1
|
Beach CM, Richardson C, Paul T. The Evolving Role of Insertable Cardiac Monitors in Patients with Congenital Heart Disease. Card Electrophysiol Clin 2023; 15:413-420. [PMID: 37865515 DOI: 10.1016/j.ccep.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Insertable cardiac monitors (ICMs) have been used more frequently and in a wider variety of circumstances in recent years. ICMs are used for symptom-rhythm correlation when patients have potentially arrhythmogenic syncope and for less traditional reasons such as rhythm surveillance in patients with genetic arrhythmia syndromes or other diseases with high arrhythmia risk. ICMs have good diagnostic yield in pediatric patients and in adults with congenital heart disease and have a low rate of complications. Implantation techniques should take patient-specific factors into account to optimize diagnostic yield and minimize risk.
Collapse
Affiliation(s)
- Cheyenne M Beach
- Section of Pediatric Cardiology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA.
| | - Chalese Richardson
- Zucker School of Medicine at Hofstra, The Cohen Children's Heart Center, Northwell Health Physician Partners, 1111 Marcus Avenue, Suite M15, New Hyde Park, NY 11042, USA
| | - Thomas Paul
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology, Georg August University Medical Center, Robert-Koch-Str. 40, Göttingen D-37075, Germany
| |
Collapse
|
2
|
Davidson S, Wong A, Cortez D. Loop recorder implantation in patients as young as 3-months of age; the benefit of the sub-scapular approach. Pacing Clin Electrophysiol 2023; 46:1073-1076. [PMID: 37585344 DOI: 10.1111/pace.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/17/2023] [Accepted: 08/01/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Loop recorder implants may have value in pediatric patients; however, size limitations exist due to the risk of erosion. METHODS Retrospective review of five patients who underwent subscapular loop recorder implantation were reviewed. RESULTS No complications occurred. Stable R-waves were noted but could be positional but with adequate diagnostics provided. CONCLUSION Subscapular loop recorder implantation is feasible in patients as young as 3 months of age.
Collapse
Affiliation(s)
- Stacy Davidson
- Department of Pediatric Cardiology, UC Davis Medical Center, Sacramento, California, USA
| | - Ashley Wong
- Department of Pediatric Cardiology, UC Davis Medical Center, Sacramento, California, USA
| | - Daniel Cortez
- Department of Pediatric Cardiology, UC Davis Medical Center, Sacramento, California, USA
| |
Collapse
|
3
|
Assaf A, Theuns DA, Michels M, Roos-Hesselink J, Szili-Torok T, Yap SC. Usefulness of insertable cardiac monitors for risk stratification: current indications and clinical evidence. Expert Rev Med Devices 2023; 20:85-97. [PMID: 36695092 DOI: 10.1080/17434440.2023.2171862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The 2018 ESC Syncope guidelines expanded the indications for an insertable cardiac monitor (ICM) to patients with unexplained syncope and primary cardiomyopathy or inheritable arrhythmogenic disorders. AREAS COVERED This review article discusses the clinical evidence for using an ICM for risk stratification in different patient populations including Brugada syndrome, long QT syndrome, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, cardiac sarcoidosis, and congenital heart disease. EXPERT OPINION Clinical data on the usefulness of ICMs in different patient populations is limited but most studies demonstrate early detection of clinically relevant arrhythmias, such as nonsustained ventricular tachycardia or atrial fibrillation. It is important to emphasize that the study populations usually comprise selected populations where conventional diagnostic methods fail to clarify the mechanism of symptoms. The effect of an ICM on prognosis by earlier detection of arrhythmias is difficult to demonstrate in populations with rare disease. Risk stratification in patients with cardiomyopathy or inheritable arrhythmogenic disorders remains a niche indication for ICMs. The most important indication for an ICM remains unexplained syncope in patients at low risk of SCD. Given the device costs and uncertain clinical value of device-detected arrhythmias, it is unclear whether it is also useful in non-syncopal patients.
Collapse
Affiliation(s)
- Amira Assaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dominic Amj Theuns
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michelle Michels
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jolien Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
4
|
Nash D, Katcoff H, Faerber J, Iyer VR, Shah MJ, O'Byrne ML, Janson C. Impact of Device Miniaturization on Insertable Cardiac Monitor Use in the Pediatric Population: An Analysis of the MarketScan Commercial and Medicaid Databases. J Am Heart Assoc 2022; 11:e024112. [PMID: 35929446 PMCID: PMC9496290 DOI: 10.1161/jaha.121.024112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Insertable cardiac monitors (ICMs) are effective in the detection of paroxysmal arrhythmias. In 2014, the first miniaturized ICM was introduced with a less invasive implant technique. The impact of this technology on ICM use in pediatric patients has not been evaluated. We hypothesized an increase in annual pediatric ICM implants starting in 2014 attributable to device miniaturization. Methods and Results A retrospective observational study was conducted using administrative claims from MarketScan Medicaid and commercial insurance claims databases. Use of ICM between January 2013 and December 2018 was measured (normalized to the total enrolled population ≤18 years) and compared with balancing measures (Holter ambulatory monitors, cardiac event monitors, encounters with syncope diagnosis, implantation of implantable cardioverter‐defibrillator/pacemaker). Secondary analyses included evaluations of subsequent interventions and complications. The study cohort included 33 532 185 individual subjects, of which 769 (0.002%) underwent ICM implantation. Subjects who underwent ICM implantation were 52% male sex, with a median age of 16 years (interquartile range, 10–17 years). A history of syncope was present in 71%, palpitations in 43%, and congenital heart disease in 28%. Following release of the miniaturized ICM, use of ICMs increased from 5 procedures per million enrollees in 2013 to 11 per million between 2015 and 2018 (P<0.001), while balancing measures remained static. Of 394 subjects with ≥1 year of follow‐up after implantation, interventions included catheter ablation in 24 (6%), pacemaker implantation in 15 (4%), and implantable cardioverter‐defibrillator implantation in 7 (2%). Conclusions Introduction of the miniaturized ICM was followed by a rapid increase in pediatric use. The effects on outcomes and value deserve further attention.
Collapse
Affiliation(s)
- Dustin Nash
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Jennifer Faerber
- Data Science and Biostatistics Unit The Children's Hospital of Philadelphia PA
| | - V Ramesh Iyer
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Maully J Shah
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
| | - Christopher Janson
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| |
Collapse
|
5
|
Akca T, Uysal F, Bostan OM, Genc A, Turkmen H. The Role of External Loop Recorders in Arrhythmia-Related Symptoms in Children: A Single Center Experience. Pediatr Cardiol 2022; 43:147-154. [PMID: 34389905 DOI: 10.1007/s00246-021-02705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/08/2021] [Indexed: 11/25/2022]
Abstract
In this study, we report our experience with the use of external loop recorders (ELRs), in terms of diagnostic efficiency according to symptoms and symptom-rhythm correlation in pediatric patients. We evaluated ELRs applied to 178 patients between April 2017 and November 2020 at our center. The mean age of 172 patients included in the study was 13.6 ± 3.8 years, and 69.8% were female. ELR indications were palpitations in 98 (56.9%) cases, chest pain and palpitations in 43 (25%) cases, presyncope/syncope in 28 (16.2%) cases, and pacemaker/ implantable cardioverter-defibrillator (ICD) problems in 3 (0.2%) cases. ELR recording times were 14.2 ± 9.7 days on average, ranging from 2 to 67 days. While the symptom-rhythm correlation was 29.1% in total, when the indications were evaluated one by one, this correlation was found to be 30.2% in palpitations, 34.7% in chest pain and palpitations, and 10.7% in presyncope/syncope. The total diagnostic efficiency was 68.1%. In the follow-up of ELR cases, a total of 139 (80.8%) patients received clinical follow-up without medication, 15 (8.8%) patients received medical treatment, and 18 (10.4%) patients underwent EPS. The cardiac ELR system is useful in detecting underlying arrhythmias. Demonstrating sinus tachycardia at the time of the symptom may be seen as negative finding, but while experiencing symptoms, it is diagnostically valuable and may help avoid further investigation with costly and invasive diagnostic procedures. For diagnostic efficiency and cost effectiveness, the optimal recording time is 2 weeks, but it should be extended to 4 weeks in cases such as of presyncope/syncope that cannot be explained with a 2-week ELR use.
Collapse
Affiliation(s)
- Tugberk Akca
- Faculty of Medicine, Department of Pediatric Cardiology, Bursa Uludag University, Gorukle Campuss, Nilufer, Bursa, Turkey.
| | - Fahrettin Uysal
- Faculty of Medicine, Department of Pediatric Cardiology, Bursa Uludag University, Gorukle Campuss, Nilufer, Bursa, Turkey
| | - Ozlem Mehtap Bostan
- Faculty of Medicine, Department of Pediatric Cardiology, Bursa Uludag University, Gorukle Campuss, Nilufer, Bursa, Turkey
| | - Abdusselam Genc
- Faculty of Medicine, Department of Pediatric Cardiology, Bursa Uludag University, Gorukle Campuss, Nilufer, Bursa, Turkey
| | - Hasan Turkmen
- Faculty of Medicine, Department of Pediatric Cardiology, Bursa Uludag University, Gorukle Campuss, Nilufer, Bursa, Turkey
| |
Collapse
|
6
|
Diagnostic Efficacy of a Single-Lead Ambulatory 14-Day ECG Monitor in Symptomatic Children. CJC Open 2021; 3:1341-1346. [PMID: 34901802 PMCID: PMC8640594 DOI: 10.1016/j.cjco.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/20/2021] [Indexed: 11/21/2022] Open
Abstract
Background The CardioSTAT is a single-lead ambulatory electrocardiography monitor that has been validated for use in adult patients. Recording is made through 2 electrodes positioned in a lead-I configuration, and the device allows monitoring for 2, 7, or 14 days. We sought to investigate the efficacy of this device in children with paroxysmal palpitations. Methods In phase I, the quality of tracings from simultaneous CardioSTAT recordings and D1-lead recordings of a standard 12-lead electrocardiography machine in 23 children were compared. Phase II was a prospective observational cohort study comparing arrhythmia detection using the CardioSTAT vs currently used devices (24-hour Holter monitor and the Cardiomemo loop recorder) in 52 children complaining of palpitations. Results In Phase I, all but 3 rhythm strips were correctly identified. The pacing spikes on 3 strips were not adequately identified by the observers for the CardioSTAT recording. In Phase II, symptomatic episodes were reported in 42%, 73%, and 100% of subjects during monitoring with the Holter, Cardiomemo, and CardioSTATdevices, respectively. An abnormal rhythm was detected in 13%, 23%, and 35% of subjects by the Holter, Cardiomemo, and CardioSTAT monitors, respectively. The underlying rhythm during symptomatic events was determined in 90% of cases with the CardioSTAT monitor, whereas it was determined in only 19% and 29% of cases using the Holter and Cardiomemo monitors, respectively. Conclusions The CardioSTAT monitor provided good-quality tracings and was superior to the 24-hour Holter monitor and the Cardiomemo loop recorder in determining the presence or absence of pathologic arrhythmia in the study cohort.
Collapse
|
7
|
Shah MJ, Silka MJ, Silva JNA, Balaji S, Beach CM, Benjamin MN, Berul CI, Cannon B, Cecchin F, Cohen MI, Dalal AS, Dechert BE, Foster A, Gebauer R, Gonzalez Corcia MC, Kannankeril PJ, Karpawich PP, Kim JJ, Krishna MR, Kubuš P, LaPage MJ, Mah DY, Malloy-Walton L, Miyazaki A, Motonaga KS, Niu MC, Olen M, Paul T, Rosenthal E, Saarel EV, Silvetti MS, Stephenson EA, Tan RB, Triedman J, Bergen NHV, Wackel PL. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Developed in collaboration with and endorsed by the Heart Rhythm Society (HRS), the American College of Cardiology (ACC), the American Heart Association (AHA), and the Association for European Paediatric and Congenital Cardiology (AEPC) Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). JACC Clin Electrophysiol 2021; 7:1437-1472. [PMID: 34794667 DOI: 10.1016/j.jacep.2021.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.
Collapse
Affiliation(s)
- Maully J Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Michael J Silka
- University of Southern California Keck School of Medicine, Los Angeles, California, USA.
| | | | | | | | - Monica N Benjamin
- Hospital de Pediatría Juan P. Garrahan, Hospital El Cruce, Hospital Británico de Buenos Aires, Instituto Cardiovascular ICBA, Buenos Aires, Argentina
| | | | | | - Frank Cecchin
- New York University Grossman School of Medicine, New York, New York, USA
| | | | - Aarti S Dalal
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Anne Foster
- Advocate Children's Heart Institute, Chicago, Illinois, USA
| | - Roman Gebauer
- Heart Centre Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - Peter P Karpawich
- University Pediatricians, Children's Hospital of Michigan, Detroit, Michigan, USA
| | | | | | - Peter Kubuš
- Children's Heart Center, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | | | | | - Aya Miyazaki
- Shizuoka General Hospital and Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Mary C Niu
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Melissa Olen
- Nicklaus Children's Hospital, Miami, Florida, USA
| | - Thomas Paul
- Georg-August-University Medical Center, Göttingen, Germany
| | - Eric Rosenthal
- Evelina London Children's Hospital and St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | | | - Reina B Tan
- New York University Langone Health, New York, New York, USA
| | | | - Nicholas H Von Bergen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | |
Collapse
|
8
|
Czosek RJ, Zang H, Baskar S, Anderson JB, Knilans TK, Ollberding NJ, Spar DS. Outcomes of Implantable Loop Monitoring in Patients <21 Years of Age. Am J Cardiol 2021; 158:53-58. [PMID: 34503824 DOI: 10.1016/j.amjcard.2021.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
Rhythm-symptom correlation in pediatric patients with syncope/palpitations or at risk cohorts can be difficult, but important given potential associations with treatable or malignant arrhythmia. We sought to evaluate the use, efficacy and outcomes of implantable loop recorders (ILR) in pediatrics. We conducted a retrospective study of pediatric patients (<21 years) with implanted ILR. Patient/historical characteristics and ILR indication were obtained. Outcomes including symptom documentation, arrhythmia detection and ILR based changes in medical care were identified. Comparison of outcomes were performed based on implant indication. Additional sub-analyses were performed in syncope-indication patients comparing those with and without changes in clinical management. A total of 116 patients with ILR implant were identified (79 syncope/37 other). Symptoms were documented 58% of patients (syncope 68% vs nonsyncope 35%; p = 0.002). A total of 37% of patients had a documented clinically significant arrhythmia and 25% of patients had a resultant change in clinical management independent of implant indication. Arrhythmia type was dependent on implant indication with nonsyncope patients having more ventricular arrhythmias. Pacemaker/defibrillator implantation and mediation management were the majority of the clinical changes. In conclusion, IRL utilization in selected pediatric populations is associated with high efficacy and supports clinical management. ILR efficacy is similar regardless of indication although patients with nonsyncope indications had a higher frequency of ventricular arrhythmias as opposed to asystole and heart block in syncope indications. The majority of arrhythmic findings occurred in the first 12 months, and new technology that would allow for less invasive monitoring for 6 to 12 months may be of value.
Collapse
Affiliation(s)
- Richard J Czosek
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio
| | - Shankar Baskar
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey B Anderson
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Timothy K Knilans
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David S Spar
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
9
|
2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients. Cardiol Young 2021; 31:1738-1769. [PMID: 34338183 DOI: 10.1017/s1047951121003413] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.
Collapse
|
10
|
Shah MJ, Silka MJ, Silva JA, Balaji S, Beach C, Benjamin M, Berul C, Cannon B, Cecchin F, Cohen M, Dalal A, Dechert B, Foster A, Gebauer R, Gonzalez Corcia MC, Kannankeril P, Karpawich P, Kim J, Krishna MR, Kubuš P, Malloy-Walton L, LaPage M, Mah D, Miyazaki A, Motonaga K, Niu M, Olen M, Paul T, Rosenthal E, Saarel E, Silvetti MS, Stephenson E, Tan R, Triedman J, Von Bergen N, Wackel P. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients. Heart Rhythm 2021; 18:1888-1924. [PMID: 34363988 DOI: 10.1016/j.hrthm.2021.07.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 01/10/2023]
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consenus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology, (ACC) and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate follow-up in pediatric patients.
Collapse
Affiliation(s)
- Maully J Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Michael J Silka
- University of Southern California Keck School of Medicine, Los Angeles, California.
| | | | | | - Cheyenne Beach
- Yale University School of Medicine, New Haven, Connecticut
| | - Monica Benjamin
- Hospital de Pediatría Juan P. Garrahan, Hospital El Cruce, Hospital Británico de Buenos Aires, Instituto Cardiovascular ICBA, Buenos Aires, Argentina
| | | | | | - Frank Cecchin
- New York Univeristy Grossman School of Medicine, New York, New York
| | | | - Aarti Dalal
- Washington University in St. Louis, St. Louis, Missouri
| | | | - Anne Foster
- Advocate Children's Heart Institute, Chicago, Illinois
| | - Roman Gebauer
- Heart Centre Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - Peter Karpawich
- University Pediatricians, Children's Hospital of Michigan, Detroit, Michigan
| | | | | | - Peter Kubuš
- Children's Heart Center, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | | | - Doug Mah
- Harvard Medical School, Boston, Massachussetts
| | - Aya Miyazaki
- Shizuoka General Hospital and Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Mary Niu
- University of Utah Health Sciences Center, Salt Lake City, Utah
| | | | - Thomas Paul
- Georg-August-University Medical Center, Göttingen, Germany
| | - Eric Rosenthal
- Evelina London Children's Hospital and St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | | | | | | | - Reina Tan
- New York University Langone Health, New York, New York
| | - John Triedman
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Nicholas Von Bergen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | |
Collapse
|
11
|
2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients. Indian Pacing Electrophysiol J 2021; 21:367-393. [PMID: 34333141 PMCID: PMC8577100 DOI: 10.1016/j.ipej.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.
Collapse
|
12
|
Bezzerides VJ, Walsh A, Martuscello M, Escudero CA, Gauvreau K, Lam G, Abrams DJ, Triedman JK, Alexander ME, Bevilacqua L, Mah DY. The Real-World Utility of the LINQ Implantable Loop Recorder in Pediatric and Adult Congenital Heart Patients. JACC Clin Electrophysiol 2020; 5:245-251. [PMID: 30784698 DOI: 10.1016/j.jacep.2018.09.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/11/2018] [Accepted: 09/19/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study sought to determine the practical use of the recently introduced LINQ implantable loop recorder (LINQ-ILR) in a cohort of pediatric and adult congenital arrhythmia patients. BACKGROUND Correlating symptoms to a causative arrhythmia is a key aspect of diagnosis and management in clinical electrophysiology. METHODS Retrospective review of clinical data, implantation indications, findings, and therapeutic decisions in patients who underwent LINQ-ILR implantation from April 1st, 2014 to January 30th, 2017 at Boston Children's Hospital. RESULTS A total of 133 patients were included, of which 76 (57%) were male. The mean age at implantation was 15.7 ± 9.1 years with a duration of follow-up of 11.8 months. Congenital heart disease was present in 34 patients (26%), a confirmed genetic diagnosis in 50 (38%), and cardiomyopathy in 22 (26%), and the remainder were without a previous diagnosis. Syncope was the most common indication for LINQ-ILR implantation, occurring in 59 patients (44%). The median time to diagnosis was 4.5 months, occurring in 78 patients (59%). Cardiac device placement occurred in 17 patients (22%), a medication change in 9 (12%), electrophysiology study/ablation in 5 (6%), or LINQ-ILR explantation in 42 (54%). Infection or erosion occurred in 5 patients. Syncope was correlated with a diagnostic transmission (54% vs. 31%, p = 0.01). CONCLUSIONS The LINQ-ILR is an important diagnostic tool, providing useful data in more than one-half of patients in <6 months. Adverse events are low. Patient selection is critical and undiagnosed syncope represents an important presenting indication for which a LINQ-ILR implant should be considered.
Collapse
Affiliation(s)
- Vassilios J Bezzerides
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Amy Walsh
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Martuscello
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Kimberlee Gauvreau
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Geralyn Lam
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Dominic J Abrams
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - John K Triedman
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark E Alexander
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Laura Bevilacqua
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Douglas Y Mah
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.
| |
Collapse
|
13
|
Sakhi R, Kauling RM, Theuns DA, Szili-Torok T, Bhagwandien RE, van den Bosch AE, Cuypers JAAE, Roos-Hesselink JW, Yap SC. Early detection of ventricular arrhythmias in adults with congenital heart disease using an insertable cardiac monitor (EDVA-CHD study). Int J Cardiol 2020; 305:63-69. [PMID: 32057477 DOI: 10.1016/j.ijcard.2020.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/27/2019] [Accepted: 02/03/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Sudden cardiac death (SCD) due to ventricular arrhythmias (VA) is an important mode of death in adults with congenital heart disease (CHD). Risk stratification is difficult in this heterogeneous population. Insertable cardiac monitors (ICM) may be useful for risk stratification. The purpose of the present study was to evaluate the use of ICM for the detection of VA in adults with CHD. METHODS In this prospective single-center observational study we included consecutive adults with CHD deemed at risk of VA who received an ICM between March 2013 and February 2019. The decision to implant an ICM was made in a Heart Team consisting of a cardiac electrophysiologist and a cardiologist specialized in CHD. RESULTS A total of 30 patients (mean age, 38 ± 15 years; 50% male) received an ICM. During a median follow-up of 16 months, 8 patients (27%) had documented nonsustained VA. Of these 8 patients, 3 (10%) received a prophylactic ICD. Furthermore, ICM-detected arrhythmias were present in 22 patients (73%) leading to a change in clinical management in 16 patients (53%). Besides the patients receiving an ICD, 10 patients (33%) had a change in their antiarrhythmic drugs, 6 patients (20%) underwent an electrophysiology study, and 1 patient (3%) received a pacemaker. CONCLUSIONS The detection of VA by the ICM contributed to the clinical decision to implant a prophylactic ICD. Furthermore, ICM-detected arrhythmias led to important changes in the clinical management. Therefore, long-term arrhythmia monitoring by an ICM seems valuable for risk stratification in adults with CHD.
Collapse
Affiliation(s)
- Rafi Sakhi
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Robert M Kauling
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dominic A Theuns
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rohit E Bhagwandien
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annemien E van den Bosch
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Judith A A E Cuypers
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| |
Collapse
|
14
|
Anderson H, Dearani J, Qureshi MY, Holst K, O'Leary P, Cannon B, Wackel P. Placement of Reveal LINQ Device in the Left Anterior Axillary Position. Pediatr Cardiol 2020; 41:181-185. [PMID: 31745583 DOI: 10.1007/s00246-019-02242-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/31/2019] [Indexed: 11/26/2022]
Abstract
Implantable loop recorders (ILR) are utilized for long-term rhythm monitoring. Typical placement of the Medtronic Reveal LINQ along the left parasternal border may compromise the quality and/or feasibility of future imaging studies. We sought to evaluate the utility of placing an ILR in the left anterior axillary position and the impact on the quality of cardiac imaging. We reviewed patients from May 2017 to June 2018 who had placement of a Reveal LINQ device in the left anterior axillary position. Demographic, procedural, and clinical data were collected via retrospective review. Cardiac magnetic resonance imaging (MRI) studies were reviewed for image quality after ILR placement. Eight patients met inclusion criteria for this study (median age 6 years, 50% female). Six patients (75%) had an ILR placed in the operating room, while all others were placed in the electrophysiology lab. All patients demonstrated acceptable R waves for diagnostic evaluation (median = 0.85 mV, range 0.24-1.7 mV). Cardiac MRI was obtained in 7 patients following ILR placement with diagnostic image quality and no adverse events. One device was explanted 28 days after placement due to concern for possible infection. No other devices required removal or revision (median follow up duration 11 months, IQR 8-13.5). ILR placement in the left anterior axillary position can record adequate signals in pediatric patients. In addition, axillary ILR device position may allow for completion of cardiac imaging, particularly cardiac MRI, without significant artifacts which is critical for patients with congenital heart disease.
Collapse
Affiliation(s)
- Heather Anderson
- Division of Pediatric Cardiology/Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Joseph Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - M Yasir Qureshi
- Division of Pediatric Cardiology/Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kimberly Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Patrick O'Leary
- Division of Pediatric Cardiology/Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Bryan Cannon
- Division of Pediatric Cardiology/Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Philip Wackel
- Division of Pediatric Cardiology/Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Abstract
Purpose In patients with structural heart disease (SHD) or inherited primary arrhythmia syndrome (IPAS), the occurrence of unexplained syncope or palpitations can be worrisome as they are at increased risk of sudden cardiac death. An implantable loop recorder (ILR) can be a useful diagnostic tool. Our purpose was to compare the diagnostic yield, arrhythmia mechanism, and management in patients with SHD, patients with IPAS, and those without heart disease. Methods Retrospective single-center study in consecutive patients who underwent an ILR implantation. Results Between March 2013 and December 2016, a total of 94 patients received an ILR (SHD, n = 20; IPAS, n = 14; no SHD/IPAS, n = 60). The type of symptoms at the time of implantation was similar between groups. During a median follow-up of 10 months, 45% had an ILR-guided diagnosis. Patients with IPAS had a lower diagnostic yield (14%) in comparison to the other groups (no SHD/IPAS 47%, P = 0.03; SHD 60%, P = 0.01, respectively). Furthermore, patients with SHD had a higher incidence of nonsustained VT in comparison to patients without SHD/IPAS (30 versus 3%, P < 0.01). ILR-guided therapy was comparable between groups. In the SHD group, a high proportion (10%) received an implantable cardioverter-defibrillator; however, this was not statistically significantly higher than the other groups (no SHD/IPAS 3%, IPAS 0%, P = 0.08). Conclusions In comparison to patients without heart disease, the diagnostic yield of an ILR was lower in patients with IPAS and the prevalence of ILR-diagnosed nonsustained VT was higher in patients with SHD.
Collapse
|
17
|
Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| |
Collapse
|
18
|
Nguyen HH, Law IH, Rudokas MW, Lampe J, Bowman TM, Van Hare GF, Avari Silva JN. Reveal LINQ Versus Reveal XT Implantable Loop Recorders: Intra- and Post-Procedural Comparison. J Pediatr 2017; 187:290-294. [PMID: 28545873 DOI: 10.1016/j.jpeds.2017.04.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/15/2017] [Accepted: 04/26/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To compare the procedure, recovery, hospitalization times, and costs along with patient/parent satisfaction after newer-generation cardiac implantable loop recorder (Reveal LINQ; Medtronic Inc, Minneapolis, Minnesota) and previous-generation implantable loop recorder (Reveal XT; Medtronic Inc). STUDY DESIGN A prospective study of patients undergoing LINQ implantations between April 2014 and October 2015 was performed. Retrospective chart review of patients undergoing XT implantations was performed for comparison. RESULTS Thirty-one patients received LINQ and 15 patients received XT. Indications included syncope/palpitations (28/46, 61%), history of arrhythmias (9/46, 20%), arrhythmia burden in congenital heart disease (5/46, 10%), and monitoring in channelopathies (4/46, 9%). The LINQ group underwent more conscious sedation procedures than the XT group (8/31 vs 0/15, P = .04) with shorter procedural time (9 vs 34 minutes, P <.001), room occupation time (38 vs 81 minutes, P <.001), recovery time (21 vs 67 minutes, P <.001), and total hospital time (214 vs 264 minutes, P = .046). The LINQ group also had shorter return to activity time (2 vs 5 days, P = 1). Three device erosions in the LINQ group required reintervention. The LINQ group had fewer body image issues than the XT group (1/26 vs 5/14, P = .01) with both groups scoring 5/5 overall patient/parent satisfaction score at follow-up. Both groups had comparable total direct hospital costs (US $5905 vs $5438, P = .8). CONCLUSIONS LINQ offers better procedural and recovery time compared with XT. LINQ implantations under conscious sedation reduce total hospitalization time.
Collapse
Affiliation(s)
- Hoang H Nguyen
- Division of Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Ian H Law
- Division of Cardiology, Department of Pediatrics, University of Iowa Carver School of Medicine, Iowa City, IA
| | - Michael W Rudokas
- Division of Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Jennifer Lampe
- Division of Cardiology, Department of Pediatrics, University of Iowa Carver School of Medicine, Iowa City, IA
| | - Tammy M Bowman
- Division of Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - George F Van Hare
- Division of Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Jennifer N Avari Silva
- Division of Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO.
| |
Collapse
|
19
|
|
20
|
Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2017; 14:e155-e217. [PMID: 28286247 DOI: 10.1016/j.hrthm.2017.03.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 12/26/2022]
|
21
|
Bieganowska K, Kaszuba A, Bieganowski M, Kaczmarek K. PocketECG: A New Noninvasive Method for Continuous and Real-Time ECG Monitoring-Initial Results in Children and Adolescents. Pediatr Cardiol 2017; 38:448-455. [PMID: 28101660 DOI: 10.1007/s00246-016-1534-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/12/2016] [Indexed: 11/24/2022]
Abstract
Long-term ECG is widely used in diagnosis and assessment of many cardiac symptoms which may be caused by dangerous arrhythmias that sometimes can be difficult to document. The PocketECG system is a new technological solution for a long-term, noninvasive, continuous and real-time ECG monitoring that provides automatic diagnosis of dysrhythmias. ECG data transmission occurs over a mobile network. The goal of this study was to assess the reliability of long-term ECG recordings acquired with the PocketECG system. One hundred and fifteen patients (43 girls and 72 boys) of an average age of 15.5 ± 2.5 years were examined at the Department of Cardiology at the Children's Memorial Health Institute. Two simultaneous 24-h ECG recordings were conducted: one with a Holter monitor and one with the PocketECG system. A linear correlation was demonstrated between the two methods with regard to the recorded QRS complexes [H = 1173.0 (-1946.40; 4838.50) + PocketECG*0.98 (0.94; 1.02)]. Mean diurnal heart rhythms were comparable (p > 0.05) despite the fact that the slowest and the fastest rates were different. The rate of detection for ventricular, supraventricular dysrhythmias and pauses in ventricular rhythm were comparable in both methods. The PocketECG system for continuous and real-time ECG recording is a reliable method for the assessment of heart rhythm and dysrhythmias in children and adolescents.
Collapse
Affiliation(s)
- Katarzyna Bieganowska
- Department of Cardiology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730, Warsaw, Poland.
| | - Agnieszka Kaszuba
- Department of Cardiology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Maciej Bieganowski
- Department of Arrhythmia, The Cardinal Stefan Wyszyński Institut of Cardiology, Alpejska 42 Str, 04-628, Warsaw, Poland
| | - Krzysztof Kaczmarek
- Clinical and Teaching Hospital Medical University of Lodz, 251 Pomorska St., 92-213, Lodz, Poland
| |
Collapse
|
22
|
Cheung CC, Krahn AD. Loop recorders for syncope evaluation: what is the evidence? Expert Rev Med Devices 2016; 13:1021-1027. [DOI: 10.1080/17434440.2016.1243463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
23
|
Galli A, Ambrosini F, Lombardi F. Holter Monitoring and Loop Recorders: From Research to Clinical Practice. Arrhythm Electrophysiol Rev 2016; 5:136-43. [PMID: 27617093 DOI: 10.15420/aer.2016.17.2] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Holter monitors are tools of proven efficacy in diagnosing and monitoring cardiac arrhythmias. Despite the fact their use is widely prescribed by general practitioners, little is known about their evolving role in the management of patients with cryptogenic stroke, paroxysmal atrial fibrillation, unexplained recurrent syncope and risk stratification in implantable cardioverter defibrillator or pacemaker candidates. New Holter monitoring technologies and loop recorders allow prolonged monitoring of heart rhythm for periods from a few days to several months, making it possible to detect infrequent arrhythmias in patients of all ages. This review discusses the advances in this area of arrhythmology and how Holter monitors have improved the clinical management of patients with suspected cardiac rhythm diseases.
Collapse
Affiliation(s)
- Alessio Galli
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Francesco Ambrosini
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Federico Lombardi
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| |
Collapse
|
24
|
Avari Silva JN, Bromberg BI, Emge FK, Bowman TM, Van Hare GF. Implantable Loop Recorder Monitoring for Refining Management of Children With Inherited Arrhythmia Syndromes. J Am Heart Assoc 2016; 5:JAHA.116.003632. [PMID: 27231019 PMCID: PMC4937287 DOI: 10.1161/jaha.116.003632] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Implantable loop recorders (ILRs) are conventionally utilized to elucidate the mechanism of atypical syncope. The objective of this study was to assess the impact of these devices on management of pediatric patients with known or suspected inherited arrhythmia syndromes. METHODS AND RESULTS A retrospective chart review was undertaken of all pediatric patients with known or suspected inherited arrhythmia syndromes in whom an ILR was implanted from 2008 to 2015. Captured data included categorization of diagnosis, treatment, transmitted tracings, and the impact of ILR tracings on management. Transmissions were categorized as symptomatic, autotriggered, or routine. Actionable transmissions were abnormal tracings that directly resulted in a change of medical or device therapy. A total of 20 patients met the stated inclusion criteria (long QT syndrome, n=8, catecholaminergic polymorphic ventricular tachycardia,n=9, Brugada syndrome, n=1, arrhythmogenic right ventricular cardiomyopathy, n=2), with 60% of patients being genotype positive. Primary indication for implantation of ILR included ongoing monitoring +/- symptoms (n=15, 75%), suspicion of noncompliance (n=1, 5%), and liberalization of recommended activity restrictions (n=4, 25%). A total of 172 transmissions were received in patients with inherited arrhythmia syndromes, with 7% yielding actionable data. The majority (52%) of symptom events were documented in the long QT syndrome population, with only 1 tracing (5%) yielding actionable data. Automatic transmissions were mostly seen in the catecholaminergic polymorphic ventricular tachycardia cohort (81%), with 21% yielding actionable data. There was no actionable data in routine transmissions. CONCLUSIONS ILRs in patients with suspected or confirmed inherited arrhythmia syndromes may be useful for guiding management. Findings escalated therapies in 30% of subjects. As importantly, in this high-risk population, the majority of symptom events represented normal or benign rhythms, reassuring patients and physicians that no further intervention was required.
Collapse
Affiliation(s)
- Jennifer N Avari Silva
- Division of Pediatric Cardiology, Washington University School of Medicine/Saint Louis Children's Hospital, Saint Louis, MO
| | - Burt I Bromberg
- Division of Pediatric Cardiology, Mercy Hospital, Saint Louis, MO
| | | | - Tammy M Bowman
- Division of Pediatric Cardiology, Washington University School of Medicine/Saint Louis Children's Hospital, Saint Louis, MO
| | - George F Van Hare
- Division of Pediatric Cardiology, Washington University School of Medicine/Saint Louis Children's Hospital, Saint Louis, MO
| |
Collapse
|
25
|
PLACIDI SILVIA, DRAGO FABRIZIO, MILIONI MADDALENA, VERTICELLI LETIZIA, TAMBURRI ILARIA, SILVETTI MASSIMOSTEFANO, DI MAMBRO CORRADO, RIGHI DANIELA, GIMIGLIANO FABRIZIO, RUSSO MARIOSALVATORE, PALMIERI ROSALINDA, REMOLI ROMOLO, SANTUCCI LORENZOMARIA, TOZZI ALBERTOEUGENIO. Miniaturized Implantable Loop Recorder in Small Patients: An Effective Approach to the Evaluation of Subjects at Risk of Sudden Death. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:669-74. [DOI: 10.1111/pace.12866] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 01/23/2023]
Affiliation(s)
- SILVIA PLACIDI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - FABRIZIO DRAGO
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - MADDALENA MILIONI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - LETIZIA VERTICELLI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - ILARIA TAMBURRI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - MASSIMO STEFANO SILVETTI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - CORRADO DI MAMBRO
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - DANIELA RIGHI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - FABRIZIO GIMIGLIANO
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - MARIO SALVATORE RUSSO
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - ROSALINDA PALMIERI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - ROMOLO REMOLI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - LORENZO MARIA SANTUCCI
- Cardiac Arrhythmia Complex Unit and Syncope Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| | - ALBERTO EUGENIO TOZZI
- Telemedicine Unit; Bambino Gesù Children's Hospital and Research Institute; Rome Italy
| |
Collapse
|
26
|
Baruteau AE, Perry JC, Sanatani S, Horie M, Dubin AM. Evaluation and management of bradycardia in neonates and children. Eur J Pediatr 2016; 175:151-61. [PMID: 26780751 DOI: 10.1007/s00431-015-2689-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 12/02/2015] [Accepted: 12/30/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED Heart rate is commonly used in pediatric early warning scores. Age-related changes in the anatomy and physiology of infants and children produce normal ranges for electrocardiogram features that differ from adults and vary with age. Bradycardia is defined as a heart rate below the lowest normal value for age. Pediatric bradycardia most commonly manifests as sinus bradycardia, junctional bradycardia, or atrioventricular block. As a result of several different etiologies, it may occur in an entirely structurally normal heart or in association with concomitant congenital heart disease. Genetic variants in multiple genes have been described to date in the pathogenesis of inherited sinus node dysfunction or progressive cardiac conduction disorders. Management and eventual prognosis of bradycardia in the young are entirely dependent upon the underlying cause. Reasons to intervene for bradycardia are the association of related symptoms and/or the downstream risk of heart failure or pause-dependent tachyarrhythmia. The simplest aspect of severe bradycardia management is reflected in the Pediatric and Advanced Life Support (PALS) guidelines. CONCLUSION Early diagnosis and appropriate management are critical in many cases in order to prevent sudden death, and this review critically assesses our current practice for evaluation and management of bradycardia in neonates and children. WHAT IS KNOWN Bradycardia is defined as a heart rate below the lowest normal value for age. Age related changes in the anatomy and physiology of infants and children produce normal ranges for electrocardiogram features that differ from adults and vary with age. Pediatric bradycardia most commonly manifests as sinus bradycardia, junctional bradycardia, or atrioventricular block. WHAT IS NEW Management and eventual prognosis of bradycardia in the young are entirely dependent upon the underlying cause. Bradycardia may occur in a structurally normal heart or in association with congenital heart disease. Genetic variants in multiple genes have been described. Reasons to intervene for bradycardia are the association of related symptoms and/or the downstream risk of heart failure or pause-dependent tachyarrhythmia. Early diagnosis and appropriate management are critical in order to prevent sudden death.
Collapse
Affiliation(s)
- Alban-Elouen Baruteau
- Morgan Stanley Children's Hospital, Division of Pediatric Cardiology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA. .,LIRYC Institute (Electrophysiology and Heart Modeling Institute), Division of Pediatric Cardiology, Hôpital Cardiologique du Haut Lévèque, Bordeaux-2 University, Bordeaux, France. .,L'Institut du Thorax, INSERM UMR1087, CNRS UMR6291, Nantes University, Nantes, France. .,Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, New York Presbyterian / Columbia University Medical Center, 3959 Broadway, New York, NY, 10032, USA.
| | - James C Perry
- Rady Children's Hospital, Department of Pediatrics, Division of Cardiology, University of California, San Diego, San Diego, CA, USA.
| | - Shubhayan Sanatani
- British Columbia Children's Hospital, Department of Pediatric Cardiology, University of British Columbia, Vancouver, BC, Canada.
| | - Minoru Horie
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Sciences, Otsu, Japan.
| | - Anne M Dubin
- Lucile Packard Children's Hospital, Division of Pediatric Electrophysiology, Stanford University, Palo Alto, CA, USA.
| |
Collapse
|
27
|
Saygi M, Ergul Y, Ozyilmaz I, Sengul FS, Guvenc O, Aslan E, Guzeltas A, Akdeniz C, Tuzcu V. Using a Cardiac Event Recorder in Children with Potentially Arrhythmia-Related Symptoms. Ann Noninvasive Electrocardiol 2016; 21:500-7. [PMID: 26791967 DOI: 10.1111/anec.12339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/16/2015] [Accepted: 11/12/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In this study, we reported our experience with the use of cardiac event recorders in pediatric patients. METHODS We evaluated 583 patients fitted with an event recorder (15-30 days) between March 2010 and November 2014 at our clinic. Excluded from the study were 117 patients with no recorded events and six with records contaminated by electrocardiogram artifacts. All of the patients received electrocardiograms, Holter monitoring, and echocardiography before the cardiac event recording. RESULTS The patient sample consisted of 460 patients (64% female). The mean age was 12.8 ± 4.1 years. The median number of recorded events was 7. The indications included palpitations in 336 (73%) patients, syncope in 27 (6%) patients, and chest pain and palpitations in 97 (21%) patients. Whereas 64 patients (14%) had structural heart disease according to echocardiographic examination, the remaining patients had normal echocardiographic examination results. The most frequent cardiac comorbidities were mitral valve prolapse (6%), operated tetralogy of Fallot (1.5%), and complicated congenital heart diseases with single ventricle physiology (1%). The recorded events were sinus tachycardia in 113 (25%) patients, supraventricular tachycardia in 35 (8%) patients, ventricular extrasystole in 20 (4%) patients, supraventricular extrasystole in nine (2%) patients, and ventricular tachycardia in two (0.4%) patients. Based on the event recorder and follow-up electrocardiogram findings, 46 patients received an electrophysiology study/ablation. The symptom-rhythm correlation was 39%. CONCLUSION In the presence of possible arrhythmia-related symptoms in children, a cardiac event recorder can be considered a useful primary diagnostic method. More research on this topic is needed.
Collapse
Affiliation(s)
- Murat Saygi
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Yakup Ergul
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Isa Ozyilmaz
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Fatma Sevinc Sengul
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Osman Guvenc
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Eyup Aslan
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Alper Guzeltas
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Celal Akdeniz
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Volkan Tuzcu
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey
| |
Collapse
|
28
|
Extracorporeal CPR and therapeutic hypothermia for out-of-hospital cardiac arrest in a patient with congenital long QT syndrome. Am J Emerg Med 2015; 34:1321.e1-3. [PMID: 26698681 DOI: 10.1016/j.ajem.2015.11.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/18/2015] [Indexed: 11/22/2022] Open
|
29
|
Abstract
Implantable loop recorders (ILRs) continuously monitor electrocardiographic signals and perform real-time analysis of heart rhythm for up to 36 months. ILRs are used to evaluate transitory loss of consciousness from possible arrhythmic origin, particularly unexplained syncope, and to evaluate difficult cases of epilepsy and unexplained falls, although current indications for their application in these areas are less clearly defined. This article analyzes the current indications for ILRs according the European Society of Cardiology guidelines on the management of syncope and the European Heart Rhythm Association guidelines on the use of implantable and external electrocardiogram loop recorders, and their limitations.
Collapse
Affiliation(s)
- Franco Giada
- Cardiovascular Rehabilitation and Sports Medicine Service, Cardiovascular Department, PF Calvi Hospital, Via Largo San Giorgio 3, Noale 30033, Venice, Italy.
| | - Angelo Bartoletti
- Cardiology Division and Syncope Centre, San Giovanni di Dio Hospital, Nuovo Ospedale S. Giovanni di Dio, Florence, Italy
| |
Collapse
|
30
|
Ergul Y, Tanidir IC, Ozyilmaz I, Akdeniz C, Tuzcu V. Evaluation rhythm problems in unexplained syncope etiology with implantable loop recorder. Pediatr Int 2015; 57:359-66. [PMID: 25348219 DOI: 10.1111/ped.12530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 09/27/2014] [Accepted: 10/16/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Syncope is a frequent complaint in children and adolescents and may be a significant sign of serious pathology. Although patient history, family history, and physical examination are sufficient to reach a diagnosis in most cases of syncope, the cause of syncope still cannot be determined after initial investigation in one-third to half of all patients. The aim of this study was to evaluate the diagnostic yield of implantable loop recorder (ILR) in children with unexplained syncope. METHODS A retrospective review was carried out of clinical data, indications, findings, and a final management strategy in patients who underwent ILR implantation. RESULTS A total of 12 patients with a mean age of 9.4 ± 4.5 years underwent ILR (Reveal Plus; Medtronic) implantation. ILR implantation indication was syncope in all of the patients. Family history, routine cardiac assessment, including resting 12-lead electrocardiogram, transthoracic echocardiography, 24 h Holter recording, and event recorder findings, were normal with the exception of one patient with (previously corrected) tetralogy of Fallot. After an average of 20 months (range, 1-36 months), six patients developed symptoms. ILR memory showed torsades de pointes-ventricular fibrillation (n = 3), catecholaminergic polymorphic ventricular tachycardia (n = 1), asystole and ventricular tachycardia (n = 1), and normal sinus rhythm (n = 1). At the time of writing six patients were still in follow up with no symptoms after an average of 25.2 months. CONCLUSION Implantable loop recorder plays an important role in the diagnosis of life-threatening arrhythmias in which syncope is otherwise unexplained. ILR implantation should be remembered in children whose symptoms are strongly correlated with rhythm disturbances.
Collapse
Affiliation(s)
- Yakup Ergul
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery Center and Research Hospital, Istanbul, Turkey
| | - Ibrahim Cansaran Tanidir
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery Center and Research Hospital, Istanbul, Turkey
| | - Isa Ozyilmaz
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery Center and Research Hospital, Istanbul, Turkey
| | - Celal Akdeniz
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery Center and Research Hospital, Istanbul, Turkey
| | - Volkan Tuzcu
- Department of Pediatric Cardiology, İstanbul Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery Center and Research Hospital, Istanbul, Turkey
| |
Collapse
|
31
|
Abstract
The autonomic nervous system, adequate blood volume, and intact skeletal and respiratory muscle pumps are essential components for rapid cardiovascular adjustments to upright posture (orthostasis). Patients lacking sufficient blood volume or having defective sympathetic adrenergic vasoconstriction develop orthostatic hypotension (OH), prohibiting effective upright activities. OH is one form of orthostatic intolerance (OI) defined by signs, such as hypotension, and symptoms, such as lightheadedness, that occur when upright and are relieved by recumbence. Mild OI is commonly experienced during intercurrent illnesses and when standing up rapidly. The latter is denoted "initial OH" and represents a normal cardiovascular adjustment to the blood volume shifts during standing. Some people experience episodic acute OI, such as postural vasovagal syncope (fainting), or chronic OI, such as postural tachycardia syndrome, which can significantly reduce quality of life. The lifetime incidence of ≥1 fainting episodes is ∼40%. For the most part, these episodes are benign and self-limited, although frequent syncope episodes can be debilitating, and injury may occur from sudden falls. In this article, mechanisms for OI having components of adrenergic hypofunction, adrenergic hyperfunction, hyperpnea, and regional blood volume redistribution are discussed. Therapeutic strategies to cope with OI are proposed.
Collapse
Affiliation(s)
- Julian M. Stewart
- Departments of Pediatrics, Physiology, and Medicine, The Maria Fareri Children’s Hospital and New York Medical College, Valhalla, New York
| |
Collapse
|
32
|
Giada F, Bertaglia E, Reimers B, Noventa D, Raviele A. Current and emerging indications for implantable cardiac monitors. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1169-78. [PMID: 22530875 DOI: 10.1111/j.1540-8159.2012.03411.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Implantable cardiac monitors (ICMs) continuously monitor the patient's electrocardiogram and perform real-time analysis of the heart rhythm, for up to 36 months. The current clinical use of ICMs involves the evaluation of transitory symptoms of possible arrhythmic origin, such as unexplained syncope and palpitations. Moreover, ICMs can also be used for the evaluation of difficult cases of epilepsy and unexplained falls, though current indications for their application in these sectors are less clearly defined. Finally, the ability of new-generation ICMs to automatically record arrhythmic episodes suggests that these devices could also be used to study asymptomatic arrhythmias, and thus could be proposed for the long-term evaluation of the total (symptomatic and asymptomatic) arrhythmic burden in patients at risk of arrhythmic events. In particular, ICMs may have an emerging role in the management of patients with atrial fibrillation and in those at risk of ventricular arrhythmias.
Collapse
Affiliation(s)
- Franco Giada
- Cardiovascular Department, General Hospitals, Noale-Mirano, Venice, Italy.
| | | | | | | | | |
Collapse
|
33
|
Strotmann C, Rüb N, Wolpert C. [Significance of diagnostic methods in the work-up of syncope]. Herzschrittmacherther Elektrophysiol 2011; 22:72-82. [PMID: 21562861 DOI: 10.1007/s00399-011-0129-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
After the initial evaluation including detailed history, physical examination, electrocardiogram, and orthostatic blood pressure measurements, risk stratification should follow, if the cause of syncope is still unclear in order to define the acuteness and extensiveness of the further diagnostic evaluation. The documentation of arrhythmia during syncope is the gold standard for diagnosis of arrhythmic syncope. The implantable loop recorder should be integrated early in the diagnostic work-up. In patients >40 years with otherwise unexplained syncope, carotid sinus massage is recommended. In suspected reflex-mediated syncope, the tilt test is able to confirm the diagnosis and gives information about the underlying pathomechanisms, while electrophysiological studies have still a proven indication in patients with previous myocardial infarction and preserved left ventricular function. The adenosine triphophate test has no clinical relevance in the diagnostics of syncope. Echocardiography plays an important role in the risk stratification by diagnosing structural cardiac disease. In patients experiencing syncope associated with exertion, exercise stress testing is indicated. Finally, a coronary angiogram should be performed, if ischemia triggered syncope is suspected. A routinely performed neurological evaluation is not recommended.
Collapse
Affiliation(s)
- C Strotmann
- Medizinische Klinik II, Klinikum Ludwigsburg, Deutschland.
| | | | | |
Collapse
|
34
|
Santilli RA, Ferasin L, Voghera SG, Perego M. Evaluation of the diagnostic value of an implantable loop recorder in dogs with unexplained syncope. J Am Vet Med Assoc 2010; 236:78-82. [DOI: 10.2460/javma.236.1.78] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
35
|
AL DHAHRI KHALIDN, POTTS JAMESE, CHIU CHRISTINEC, HAMILTON ROBERTM, SANATANI SHUBHAYAN. Are Implantable Loop Recorders Useful in Detecting Arrhythmias in Children with Unexplained Syncope? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1422-7. [DOI: 10.1111/j.1540-8159.2009.02486.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
36
|
Brignole M, Vardas P, Hoffman E, Huikuri H, Moya A, Ricci R, Sulke N, Wieling W, Auricchio A, Lip GYH, Almendral J, Kirchhof P, Aliot E, Gasparini M, Braunschweig F, Lip GYH, Almendral J, Kirchhof P, Botto GL. Indications for the use of diagnostic implantable and external ECG loop recorders. Europace 2009; 11:671-87. [PMID: 19401342 DOI: 10.1093/europace/eup097] [Citation(s) in RCA: 222] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
|
37
|
Kanjwal K, Kanjwal Y, Karabin B, Grubb BP. Clinical symptoms associated with asystolic or bradycardic responses on implantable loop recorder monitoring in patients with recurrent syncope. Int J Med Sci 2009; 6:106-10. [PMID: 19381350 PMCID: PMC2669599 DOI: 10.7150/ijms.6.106] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 04/08/2009] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Implantable loop recorders (ILR) have been found to be useful in the diagnosis and management of syncope of unclear etiology. The clinical symptoms of abnormalities seen during ILR monitoring have not been adequately studied. AIM The aim of this retrospective study was to determine the clinical symptoms which were the best predictors of asystolic or bradycardic responses during ILR monitoring. METHODS Patients with either asystole or bradycardia recorded during ILR monitoring were analyzed from our database. The clinical characteristics of these patients were compared to the patients with ILR's who did not have recorded bradycardic episodes. The episodes were characterized as being convulsive or nonconvulsive, brief (<5 minutes) or prolonged (> 5 minutes), and having had a prodrome or no prodrome. RESULTS Eleven patients (4 males and 7 females; age 39 +/-11 years) had asystole or bradycardia on ILR monitoring. Eleven patients (2 males and 9 females; age 46+/-23) had no bradycardiac events. Palpitations, convulsive syncope, prolonged episode, and prodrome were present in 37% vs. 74% (P = 0.125), 62% vs. 0% (P = 0.002), 87% vs. 0% (P=0), and 73% vs. 13% (P=0.009) patients, respectively, in the asystole/bradycardia and non-bradycardia groups. In the asystole/bradycardia group eight patients had bradycardia (HR < 20) for > 10 seconds and three patients had asystole >10 seconds. CONCLUSION Convulsive syncope, prolonged loss of consciousness during syncopal episode, and absence of prodrome or aura are clinical predictors of asystole or bradycardia on ILR monitoring.
Collapse
Affiliation(s)
- Khalil Kanjwal
- Department of Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA
| | | | | | | |
Collapse
|
38
|
Schuchert A. [Event-recorder]. Herzschrittmacherther Elektrophysiol 2008; 19:130-6. [PMID: 18956159 DOI: 10.1007/s00399-008-0011-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Accepted: 08/14/2008] [Indexed: 10/19/2022]
Abstract
Event or loop recorders monitor heart rhythm using discontinuous ECG storage which enables them to obtain a correlation between symptoms and the underlying heart rhythm in patients with infrequent, short-lasting episodes. External event recorders with intermittent monitoring, i.e., with electrodes within the device, are suitable for patients with palpitations or tachycardia who remain conscious. External event recorders with continuous monitoring are tolerated by patients for a few weeks and have a limited diagnostic impact in patients with recurrent syncope. The implantable loop recorder (ILR) monitors heart rhythm for one year and after patient-triggered or automatic activation stores a one-lead ECG up to 42 minutes prior to device activation. The diagnostic benefit of ILR in comparison to conventional approaches has been demonstrated in randomised studies. Furthermore, an ILR identifies patients with recurrent syncope of unknown origin in whom a pacemaker implantation can avoid further episodes. Additional possible indications are the monitoring of atrial fibrillation, the diagnostics of infrequent palpitations and patients with seizures.
Collapse
Affiliation(s)
- Andreas Schuchert
- Friedrich-Ebert-Krankenhaus, Medizinische Klinik, Friesenstr. 11, 24534 Neumünster, Deutschland.
| |
Collapse
|
39
|
Brignole M. Experience with implantable loop recorders for recurrent unexplained syncope. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2008; 14:7-13. [PMID: 19891290 DOI: 10.1111/j.1751-7133.2008.tb00014.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Knowledge of what occurs during spontaneous syncope is the gold standard for evaluation. Initially, implantable loop recorders (ILRs) were used in patients with unexplained syncope at the end of unsuccessful full, conventional work-up. In pooled data regarding 247 patients, a correlation between syncope and electrocardiographic findings was found in 84 patients (34%); of these, 52% had a bradycardia or asystole at the time of the recorded event, 11% had tachycardia, and 37% had no arrhythmia. Presyncope-electrocardiography correlation was observed in another third of the patients; presyncope was much less likely to be associated with an arrhythmia than was syncope. The diagnostic yield was similar in patients with and without structural heart diseases and was higher in older than in younger patients. Recent studies showed that ILR implantation can be safely performed in an early phase of the diagnostic evaluation--provided that patients at risk for life-threatening events are carefully excluded--in the patients who have a severe presentation of syncope (because of high risk of trauma or high frequency of episodes) which can be a benefit of a mechanism-specific therapy.
Collapse
Affiliation(s)
- Michele Brignole
- Arrhythmologic Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy.
| |
Collapse
|