The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.
Key Findings▪Digital health technologies have been advocated as instruments to resolve worldwide disparities in health care. Among these, remote monitoring of cardiac implantable electronic devices is recommended as standard of care and may be particularly useful for more complex devices and sicker patients. However, international adoption has not been characterized.▪Among patients receiving cardiac resynchronization therapy (CRT), devices implanted in the Americas had remote monitoring implemented in approximately 60%, contrasting with only <6% in Asia. Following diagnosis of nonresponse, there was no change in remote monitoring utilization.▪Barriers to remote monitoring need to be identified to improve patient care of patients receiving CRT. This is important to this high-risk group of patients and to adoption of digital health technologies in general. ▪Digital health technologies have been advocated as instruments to resolve worldwide disparities in health care. Among these, remote monitoring of cardiac implantable electronic devices is recommended as standard of care and may be particularly useful for more complex devices and sicker patients. However, international adoption has not been characterized.▪Among patients receiving cardiac resynchronization therapy (CRT), devices implanted in the Americas had remote monitoring implemented in approximately 60%, contrasting with only <6% in Asia. Following diagnosis of nonresponse, there was no change in remote monitoring utilization.▪Barriers to remote monitoring need to be identified to improve patient care of patients receiving CRT. This is important to this high-risk group of patients and to adoption of digital health technologies in general. There is increasing momentum in application of digital solutions in medicine to improve patient outcomes and reduce global health inequities.1World Health Organization mHealth: Use of appropriate digital technologies for public health.2017https://apps.who.int/gb/ebwha/pdf_files/EB142/B142_20-en.pdfGoogle Scholar,2Varma N. Cygankiewicz I. Turakhia M.P. et al.2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in arrhythmia management: digital medical tools for heart rhythm professionals: from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society.Circ Arrhythm Electrophysiol. 2021; 14e009204Google Scholar Remote monitoring (RM) of patients with cardiac implantable electronic devices received a Class 1 recommendation in 2015 in the United States.3Slotwiner D. Varma N. Akar J.G. et al.HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices.Heart Rhythm. 2015; 12: e69-e100Abstract Full Text Full Text PDF PubMed Scopus (408) Google Scholar However, adoption varies by device type (eg, pacemakers less frequently) and patient condition, possibly because sicker patients and/or those with more complex devices are perceived to have the most to gain. Cardiac resynchronization therapy (CRT) is the most complex cardiac implantable electronic device, and "nonresponders" (CRT-NR) have one of the poorest prognoses among heart failure patients.4Varma N. Boehmer J. Bhargava K. et al.Evaluation, management, and outcomes of patients poorly responsive to cardiac resynchronization device therapy.J Am Coll Cardiol. 2019; 74: 2588-2603Crossref PubMed Scopus (48) Google Scholar RM enables early detection of potential precipitants of decompensation (eg, atrial fibrillation, loss of %CRT pacing, volume changes), and thereby facilitates early preemptive intervention to improve patient outcomes.5Hindricks G. Varma N. Kacet S. et al.Daily remote monitoring of implantable cardioverter defibrillators: insights from the pooled patient-level data from three randomised controlled trials (IN-TIME, ECOST, TRUST).Eur Heart J. 2017; 38: 1749-1755Crossref PubMed Scopus (107) Google Scholar Nevertheless, utilization among CRT patients is not well characterized. Moreover, little is known of practice in Asia. We contrasted RM use among CRT recipients in Asia vs the United States, before and after the determination of "nonresponse" status, in the international, multicenter, prospective ADVANCE CRT registry, which enrolled the largest studied cohort of Asian CRT patients in global trials. ADVANCE CRT was a prospective parallel cohort study of CRT follow-up in the Americas vs Asia. Overall results were reported previously.4Varma N. Boehmer J. Bhargava K. et al.Evaluation, management, and outcomes of patients poorly responsive to cardiac resynchronization device therapy.J Am Coll Cardiol. 2019; 74: 2588-2603Crossref PubMed Scopus (48) Google Scholar In brief, during 2013–2015, the study enrolled patients receiving Abbott CRT implants for standard indications. The registry was approved by the institutional review board at each participating site, and all patients provided written informed consent before enrollment. Sites followed each patient every 3 months for 1 year. RM was advised but not mandated. Response status was evaluated using the Clinical Composite Score 6 months postimplant. Subsequent treatment strategies were assessed, including the use of RM (prespecified analysis). Practice was compared between Asia and the Americas. More patients were enrolled in the Americas (total 653 [United States 604, Brazil 23, Colombia 23, Argentina 5]) than in Asia (total 231 [India 156, China 30, Japan 25, South Korea 20]). From implant to 6 months in Asia, 94.4% of patients were followed with in-clinic visits only (Figure 1). RM (with or without an in-clinic visit) was used in 5.6% of patients. Among American patients, RM was used in the majority (58.5%). More Asian patients responded to CRT (85.7% [198/231] vs 67.5% [441/653] Americans, P < .001). Following assessment of response, in the Americas RM significantly increased among CRT responders (57.8% [255/441] to 63.3% [269/425], P = .029) and trended upwards in the CRT-NR cohort (59.9% [127/212] vs 66% [134/200], P = .208). However, among Asians, RM use did not change in the CRT responder or CRT-NR group (pre vs post 5.6% [11/198] vs 5.9% [10/170], P = .317; 36.4% [12/33] vs 32.3% [10/31], respectively, P = .157). This study informs on practice patterns of RM utilization among CRT recipients internationally. Utilization was negligible in Asia, where in-person follow-up was strongly preferred. Although 10-fold higher in the Americas, level was still less than two-thirds of patients, despite recommendations. Of most concern, RM use did not increase significantly following the determination of high-risk CRT-NR in either the Americas or Asia. The reasons for the lack of adoption of RM in Asia were not identified in this study. Possibly, the cost of RM-capable devices, increased service burden associated with specialized staffing, lack of reimbursement, lack of physician awareness, and/or the need for more evidence for improved clinical outcome, as well as the "digital divide," may all inhibit RM adoption. CRT-NRs numbered very few in Asia. Practice post-COVID may differ and it is necessary to conduct a detailed survey for each country (noting RM received a Class IA recommendation in Japan in 2021). Adoption of RM is relatively minor in Asia, even when encouraged and under trial conditions. Barriers need to be identified and resolved to enable the application of digital health care worldwide as advocated by the World Health Organization.1World Health Organization mHealth: Use of appropriate digital technologies for public health.2017https://apps.who.int/gb/ebwha/pdf_files/EB142/B142_20-en.pdfGoogle Scholar,2Varma N. Cygankiewicz I. Turakhia M.P. et al.2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in arrhythmia management: digital medical tools for heart rhythm professionals: from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society.Circ Arrhythm Electrophysiol. 2021; 14e009204Google Scholar
Abstract Background or Purpose The prognosis of m ixed cardiomyopathy (CMP) in patients with implanted cardioverter-defibrillators (ICDs) has not been investigated. We aim to study the demographic, clinical, device therapies and survival characteristics of mixed CMP in a cohort of patients implanted with a defibrillator. Methods The term mixed CMP was used to categorise patients with impaired left ventricular ejection fraction attributed to documented non-ischemic triggers with concomitant moderate coronary artery disease. This is a single center observational cohort of 526 patients with a mean follow-up of 8.7 ± 3.5 years. Results There were 42.5% patients with ischemic cardiomyopathy (ICM), 26.9% with non-ischemic cardiomyopathy (NICM) and 30.6% with mixed CMP. Mixed CMP, compared to NICM, was associated with higher mean age (69.1 ± 9.6 years), atrial fibrillation (55.3%) and greater incidence of comorbidities. The proportion of patients with mixed CMP receiving device shocks was 23.6%, compared to 18.4% in NICM and 27% in ICM. The VT cycle length recorded in mixed CMP (281.6 ± 43.1 ms) was comparable with ICM (282.5 ± 44 ms; p = 0.9) and lesser than NICM (297.7 ± 48.7 ms; p = 0.1). All-cause mortality in mixed CMP (21.1%) was similar to ICM (20.1%; p = 0.8) and higher than NICM (15.6%; p = 0.2). The Kaplan–Meier curves revealed hazards of 1.57 (95% CI: 0.91, 2.68) for mixed CMP compared to NICM. Conclusion In a cohort of patients with ICD, the group with mixed CMP represents a phenotype predominantly comprised of the elderly with a higher incidence of comorbidities. Mixed CMP resembles ICM in terms of number of device shocks and VT cycle length. Trends of long-term prognosis of patients with mixed CMP are worse than NICM and similar to ICM.
Context: Radiofrequency ablation (RFA) is a recognised mode of therapy for cardiac arrhythmias. The procedure is carried our regularly at the Cardiac Catheterization Laboratory of Madras Medical Mission, India. Aim: To evaluate the intermediate term follow-up results of radiofrequency catheter ablations. Subjects and Methods: This was a retrospective study carried out in the Cardiac Electrophysiology Department of the Institute of Cardiovascular Diseases, Madras Medical Mission (MMM), India. Records of consecutive cardiac electrophysiologic studies carried out between January and October 2009, together with records of follow-up to March 2014 for those that underwent RFAs were reviewed. In total, the records of 139 cases that had RFAs were analysed. Results: The 139 patients comprised of 65 males and 74 females. The indication for RFA was drug refractory arrhythmias in the vast majority (137 patients). There was a very high success rate (97.1%), following cardiac ablations. Early complications were observed in only 3 (2.2%) patients. Recurrence rate of the indication for RFA was very low (1.43%), and there was no mortality associated with the procedure. Conclusions: The treatment of patients with cardiac arrhythmias using RFA, was associated with a high rate of success, and low rate of complications.
'%3e%3ccircle r='20' fill='%23008'/%3e%3ccircle r='17.5' fill='%23fff'/%3e%3ccircle r='3.5' fill='%23008'/%3e%3cg id='d'%3e%3cg id='c'%3e%3cg id='b'%3e%3cg id='a' fill='%23008'%3e%3ccircle r='.875' transform='rotate(7.5 -8.75 133.5)'/%3e%3cpath d='M0 17.5.6 7 0 2l-.6 5L0 17.5z'/%3e%3c/g%3e%3cuse xlink:href='%23a' transform='rotate(15)'/%3e%3c/g%3e%3cuse xlink:href='%23b' transform='rotate(30)'/%3e%3c/g%3e%3cuse xlink:href='%23c' transform='rotate(60)'/%3e%3c/g%3e%3cuse xlink:href='%23d' transform='rotate(120)'/%3e%3cuse xlink:href='%23d' transform='rotate(-120)'/%3e%3c/g%3e%3c/svg%3e)
