[STRATEGIES FOR IMPLEMENTATIONS OF REMOTE MONITORING FOR PATIENTS WITH CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICES (CIED) IN ISRAEL]

Remote monitoring (RM) of patients with cardiovascular implantable electronic devices (CIED) offers clinical benefits by providing early alert for system failure and actionable changes in patient health. Professional societies recommend utilization of RM for CIED patients (Level of recommendation I Level of evidence A). It must be emphasized that RM technology does not provide continuous monitoring but rather "remote snapshot clinics". On the other hand, pacemakers (PCM) and implantable cardiac defibrillators (ICD) are designed to work automatically and continuously without any need for immediate external intervention. Therefore, the guidelines recommend that the clinical response to RM notification will take place during the normal office hours. With appropriate organization, the utilization of RM will save a significant number of unnecessary pacemaker clinic visits and will allow better utilization of healthcare resources on patients in whom early intervention may prevent hospitalization, complication and mortality. The guidelines recommend offering RM to all patients with CIED. In Israel however, RM is offered sporadically only to a few patients. If a patient will suffer from delayed or inadequate treatment due to lack of RM, grave ethical and legal consequences may occur. Follow-up of CIED patients utilizing RM should be performed by a team including a primary physician, primary cardiologist, electrophysiologist, nurses and CIED technologist working in concert utilizing modern information technologies. Data should be shared electronically (with strict data security protocols) utilizing the electronic patient file with secure connection to RM systems. In summary, we believe that RM should be offered to all CIED patients in Israel.

Clinical Outcomes in Patients with Severe Renal Dysfunction Including Dialysis Following Defibrillator Implantation

BACKGROUND

Renal dysfunction is associated with increased mortality in heart failure (HF) patients. However, there are limited data regarding clinical and arrhythmic outcomes associated with implantable cardioverter defibrillator (ICD) therapy in this population.

METHODS

We evaluated outcomes associated with the severity of renal dysfunction with or without dialysis among 2,289 patients who were enrolled and prospectively followed up in the Israeli ICD Registry. The primary endpoint of the study was all-cause mortality. Secondary endpoints included cardiac mortality, HF hospitalization, non-cardiac hospitalization, and appropriate and inappropriate ICD therapy.

RESULTS

Severe renal dysfunction patients (estimated glomerular filtration rate<30 ml/min/1.73 m2; n=144 patients; 6%) were older, with higher comorbidities prevalence, and more likely to suffer from advanced HF. Among severe renal dysfunction patients, those on dialysis had a lower prevalence of wide QRS and complete left bundle branch morphology, resulting in lower cardiac resynchronization therapy defibrillator (CRTD) implantation rates. Dialysis was associated with an overall increased risk for all-cause mortality (hazard ratio (HR) 3.22; 95% CI 1.69-6.13; p<0.01) and for noncardiac hospitalizations (HR 2.80; p<0.001) compared to all other study patients. However, within the subgroup of patients with severe renal dysfunction, the presence of dialysis was not an independent risk factor for all-cause mortality (HR 0.99; p=0.97) as compared to non-dialysis. The rate of appropriate ICD therapy for ventricular tachyarrhythmias increased with declining renal function, with the highest rate observed among those undergoing dialysis.

CONCLUSIONS

The present findings suggest that dialysis does not significantly modify the adverse outcomes associated with severe renal dysfunction following ICD/CRTD implantation.