[The implantable loop recorder].
Denis GrafMarc-Olivier RoussianosJürg SchlaepferAndreï ForclazThomas ZermJacques MetzgerMartin FromerÉtienne Pruvot
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The implantable loop recorder developed by Medtronic (Reveal plus) is a small device inserted subcutaneously under local anesthesia in patients with syncope of unexplained origin. This device enables a single lead-ECG recording and has autonomy of two years. Memories are activated during episodes of bradycardia or tachycardia, either automatically or manually. Several studies have shown a high diagnostic rate reaching 50% and demonstrated its cost-effectiveness. There is also a significant reduction in syncopal episodes and a higher quality of life score in patients with syncope of unexplained origin.Keywords:
Implantable loop recorder
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A 63-year-old man with frequent unexplained syncope was implanted with a second generation remotely monitored implantable loop recorder for continuous electrocardiogram (ECG) monitoring. He had a subsequent syncopal episode and despite accidental destruction of his patient activator, vital ECG data from the event were transmitted wirelessly, enabling a cardiac arrhythmia to be excluded. This case highlights the benefit of remote monitoring in syncope assessment, as well as a transmission system that ensures prompt analysis of the ECG data and therefore rapid optimal patient management. (PACE 2010; 33:763–765)
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According to recent studies, silent atrial fibrillation (AF) is a common cause of cryptogenic ischemic stroke (CIS). 12-lead electrocardiogram (ECG) and 24 h Holter are not efficient to reveal an occult arrhythmic cause of stroke.The aim of the study was to evaluate 72 h Holter, 7 day Holter monitoring, and intermittent single-lead ECG recording in patients with CIS to identify cases with the arrhythmic cause of stroke in patients with CIS in whom 24 h ECG Holter was free from arrhythmia.72 patients (aged 60 ± 9 years, 44 males) with CIS and no arrhythmic findings in 24 h Holter were enrolled. All patients had 7 day Holter monitoring and received handheld ECG recorder (CheckMe, Viatom) for ambulatory 30 ± 3 days ECG recording. AF, supraventricular tachycardia (SVT runs of ≥5 QRS), and other arrhythmias were assessed in the first 72 h of Holter recording, in 7 day-recording, and in handheld ECG strips.72 h-recording revealed AF in four cases (5.6%) and SVT in 18 (25%) cases. 7 day Holter confirmed AF in seven patients (10%) and SVT in 27 patients (37.5%). There was no difference in regards to CHADS2VASc score between patients with SVT and non-arrhythmic group (3.6 ± 1.1 vs 3.4 ± 1.6; p = NS). Symptoms did not correlate with findings. Patient-activated handheld ECG recorders were used with good compliance. The mean number of recordings was 49 ± 30. Except for PACs, there was only one case of AF documented in 3,531 strips.7 day Holter performs better than 72 h and reveals supraventricular arrhythmias in every third and AF in 10% of CIS patients who were free from arrhythmia in 24 h ECG monitoring. 30 day intermittent ECG monitor does not yield diagnostic value in CIS.
Holter monitor
Ambulatory ECG
Premature atrial contraction
Supraventricular Tachycardia
Supraventricular arrhythmia
Stroke
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Implantable loop recorder
Ambulatory ECG
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A dedicated pacemaker Holter system facilitates recognition of the pacemaker stimulus by amplifying and displaying it in an ECG channel without any other data. Such a Holter pacemaker channel may occasionally generate electrostatic charges that produce deflections resembling pacemaker stimuli (pseudopacemaker spikes) arising from a loose ECG electrode, crushed tape, or a dirty recording head. False‐positive spikes or spurious marker deflections in Holter pacemaker channels and occasional failure to detect tiny bipolar stimuli can present challenging problems in the interpretation of pacemaker function. In multiple‐channel recorders, skewing of the recording heads may lead to timing errors and puzzling recordings when one of the ECG or pacemaker channels lags behind others producing asynchrony or malalignment in simultaneously recorded tracings. The interpretation of Holter recordings from contemporary complex pacemakers requires knowledge of pacemaker timing cycles and their interrelationships, a large variety of programmable parameters or functions, behavior of the nonatrial sensor or sensors in rate‐adaptive systems, device‐specific responses to protect the system from a variety of undesirable situations, and an appreciation of pacemaker eccentricities. There are a few prospective studies on the value of routine Holter recordings in pacemaker patients. The real value of Holter recordings lies with symptomatic patients when symptoms occur during the recording period. Correlation between symptoms and occasional abnormality of pacemaker function during Holter monitoring remains poorly characterized. The cause of the symptoms is frequently unrelated to the pacemaker system and may not be related to coexisting arrhythmias. In asymptomatic patients, Holter recordings are particularly useful to uncover a lead problem after an unrevealing thorough investigation in the pacemaker clinic. Special instrumentation was recently developed to register telemetry data from implanted pacemakers simultaneously with ambulatory electrocardiography. In this way, diagnostic marker signals and/or intracardiac electrograms transmitted from the pacemaker can be recorded continuously for 24 hours by a Holter recorder. Advanced technology involving the memory capability of pacemakers will transform the pacemaker itself into a 24‐hour Holter recorder, probably in 4 to 5 years. At present, the memory for storage of intracardiac electrograms is limited from a few seconds to less than a minute according to the manufacturer, but even such mini‐Holter recordings can be diagnostically important.
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Presyncope
Implantable loop recorder
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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.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.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.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.Le CardioSTAT est un moniteur d’électrocardiographie ambulatoire à dérivation unique dont l’utilisation a été validée chez les patients adultes. L’enregistrement se fait au moyen de 2 électrodes positionnées dans une configuration de type « dérivation I », et l’appareil permet un suivi pendant 2, 7 ou 14 jours. Nous avons cherché à étudier l’efficacité de cet appareil chez les enfants atteints de palpitations paroxystiques.Dans la phase I, la qualité des tracés provenant d’enregistrements simultanés de CardioSTAT et d’enregistrements de la dérivation I d’un appareil d’électrocardiographie standard à 12 dérivations a été comparée chez 23 enfants. La phase II était une étude de cohorte observationnelle prospective comparant la détection de l’arythmie à l’aide du moniteur CardioSTAT par rapport aux appareils utilisés actuellement (moniteur Holter à surveillance sur 24 heures et enregistreur d’événements portatif Cardiomémo) chez 52 enfants se plaignant de palpitations.Dans la phase I, toutes les bandes d’enregistrement sauf trois ont été correctement identifiées. Les spicules de stimulation n’ont pas été correctement détectés par les observateurs sur trois bandes d’enregistrement du moniteur CardioSTAT. Dans la phase II, des épisodes symptomatiques ont été signalés chez 42 %, 73 % et 100 % des sujets pendant la surveillance avec les appareils Holter, Cardiomémo et CardioSTAT, respectivement. Un rythme anormal a été détecté chez 13 %, 23 % et 35 % des sujets par les moniteurs Holter, Cardiomémo et CardioSTAT, respectivement. Le rythme sous-jacent pendant les événements symptomatiques a été déterminé dans 90 % des cas avec le moniteur CardioSTAT, alors qu’il n’a été déterminé que dans 19 % et 29 % des cas, respectivement, avec les moniteurs Holter et Cardiomémo.Le moniteur CardioSTAT a fourni des tracés de bonne qualité et s’est révélé supérieur à l’appareil Holter à surveillance sur 24 heures et à l’enregistreur d’événements portatif Cardiomémo pour déterminer la présence ou l’absence d’arythmie pathologique dans la cohorte étudiée.
Palpitations
Ambulatory ECG
Implantable loop recorder
Lead (geology)
Holter monitor
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ECG, 24-h ambulatory ECG, and related tests have been used to clarify the pathophysiological features of atrial fibrillation as well as to detect the relationship between symptoms and episodes of tachyarrhythmia. These testes are also potent to estimate the efficacy of pharmacological and nonpharmacological treatments. Proarrhythmic events during the treatment with antiarrhythmic agents may be avoided by careful follow-up using ECG. Recently, an implantable loop recorder electrocardiogram is available to identify the culprit episode of syncope. Atrial fibrillation is a cause of syncope in only a small proportion of patients.
Ambulatory ECG
Culprit
Implantable loop recorder
Holter monitor
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The most crucial step in diagnosing syncope is determining whether or not an arrhythmia is the cause. A new recording device, the continuous cardiac loop ECG recorder, affords prolonged ambulatory monitoring and can capture the rhythm at the time of syncope. To determine the impact of cardiac loop ECG recorders in diagnosing syncope, we reviewed the records of the first 48 patients referred for cardiac loop recording because of unexplained syncope or presyncope. Previous cardiac studies were nondiagnostic in all patients. In 36% of these patients, loop recording definitively determined whether an arrhythmia was the cause of symptoms. Median duration of monitoring was 28 days, with an average charge of $180 per month. Cardiac loop ECG recording is a convenient, safe, inexpensive, and potentially highly effective means of diagnosing unexplained syncope.
Presyncope
Implantable loop recorder
Cardiac monitoring
Cardiac arrhythmia
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Ambulatory ECG
Implantable loop recorder
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