Safety and efficiency of emergency department interrogation of cardiac devices

[Follow-up of the patient with pacemakers: Interrogation and basic programming]

Permanent pacemakers are a frequently used therapeutic modality. Its use has had a great impact on the morbidity and mortality and quality of life of patients with heart rhythm disturbances, with an exponential increase observed in recent decades. The use of this strategy presents different phases, in which follow-up throughout the useful life of the device is a fundamental and determinant pillar of the efficacy and safety of this therapeutic modality. This review seeks to provide a clear and structured update of the fundamental aspects to consider in the follow-up of all patients with pacemakers. The follow-up of the patient with a pacemaker must follow a complete, systematic and periodic protocol, evaluating aspects and parameters related to the patient and the pacemaker, in order to ensure the proper and safe operation of the device adapted to the person.

Should We Check It? Assessing Interrogation of Cardiac Implantable Electronic Devices in the Emergency Department-The CHECK-ED Study: Implications for Service Planning and Care Delivery

BACKGROUND

Requests from the emergency department (ED) for cardiac implantable electronic device (CIED) checks constitute a large workload for cardiac electrophysiology services. We sought to determine the yield of, and clinical characteristics associated with, clinically relevant (remarkable) issues from ED CIED checks.

METHODS

Consecutive CIED checks from our ED over a 12-month period were studied. A remarkable issue (RI) was defined as arrhythmia relating to the presentation or device/lead issue requiring reprogramming or intervention. The association between the presenting complaint and an RI was assessed using regression analysis. Multivariable regression model was used to identify pre-specified patient-level characteristics that were predictive of a RI.

RESULTS

A RI was found in 28% (n=98) of 354 ED CIED checks for 306 patients (76±16 yrs 59% male). Most patients had no RI (n=224 73%). One third of checks occurred after-hours and these had a higher yield of RIs than those during routine clinic hours (35% vs 23% p=0.018). Presenting with a perceived ICD shock was predictive of a RI (odds ratio [OR] 6.0 95% CI=1.8-20.0). Syncope/presyncope was five-fold less likely to be predictive of a RI (OR 0.19 95% CI=0.13-0.28) despite being the most common indication for CIED check (51% n=180 checks). Only history of AF was predictive of RI while advancing age was predictive of not finding a RI.

CONCLUSION

Almost three-quarters of ED CIED checks did not yield any RI. Patient-reported ICD shock and history of AF were predictive of RI, while syncope/presyncope was not. New models of care especially during after-hours, may help to reduce the burden on cardiac electrophysiology services and health care costs.

Assessing the safety of interrogating cardiac-implantable electronic devices with brand-mismatched remote interrogators: a pilot study

Objective

Remote cardiac implantable electronic device (CIED) interrogators, originally developed for home use, have been proven to be efficacious in clinical settings, especially emergency departments. Concern exists that attempting to interrogate a CIED with the remote interrogator of a different brand, i.e., a brand-mismatched interrogator, may cause device malfunction. The aim of this study was to determine if intentionally attempting to interrogate a CIED with a brand-mismatched remote interrogator resulted in device malfunction.

Methods

A total of 75 ex vivo CIEDs manufactured by various companies underwent attempted interrogation by a brand-mismatched remote interrogator. CIED settings were compared before and after attempted mismatch interrogation. A total of 30 in vivo CIEDs were then randomized for an attempted 2-minute mismatched remote interrogation by one of the two possible mismatched remote interrogators. CIED settings were compared before and after attempted mismatch interrogation.

Results

Of 150 ex vivo brand-mismatched interrogations, no device setting changes or malfunctions occurred; no remote interrogators connected to a mismatched CIED, and no devices were turned off. In the 30 patients undergoing brand-mismatched interrogations, the mean (standard deviation) age was 71.6 ( ± 14.7) years, 16 (53%) were male, with 24 pacemakers (80%), four pacemaker/implantable cardioverter defibrillators (13%), and two implantable cardioverter defibrillators (7%). Of the 30 mismatched interrogations performed, no device setting changes or malfunctions occurred; no remote interrogators connected to a mismatched CIED, and no devices turned off.

Conclusion

In a total 180 attempted brand-mismatched CIED interrogations, no CIED malfunctions occurred. This suggests that the use of remote CIED interrogators when device manufacturer is unknown is unlikely to result in adverse CIED-related events.

Comparing sensitivity and specificity of pacemaker ID application and cardiac rhythm management device-finder application in identifying cardiac implantable electronic device manufacturer using chest radiograph - An observational study

Background

Smartphone-based applications to identify cardiac implantable electronic devices (CIED) are extremely useful in circumstances, where urgent device interrogation is needed, and a device identification card is not available. Few studies have provided insights regarding the utility of these applications. We have studied two widely available applications i.e., Pacemaker ID app (PMIDa) or Cardiac Rhythm Management Device-Finder (CRMD-f) to identify device manufacturers in CIEDs.

Methods

547 patients who underwent CIED implantation from the year 2016-2020 in our institute were enrolled. There were 438 Medtronic and 109 St. Jude's devices. All chest radiographs were de-identified and resized into 225*225 pixels focusing on the CIED. PMIDa and CRMD-f applications were used to identify the CIED. Accuracy, sensitivity, specificity, negative predictive value, and positive predictive value for both applications were calculated and compared.

Results

Overall, CRMD-f application has higher specificity (93.58 vs. 82.5%) but lower sensitivity (53.6 vs. 55%) than PMIDa. The accuracy of both applications was comparable (61.6% vs. 60.5%). Accuracy varied with CIED model and type tested, and radiograph projection used. Accuracy is greatest with Cardiac-Resynchronization-Therapy (CRT) devices for both applications, followed by a single lead pacemaker.

Conclusion

CRMD-f has higher accuracy and specificity for CIED manufacturer identification. Both PMIDa and CRMD-f are specific tools to identify CIED but have low sensitivity.