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Omar R, Saliba W, Khatib M, Zheng Y, Pieters C, Oved H, Silberman E, Zohar O, Hu Z, Kloper V, Broza YY, Dvir T, Grinberg Dana A, Wang Y, Haick H. Biodegradable, Biocompatible, and Implantable Multifunctional Sensing Platform for Cardiac Monitoring. ACS Sens 2024; 9:126-138. [PMID: 38170944 PMCID: PMC10825867 DOI: 10.1021/acssensors.3c01755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/17/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
Cardiac monitoring after heart surgeries is crucial for health maintenance and detecting postoperative complications early. However, current methods like rigid implants have limitations, as they require performing second complex surgeries for removal, increasing infection and inflammation risks, thus prompting research for improved sensing monitoring technologies. Herein, we introduce a nanosensor platform that is biodegradable, biocompatible, and integrated with multifunctions, suitable for use as implants for cardiac monitoring. The device has two electrochemical biosensors for sensing lactic acid and pH as well as a pressure sensor and a chemiresistor array for detecting volatile organic compounds. Its biocompatibility with myocytes has been tested in vitro, and its biodegradability and sensing function have been proven with ex vivo experiments using a three-dimensional (3D)-printed heart model and 3D-printed cardiac tissue patches. Moreover, an artificial intelligence-based predictive model was designed to fuse sensor data for more precise health assessment, making it a suitable candidate for clinical use. This sensing platform promises impactful applications in the realm of cardiac patient care, laying the foundation for advanced life-saving developments.
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Affiliation(s)
- Rawan Omar
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Walaa Saliba
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Muhammad Khatib
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Youbin Zheng
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Calvin Pieters
- Department
of Chemical Engineering, Technion-Israel
Institute of Technology, Haifa 320003, Israel
| | - Hadas Oved
- Shmunis
School of Biomedicine and Cancer Research, Faculty of Life Sciences, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Eric Silberman
- Shmunis
School of Biomedicine and Cancer Research, Faculty of Life Sciences, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Orr Zohar
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Zhipeng Hu
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Viki Kloper
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Yoav Y. Broza
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Tal Dvir
- Shmunis
School of Biomedicine and Cancer Research, Faculty of Life Sciences, Tel Aviv University, Tel Aviv 6997801, Israel
- Department
Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
- The
Chaoul Center for Nanoscale Systems, Tel
Aviv University Center for Nanoscience and Nanotechnology, Tel Aviv 6997801, Israel
- Sagol Center
for Regenerative Biotechnology, Tel Aviv
University, Tel Aviv 6997801, Israel
| | - Alon Grinberg Dana
- Department
of Chemical Engineering, Technion-Israel
Institute of Technology, Haifa 320003, Israel
| | - Yan Wang
- Department
of Chemical Engineering, Guangdong Technion-Israel
Institute of Technology (GTIIT), Shantou 515063, Guangdong, China
| | - Hossam Haick
- Department
of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion-Israel Institute of Technology, Haifa 3200003, Israel
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Stolen C, Rosman J, Manyam H, Kwan B, Kelly J, Perschbacher D, Garner J, Richards M. Preliminary results from the LUX-Dx insertable cardiac monitor remote programming and performance (LUX-Dx PERFORM) study. Clin Cardiol 2022; 46:100-107. [PMID: 36208096 PMCID: PMC9849434 DOI: 10.1002/clc.23930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 01/26/2023] Open
Abstract
Despite the wide adoption of insertable cardiac monitors (ICMs), high false-positive rates, suboptimal signal quality, limited ability to detect atrial flutter, and lack of remote programming remain challenging. The LUX-Dx PERFORM study was designed to evaluate novel technologies engineered to address these issues. Here, we present preliminary results from the trial focusing on the safety of ICM insertion, remote monitoring rates, and the feasibility of remote programming. LUX-Dx PERFORM is a multicenter, prospective, single-arm, post-market, observational study with planned enrollment of up to 827 patients from 35 sites in North America. A preliminary cohort consisting of the first 369 patients who were enrolled between March and October 2021 was selected for analysis. Three hundred sixty-three (363) patients had ICM insertions across inpatient and outpatient settings. The mean time followed was 103.4 ± 61.8 days per patient. The total infection rate was 0.8% (3/363). Interim results show high levels of remote monitoring with a median 94% of days with data transmission (interquartile range: 82-99). Thirteen (13) in-clinic and 24 remote programming sessions were reported in 34 subjects. Reprogramming examples are presented to highlight signal quality, the ability to detect atrial flutter, and the positive impact of remote programming on patient management. Interim results from LUX-Dx PERFORM study demonstrate the safety of insertion, high data transmission rates, the ability to detect atrial flutter, and the feasibility of remote programming to optimize arrhythmia detection and improve clinical workflow. Future results from LUX-Dx PERFORM will further characterize improvements in signal quality and arrhythmia detection.
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Affiliation(s)
- Craig Stolen
- Cardiac Rythm ManagementBoston ScientificSt PaulMinnesotaUSA
| | - Jonathan Rosman
- Cardiac Arrhythmia ServiceFlorida Atlantic University CESCOMBoca RatonFloridaUSA
| | - Harish Manyam
- Department of Cardiology, Erlanger HospitalUniversity of TennesseeKnoxvilleTennesseeUSA
| | - Brian Kwan
- Cardiac Rythm ManagementBoston ScientificSt PaulMinnesotaUSA
| | - Jonathan Kelly
- Cardiac Rythm ManagementBoston ScientificSt PaulMinnesotaUSA
| | | | - John Garner
- Department of Clinical MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
| | - Mark Richards
- Yakima Heart Lung & Vascular ClinicYakima Valley MemorialYakimaWashingtonUSA
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White RD, Demirer M, Gupta V, Sebro RA, Kusumoto FM, Erdal BS. Pre-deployment assessment of an AI model to assist radiologists in chest X-ray detection and identification of lead-less implanted electronic devices for pre-MRI safety screening: realized implementation needs and proposed operational solutions. J Med Imaging (Bellingham) 2022; 9:054504. [PMID: 36310648 PMCID: PMC9603740 DOI: 10.1117/1.jmi.9.5.054504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 09/23/2022] [Indexed: 09/29/2023] Open
Abstract
Purpose Chest X-ray (CXR) use in pre-MRI safety screening, such as for lead-less implanted electronic device (LLIED) recognition, is common. To assist CXR interpretation, we "pre-deployed" an artificial intelligence (AI) model to assess (1) accuracies in LLIED-type (and consequently safety-level) identification, (2) safety implications of LLIED nondetections or misidentifications, (3) infrastructural or workflow requirements, and (4) demands related to model adaptation to real-world conditions. Approach A two-tier cascading methodology for LLIED detection/localization and identification on a frontal CXR was applied to evaluate the performance of the original nine-class AI model. With the unexpected early appearance of LLIED types during simulated real-world trialing, retraining of a newer 12-class version preceded retrialing. A zero footprint (ZF) graphical user interface (GUI)/viewer with DICOM-based output was developed for inference-result display and adjudication, supporting end-user engagement and model continuous learning and/or modernization. Results During model testing or trialing using both the nine-class and 12-class models, robust detection/localization was consistently 100%, with mAP 0.99 from fivefold cross-validation. Safety-level categorization was high during both testing ( AUC ≥ 0.98 and ≥ 0.99 , respectively) and trialing (accuracy 98% and 97%, respectively). LLIED-type identifications by the two models during testing (1) were 98.9% and 99.5% overall correct and (2) consistently showed AUC ≥ 0.92 (1.00 for 8/9 and 9/12 LLIED-types, respectively). Pre-deployment trialing of both models demonstrated overall type-identification accuracies of 94.5% and 95%, respectively. Of the small number of misidentifications, none involved MRI-stringently conditional or MRI-unsafe types of LLIEDs. Optimized ZF GUI/viewer operations led to greater user-friendliness for radiologist engagement. Conclusions Our LLIED-related AI methodology supports (1) 100% detection sensitivity, (2) high identification (including MRI-safety) accuracy, and (3) future model deployment with facilitated inference-result display and adjudication for ongoing model adaptation to future real-world experiences.
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Affiliation(s)
- Richard D. White
- Mayo Clinic, Department of Radiology, Center for Augmented Intelligence in Imaging, Jacksonville, Florida, United States
| | - Mutlu Demirer
- Mayo Clinic, Department of Radiology, Center for Augmented Intelligence in Imaging, Jacksonville, Florida, United States
| | - Vikash Gupta
- Mayo Clinic, Department of Radiology, Center for Augmented Intelligence in Imaging, Jacksonville, Florida, United States
| | - Ronnie A. Sebro
- Mayo Clinic, Department of Radiology, Center for Augmented Intelligence in Imaging, Jacksonville, Florida, United States
| | - Frederick M. Kusumoto
- Mayo Clinic, Department of Cardiovascular Medicine, Jacksonville, Florida, United States
| | - Barbaros Selnur Erdal
- Mayo Clinic, Department of Radiology, Center for Augmented Intelligence in Imaging, Jacksonville, Florida, United States
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Impact of device length on electrogram sensing in miniaturized insertable cardiac monitors. J Electrocardiol 2022; 73:42-48. [DOI: 10.1016/j.jelectrocard.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/24/2022] [Accepted: 05/15/2022] [Indexed: 11/23/2022]
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Guarracini F, Testolina M, Giacopelli D, Martin M, Triglione F, Coser A, Quintarelli S, Bonmassari R, Marini M. Programming Optimization in Implantable Cardiac Monitors to Reduce False-Positive Arrhythmia Alerts: A Call for Research. Diagnostics (Basel) 2022; 12:diagnostics12040994. [PMID: 35454042 PMCID: PMC9025722 DOI: 10.3390/diagnostics12040994] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 01/25/2023] Open
Abstract
No studies have investigated whether optimizing implantable cardiac monitors (ICM) programming can reduce false-positive (FP) alerts. We identified patients implanted with an ICM (BIOMONITOR III) who had more than 10 FP alerts in a 1-month retrospective period. Uniform adjustments of settings were performed based on the mechanism of FP triggers and assessed at 1 month. Eight patients (mean age 57.5 ± 23.2 years; 37% female) were enrolled. In 4 patients, FPs were caused by undersensing of low-amplitude premature ventricular contractions (PVCs). No further false bradycardia was observed with a more aggressive decay of the dynamic sensing threshold. Furthermore, false atrial fibrillation (AF) alerts decreased in 2 of 3 patients. Two patients had undersensing of R waves after high-amplitude PVCs; false bradycardia episodes disappeared or were significantly reduced by limiting the initial value of the sensing threshold. Finally, the presence of atrial ectopic activity or irregular sinus rhythm generated false alerts of AF in 2 patients that were reduced by increasing the R-R variability limit and the confirmation time. In conclusion, adjustments to nominal settings can reduce the number of FP episodes in ICM patients. More research is needed to provide practical recommendations and assess the value of extended ICM programmability.
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Affiliation(s)
- Fabrizio Guarracini
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy; (M.M.); (A.C.); (S.Q.); (R.B.); (M.M.)
- Correspondence: ; Tel.: +39-33-9642-4477
| | | | - Daniele Giacopelli
- Clinical Unit, Biotronik Italia, Vimodrone, 20090 Milano, Italy; (D.G.); (F.T.)
- Department of Cardiac, Thoracic, Vascular Sciences & Public Health, University of Padova, 35128 Padova, Italy
| | - Marta Martin
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy; (M.M.); (A.C.); (S.Q.); (R.B.); (M.M.)
| | - Francesco Triglione
- Clinical Unit, Biotronik Italia, Vimodrone, 20090 Milano, Italy; (D.G.); (F.T.)
| | - Alessio Coser
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy; (M.M.); (A.C.); (S.Q.); (R.B.); (M.M.)
| | - Silvia Quintarelli
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy; (M.M.); (A.C.); (S.Q.); (R.B.); (M.M.)
| | - Roberto Bonmassari
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy; (M.M.); (A.C.); (S.Q.); (R.B.); (M.M.)
| | - Massimiliano Marini
- Department of Cardiology, S. Chiara Hospital, 38122 Trento, Italy; (M.M.); (A.C.); (S.Q.); (R.B.); (M.M.)
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The BIOMONITOR III Injectable Cardiac Monitor: Clinical Experience with a Novel Injectable Cardiac Monitor. J Clin Med 2022; 11:jcm11061634. [PMID: 35329960 PMCID: PMC8954265 DOI: 10.3390/jcm11061634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Injectable cardiac monitors (ICMs) are leadless subcutaneous devices for long-term monitoring of arrhythmias. The BIOTRONIK BIOMONITOR III is a novel ICM with a miniaturized profile, long sensing vector, and simplified implantation technique. Methods: R-wave amplitude was recorded immediately after implantation, the day after implantation, and after 3 months. Follow-up was scheduled after 3 months or after an event. All data from the ICM were retrieved. The anatomical position of the ICM was determined post-implantation and after 3 months. A patient questionnaire was conducted after 3 months. Results: In 36 patients (mean age 67 ± 13 years; 40% male) an ICM was inserted. Six patients were not included in the final analysis. The median time from skin cut to wound closure was 6 [IQR 5–7] minutes. Mean R-wave amplitude increased over time (0.73 ± 32 mV vs. 0.78 ± 0.38 mV vs. 0.81 ± 0.39 mV; p = ns). Three months after implantation, the ICM was in an anatomically stable position. In 14 (47%) patients, true episodes were detected. False arrhythmia alerts were detected in 13 (43%) patients. The total number of false detections was low, and the patient satisfaction rate was high. Conclusion: Implantation of the novel BIOMONITOR III is fast and uncomplicated; its sensing characteristics are excellent and improve over time, and patient satisfaction is high.
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Forleo GB, Amellone C, Sacchi R, Lombardi L, Lucciola MT, Scotti V, Viecca M, Schiavone M, Giacopelli D, Giammaria M. Factors affecting signal quality in implantable cardiac monitors with long sensing vector. J Arrhythm 2021; 37:1061-1068. [PMID: 34386133 PMCID: PMC8339108 DOI: 10.1002/joa3.12585] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/20/2021] [Accepted: 06/04/2021] [Indexed: 12/04/2022] Open
Abstract
PURPOSE Electrical artefacts are frequent in implantable cardiac monitors (ICMs). We analyzed the subcutaneous electrogram (sECG) provided by an ICM with a long sensing vector and factors potentially affecting its quality. METHODS Consecutive ICM recipients underwent a follow-up where demographics, body mass index (BMI), implant location, and surface ECG were collected. The sECG was then analyzed in terms of R-wave amplitude and P-wave visibility. RESULTS A total of 84 patients (43% female, median age 68 [58-76] years) were enrolled at 3 sites. ICMs were positioned with intermediate inclination (n = 44, 52%), parallel (n = 35, 43%), or perpendicular (n = 5, 6%) to the sternum. The median R-wave amplitude was 1.10 (0.72-1.48) mV with P waves readily visible in 69.2% (95% confidence interval, CI: 57.8%-79.2%), partially visible in 23.1% [95% CI: 14.3%-34.0%], and never visible in 7.7% [95% CI: 2.9%-16.0%] of patients. Men had higher R-wave amplitudes compared to women (1.40 [0.96-1.80] mV vs 1.00 [0.60-1.20] mV, P = .001), while obese people tended to have lower values (0.80 [0.62-1.28] mV vs 1.10 [0.90-1.50] mV, P = .074). The P-wave visibility reached 86.2% [95% CI: 68.3%-96.1%] in patients with high-voltage P waves (≥0.2 mV) at surface ECG. The sECG quality was not affected by implant site. CONCLUSION In ordinary clinical practice, ICMs with long sensing vector provided median R-wave amplitude above 1 mV and reliable P-wave visibility of nearly 70%, regardless of the position of the device. Women and obese patients showed lower but still very good signal quality.
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Affiliation(s)
- Giovanni B. Forleo
- Cardiology UnitASST‐Fatebenefratelli SaccoLuigi Sacco University HospitalMilanItaly
| | | | | | - Leonida Lombardi
- Cardiology UnitASST‐Fatebenefratelli SaccoLuigi Sacco University HospitalMilanItaly
| | | | | | - Maurizio Viecca
- Cardiology UnitASST‐Fatebenefratelli SaccoLuigi Sacco University HospitalMilanItaly
| | - Marco Schiavone
- Cardiology UnitASST‐Fatebenefratelli SaccoLuigi Sacco University HospitalMilanItaly
| | - Daniele Giacopelli
- Clinical Research UnitBIOTRONIK ItaliaVimodrone, MilanItaly
- Department of Cardiac, Thoracic, Vascular Sciences & Public HealthPadovaItaly
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Sohns C, Khalaph M, Bergau L, Sommer P. [Smart and simple : Current role of implantables and wearables in daily practice]. Herzschrittmacherther Elektrophysiol 2020; 31:265-272. [PMID: 32757084 PMCID: PMC7403787 DOI: 10.1007/s00399-020-00707-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/03/2020] [Indexed: 12/02/2022]
Abstract
In den letzten Jahren hat die Verwendung von Implantables und Wearables zum Monitoring von Herzfrequenz und -rhythmus stetig zugenommen. Inzwischen stehen smarte und einfache Lösungen zur Verfügung, um den Herzrhythmus kontinuierlich zu überwachen und die dokumentierten Daten weiterzuleiten. Aus diesem Grund können Implantables und Wearables auch einfach und direkt an telemedizinische Zentren angebunden werden. Als große Herausforderung für den verstärkten Einsatz von Monitoring-Devices gilt weiterhin eine relativ ungefilterte Datenflut. Dieser Übersichtsartikel zeigt anhand einiger ausgewählter Beispiele die Anwendung und Funktionalität von Monitoring-Devices und soll auf diesem Wege den potenziellen Stellenwert von Implantables und Wearables in unserem klinischen elektrophysiologischen Alltag darstellen und differenziert diskutieren.
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Affiliation(s)
- Christian Sohns
- Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland.
| | - Moneeb Khalaph
- Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Leonard Bergau
- Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Philipp Sommer
- Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
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Awad K, Weiss R, Yunus A, Bittrick JM, Nekkanti R, Houmsse M, Okabe T, Adamson T, Miller C, Alawwa AK. BioMonitor 2 in-office setting insertion safety and feasibility evaluation with device functionality assessment: results from the prospective cohort BioInsight study. BMC Cardiovasc Disord 2020; 20:171. [PMID: 32293279 PMCID: PMC7161128 DOI: 10.1186/s12872-020-01439-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insertable cardiac monitors are utilized for the diagnosis of arrhythmias and traditionally have been inserted within hospitals. Recent code updates allow for reimbursement of office-based insertions; however, there is limited information regarding the resources and processes required to support in-office insertions. We sought to determine the safety and feasibility of in-office insertion of the BioMonitor 2 and better understand in-office procedures, including patient selection, pre-insertion protocols, resource availability, and staff support. METHODS Patients meeting an indication for a rhythm monitor were prospectively enrolled into this single-arm, non-randomized trial. All patients underwent insertion in an office setting. Two follow-up visits at days 7 and 90 were required. Information on adverse events, device performance, office site preparations, and resource utilization were collected. RESULTS Eighty-two patients were enrolled at six sites. Insertion was successful in all 77 patients with an attempt. Oral anticoagulation was stopped in 20.8% of patients and continued through insertion in 23.4%, while prophylactic antibiotics were infrequently utilized (37.7% of study participants). On average, the procedure required a surgeon plus two support staff and 35 min in an office room to complete the 8.4 min insertion procedure. The mean R-wave amplitude was 0.77 mV at insertion and 0.67 mV at 90-days with low noise burden (2.7%). There were no procedure related complications. Two adverse events were reported (event rate 2.7% [95% CI 0.3, 9.5%]). CONCLUSIONS In-office insertion of the BioMonitor 2 is safe and feasible. Devices performed well with high R-wave amplitudes and low noise burden. These results further support shifting cardiac monitor insertions to office-based locations. TRIAL REGISTRATION clinicaltrials.gov, NCT02756338. Registered 29 April 2016.
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Affiliation(s)
- Khaled Awad
- Mercy Clinic Heart and Vascular at Mercy Heart Hospital, St. Louis, MO, USA.
| | - Raul Weiss
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Asim Yunus
- Michigan CardioVascular Institute, Saginaw, MI, USA
| | | | - Rajasekhar Nekkanti
- The Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Mahmoud Houmsse
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Toshimasa Okabe
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Mariani JA, Weerasooriya R, van den Brink O, Mohamed U, Gould PA, Pathak RK, Lin T, Conradie A, Illes P, Pavia S, Rajamani K, Lovibond S, Matthews I, DiFiore D, Arumugam D, Schrader J, Lau DH. Miniaturized implantable cardiac monitor with a long sensing vector (BIOMONITOR III): Insertion procedure assessment, sensing performance, and home monitoring transmission success. J Electrocardiol 2020; 60:118-125. [PMID: 32361086 DOI: 10.1016/j.jelectrocard.2020.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/26/2020] [Accepted: 04/07/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Implantable Cardiac Monitors (ICMs) are used for long-term monitoring of arrhythmias. BIOMONITOR III is a novel ICM with a miniaturized profile, long sensing vector due to a flexible antenna, simplified implantation with a dedicated insertion tool for pocket formation and ICM placement in a single step, and daily automatic Home Monitoring (HM) function. METHODS In 47 patients undergoing BIOMONITOR III insertion for any ICM indication, 16 investigators at 10 Australian sites assessed handling characteristics of the insertion tool, R-wave amplitudes, noise burden, P-wave visibility, and HM transmission success. Patients were followed for 1 month. RESULTS All 47 attempted insertions were successful. Median time from skin incision to removal of the insertion tool after ICM insertion was 39 s (IQR 19-65) and to wound closure and cleaning was 4.7 min (IQR 3.5-7.8). All aspects of the insertion tool were rated as "good" or "excellent" in ≥97.9% and "fair" in ≤2.1% of patients, except for "force needed for tunnelling" (91.5% good/excellent, 8.5% fair). Based on HM data, R-waves in the first month were stable at 0.70 ± 0.37 mV. Median noise burden (disabling automatic rhythm evaluation) was 0.19% (IQR 0.00-0.93), equivalent to 2.7 min (IQR 0.0-13.4) per day. In HM-transmitted ECG strips with regular sinus rhythm, P-waves were visible in 89 ± 24% of heart cycles. Patient-individual automatic Home Monitoring transmission success was 98.0% ± 5.5%. CONCLUSIONS The novel ICM performed well in all aspects studied, including fast insertion, reliable R-wave sensing, good P-wave visibility, and highly successful HM transmissions.
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Affiliation(s)
- Justin A Mariani
- The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia; Central Clinical School, Monash University, 99 Commercial Rd, Melbourne, VIC 3004, Australia.
| | - Rukshen Weerasooriya
- University of Western Australia, Department of Medicine, Crawley, WA 6000, Australia.
| | - Olivier van den Brink
- The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia; Central Clinical School, Monash University, 99 Commercial Rd, Melbourne, VIC 3004, Australia.
| | - Uwais Mohamed
- St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065, Australia.
| | - Paul A Gould
- The University of Queensland, and Department of Cardiology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia.
| | - Rajeev K Pathak
- Australian National University and The Canberra Hospital, Yamba Dr, Canberra, ACT 2605, Australia.
| | - Tina Lin
- GenesisCare Victoria, 5/126 Wellington Pde, East Melbourne, VIC 3002, Australia.
| | - Andre Conradie
- GenesisCare, Friendly Society Private Hospital, 19-23 Bingera Street, Bundaberg, QLD 4670, Australia.
| | - Peter Illes
- Sydney Adventist Hospital, 185 Fox Valley Road, Wahroonga, NSW 2076, Australia
| | - Stephen Pavia
- GenesisCare, The Wesley Hospital, 30 Chasely St, Auchenflower, QLD 4066, Australia.
| | - Kushwin Rajamani
- University of Western Australia, Department of Medicine, Crawley, WA 6000, Australia
| | - Sam Lovibond
- The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia; Central Clinical School, Monash University, 99 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Ian Matthews
- St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065, Australia.
| | - David DiFiore
- GenesisCare, Friendly Society Private Hospital, 19-23 Bingera Street, Bundaberg, QLD 4670, Australia.
| | - Deepak Arumugam
- GenesisCare, The Wesley Hospital, 30 Chasely St, Auchenflower, QLD 4066, Australia.
| | - Jürgen Schrader
- Biotronik SE & Co. KG, Woermannkehre 1, 12359 Berlin, Germany.
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.
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Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G. Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation. Health Technol Assess 2020; 24:1-184. [PMID: 31944175 PMCID: PMC6983910 DOI: 10.3310/hta24050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cryptogenic stroke is a stroke for which no cause is identified after standard diagnostic tests. Long-term implantable cardiac monitors may be better at diagnosing atrial fibrillation and provide an opportunity to reduce the risk of stroke recurrence with anticoagulants. OBJECTIVES The objectives were to assess the diagnostic test accuracy, clinical effectiveness and cost-effectiveness of three implantable monitors [BioMonitor 2-AF™ (Biotronik SE & Co. KG, Berlin, Germany), Confirm Rx™ (Abbott Laboratories, Lake Bluff, IL, USA) and Reveal LINQ™ (Medtronic plc, Minneapolis, MN, USA)] in patients who have had a cryptogenic stroke and for whom no atrial fibrillation is detected after 24 hours of external electrocardiographic monitoring. DATA SOURCES MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases were searched from inception until September 2018. REVIEW METHODS A systematic review was undertaken. Two reviewers agreed on studies for inclusion and performed quality assessment using the Cochrane Risk of Bias 2.0 tool. Results were discussed narratively because there were insufficient data for synthesis. A two-stage de novo economic model was developed: (1) a short-term patient flow model to identify cryptogenic stroke patients who have had atrial fibrillation detected and been prescribed anticoagulation treatment (rather than remaining on antiplatelet treatment) and (2) a long-term Markov model that captured the lifetime costs and benefits of patients on either anticoagulation or antiplatelet treatment. RESULTS One randomised controlled trial, Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL-AF) (Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86), was identified, and no diagnostic test accuracy study was identified. The CRYSTAL-AF trial compared the Reveal™ XT (a Reveal LINQ predecessor) (Medtronic plc) monitor with standard of care monitoring. Twenty-six single-arm observational studies for the Reveal devices were also identified. The only data for BioMonitor 2-AF or Confirm Rx were from mixed population studies supplied by the companies. Atrial fibrillation detection in the CRYSTAL-AF trial was higher with the Reveal XT than with standard monitoring at all time points. By 36 months, atrial fibrillation was detected in 19% of patients with an implantable cardiac monitor and in 2.3% of patients receiving conventional follow-up. The 26 observational studies demonstrated that, even in a cryptogenic stroke population, atrial fibrillation detection rates are highly variable and most cases are asymptomatic; therefore, they probably would not have been picked up without an implantable cardiac monitor. Device-related adverse events, such as pain and infection, were low in all studies. The de novo economic model produced incremental cost effectiveness ratios comparing implantable cardiac monitors with standard of care monitoring to detect atrial fibrillation in cryptogenic stroke patients based on data for the Reveal XT device, which can be related to Reveal LINQ. The BioMonitor 2-AF and Confirm RX were included in the analysis by making a strong assumption of equivalence with Reveal LINQ. The results indicate that implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold. When each device is compared incrementally, BioMonitor 2-AF dominates Reveal LINQ and Confirm RX. LIMITATIONS The cost-effectiveness analysis for implantable cardiac monitors is based on a strong assumption of clinical equivalence and should be interpreted with caution. CONCLUSIONS All three implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold, compared with standard of care monitoring, for cryptogenic stroke patients with no atrial fibrillation detected after 24 hours of external electrocardiographic monitoring; however, further clinical studies are required to confirm their efficacy in cryptogenic stroke patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42018109216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steven J Edwards
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | | | - Tracey Jhita
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Kayleigh Kew
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Peter Cain
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Gemma Marceniuk
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
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Søgaard P, Behrens S, Konyi A, Taborsky M, Christiansen PD, Jacobsen PK, Faluközy J, Malczynski J, Brachmann J, Samol A, Kluding M, Schrader J, Bloch Thomsen PE, Jøns C. Transmission and loss of ECG snapshots: Remote monitoring in implantable cardiac monitors. J Electrocardiol 2019; 56:24-28. [PMID: 31233982 DOI: 10.1016/j.jelectrocard.2019.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 05/23/2019] [Accepted: 06/12/2019] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Remote monitoring including transmission of electrocardiogram (ECG) strips has been implemented in implantable cardiac monitors (ICM). We appraise whether the physician can rely on remote monitoring to be informed of all possibly significant arrhythmias. METHODS We analyzed remote monitoring transmissions of patients in the ongoing BIO|GUARD-MI study, in which Biotronik devices are used. Once per day, the devices automatically transmit messages with up to six ECG snapshots to the Home Monitoring Service Center. If more than one type of arrhythmia is recorded during a day, at least one ECG of each arrhythmia type is transmitted. RESULTS 212 study patients were registered at the service center. The mean age of the patients was 70 ± 8 years, and 74% were male. Patients were followed for an average of 13 months. The median time from device implantation until the first message receipt in the service center was 2 days. The median patient-individual transmission success was 98.0% (IQR 93.6-99.8) and remained stable in the second and third year. The most frequent arrhythmias were atrial fibrillation, bradycardia and high ventricular rate. 17.3% of the messages with ECG snapshots contained more than one arrhythmia type. DISCUSSION Our analysis confirms that the physician can rely on Home Monitoring to be informed of all possibly significant arrhythmias during long-term follow-up. We have found hints that the transmission of only one episode per day may lead to the loss of clinically relevant information if patients with ICMs are followed by remote monitoring only.
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Affiliation(s)
- Peter Søgaard
- Aalborg University Hospital, Cardiology, Hobrovej 18-22, 9100 Aalborg, Denmark.
| | - Steffen Behrens
- Vivantes Humboldt-Klinikum, Cardiology, Am Nordgraben 2, 13509 Berlin, Germany.
| | - Attila Konyi
- University of Pecs, Heart Institute, Ifjúság street 13, 7624 Pecs, Hungary.
| | - Miloš Taborsky
- Fakultní nemocnice Olomouc, Cardiology, I.P. Pavlova 6, 77900 Olomouc, Czech Republic.
| | | | - Peter Karl Jacobsen
- Rigshospitalet Copenhagen, Cardiology, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Jozsef Faluközy
- National Hospital of Cardiology, Gyogy ter 2, 8231 Balatonfüred, Hungary
| | | | - Johannes Brachmann
- Klinikum Coburg, Cardiology, Ketschendorfer Straße 33, 96450 Coburg, Germany.
| | - Alexander Samol
- Johannes-Wesling-University Hospital Minden, Cardiology and Critical Care Medicine, Hans-Nolte-Str. 1, 32429 Minden, Germany.
| | - Maike Kluding
- Biotronik SE & Co.KG, Woermannkehre 1, 12359 Berlin, Germany.
| | - Jürgen Schrader
- Biotronik SE & Co.KG, Woermannkehre 1, 12359 Berlin, Germany.
| | | | - Christian Jøns
- Rigshospitalet Copenhagen, Cardiology, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Sakhi R, Theuns DAMJ, Szili-Torok T, Yap SC. Insertable cardiac monitors: current indications and devices. Expert Rev Med Devices 2018; 16:45-55. [PMID: 30522350 DOI: 10.1080/17434440.2018.1557046] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Recurrent unexplained syncope is a well-established indication for an insertable cardiac monitor (ICM). Recently, the indications for an ICM have been expanded. AREAS COVERED This review article discusses the current indications for ICMs and gives an overview of the latest generation of commercially available ICMs. EXPERT COMMENTARY The 2018 ESC Syncope guidelines have expanded the indications for an ICM to patients with inherited cardiomyopathy, inherited channelopathy, suspected unproven epilepsy, and unexplained falls. ICMs are also increasingly used for the detection of subclinical atrial fibrillation (AF) in patients with cryptogenic stroke. Whether treatment of subclinical AF (SCAF) with oral anticoagulation prevents recurrent stroke is yet unknown. The current generation of ICMs are smaller, easier to implant, have better diagnostics, and are capable of remote monitoring. The Reveal LINQ (Medtronic) is the smallest ICM and has the most extensive performance and clinical data. The BioMonitor 2 (Biotronik) is the largest ICM but has excellent R-wave amplitudes, longest longevity, and reliable remote monitoring. The Confirm Rx (Abbott) is capable to provide mobile data transmission enabled by a smartphone app. Future generation of ICMs will incorporate heart failures indices to facilitate remote monitoring of heart failure patients.
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Affiliation(s)
- Rafi Sakhi
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Dominic A M J Theuns
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Tamas Szili-Torok
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Sing-Chien Yap
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
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The BioMonitor 2 insertable cardiac monitor: Clinical experience with a novel implantable cardiac monitor. J Electrocardiol 2018; 51:751-755. [PMID: 30177307 DOI: 10.1016/j.jelectrocard.2018.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/14/2018] [Accepted: 05/29/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Implantable loop recorders (ILR) are leadless subcutaneous devices that allow cardiac monitoring for up to 3 years and are a valuable tool in the diagnosis of arrhythmias, cryptogenic stroke and unexplained syncope. The Biotronik BioMonitor 2 is a novel, insertable ILR allowing long-term continuous monitoring with wireless telemetry options. METHODS A single-center, prospective, observational study investigating the reliability of sensing quality and detection performance in the BioMonitor 2 ILR, as well as post-implantation patient satisfaction. R-wave amplitude was recorded immediately post implantation and 1 day post implantation, followed by extensive patient instruction. Follow-up was scheduled after 3 months, or after an event. Data from the ILR were retrieved, with documentation of all episodes, R-wave amplitude and noise burden. The anatomical position of the ILR was determined 1 day post implantation and after 3 months. A patient questionnaire was conducted after 3 months. RESULTS 30 consecutive patients (mean age 71 ± 12 years, 56% male) were analyzed. Indications for ILR implantation were: unexplained syncope (n = 24, 80%), suspected atrial fibrillation (n = 4, 13%), cryptogenic stroke (n = 1, 3%) and palpitations (n = 1, 3%). Median time from skin cut to suture was 8 min. No complications occurred. Mean R-wave amplitude at implantation was 0.84 ± 0.32 mV, at day 1 post implantation 0.96 ± 0.31 mV, and after a mean follow-up of 85 ± 24 days 1.02 ± 0.47 mV (p = 0.01). The mean noise burden was 1.4 ± 2%. CONCLUSION Implantation of the novel BioMonitor 2 ILR is fast and uncomplicated. Initial sensing values are good and improve over time.
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