Dual-chamber Implantable Cardioverter-defibrillator Research Articles

P5426His-bundle pacing in CHF-patients with narrow QRS and chronic AF using dual-chamber ICD - an upgrade from single-chamber to dual-chamber ICD

Abstract A single-chamber ICD is a standard method for primary SCD prophylaxis. In patients with chronic atrial fibrillation it dose not contribute to the regularization of heart rate, which is crucial for proper treatment. The aim of our study was to assess the efficacy of direct His-bundle pacing in patients with congestive heart failure and chronic atrial fibrillation using upgrade from single chamber to dual-chamber ICD. Methods The study population included 21 patients with CHF and chronic AF implanted primarily with single chamber ICD with etablished pharmacotherapy and stable clinical status. Results The echocardiography measurements at baseline and during ollow-up were presented in the table: Table 1 Baseline Follow-up p-value LVEDD (ms) 67.7±10.7 64.5±8.6 <0.05 EF (%) 27.0±4.8 33.2±6.9 <0.05 NYHA class 2.8±0.6 1.9±0,5 <0.05 During short 4-months of follow-up the mean values of EF and LV dimensions significantly improved. This was also accompanied by functional status improvement. Conclusions His-bundle-based pacing in CHF-chronic AF patients contributes to significant echocardiographic and clinical improvement. Standard single-chamber ICD implantation in CHF-chronic AF patients yields only SCD prevention without influence on remodeling process.

P2878Higher all-cause mortality in patients with implanted dual-chamber cardioverter-defibrillators for secondary prevention: an analysis from the Polish ICD Registry

Abstract Background In the Polish ICD Registry population secondary prevention recipients account for over 27%. Despite the evolution of indications for secondary prevention implantable cardioverter defibrillators (ICDs), recommendations regarding the use of ICDs for secondary prevention of sudden cardiac death (SCD) rely on information from a small number of randomized controlled trials that were performed decades ago, with mixed results. Moreover, research on the outcomes after implantations for secondary prevention of ICDs is limited. While dual-chamber devices offer theoretical advantage over single-chamber devices, dual-chamber ICDs (DC-ICDs) were announced not superior to single-chamber (SC-ICDs) in some research. Purpose Therefore, the aim of the study was to evaluate the all-cause mortality among patients from the Polish ICD Registry receiving either a single- or a dual-chamber device for secondary prevention in contemporary clinical practice. Methods All patients enrolled in the Polish ICD Registry from 1995 to 2016 were identified. Patients were included in the study if they were designated as receiving an ICD for secondary prevention of SCD after documented tachycardic arrest, sustained ventricular tachycardia (VT), or syncope. Kaplan-Meier survival analysis was used to assess all-cause mortality. Results In the study population of 3596 ICD recipients (mean age 69±12 years, 81% male, SC-ICD 61%, DC-ICD 39%), during mean follow-up of 79±43 months all-cause mortality rate was higher in the dual-chamber group than in the single chamber group, with a significant difference between the two groups as depicted in Kaplan-Meier curve (p<0,05). The median survival time was 98 months versus 110 months for SC and DC-ICD, respectively. Conclusions This study is the first to describe the characteristics of a national cohort of patients receiving a secondary prevention ICD in such a long follow-up period in contemporary practice. Implantation of a dual-chamber ICD was associated with higher all-cause mortality compared with single chamber devices.

P1239His-bundle pacing in CHF-patients with narrow QRS and chronic AF using dual-chamber ICD

Abstract The heart rate regularization is crucial for proper treatment of patients with atrial fibrillation and congestive heart failure. The standard resynchronization can be applied, but in patients with narrow QRS this procedure is of no use. The aim of our study is to assess the efficacy of direct His-bundle pacing in patients with congestive heart failure and chronic atrial fibrillation using dual chamber ICD implanted for prevention of sudden cardiac death. Methods The study population included 78 patients with CHF and chronic AF: group A - 56 pts treated with direct His-bundle pacing using atrial port of dual chamber ICD and group B - 22 patients implanted with single chamber ICD as recommended by the guidelines. The patients in group B constituting clinical controls were derived from the Heart Failure Outpatients Clinic with established clinical status and pharmacotherapy. Results The demographic data, clinical characteristics and echocardiography measurements at baseline and during follow-up were presented in the table: Table 1 Group A Group B P value Age (years) 69.7±6.9 66.7±11.3 n.s. Sex (% of male sex) 84.0 86.4 n.s. Ventricular pacing (%) – 46.3±31.2 – His-bundle pacing (%) 81.7±9.2 – – pre post pre post pre vs. post LVEDD (mm) 66.9±4.9 59.9±4.7 64.8±8.0 64.7±8.1 <0.01 n.s. EF (%) 29.6±3.8 43.6±5.9 28.1±6.1 28.8±7.3 <0.01 n.s. NYHA class 2.7±0.6 1.4±0.6 2.5±0.6 2.0±0.2 <0.05 n.s. B-blocker dose (metoprolol equivalent dose) 104.6±41.6 214.3±82.6 78.3±56.6 103.1±49.2 <0.001 <0.05 During 12-months of follow-up the mean values of NYHA functional class, EF and LV dimensions did not change in group B but significantly improved in group A. The physiological His-bundle based pacing enabled optimal beta-blocker dosing. The studied groups had no tachyarrhythmia at baseline so the presumable atrial fibrillation-related harm depends on the rhythm irregularity. Conclusions His-bundle-based pacing in CHF-chronic AF patients contributes to significant echocardiographic and clinical improvement. Standard single-chamber ICD implantation in CHF-chronic AF patients yields only SCD prevention without influence on remodeling process. The CHF-patients with narrow QRS and chronic AF benefit from substantially higher beta-blockade which can be instituted in His-bundle pacing group.

Right atrial ghost following device extraction for infective endocarditis

A 64-year-old male required extraction of a dual chamber implantable cardioverter defibrillator (ICD) due to lead endocarditis. Blood cultures were positive for Staphylococcus lugdunensis. Transoesophageal echocardiography (TOE) demonstrated a 11.7 mm vegetation attached to the right ventricular (RV) lead (Fig. 1 and Video 1). No vegetation was identified on the right atrial (RA) lead. Device extraction took place using TOE guidance. It was uncomplicated, but at the end of the procedure a cast-like structure was seen in the right atrium thought to represent fibrous or infective debris which had been encasing one of the leads (Fig. 2 and Video 2). All lead insulation from the extracted leads was intact. Device lead endocarditis is an indication for complete removal of the pacemaker system and intra-procedural imaging such as TOE is strongly recommended during device extraction to assess for complications which may lead to haemodynamic instability (1). The presence of residual debris or ghosts in the RA or superior vena cava (SVC) following lead extraction has an incidence of 8–14% (2, 3), occurring more commonly with infected leads. There is no specific therapy when this is identified, but it has been associated with higher mortality (3). Its presence ought to be documented at the time of extraction. Open in a separate window Figure 1 Pre-extraction TOE, bi-caval view. A vegetation is seen attached to the RV lead as it enters from the SVC at the RA junction.

Projected longevities of cardiac implantable defibrillators: a retrospective analysis over the period 2007-17 and the impact of technological factors in determining longevity.

Implanters of cardiac implantable electronic devices cannot easily choose devices by longevity as usually current models only have projected longevity data since those with known performance are obsolete. This study examines how projected device longevities are derived, the influencing factors, and their roles in guiding model choice. Ninety-eight implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy-defibrillator (CRT-D) models released in Europe in 2007-17 were analysed for reported battery capacities, projected longevities for standardized settings stipulated by the French Haute Autorité de Santé (HAS) and manufacturer-chosen settings. Battery capacities and HAS projected longevities increased during the study period. Based on current drain estimation, therapy functions consumed only a small portion (2-7%) of the battery energy for single- and dual-chamber ICDs, but up to 50% (from biventricular pacing) for CRT-Ds. Large differences exist between manufacturers and models both in terms of battery capacity and energy consumption. Battery capacity is not the sole driver of longevity for electronic implantable cardiac devices and, particularly for ICDs, the core function consume a large part of the battery energy even in the absence of therapy. Providing standardized current drain consumption in addition to battery capacity may provide more meaningful longevity information among implantable electronic cardiac devices.

Mode of death in Shapiro syndrome: a case report.

BackgroundShapiro syndrome is extremely rare and is characterized by the triad of spontaneous periodic hypothermia, hyperhidrosis and agenesis of the corpus callosum, resulting in neurological and psychological disorders. The exact mechanism of this syndrome is unknown and treatment consists of controlling the periodic attacks. This case report describes a case of Shapiro syndrome presenting with ventricular fibrillation (VF) who was treated with dual chamber implantable cardioverter defibrillator (ICD) therapy.Case summaryA 45-year-old man, suffering from Shapiro syndrome with frequent hypothermic attacks, was admitted to the emergency department with an out of hospital cardiac arrest caused by VF due to hypothermia. To prevent cardiac death during future hypothermic attacks with VF, the patient was treated with a dual chamber ICD. Within 1 month after ICD implantation the patient had two events of ventricular tachycardia/VF during hypothermia, which were both successfully terminated by an ICD shock. One year after ICD implantation the patient suffered from an uncontrolled urinary tract infection and the patient passed away. Post-mortem interrogation of the ICD did not reveal further episodes of VF and showed a higher supraventricular heartrate in the last days before his death, probably due to a sinus tachycardia driven by the infection. It was concluded that the most likely cause of death was an uncontrolled sepsis.DiscussionThe current case showed that ICD therapy can be successful in treating VF episodes in patients with unexpected periods of hypothermia.

Atrial pacing every other beat: Is it pacemaker malfunction?

A 45 year old female with hypertrophic obstructive cardiomyopathy and a dual chamber ICD underwent left ventricular outflow and mid ventricular cavity myectomy and mitral valve replacement. On her 5th day after surgery, ECG shows electronic atrial pacing every other complex with monomorphic wide QRS rhythm. The explanation of this ECG pattern is discussed.

MON-129 An Unusual LMNA Mutation Causing a Complex Phenotype: When the Genetic Diagnosis Uncovers Novel Features

Background: Lipodystrophy syndromes are characterized by loss of body fat. Although classical Familial Partial Lipodystrophy (FPLD) and Congenital Generalized Lipodystrophy (CGL) have different clinical presentations, we have encountered a unique case where the distinction was quite challenging. Clinical Case: Our patient first presented to an endocrinologist at age 19 with secondary amenorrhea and hypothyroidism. After normalization of TSH, further investigation revealed central hypogonadism, hypertriglyceridemia (>3,000 mg/dL, normal<150mg/dL), xanthomas and fatty liver disease. By that time, she had adiposity changes such as lack of subcutaneous fat in the limbs and abdomen and prominent muscles. She believed she had those traits since early childhood. After puberty, she developed generalized muscle pain and was noted to have elevated CK. At 59 years old, she developed diabetes as well as liver fibrosis. These led to the diagnosis of lipodystrophy (initially classified as FPLD due to inheritance pattern). However, physical examination revealed acromegaloid features, BMI of 23.2 kg/m2, minimal fat palpable around the neck and minimal fullness of the supraclavicular fossa. The rest of the body was virtually devoid of subcutaneous fat tissue, consistent more with the CGL phenotype and inspection of older photos demonstrated progressive fat loss. She displayed prominent and hypertrophic muscles, phlebomegaly on limbs and trunk, umbilical hernia and acanthosis nigricans around the neck and armpits. Enlarged spleen and liver were also noted. There was labial hypertrophy with no cliteromegaly. Dual-Energy X-ray Absorptiometry (DEXA) showed total fat percentage of 22% and a "fat shadow” was obtained highlighting the generalized pattern of fat loss. Genetic analysis revealed a pathogenic variant (p. Arg541Pro) at exon 8 of the LMNA gene. Upon identification of the variant, her previously obtained muscle biopsy was reevaluated as muscular dystrophy. Cardiovascular investigations demonstrated first-degree atrioventricular block and non-sustained ventricular tachycardia on the ECG and fibrosis on cardiac MRI. Given her family history of sudden death, a dual-chamber implantable cardioverter-defibrillator was placed. When her HbA1c rose to 7.2% on Metformin monotherapy and her triglycerides exceeded 250 mg/dL on fibrates, we presented her case to her insurance company. She was approved for Metreleptin therapy even though she does not meet the consensus definition of generalized lipodystrophy. Conclusion: We present a unique case with lipodystrophy who had progressive fat loss from partial to generalized. Making the correct classification is important in the US where treatment with Metreleptin is approved only for generalized lipodystrophy. We also highlight a complex genotype-phenotype association of laminopathy that challenges the distinction between FPLD and CGL.

Implant-based multi-parameter telemonitoring of patients with heart failure and a defibrillator with vs. without cardiac resynchronization therapy option: a subanalysis of the IN-TIME trial

AimsIn the IN-TIME trial, automatic daily implant-based multiparameter telemonitoring significantly improved clinical outcomes in patients with chronic systolic heart failure and implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D). We compared IN-TIME results for ICD and CRT-D subgroups.MethodsPatients with LVEF ≤ 35%, NYHA class II/III, optimized drug treatment, no permanent atrial fibrillation, and a dual-chamber ICD (n = 274) or CRT-D (n = 390) were randomized 1:1 to telemonitoring or no telemonitoring for 12 months. Primary outcome measure was a composite clinical score, classified as worsened if the patient died or had heart failure-related hospitalization, worse NYHA class, or a worse self-reported overall condition.ResultsThe prevalence of worsened score at study end was higher in CRT-D than ICD patients (26.4% vs. 18.2%; P = 0.014), as was mortality (7.4% vs. 4.1%; P = 0.069). With telemonitoring, odds ratios (OR) for worsened score and hazard ratios (HR) for mortality were similar in the ICD [OR = 0.55 (P = 0.058), HR = 0.39 (P = 0.17)] and CRT-D [OR = 0.68 (P = 0.10), HR = 0.35 (P = 0.018)] subgroups (insignificant interaction, P = 0.58–0.91).ConclusionDaily multiparameter telemonitoring has a potential to reduce clinical endpoints in patients with chronic systolic heart failure both in ICD and CRT-D subgroups. The absolute benefit seems to be higher in higher-risk populations with worse prognosis.

THE MISPLACED LEADS: A RARE COMPLICATION OF IMPLANTABLE DEVICES

Complications associated with pacemaker insertion are minimal. Of those, placement of leads within the left chambers is rare, making the recognition and diagnosis often overlooked. A 73 year old man with previous history of CABG and dual chamber ICD placement presented with one month history of

Can we rely on Danish? Real-world data on patients with nonischemic cardiomyopathy from the German Device Registry.

According to current guidelines prophylactic implantable cardioverter-defibrillator (ICD) therapy is recommended in patients with significantly impaired left ventricular systolic function. However, the recently published DANISH trial did not find a significantly lower long-term rate of death from any cause compared with usual clinical care in patients with non-ischemic cardiomyopathy. We investigated whether registry data from a multi-center 'real-life' registry on patients with non-ischemic cardiomyopathy are similar to this trial. The German Device Registry (DEVICE) is a nationwide, prospective registry with one-year follow-up investigating 5451 patients receiving device implantations in 50 German centers. The present analysis of DEVICE focused on patients with non-ischemic cardiomyopathy and a left ventricular ejection fraction ≤35% who received a prophylactic ICD. Out of 779 patients with symptomatic heart failure and nonischemic cardiomyopathy, 33.1% received a single chamber ICD (VVI), while 11.0% were implanted with a dual-chamber ICD (DDD), and 55.8% received a defibrillator system for cardiac resynchronization therapy. Median follow-up was 16.1months. 90.7% were alive at follow-up, 9.3% had died during this period. Overall mortality after one year was 5.4%. Overall mortality one year after implantation was significantly increased in patients 68years and older(7.9%) as compared to younger patients (59-68years: 2.5%; < 59years: 3.8%; p < 0.015). Data from the present registry support the recently published results of the DANISH trial. In particular the influence of an increased age as proven in the DANISH trial might also play a role in the present collective. This limits the potential beneficial effect of ICD therapy in particular in the elderly population.

What is the Diagnosis?

Paciente YB, 50 anos, sexo feminino, com hipotireoidismo, disfunção ventricular esquerda grave, ventrículo esquerdo não compactado e taquicardia ventricular mal tolerada, submetida a implante de cardioversor-des brilador implantável (CDI) de dupla câmara em fevereiro de 2012 com sucesso (gerador Secura DR Medtronic, eletrodo atrial 4076 Medtronic e eletrodo ventricular Sprint Quattro 6947 Medtronic). Retorna assintomática nove meses após o implante para avaliação de rotina.

What is the Diagnosis?

Patient YB, 50 years old, female, with hypothyroidism, severe left ventricular dysfunction, uncompressed left ventricle and poorly tolerated ventricular tachycardia, submitted to implantation of a dual chamber implantable cardioverter-defibrillator (ICD) in February 2012 (generator Secura DR Medtronic, 4076 Medtronic atrial electrode, and Sprint Quattro 6947 Medtronic ventricular electrode). Returns asymptomatic nine months after the implant for routine evaluation.

Estimating the incidence of atrial fibrillation in single-chamber implantable cardioverter defibrillator patients.

Atrial arrhythmias are associated with major adverse cardiovascular events. Recent reports among implantable cardioverter defibrillator (ICD) patients have demonstrated a high prevalence of atrial fibrillation (AF), predominantly in dual-chamber recipients. AF incidence among patients with single-chamber systems (approximately 50% of all ICDs) is currently unknown. The objective was to estimate the prevalence of new-onset AF among single-chamber ICD patients by observing the rates of new atrial tachycardia (AT)/AF among a propensity scoring matched cohort of dual-chamber ICD patients from the PainFree SmartShock technology study, to better inform screening initiatives. Among 2770 patients enrolled, 1862 single-chamber, dual-chamber, and cardiac resynchronization therapy subjects with no prior history of atrial tachyarrhythmias were included. Daily AT/AF burden was estimated using a propensity score weighted model against data from dual-chamber ICDs. Over 22±9months of follow-up, the estimated incidence of AT/AF-lasting at least 6min, 6h, and 24h per day -in the single-chamber cohort was 22.0, 9.8, and 6.3%, whereas among dual-chamber patients, the prevalence was 26.6, 13.1, and 7.1%, respectively. Initiation of oral anticoagulation was estimated to occur in 9.8% of the propensity matched single-chamber cohort, which was higher than the actual observed rate of 6.0%. Stroke and transient ischemic attack occurred at low rates in all device subgroups. Atrial arrhythmias occur frequently, and significant underutilization of anticoagulation is suggested in single-chamber ICD recipients. Routine screening for AF should be considered among single-chamber ICD recipients.

Clinical Course of Dual-Chamber Implantable Cardioverter-Defibrillator Recipients followed by Cardiac Remote Monitoring: Insights from the LION Registry.

Patients receiving dual-chamber implantable cardioverter-defibrillator (DR-ICD) therapy are at risk of developing atrial arrhythmia because of the increased rate of ventricular pacing and the progression of heart failure. Remote monitoring (RM) may identify the patients at highest risk of adverse events such as atrial arrhythmias. A total of 283 patients with 91,632 remote transmissions during a 15-month follow-up (FU) period enrolled in the LION registry were analysed. The parameters retrieved included the pacing mode, lower rate limit, percentage of atrial (%AP) and ventricular pacing (%VP), and percentage of atrial arrhythmia burden (%AB). In 92.7% of patients, the devices were initially programmed in DDD(R) or DDI(R), with changes of the pacing mode in 19.3% only. The lower rate limit remained stable in 80.4% of patients. At the first transmission, 8.7% of patients suffered from RM-detected atrial arrhythmia, which reached 36% during FU. The %AP was not associated with increased AB (p = 0.67), but the %VP was different in patients developing RM-detected atrial arrhythmia (26.9% vs. 13.7%, p < 0.00001). The %VP increased in 105 patients (significance level of α = 0.05), and 11 patients crossed the border of 50% VP. The LION substudy supports the concept of using RM in a real-world DR-ICD population. Remote monitoring of DR-ICDs allows for the quantification of the course of the pacing parameters and AB. Based on these observations, device parameters can be adjusted and optimized.

Silent atrial fibrillation in patients with an implantable cardioverter defibrillator and coronary artery disease (INDICO AF) trial: study rationale and design.

BackgroundTimely detection of atrial fibrillation (AF) in implantable cardioverter defibrillator (ICD) patients is clinically important for prevention of AF-related complications and inappropriate shocks. Patients with coronary artery disease (CAD) and a dual or triple chamber ICD show a high incidence of device-detected AF. Whether CAD patients with a single chamber ICD carry a similar risk for device-detected AF remains unknown.Study designThe INDICO AF trial is an investigator-initiated, multicentre, observational study evaluating the incidence of subclinical AF (SCAF) in CAD patients who will receive a single chamber ICD as primary prevention for sudden cardiac death (SCD). Fifty patients will receive a single chamber ICD with an integrated RR interval based AF detection algorithm. In combination with remote monitoring, rhythm data will be collected monthly. The primary endpoint is the incidence of SCAF at 1 year of follow-up; secondary endpoints include time until 10 and 20% of the patients have a first episode of SCAF. All patients in whom SCAF is detected will be invited for an outpatient visit and will receive adequate anticoagulation treatment when appropriate according to the CHA2DS2-VASc score and current guidelines.ConclusionThe INDICO AF trial will quantify the incidence of SCAF in patients with an ICD and CAD. The study will underscore the clinical value of SCAF detection in single chamber ICD patients using remote patient monitoring and may improve patient care. This trial is registered at trialregister.nl with trial NTR6910.

The optimal management of patient with permanent atrial fibrillation and heart failure with reduced ejection fraction – The permanent His-bundle pacing is a solution. A case report

Atrial fibrillation (AF) coexists frequently with heart failure (HF). Permanent His-bundle pacing (pHBP) seems to be an optimal approach to the management of patients with HF and concomitant AF, which are the indication for single chamber ICD implantation. This management allows to up-titrate the beta-blocker dose in order to prevent tachyarrhythmia with no risk of bradyarrhythmia or triggering deleterious right ventricular pacing. We present a case of 69-years-old male with AF, worsening HF and high burden of RV pacing. The upgrade from single chamber ICD to dual chamber ICD with pHBP alleviated the symptoms and contributed to substantial echocardiographic improvement.

Avoiding inappropriate therapy of single-lead implantable cardioverter-defibrillator by using atrial-sensing electrodes.

The single-chamber implantable cardioverter-defibrillator (ICD) can be associated with more frequent inappropriate therapies compared with dual-chamber ICDs, whenthey are accompanied by a simpler implantation procedure. The aim of this study was to investigate whether the use of a single-lead ICD system with atrial-sensing electrodes results in a reduction of inappropriate ICD therapy. The study population consisted of 212 consecutive patients, who underwent primary prophylactic single-lead ICD implantation at our institute. A ventricular lead with atrial-sensing electrodes was implanted in 77 patients (36%; Group-VDD) and a ventricular lead without atrial-sensing electrodes was implanted in 135 patients (64%; Group-VVI). Procedural and follow-up data were collected in a prospective registry. A higher prevalence of atrial fibrillation was present in Group-VDD. There were no other significant differences in patient baseline characteristics (age, sex, and other comorbidities) or follow-up period between the two groups. The operative parameters including fluoroscopic burden showed no significant differences between Group-VDD and Group-VVI. During a mean follow-up period of 697 ± 392 days, 26 patients (12%) experienced appropriate ICD therapies and 13 patients (6%) suffered inappropriate ICD therapies. The incidence of inappropriate ICD therapies in Group-VDD was significantly lower as compared to that of Group-VVI (1/77 [1%] vs 12/135 [9%]; log-rank, P = 0.028). The incidence of appropriate ICD therapies and the occurrence of device-related complications showed no significant difference between the two groups. Single-lead ICD with atrial-sensing electrodes shows a lower incidence of inappropriate ICD therapy compared with the absence of atrial-sensing electrodes, without additional operative burden or increased complications.

GW29-e0243 Comparison study on sensing and identification of Single-Lead Atrial Sensing System, Single-Chamber and Dual-Chamber Implantable Cardioverter Defibrillator System

The study was performed to evaluate the postoperative parameters stability, classified ventricular arrhythmia sensibility and supraventricular arrhythmia specificity on Single-Lead Atrial Sensing System, Single-Chamber (VR) and Dual-Chamber (DR) Implantable Cardioverter Defibrillator (ICD) System,

Intermittent anticoagulation guided by continuous atrial fibrillation burden monitoring using dual-chamber pacemakers and implantable cardioverter-defibrillators: Results from the Tailored Anticoagulation for Non-Continuous Atrial Fibrillation (TACTIC-AF) pilot study

Chronic anticoagulation is recommended for atrial fibrillation (AF) patients with thromboembolic risk factors regardless of AF duration/frequency. Continuous rhythm assessment with pacemakers (PMs)/implantable cardioverter-defibrillators (ICDs) and use of direct-acting oral anticoagulants (DOACs) may allow anticoagulation only around AF episodes, reducing bleeding without increasing thromboembolic risk. The purpose of this study was to evaluate the feasibility/safety of intermittent DOAC use guided by continuous remote AF monitoring via dual-chamber PMs or ICDs. Patients with nonpermanent AF, current DOAC use, CHADS2 score ≤3, a St. Jude Medical dual-chamber PM or ICD, and rare AF episodes were followed with biweekly and AF-alert based remote transmissions. Patients free of AF episodes lasting ≥6 minutes with a total AF burden <6 hours/day for 30 consecutive days discontinued DOAC. If AF burden surpassed these limits, DOAC was restarted and/or continued. Total days on DOAC and adverse events were assessed. Among 48 patients (mean age 71.3 years; 65% male; 79% paroxysmal AF; 87% CHADS2 score 1-2), 14,826 days of monitoring were completed. Patients used DOACs for 3763 days, representing a 74.6% reduction in anticoagulation time compared to chronic administration. Adverse events included 2 gastrointestinal bleeds (both on DOAC), 1 fatal intracerebral bleed (off DOAC), and no thromboembolic/stroke events. Among patients with rare AF episodes and low-to-moderate stroke risk, PM/ICD-guided DOAC administration is feasible and decreased anticoagulation utilization by 75%. Few adverse events occurred, although the study was not powered to assess these outcomes. PM/ICD-guided DOAC administration may prove a viable alternative to chronic anticoagulation. Future studies are warranted.