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  • In patients with systolic heart

    2019-05-13

    In patients with systolic heart failure and a wide QRS complex, cardiac resynchronisation therapy (CRT) using left ventricular (LV) pacing has been shown to enhance survival, reduce heart failure hospitalisation and enhance exercise capacity in patients with all Regorafenib of heart failure. The patient subsets most likely to benefit are those with class II–IV heart failure, LBBB and a QRS width ≥ 150ms . The application of CRT in patients with less wide QRS, non-LBBB and atrial fibrillation may be associated with less benefit. Coronary sinus placement of LV lead is the main channel of CRT delivery. This can be challenging at times during implantation, and can restrict LV pacing to suboptimal site . There are post-implant complications such as LV lead dislodgment, diaphragmatic pacing and device infection. A major limitation of CRT is the problem of non-responders, which can be up to 30% of all indicated patients. The response rate could be better when a QRS width ≥ 150ms is used as an indication for CRT. Apart from lead location and lack of enough residual viable myocardium for resynchronisation, post-implant programming may play a role in reducing non-responders. This includes adjustment of atrioventricular and interventricular timing and the use of fusion pacing . The guideline for use of implantable cardioverter defibrillator (ICD) has not substantially changed since 2008 . However, the application of ICD especially for primary prevention therapy in the Asia-Pacific region has been limited not only by cost and reimbursement, but also because of controversy as to the application of the primary prevention studies to the Asian populations . Both appropriate and inappropriate ICD shocks carry adverse prognosis , and device programming to minimise ICD therapies and ablation of ventricular tachycardia have been used either prophylactically or to treat VT/VF ICD storms. The most important problem now encountered is defibrillation lead failure by some manufacturers. This has call forth the need to develop a system of lead management that includes surveillance, programming and lead extraction for ICD leads.
    Introduction The implantation of cardiac electronic devices has increased exponentially during the last decade in response to widening indications. Subsequent monitoring is an integral part of both device and patient care. However, follow-up schedules vary according to facility, physician preference and available resources [1]. A review of recent US Medicare beneficiaries revealed that almost a quarter of patients were not seen in the year after implant [2]. This represents a quality of care deficit. To address this, professional organizations have advocated institution of regular periodic assessment for patients receiving CIEDs [3]. However, frequent in-office evaluation generates a large service commitment and challenges patient compliance, yet its efficacy with regard to patient safety, adherence, incidence of unscheduled encounters and rate of problem detection have remain unappraised until recently. This is added to when the volume of unscheduled encounters periodically increases, for example, when a device reaches elective replacement indicator (ERI) status or in response to product advisories or recalls. Symptomatic events (e.g., shock therapy) prompt additional encounters, including unscheduled office/emergency room (ER) visits or even hospitalization. A major limitation of flagella conventional follow-up method, which is based on patient presentation, is that no monitoring takes place between hospital visits, i.e., the majority of the time. This will miss important events especially if asymptomatic, e.g. regarding system integrity or onset of arrhythmias (e.g. atrial fibrillation (AF)). Their early detection is critical to patient safety.
    Remote follow-up and remote monitoring Remote monitoring may be the optimal mechanism for performing intensive device and patient surveillance, for managing increasing volume of data, and relieving the burden of routine follow-up performed by device clinics. In this regard, different functions are identified. Remote follow-up involves scheduled automatic device interrogation, which replaces in-office visits aimed at assessing device function (e.g. battery status, thresholds etc.) The interrogations can be performed automatically in patients implanted with modern wireless devices, and manually using wanded home transmitters if the implanted device is not enabled with wireless technology. Remote monitoring involves automatic unscheduled transmission of alert events (e.g. atrial fibrillation, abnormal lead impedance etc.) This is only possible in some modern wireless devices. Patient initiated interrogations are non-scheduled follow-ups initiated manually by the patient as a result of a real or perceived clinical event.