permanent atrial fibrillation and 31,9% had an epicardial coronary artery disease, that was a negative predictor of NYHA response (p=0,012). A total of 35 (19,7%) enrolled patients experience non-sustained ventricular tachycardia (NSVT) and 74,3% were non-responders (p=0,019). There was fifteen and twenty HFH at 2 and 5 years of follow-up, respectively, and we observed that an improvement in NYHA class was associated with a reduction in HFH at 2 years of follow-up (p=0,043; OR 0,029, 95% CI 0,050–1,06) and 5 years of follow-up (p 0,027, OR 0,252; 95% CI 0,069 – 0,915). Emergency department (ED) admission related to HF decompensations was significantly reduced at 2 years of follow-up (p=0,035, OR 0,22, 95% CI 0,048 – 1,0) and at 5 years of follow-up (p=0,001, OR 0,15, 95% CI 0,044 – 0,55). There was no difference on cardiovascular or all-cause mortality. Conclusion CHF patients with CIEDs and improving on NYHA class have less NSVT episodes, HFH and HF decompensations with ED admission, both at 2 and 5 years of follow-up. Funding Acknowledgement Type of funding sources: None.

Check the Need-Prevalence and Outcome after Transvenous Cardiac Implantable Electric Device Extraction without Reimplantation.

Background: after transvenous lead extraction (TLE) of cardiac implantable electric devices (CIEDs), some patients may not benefit from device reimplantation. This study sought to analyse predictors and long-term outcome of patients after TLE with vs. without reimplantation in a high-volume centre. Methods: all patients undergoing TLE at our centre between January 2010 and November 2015 were included into this analysis. Results: a total of 223 patients (median age 70 years, 22.0% female) were included into the study. Cardiac resynchronization therapy-defibrillator (CRT-D) was the most common device (40.4%) followed by pacemaker (PM) (31.4%), implantable cardioverter-defibrillator (ICD) (26.9%), and cardiac resynchronization therapy-PM (CRT-P) (1.4%). TLE was performed due to infection (55.6%), malfunction (35.9%), system upgrade (6.7%) or other causes (1.8%). In 14.8%, no reimplantation was performed after TLE. At a median follow-up of 41 months, no preventable arrhythmia-related events were documented in the no-reimplantation group, but 11.8% received a new CIED after 17–84 months. While there was no difference in short-term survival, five-year survival was significantly lower in the no-reimplantation group (78.3% vs. 94.7%, p = 0.014). Conclusions: in patients undergoing TLE, a re-evaluation of the indication for reimplantation is safe and effective. Reimplantation was not related to preventable arrhythmia events, but all-cause survival was lower.

Impact of different radiation techniques and doses on cardiac implantable electronic devices

Background and objectivePurpose of this investigation was to get deeper insight into the impact of different radiation techniques and doses on cardiac implantable electric devices (CIEDs). We aimed to mimic a worst-case scenario with very high doses and external radiation being applied directly on the devices. MethodsRadiation was applied on 21 CIEDs as photon or electron therapy with maximum dose of 150Gy in fractions of 2 -20Gy. CIEDS were put directly into the beam. Brachytherapy was applied with doses of 6Gy to a maximum of 42Gy. Check-ups took place after every fraction and one week after radiation. We calculated the estimated potential risk for the health and survival of patients as well as the risk for CIEDs’ loss of function. Results28 life- or health-threatening errors occurred during photon therapy, 3/7 devices showed complete loss of function. During electron therapy, 31 potentially patient-threatening errors and 2 losses of function were detected. During brachytherapy, none of the devices showed loss of function but 8 patient-threatening errors occurred. Inadequate shock releases were mostly seen after photon and brachytherapy, random noises occurred more often during electron therapy. The earliest potentially serious error occurred during after 2Gy photon radiation and 6Gy brachytherapy. Losses of function occurred earliest at 80Gy. ConclusionThe results underline the warning for precaution concerning CIED patients derived from recommendations in the literature. Our study offers new information especially about the impact of electron radiation and brachytherapy on CIEDs. Risk for the devices to for loss of telemetry or battery capacity might be negligible with normafractionated therapy.

Histological properties of oscillating intracardiac masses associated with cardiac implantable electric devices.

BackgroundThere have been a few cases of echogenic cardiac implantable electric device (CIED) lead‐associated oscillating intracardiac masses (ICMs) in leads imaged by echocardiography. The histological properties of ICMs could help clarify the etiological diagnosis. Although there is extensive literature on mass size, the histological properties of such masses have not been characterized. The aim of this research was to clarify the histological features of oscillating ICMs in CIED patients.MethodsPreoperative echocardiography was performed in all candidates for CIED removal. In the patients with ICMs, specimens were obtained by 3 methods: direct tissue collection during open‐heart surgery; tissue collection together with the CIED lead during transvenous extraction; and tissue collection by catheter vacuum during transvenous CIED removal. A standard histopathological examination of ICM tissue was performed.ResultsA total of 106 patients underwent lead removal in our institute (April 2009‐March 2018); 14 patients had an ICM (13.2%), and 7 specimens were obtained in patients with CIED lead‐related ICM. Following histological examination, 2 types of ICM were identified: one mainly composed of thickened endocardium (EN type; 3 patients), and the other mainly an aggregate of inflammatory cells as a neutrophil cell (NC type; 4 patients).ConclusionsTwo histological types of intracardiac masses, including a thickened endocardium type and a neutrophil cell type, were identified. These classifications might help make an accurate histological diagnosis of lead‐associated intracardiac masses.

Interaction between CIEDs and modern radiotherapy techniques: Flattening filter free-VMAT, dose-rate effects, scatter radiation, and neutron-generating energies

Background and purposeProviding evidence for radiotherapy (RT)-induced effects on cardiac implantable electric devices (CIEDs) with focus on flattening filter free-volumetric modulated arc therapy (FFF-VMAT) at 6 and 10 MV as well as 3D-conformal radiotherapy (3D-CRT) at 18 MV. Materials and methods68 CIEDs (64 implantable cardioverter-defibrillators (ICDs) and 4 cardiac pacemakers (PMs)) were located on the left chest position on a slab phantom and irradiated under telemetrical surveillance either directly, or distant to 3D-CRT or FFF-VMAT, dose-rate 2500 cGy/min, and target dose of 150 Gy. Devices were placed within, close by (2.5 cm and 5 cm), and distant (35 cm) to the radiation field. Scatter radiation (SR) and photon neutrons (PN) were recorded. CIEDs were investigated in following groups: 1a) 18 MV 3D-CRT − 4 ICDs/4 PMs out of radiation field, 1b) 18 MV open field − 4 ICDs/4 PMs within radiation field, 2) 6 MV FFF-VMAT, 15 ICDs in 35 cm distance to VMAT, 3) 10 MV-FFF VMAT, 15 ICDs in 35 cm distance to VMAT, 4) 6 MV FFF-VMAT, 15 ICDs in 2.5 cm distance to VMAT, 5) 10 MV FFF-VMAT, 15 ICDs in 2.5 cm distance to VMAT. ResultsNo incidents occurred at 6 MV FFF. 10 MV FFF-VMAT and 18 MV 3D-CRT resulted in data loss, reset, and erroneous sensing with inhibition of pacing (leading to inadequate defibrillation) in 8/34 ICDs and 2/4 PMs which were not located within radiation. Direct radiation triggered instantaneous defibrillation in 3/4 ICDs. Conclusions6 MV FFF-VMAT is safe even at high dose-rates of 2500 cGy/min, regardless whether CIEDs are located close (2.5 cm) or distant (35 cm) to the radiation beam. CIEDs should never be placed within radiation and energy should always be limited to 6 MV. At 6 MV, VMAT at high dose-rates can be used to treat tumors, which are located close to CIEDs.

P3778Long-term outcome of non-pharmacologial treatment of atrial fibrillation in hypertrophic cardiomyopathy: a large single-centre experience

Abstract Introduction Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM) and is generally associated with a significant deterioration of clinical status. Non-pharmacological treatment such as surgical and catheter ablation has become an established therapy for symptomatic AF but in patients with HCM often having a chronically increased left atrial pressure and extensive atrial cardiomyopathy the long-term outcome is uncertain. Purpose The present study aimed to analyse the long-term outcome of AF ablation in HCM and the mechanism of recurrent atrial arrhythmias using high-density mapping systems. Methods A total of 65 patients (age 64.5±9.9 years, 42 (64.6%) male) with HCM undergoing AF ablation for symptomatic AF were included in our study. The ablation strategy for catheter ablation included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines if appropriate. In patients with suspected atrial tachycardia (AT) high-density activation and substrate mapping were performed. A surgical ablation at the time of an operative myectomy for left ventricular outflow tract obstruction was performed in 8 (12.3%) patients. The outcome was analysed using clinical assessment, Holter ECG and continuous rhythm monitoring of cardiac implantable electric devices. Results Paroxysmal AF was present in 27 (41.6%), persistent AF in 37 (56.9%) and primary AT in 1 (1.5%) patients. The mean left atrial diameter was 54.1±12.5 ml. In 11 (16.9%) patients with AT high-density mapping was used to characterize the mechanism of the ongoing tachycardia. After 1.9±1.2 ablation procedures and a follow-up of 48.5±37.2 months, ablation success was demonstrated in 58.9% of patients. The success rate for paroxysmal and persistent AF was 70.0% and 55.8%, respectively (p=0.023). Of those patients with AT high-density mapping guided ablation was successful in 44.4% of patients. The LA diameter of patients with a successful ablation was smaller (52.2 vs. 58.1 mm; p=0.003). Conclusion Non-pharmacological treatment of AF in HCM is effective during long-term follow-up. Paroxysmal AF and a smaller LA diameter are favourable for successful ablation. In patients with complex AT the use of high-density mapping can guide ablation resulting in further ablation success in a reasonable number of patients.

A Low Critical Event Rate Despite a High Abnormal Event Rate in Patients with Cardiac Implantable Electric Devices Followed Up by Remote Monitoring.

Objective Remote monitoring (RM) of cardiac implantable electric devices (CIEDs) has been advocated as a healthcare standard. However, expert consensus statements suggest that all patients require annual face-to-face follow-up consultations at outpatient clinics even if RM reveals no episodes. The objective of this study was to determine the critical event rate after CIED implantation through RM. Methods This multicenter, retrospective, cohort study evaluated patients with pacemakers (PMs), implantable cardioverter defibrillators (ICDs), or cardiac resynchronization therapy defibrillator (CRT-Ds) and analyzed whether or not the data drawn from RM included abnormal or critical events. Patients A total of 1,849 CIED patients in 12 hospitals who were followed up by the RM center in Okayama University Hospital were included in this study. Results During the mean follow-up period of 774.9 days, 16,560 transmissions were analyzed, of which 11,040 (66.7%) were abnormal events and only 676 (4.1%) were critical events. The critical event rate in the PM group was significantly lower than that in the ICD or CRT-D groups (0.9% vs. 5.0% or 5.9%, p<0.001). A multivariate analysis revealed that ICD, CRT-D, and a low ejection fraction were independently associated with critical events. In patients with ICD, the independent risk factors for a critical event were old age, low ejection fraction, Brugada syndrome, dilated phase hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. Conclusion Although abnormal events were observed in two-thirds of the transmitted RM data, the critical event rate was <1% in patients with a PM, which was lower in comparison to the rates in patients with ICDs or CRT-Ds. A low ejection fraction was an independent predictor of critical events.

Single-center experience with percutaneous lead extraction of cardiac implantable electric devices

BackgroundThe estimated incidence of infected cardiac implantable electric devices (CIED) has recently increased to 1–2% in Japan. Extraction of long-term implanted devices is generally difficult. There are few reports about lead extraction in Japan. We describe our experience with and outcomes of lead extraction using excimer lasers, mechanical sheaths, and manual extraction. MethodsWe retrospectively analyzed the characteristics, types of devices, and indications for extraction in 29 patients with 67 leads who required CIED lead extraction at Shinshu University Hospital between April 2014 and October 2016. Mean patient age was 71 years and 25 patients were male. The indications for device extraction were infections (n=25) and non-functioning leads (n=4). ResultsA total of 67 leads (active fixation lead, n=28; passive fixation lead, n=39) had been implanted for a median duration of 6.3±5.6 years. Extractions were performed using an excimer laser sheath (n=26), laser with mechanical sheath (n=7), only mechanical sheath (Cook Vascular Inc., Leechburg, PA, USA) (n=1), and manually (n=1). The procedure was successful in all patients. There were no major or minor complications during extraction. There was no recurrence of infection after infected device extraction. Two patients were implanted with subcutaneous implantable defibrillators after extraction of the implantable cardioverter defibrillator (ICD). ConclusionsCIED lead extraction, especially of those that are adherent to the subclavian vein, can be successfully performed in Japanese subjects using an excimer laser and mechanical sheath, without complications.

Cardiac Implantable Electric Devices: Indications and Complications

As the evidence base for cardiac implantable electric devices (CIED), which include pacemakers, defibrillators, and devices with both functionalities, continues to expand, so does the rate of usage in patients with chronic heart failure (CHF), atrial fibrillation (AF), or both. Given that no medical intervention is ever free from complications and unintended consequences, it is expected that patients will present to the Emergency Department (ED) for unscheduled, acute care secondary to CIED complications. In this article, we will examine first the indications for CIED placement in patients with chronic cardiac disease. Then, management of various common device-related complications and pathologies will be discussed. Indications for CIED continue to expand and be refined. With substantial monitoring, patients with certain CIED may undergo MRI; however, the risk-benefit ratio should be examined closely on an individual occurrence level. Understanding the indications, the complications, and how CIED affect diagnostic options is crucial to providing optimum care for these patients.

New Energy Source for Cardiac Implantable Electric Device

Recently, many cardiac implantable electric devices (CIED) have been used in specific patients. Artificial cardiac pacemakers significantly contribute to the regulation of heart rate by using electrical impulses for contracting the heart muscles of patients with sick sinus syndrome or heart block. The implantable cardioverter defibrillator is used for defibrillation. However, owing to the limited lifespan of the battery, replacement surgery for the artificial pacemaker implanted under the chest skin should be performed every 7 to 10 years. The batteries that power implantable cardioverter defibrillators (ICDs) differ from those used to power implantable pacemakers and most other implantable devices, in that, they must deliver much higher power. Enhancing the battery life is thus a critical issue to assure longer working time of the implanted pacemakers and to increase the replacement cycle. This paper will present several attractive approaches to address this challenge. Key words: Pacemaker, Artificial; Implantable Cardioverter-Defibrillator

Initial Experience of Percutaneous Extraction of Infected Cardiac Implantable Electric Devices Using Excimer Laser

Background:The estimated incidence of infected cardiac implantable electric devices (CIED)has recently increased to 1% -2%.Prompt removal of infected devices improves survival rates.We describe our initial experience of lead extraction from infected devices using an excimer laser that was approved for this application in 2010. Methods and results:We retrospectively analyzed the characteristics,type of devices and leads,as well as indications and complications in 13 patients with CIED infection between 2011 and 2014 at our hospital. The clinical presentation comprised isolated pocket infection(n=12),lead endocarditis(n=3)and methicillinresistant Staphylococcus aureus-positive blood cultures.The patients had been implanted with a total of 29 leads(atrial,n=13;ventricular,n=16)for a median duration of 10.2±5.2 years.The procedure was successful in all patients,but two patients who developed recurrent infection required repeated removal of devices and an implant device from epicardial cardiac muscle.Acute cardiac tamponade occurred in one patient after ventricular lead extraction due to perforation of the right ventricle. This patient required an emergency thoracotomy,but was discharged one month after the procedure. Conclusion :Infected CIED leads can be quickly extracted using an excimer laser.Shinshu Med J 63 :103― 108, 2015 (Received for publication August 18,2014;accepted in revised form November 28,2014)

Hemodynamic Sensor in Cardiac Implantable Electric Devices: The Endocardial Accelaration Technology

There have been substantial progresses in the technology of cardiac implantable electric devices (CIEDs) during the past decades. One of the progresses is represented by the development of a hemodynamic sensor embedded at the tip of a pacing lead that measures myocardial contractility by the analysis of myocardial mechanical vibrations occurring during the cardiac cycle. This sensor, providing continuous hemodynamic monitoring, could play an important role in clinical practice because of several clinical applications in CIEDs recipients. The objectives of this work are to report how this sensor operates and to review the main findings about its clinical applications.

Cost-consequence analysis of daily continuous remote monitoring of implantable cardiac defibrillator and resynchronization devices in the UK

AimsThe need for ongoing and lifelong follow-up (FU) of patients with cardiac implantable electric devices (CIED) requires significant resources. Remote CIED management has been established as a safe alternative to conventional periodical in-office FU (CFU). An economic model compares the long-term cost and consequences of using daily Home Monitoring® (HM) instead of CFU.Methods and resultsA cost–consequence evaluation comparing HM vs. CFU was performed using a Markov cohort model and data relating to events and costs identified via a systematic review of the literature. The model is conservative, without assuming a reduction of cardiovascular events by HM such as decompensated heart failure or mortality, or considering cost savings such as for transportation. Also cost savings due to an improved timing of elective device replacement, and fewer FU visits needed in patients near device replacement are not considered. Over 10 years, HM is predicted to be cost neutral at about GBP 11 500 per patient in either treatment arm, with all costs for the initial investment into HM and fees for ongoing remote monitoring included. Fewer inappropriate shocks (−51%) reduce the need for replacing devices for battery exhaustion (−7%); the number of FU visits is predicted to be halved by HM.ConclusionFrom a UK National Health Service perspective, HM is cost neutral over 10 years. This is mainly accomplished by reducing the number of battery charges and inappropriate shocks, resulting in fewer device replacements, and by reducing the number of in-clinic FU visits.