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Sarkar S, Koehler J, Vasudevan N. Ambulatory Risk Stratification for Worsening Heart Failure in Patients with Reduced and Preserved Ejection Fraction Using Diagnostic Parameters Available in Implantable Cardiac Monitors. Diagnostics (Basel) 2024; 14:771. [PMID: 38611683 PMCID: PMC11012110 DOI: 10.3390/diagnostics14070771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Ambulatory risk stratification for worsening heart failure (HF) using diagnostics measured by insertable cardiac monitors (ICM) may depend on the left ventricular ejection fraction (LVEF). We evaluated risk stratification performance in patients with reduced versus preserved LVEF. METHODS ICM patients with a history of HF events (HFEs) were included from the Optum® de-identified Electronic Health Record dataset merged with ICM device-collected data during 2007-2021. ICM measures nighttime heart rate (NHR), heart rate variability (HRV), atrial fibrillation (AF) burden, rate during AF, and activity duration (ACT) daily. Each diagnostic was categorized into high, medium, or low risk using previously defined features. HFEs were HF-related inpatient, observation unit, or emergency department stays with IV diuresis administration. Patients were divided into two cohorts: LVEF ≤ 40% and LVEF > 40%. A marginal Cox proportional hazards model compared HFEs for different risk groups. RESULTS A total of 1020 ICM patients with 18,383 follow-up months and 301 months with HFEs (1.6%) were included. Monthly evaluations with a high risk were 2.3, 4.2, 5.0, and 4.5 times (p < 0.001 for all) more likely to have HFEs in the next 30 days compared to those with a low risk for AF, ACT, NHR, and HRV, respectively. HFE rates were higher for patients with LVEF > 40% compared to LVEF ≤ 40% (2.0% vs. 1.3%), and the relative risk between high-risk and low-risk for each diagnostic parameter was higher for patients with LVEF ≤ 40%. CONCLUSIONS Diagnostics measured by ICM identified patients at risk for impending HFEs. Patients with preserved LVEF showed a higher absolute risk, and the relative risk between risk groups was higher in patients with reduced LVEF.
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Matsui Y, Mori F, Okano H, Inutsuka K, Takahashi M, Kikuchi K, Kikuchi H, Serikawa N, Sakai M, Maeda R, Tsukamoto K, Saito T. A case report of undetected cardiac arrest in a patient with an insertable cardiac monitor. J Cardiol Cases 2024; 29:89-92. [PMID: 38362579 PMCID: PMC10865137 DOI: 10.1016/j.jccase.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 10/16/2023] [Accepted: 11/06/2023] [Indexed: 02/17/2024] Open
Abstract
Insertable cardiac monitors (ICMs) are small electrocardiographs implanted subcutaneously to automatically record electrocardiograms when arrhythmia is detected in patients with syncope. If the ICM misses a significant arrhythmia, it may delay the diagnosis of arrhythmogenic syncope and put the patient at risk. Herein, we describe a case of undetected cardiac arrest in a patient with ICM. An 87-year-old man with syncope was admitted to the hospital. After 8 days of monitoring, the cause could not be determined, and an ICM was implanted. Nine hours after implantation, the patient experienced cardiopulmonary arrest. Despite a body surface electrocardiogram showing ventricular flatline and fibrillation, the ICM failed to record. The cause of failure to record was considered to be the fluctuation in the R-wave amplitude of the ICM and noise oversensing. In conclusion, albeit infrequently, ICMs might overlook life-threatening arrhythmias. Even in cases where the ICM fails to detect an arrhythmia matching the symptoms, it may not be feasible to entirely rule out the presence of arrhythmias. Learning objective Insertable cardiac monitors (ICMs) are used to diagnose arrhythmogenic syncope. However, extremely infrequently, ICM may fail to record life-threatening arrhythmias. Failure to capture arrhythmias can happen due to an unfortunate combination of factors such as a low amplitude of the recorded R wave and noise. Even in cases where the ICM does not detect an arrhythmia that matches the symptoms, it may not be feasible to completely exclude the presence of arrhythmias.
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Affiliation(s)
- Yuko Matsui
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Fumiaki Mori
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Hiromu Okano
- International University of Health and Welfare Graduate School of Public Health, Minato City, Tokyo, Japan
| | - Kei Inutsuka
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Mirai Takahashi
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Kensuke Kikuchi
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Haruka Kikuchi
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Naoki Serikawa
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Masayuki Sakai
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Ryozo Maeda
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Kei Tsukamoto
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
| | - Takashi Saito
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Yokohama-shi, Kanagawa, Japan
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Kawatani Y, Hori T. Correlation between the electrocardiogram amplitude detected by an implantable cardiac monitor and the implantation depth. Ann Noninvasive Electrocardiol 2024; 29:e13102. [PMID: 38088202 PMCID: PMC10770816 DOI: 10.1111/anec.13102] [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: 08/11/2023] [Revised: 09/17/2023] [Accepted: 11/28/2023] [Indexed: 12/22/2023] Open
Abstract
INTRODUCTION Implantable cardiac monitors (ICMs) primarily use R-R intervals in subcutaneous electrocardiograms (ECGs) to detect arrhythmias. Therefore, reliable detection of R-wave amplitude by an ICM is vital. Since ICMs detect subcutaneous ECGs, the impact of the implantation depth should be assessed. METHODS AND RESULTS This study investigated the influence of ICM depth on R-wave (ICM-R) amplitude on an ECG generated by an ICM (JOT Dx; Abbott). Overall, 58 patients who underwent ICM implantation at Kamagaya General Hospital from May 2022 to April 2023 were retrospectively reviewed. The depth-position was measured using ultrasound imaging after implantation. The depth of the ICM did not show any correlation with ICM-R amplitude (r = -.0141, p = .294). However, the distance between the ICM and the heart surface showed a significant correlation with ICM-R amplitude (r = -.581, p < .001). Body weight (r = -.0283, p = .033) and body mass index (r = -.0342, p = .009) were associated with ICM-R amplitude. S wave in the V1 -lead was also associated with ICM-R amplitude (r = .481, p < .001). After multivariate analysis, the distance between the ICM and heart surface and the S wave in V1 were independent determinants for the ICM-R amplitude. CONCLUSION The ICM-R amplitude may be higher with the ICM implanted deeper.
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Affiliation(s)
- Yohei Kawatani
- Cardiovascular SurgeryKamagaya General HospitalKamagaha‐ShiJapan
| | - Takaki Hori
- Cardiovascular SurgeryKamagaya General HospitalKamagaha‐ShiJapan
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Automatic Atrial Fibrillation Arrhythmia Detection Using Univariate and Multivariate Data. ALGORITHMS 2022. [DOI: 10.3390/a15070231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Atrial fibrillation (AF) is still a major cause of disease morbidity and mortality, making its early diagnosis desirable and urging researchers to develop efficient methods devoted to automatic AF detection. Till now, the analysis of Holter-ECG recordings remains the gold-standard technique to screen AF. This is usually achieved by studying either RR interval time series analysis, P-wave detection or combinations of both morphological characteristics. After extraction and selection of meaningful features, each of the AF detection methods might be conducted through univariate and multivariate data analysis. Many of these automatic techniques have been proposed over the last years. This work presents an overview of research studies of AF detection based on RR interval time series. The aim of this paper is to provide the scientific community and newcomers to the field of AF screening with a resource that presents introductory concepts, clinical features, and a literature review that describes the techniques that are mostly followed when RR interval time series are used for accurate detection of AF.
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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.
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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.
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Bong J, Yasin O, Vaidya VR, Park J, Attia ZI, Padmanabhan D, Cho SJ, Asirvatham R, Schneider N, Lee J, Kim EM, Friedman PA, Ma Z. Injectable Flexible Subcutaneous Electrode Array Technology for Electrocardiogram Monitoring Device. ACS Biomater Sci Eng 2019; 6:2652-2658. [DOI: 10.1021/acsbiomaterials.9b01102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jihye Bong
- Department of Electrical and Computer Engineering, University of Wisconsin−Madison, Madison, Wisconsin 53706, United States
| | - Omar Yasin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, United States
| | - Vaibhav R. Vaidya
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, United States
| | - Jeongpil Park
- Department of Electrical and Computer Engineering, University of Wisconsin−Madison, Madison, Wisconsin 53706, United States
| | - Zachi I. Attia
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, United States
| | - Deepak Padmanabhan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, United States
| | - Sang June Cho
- Department of Electrical and Computer Engineering, University of Wisconsin−Madison, Madison, Wisconsin 53706, United States
| | - Roshini Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, United States
| | - Noah Schneider
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, United States
| | - Juhwan Lee
- Department of Electrical and Computer Engineering, University of Wisconsin−Madison, Madison, Wisconsin 53706, United States
| | - Eun Mee Kim
- Department of Emergency Medical Technology, Korea Nazarene University, Cheonan 31172, South Korea
| | - Paul A. Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, United States
| | - Zhenqiang Ma
- Department of Electrical and Computer Engineering, University of Wisconsin−Madison, Madison, Wisconsin 53706, United States
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Svennberg E, Stridh M, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Safe automatic one-lead electrocardiogram analysis in screening for atrial fibrillation. Europace 2018; 19:1449-1453. [PMID: 28339578 DOI: 10.1093/europace/euw286] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/13/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Screening for atrial fibrillation (AF) using intermittent electrocardiogram (ECG) recordings can identify individuals at risk of AF-related morbidity in particular stroke. We aimed to validate the performance of an AF screening algorithm compared with manual ECG analysis by specially trained nurses and physicians (gold standard) in 30 s intermittent one-lead ECG recordings. Methods and results The STROKESTOP study is a mass-screening study for AF using intermittent ECG recordings. All individuals in the study without known AF registered a 30-s ECG recording in Lead I two times daily for 2 weeks, and all ECGs were manually interpreted. A computerized algorithm was used to analyse 80 149 ECG recordings in 3209 individuals. The computerized algorithm annotated 87.1% (n = 69 789) of the recordings as sinus rhythm/minor rhythm disturbances. The manual interpretation (gold standard) was that 69 758 ECGs were normal, making the negative predictive value of the algorithm 99.9%. The number of ECGs requiring manual interpretation in order to find one pathological ECG was reduced from 288 to 35. Atrial fibrillation was diagnosed in 84 patients by manual interpretation, in all of whom the algorithm indicated pathology. On an ECG level, 278 ECGs were manually interpreted as AF, and of these the algorithm annotated 272 ECGs as pathological (sensitivity 97.8%). Conclusion Automatic ECG screening using a computerized algorithm safely identifies normal ECGs in Lead I and reduces the need for manual evaluation of individual ECGs with >85% with 100% sensitivity on an individual basis.
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Affiliation(s)
- Emma Svennberg
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
| | - Martin Stridh
- Department of Biomedical Engineering, Lund University, Lund and Cardiolund Research AB, Lund, Sweden
| | - Johan Engdahl
- Department of Medicine, Halland Hospital, Halmstad, Sweden
| | - Faris Al-Khalili
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
| | - Viveka Frykman
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
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Passman RS, Rogers JD, Sarkar S, Reiland J, Reisfeld E, Koehler J, Mittal S. Development and validation of a dual sensing scheme to improve accuracy of bradycardia and pause detection in an insertable cardiac monitor. Heart Rhythm 2017; 14:1016-1023. [DOI: 10.1016/j.hrthm.2017.03.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Indexed: 11/24/2022]
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D'Souza R, Thomas E, Macicek S, Aziz P, Shivapour JK, Snyder C. P- and R-wave Amplitude Sensed by Reveal LINQ™ Loop Recorder in Pediatric Patients. J Innov Card Rhythm Manag 2017; 8:2584-2588. [PMID: 32477753 PMCID: PMC7252757 DOI: 10.19102/icrm.2017.080102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/30/2017] [Indexed: 11/29/2022] Open
Abstract
Implantable loop recorders are commonly used to sense arrhythmias. The purpose of this study is to assess the P- and R-wave amplitudes at implantation (I) and follow-up (F) following insertion of the Reveal LINQ™ Insertable Cardiac Monitor (Medtronic, Minneapolis, MN) in an institutional review board-approved, multicenter study performed on pediatric patients younger than 18 years old. Collected data included demographics, presence of congenital heart disease (CHD), P- and R-wave-sensed amplitude at I and F, and the method of implant (i.e. mapping or standard.) P waves were manually measured and R-wave sensing was recorded by the device. A total of 87 patients had a Reveal LINQ™ (Medtronic, Minneapolis, MN) device implanted; the mean patient age was 11.8 years (0.5 years to 18 years) with 48% of patients being female and 19% of patients having CHD; mapping was used in 43% of patients. The Reveal LINQ™ (Medtronic, Minneapolis, MN) experienced no change in average sensed R-wave amplitude at either I or F (1.28 mV vs 1.26 mV, p = NS). There was no difference in sensed R-wave amplitude noted with or without mapping used at I (1.29 mV vs 1.26 mV, p = NS) or F (1.48 mV vs 1.18 mV, p = NS). Additionally, no difference could be found in R-wave sensing of patients with CHD or without CHD at I (1.26 mV vs 1.4 mV, p = NS) or F (1.32 mV vs 1.32 mV, p = NS). R-wave sensing trended towards being inversely proportional to patient body surface area (BSA) (p = NS). P waves were detected on 48% of tracings in all patients at I and/or F, irrespective of whether the Reveal LINQ™ (Medtronic, Minneapolis, MN) device was placed with mapping. The R wave was (0.37–3.5 mV) at I and (0.3–3 mV) (p = NS) at F when P waves were detected. From these results, it can be said that the Reveal LINQ™ Insertable Cardiac Monitor (Medtronic, Minneapolis, MN) has an excellent ability to sense R-wave amplitude in pediatric patients. No significant difference in the sensing ability of the device could be identified with respect to the presence of CHD, use of mapping or BSA. P waves tended to be identified when there was a higher baseline R-wave amplitude.
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Affiliation(s)
- Roshan D'Souza
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | - Peter Aziz
- Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Jill K Shivapour
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Christopher Snyder
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
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Chow C, Subiakto I, Tsay I, Danny I, Mohammed U, Obeyesekere M, Lim H. A Retrospective Analysis of Implantable Loop Recorder in Victoria - Time to Diagnosis of Aetiology, and Correlation with R-Wave Amplitude. Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Miracapillo G, Addonisio L, Breschi M, DE Sensi F, Manfredini E, Corbucci G, Severi S, Barold SS. Left Axillary Implantation of Loop Recorder versus the Traditional Left Chest Area: A Prospective Randomized Study. Pacing Clin Electrophysiol 2016; 39:830-6. [PMID: 27119309 DOI: 10.1111/pace.12875] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/04/2016] [Accepted: 04/06/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Based upon the results of a previous small pilot study, we present the results of a prospective single-center randomized study comparing the performance of the implantable loop recorder (ILR) at two implanting sites. METHODS A group of patients whose ILRs were implanted via a left axillary approach were compared with a group who received an ILR in the traditional left site of the chest. Follow-up (FU) was scheduled every 6 months or when symptoms occurred. All patients enrolled in the study had a complete FU from implantation to explantation. R- and P-wave amplitudes were measured at implantation and during FU. Explantation of the device was programmed at the end of service life or when ILR analysis resulted in a complete and exhaustive diagnosis. RESULTS Sixty-three patients were enrolled (70 ± 12 years, range: 21-92, 59% male): 31 standard and 32 with axillary access. The R-wave amplitude obtained with the new technique was comparable with that obtained with the standard procedure. The diagnostic accuracy of the ILR was comparable in the two groups. The axillary implantation procedure was slightly longer but no complications were observed. CONCLUSION This long-term randomized study confirmed that axillary access for ILR implantation is feasible, safe, well tolerated, and reliable in terms of device performance. Moreover, it is aesthetically superior to the standard approach and carries the potential of minimizing permanent scarring after ILR extraction.
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Affiliation(s)
| | - Luigi Addonisio
- Division of Cardiology, Misericordia Hospital, Grosseto, Italy
| | - Marco Breschi
- Division of Cardiology, Misericordia Hospital, Grosseto, Italy
| | | | | | - Giorgio Corbucci
- Formerly, Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Silva Severi
- Division of Cardiology, Misericordia Hospital, Grosseto, Italy
| | - S Serge Barold
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Kawashima A, Tanimoto F, Nagao T, Toyoshima T, Okuyama Y. Investigation of optimal position for implantable loop recorders by potential mapping with Reveal DX. J Arrhythm 2014; 31:130-6. [PMID: 26336546 DOI: 10.1016/j.joa.2014.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 09/03/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Electrode positioning is important for the operation of implantable loop recorders (ILRs). This study aimed to investigate optimal electrode positions for the implantation of ILRs. METHODS Fifteen male subjects participated in the study and R wave amplitude data were collected from 15 areas in the left anterior chest area, with 4 variations of electrode angles and body positions. RESULTS The estimated minimum R wave amplitude values were greater than 0.3 mV (manufacturer-recommended value) when electrodes were angled vertically and positioned on the midclavicular line of the third and the forth intercostal spaces or on the left sternal border of the fourth and fifth intercostal space and when angled at 45° to the right on the left sternal border of the third and the forth intercostal space. CONCLUSIONS Exploring areas around the left sternal border of the fourth intercostal space - where the R wave amplitudes are least affected by body positions - is a reliable method for choosing implantation locations for ILRs.
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Affiliation(s)
| | | | | | | | - Yuji Okuyama
- Department of Advanced Cardiovascular Therapeutics, Osaka University, Graduate School of Medicine, Japan
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Providência R, Candeias R, Morais C, Reis H, Elvas L, Sanfins V, Farinha S, Eggington S, Tsintzos S. Financial impact of adopting implantable loop recorder diagnostic for unexplained syncope compared with conventional diagnostic pathway in Portugal. BMC Cardiovasc Disord 2014; 14:63. [PMID: 24884560 PMCID: PMC4101834 DOI: 10.1186/1471-2261-14-63] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 04/28/2014] [Indexed: 11/20/2022] Open
Abstract
Background To estimate the short- and long-term financial impact of early referral for implantable loop recorder diagnostic (ILR) versus conventional diagnostic pathway (CDP) in the management of unexplained syncope (US) in the Portuguese National Health Service (PNHS). Methods A Markov model was developed to estimate the expected number of hospital admissions due to US and its respective financial impact in patients implanted with ILR versus CDP. The average cost of a syncope episode admission was estimated based on Portuguese cost data and landmark papers. The financial impact of ILR adoption was estimated for a total of 197 patients with US, based on the number of syncope admissions per year in the PNHS. Sensitivity analysis was performed to take into account the effect of uncertainty in the input parameters (hazard ratio of death; number of syncope events per year; probabilities and unit costs of each diagnostic test; probability of trauma and yield of diagnosis) over three-year and lifetime horizons. Results The average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Over a lifetime horizon, the total discounted costs of hospital admissions and syncope diagnosis for the entire cohort were 23% lower amongst patients in the ILR group compared with the CDP group (1,204,621€ for ILR, versus 1,571,332€ for CDP). Conclusion The utilization of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. The result is robust to changes in the input parameter values, and cost savings become more pronounced over time.
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Affiliation(s)
- Rui Providência
- Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra, Portugal.
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14
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Forleo GB, Casella M, Dello Russo A, Moltrasio M, Fassini G, Tesauro M, Tondo C. Monitoring Atrial Fibrillation After Catheter Ablation. J Atr Fibrillation 2014; 6:1040. [PMID: 27957062 DOI: 10.4022/jafib.1040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/12/2014] [Accepted: 03/12/2014] [Indexed: 12/31/2022]
Abstract
Although catheter ablation is an effective treatment for recurrent atrial fibrillation (AF), there is no consensus on the definition of success or follow-up strategies. Symptoms are the major motivation for undergoing catheter ablation in patients with AF, however it is well known that reliance on perception of AF by patients after AF ablation results in an underestimation of recurrence of the arrhythmia. Because symptoms of AF occurrence may be misleading, a reliable assessment of rhythm outcome is essential for the definition of success in both clinical care and research trials. Continuous rhythm monitoring over long periods of time is superior to intermittent recording using external monitors to detect the presence of AF episodes and to quantify the AF burden. Today, new devices implanted subcutaneously using a minimally invasive technique have been developed for continuous AF monitoring. Implantable devices keep detailed information about arrhythmia recurrences and might allow identification of very brief episodes of AF, the significance of which is still uncertain. In particular, it is not known whether there is any critical value of daily AF burden that has a prognostic significance. This issue remains an area of active discussion, debate and investigation. Further investigation is required to determine if continuous AF monitoring with implantable devices is effective in reducing stroke risk and facilitating maintenance of sinus rhythm after AF ablation.
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Affiliation(s)
| | - Michela Casella
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino IRCCS. Milan. Italy
| | - Antonio Dello Russo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino IRCCS. Milan. Italy
| | - Massimo Moltrasio
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino IRCCS. Milan. Italy
| | - Gaetano Fassini
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino IRCCS. Milan. Italy
| | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino IRCCS. Milan. Italy
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15
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AF Detected on Implanted Cardiac Implantable Electronic Devices: Is There a Threshold for Thromboembolic Risk? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:289. [PMID: 24500679 DOI: 10.1007/s11936-013-0289-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with elevated thromboembolism risk caused by multiple pathophysiologies, including a hypercoagulable state, structural heart changes, left atrial appendage stasis, inflammation, and endothelial dysfunction. With the exception of lone AF, most other categories of AF, whether paroxysmal or persistent, have been shown to share a high thromboembolism risk. Risk stratification schemes such as CHADS2 and CHA2DS2-VASc scores help to identify the level at which anticoagulation may mitigate thromboembolism risk. AF may be episodic and asymptomatic; therefore, AF diagnosis that depends entirely on office electrocardiogram (ECG) may be easily missed. With the increasing use of pacemakers, implantable cardioverter defibrillators (ICDs), and insertable loop recorders (ILRs) for diagnosis and treatment of arrhythmias, AF has been incidentally detected with increasing frequency. However, the sensitivity and specificity for detection of AF, especially brief episodes, vary from one type of device to another, and rhythm confirmation should be considered. Several recent studies have examined device-detected AF and have tried to follow associated clinical outcomes. In this paper, we review studies that have addressed device-detected AF and associated thromboembolism risk to try to identify the burden of AF that is associated with an elevated risk of thromboembolism and may therefore warrant anticoagulation therapy.
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16
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van Hemel NM. Improving the detection of ventricular tachycardia: a smarter implantable loop recorder. Europace 2013; 15:1067-9. [DOI: 10.1093/europace/eut067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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Volosin K, Stadler RW, Wyszynski R, Kirchhof P. Tachycardia detection performance of implantable loop recorders: results from a large 'real-life' patient cohort and patients with induced ventricular arrhythmias. Europace 2013; 15:1215-22. [DOI: 10.1093/europace/eut036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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18
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Jung WH, Lee SG. An R-peak detection method that uses an SVD filter and a search back system. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2012; 108:1121-1132. [PMID: 22922087 DOI: 10.1016/j.cmpb.2012.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 07/23/2012] [Accepted: 08/01/2012] [Indexed: 06/01/2023]
Abstract
In this paper, we present a method for detecting the R-peak of an ECG signal by using an singular value decomposition (SVD) filter and a search back system. The ECG signal was detected in two phases: the pre-processing phase and the decision phase. The pre-processing phase consisted of the stages for the SVD filter, Butterworth High Pass Filter (HPF), moving average (MA), and squaring, whereas the decision phase consisted of a single stage that detected the R-peak. In the pre-processing phase, the SVD filter removed noise while the Butterworth HPF eliminated baseline wander. The MA removed the remaining noise of the signal that had gone through the SVD filter to make the signal smooth, and squaring played a role in strengthening the signal. In the decision phase, the threshold was used to set the interval before detecting the R-peak. When the latest R-R interval (RRI), suggested by Hamilton et al., was greater than 150% of the previous RRI, the method of detecting the R-peak in such an interval was modified to be 150% or greater than the smallest interval of the two most latest RRIs. When the modified search back system was used, the error rate of the peak detection decreased to 0.29%, compared to 1.34% when the modified search back system was not used. Consequently, the sensitivity was 99.47%, the positive predictivity was 99.47%, and the detection error was 1.05%. Furthermore, the quality of the signal in data with a substantial amount of noise was improved, and thus, the R-peak was detected effectively.
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Affiliation(s)
- Woo-Hyuk Jung
- Department of Multimedia System Engineering, The Catholic University of Korea, Bucheon, Gyeonggi, South Korea.
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19
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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.
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Affiliation(s)
- Franco Giada
- Cardiovascular Department, General Hospitals, Noale-Mirano, Venice, Italy.
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20
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Bortnik M, Occhetta E, Magnani A, Degiovanni A, Marino P. Inappropriate asystole detection in early postoperative phase after loop recorder implantation. ISRN CARDIOLOGY 2012; 2011:146062. [PMID: 22347628 PMCID: PMC3262500 DOI: 10.5402/2011/146062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 04/08/2011] [Indexed: 11/23/2022]
Abstract
The implantable loop recorder is a useful diagnostic tool for patients with unexplained syncope. The capability to automatically detect and store arrhythmic events, implemented in the last generations of these devices, can further improve the diagnostic yield, but this feature can be compromised by inappropriate detection of false arrhythmias. We herein report the case of a patient in which several inappropriate activations of long-lasting asystole occurred in the two days following the implant, probably because of an intermittently loose contact between the device and subcutaneous tissue for a small pocket haematoma.
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Affiliation(s)
- Miriam Bortnik
- Cardiology Division, Azienda Ospedaliera Maggiore della Carità, 28100 Novara, Italy
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21
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Paruchuri V, Adhaduk M, Garikipati NV, Steinberg JS, Mittal S. Clinical utility of a novel wireless implantable loop recorder in the evaluation of patients with unexplained syncope. Heart Rhythm 2011; 8:858-63. [DOI: 10.1016/j.hrthm.2011.01.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 01/26/2011] [Indexed: 10/18/2022]
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22
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Furukawa T, Maggi R, Bertolone C, Ammirati F, Santini M, Ricci R, Giada F, Brignole M. Effectiveness of remote monitoring in the management of syncope and palpitations. Europace 2011; 13:431-7. [DOI: 10.1093/europace/euq503] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Miracapillo G, Costoli A, Addonisio L, Gemignani L, Manfredini E, Corbucci G, Severi S, Barold SS. Left axillary implantation of loop recorder. Pacing Clin Electrophysiol 2010; 33:999-1002. [PMID: 20487344 DOI: 10.1111/j.1540-8159.2010.02764.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We compared the clinical course of 10 patients who received an implantable loop recorder (ILR) at a traditional site with 11 patients whose ILRs were implanted via a subpectoral site via a left axillary approach without complications. METHODS AND RESULTS R-wave amplitude was determined at implantation and during follow-up. Each patient was followed after 7 days to optimize device setting and then at 1 and 3 months. The R-wave amplitude obtained with the new technique was significantly higher and more stable than that obtained with the standard procedure. Our preliminary experience suggests that axillary access for ILR implantation is feasible, safe, well tolerated, and reliable in terms of sensing function and device performance. Moreover, it is superior aesthetically to the standard approach and carries the potential of minimizing permanent scarring after ILR extraction.
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BELLARDINE BLACK CARISSAL, STROMBERG KURT, VAN BALEN GEORGETTEPLEMPER, GHANEM RAJAN, BREEDVELD ROBERTW, TIELEMAN ROBERTG. Is Surface ECG a Useful Surrogate for Subcutaneous ECG? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:135-45. [DOI: 10.1111/j.1540-8159.2009.02616.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Bartoletti A. Implantable loop recorders for assessment of syncope: is 'Saint Thomas approach' still the best diagnostic strategy? Europace 2009; 11:1262-4. [DOI: 10.1093/europace/eup266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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van Dam P, van Groeningen C, Houben RPM, Hampton DR. Improving sensing and detection performance in subcutaneous monitors. J Electrocardiol 2009; 42:580-3. [PMID: 19665727 DOI: 10.1016/j.jelectrocard.2009.06.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Indexed: 11/19/2022]
Abstract
Implantable loop recorders (ILRs) are used for continuous assessment of patients at risk for syncope and arrhythmia. Device accuracy depends on appropriate sensing of the patient's electrocardiogram (ECG) signal. However, current methods for sensing cardiac electrical activity rely on simple threshold detectors that are computationally efficient but nonspecific. We test the hypothesis that better ILR implant positions will increase detection accuracy. Ten healthy subjects were studied as they assumed 12 different postures. Body surface potential map (BSM) recordings were used to estimate bipolar R-wave amplitudes for 64 potential implant sites at 360 orientations per site. Optimal sites were identified as the combination of position and orientation that consistently gave the largest signal and the lowest variability during posture changes. Results showed that posture impacts the R-wave amplitude in both BSM and derived bipolar ECGs in healthy subjects. Specific postures are associated with significant drops in R-wave signal amplitude that could cause loss of signal detection in ILRs, especially in positions likely to displace the diaphragm. R-wave changes occurred abruptly as posture was changed. Optimal implant locations cluster near the center of the chest, aligned with the cardiac axis, consistent with the steeper isoelectric gradients known to be associated with these positions.
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Affiliation(s)
- Peter van Dam
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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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
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