Cardiac implantable electronic devices: Patient follow-up
- Leonard I Ganz, MD, FHRS, FACC
Leonard I Ganz, MD, FHRS, FACC
- Section Editor — Cardiac Arrhythmias
- Director of Cardiac Electrophysiology
- Heritage Valley Health System
- David L Hayes, MD
David L Hayes, MD
- Professor of Medicine
- Mayo Medical School
- Section Editors
- Samuel Lévy, MD
Samuel Lévy, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Cardiology
- University of Marseille, France
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
As more people are living longer with more significant cardiac disease, permanent pacemakers (PPMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices are being inserted more frequently. Beginning early in the 21st century, there has also been an expansion in the indications for cardiac implantable electronic devices (CIEDs, a term which includes PPMs, ICDs, and CRT devices, as well as other devices such as implantable loop recorders and left ventricular assist devices), and device therapy has become more commonplace.
Issues related to follow-up of patients with a CIED (PPM, ICD, or CRT devices only) will be reviewed here. The indications for PPM, ICD, and CRT use, as well as general issues related these devices, are discussed separately. (See "Permanent cardiac pacing: Overview of devices and indications" and "Secondary prevention of sudden cardiac death in heart failure and cardiomyopathy" and "Primary prevention of sudden cardiac death in heart failure and cardiomyopathy" and "Cardiac resynchronization therapy in heart failure: Indications" and "General principles of the implantable cardioverter-defibrillator" and "Modes of cardiac pacing: Nomenclature and selection".)
METHODS AND FREQUENCY OF CIED FOLLOW-UP
For several decades, follow-up evaluation of cardiac implantable electronic devices (CIEDs) required in-person assessment, with the subsequent availability of transtelephonic monitoring for some types of permanent pacemakers (PPMs). Current technology, however, has evolved to enable comprehensive and safe remote monitoring for nearly all types of CIEDs [1,2]. The equipment required for remote monitoring, along with requirements (eg, internet connection) and instructions for use, should be discussed with the patient as part of the implantation process.
Office-based versus remote follow-up — For most patients, the majority of CIED follow-up assessments can be done either in person or remotely (table 1) [3-5]. Following the immediate post-implant check, an initial in-person visit should occur within weeks to three months post-implantation, and ideally one in-person visit annually for the duration of therapy with a CIED . With the exception of these initial and annual in-person visits, all other CIED follow-up assessments may be done either in person or remotely (table 2), an approach consistent with the 2015 Heart Rhythm Society expert consensus statement on the remote device interrogation and monitoring .
Several prospective randomized trials have demonstrated the feasibility and safety of remote CIED monitoring as well as the potential for shortening the time to clinical action [7-15]. Multiple nonrandomized observational studies have suggested improved survival for patients with remote CIED monitoring; however, this has not been universally replicated in prospective randomized trials [16-18]. In a 2015 systematic review and meta-analysis of nine randomized trials involving 6469 ICD recipients who were randomized to either remote monitoring (3496 patients) or in-office follow-up (2973 patients), patients assigned to remote monitoring had nonsignificant reductions in total mortality (OR 0.83; 95% CI 0.58-1.17), cardiovascular mortality (OR 0.66; 95% CI 0.41-1.09), and hospitalizations (OR 0.83; 95% CI 0.63-1.10) along with significantly fewer inappropriate shocks (OR 0.55; 95% CI 0.38-0.80) .
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- METHODS AND FREQUENCY OF CIED FOLLOW-UP
- Office-based versus remote follow-up
- Frequency of CIED follow-up visits
- FOLLOW-UP OF THE PATIENT WITH A PACEMAKER
- PPM evaluation
- - Establish programmed parameters
- - Evaluate capture
- - Evaluate sensing
- - Event markers
- - Electrogram assessment
- FOLLOW-UP OF THE PATIENT WITH AN ICD
- Routine ICD follow-up
- - DFT testing as part of routine ICD follow-up
- Follow-up after ICD discharge
- Prognosis following ICD shocks
- Driving following ICD shocks
- FOLLOW-UP OF THE PATIENT WITH A CRT DEVICE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS