key: cord-1001381-0aj1031j authors: De Larochellière, Hugo; Champagne, Jean; Sarrazin, Jean‐François; Steinberg, Christian; Philippon, François; Roy, Karine; Molin, Franck; O'Hara, Gilles; Plourde, Benoit; Blier, Louis; Nault, Isabelle title: Findings of remote monitoring of implantable cardioverter defibrillators during the COVID‐19 pandemic date: 2020-10-26 journal: Pacing Clin Electrophysiol DOI: 10.1111/pace.14086 sha: 6e60ec8f4216e98d74713c477016b3e1e5ed0c43 doc_id: 1001381 cord_uid: 0aj1031j BACKGROUND: Monitoring of cardiac implantable electronic devices was highly impacted by the COVID‐19 pandemic considering the high volume of in‐person visits for regular follow‐up. Recent recommendations highlight the important role of remote monitoring to prevent exposure to the virus. This study compared remote monitoring of implantable cardioverter defibrillators (ICDs) in patients whose in‐person annual visit was substituted for a remote monitoring session with patients who were already scheduled for a remote monitoring session. METHODS: This was a cross‐sectional observational study of 329 consecutive patients between 20 March and 24 April 2020. Group 1 included 131 patients whose in‐person annual visit was substituted for a remote monitoring session. Group 2 included 198 patients who underwent a remote monitoring session as scheduled in their usual device follow‐up. The time interval since the last in‐person visit was 13.3 ± 3.2 months in group 1 and 5.9 ± 1.7 months in group 2 (P < .01). RESULTS: In group 1, 15 patients (11.5%) experienced a clinical event compared to 15 patients (7.6%) in group 2 (P = .25). Nineteen patients (14.5%) required a physician intervention in group 1 compared to 19 patients (9.6%) in group 2 (P = .22). Two patients (1.5%) in group 1 and four patients (2.0%) in group 2 required an early in‐person follow‐up visit during the pandemic (P > .99). CONCLUSION: Remote monitoring of ICDs is useful to identify clinical events and allows physicians to treat patients appropriately during the COVID‐19 pandemic regardless of the time interval since their last in‐person visit. It reduces significantly in‐person visit for regular follow‐up. gramming parameters, arrhythmia logbook with intracardiac electrograms, heart rhythm statistics and patient activity level. Alternate electrophysiologists revised these sessions without blinding of patients' groups. Clinical events were defined as clinically significant arrhythmia, antitachycardia pacing, shock, inappropriate antitachycardia pacing or shock, battery issues, and device/lead anomalies. Clinically significant arrhythmias were defined as new-onset atrial fibrillation/atrial flutter, sustained ventricular tachycardia, or any arrhythmia leading to a therapeutic change. Battery issues referred to low battery voltage or elective replacement indicator (ERI) requiring early follow-up or generator change, and device/lead anomalies referred to impedance, sensing, threshold, or LV pacing anomalies leading to early follow-up, programming change, or any intervention. Physicians' interventions were categorized as completely remote interventions, interventions requiring early in-person visit during the pandemic, and interventions postponed to the next in-person visit. Remote interventions included phone call to patient to enquire about symptoms, change in medication, recommendation to the treating physician concerning medication or investigations, and early remote monitoring follow-up. Interventions requiring early in-person visit included early in-person follow-up, planned generator change, or any other planned procedure. Visits or remote monitoring follow-up before the next scheduled visit was considered 'early' . Interventions postponed to the next in-person visit referred to suggested nonurgent programming changes. A total of 329 consecutive patients (76% male) with a mean age of 67 ± 12 years were included in the study ( Clinical events were reported in fifteen patients (11.5%) in group 1 and 15 patients (7.6%) in group 2 (P = .25) ( Interventions postponed to next visit 9 (6.9%) 7 (3.5%) P = .20 1 One patient in each group had two clinical events. sustained ventricular tachycardias. One patient had a successful antitachycardia pacing to convert a sustained ventricular tachycardia. Two ventricular tachycardia events were analysed as ventricular tachycardia below the detection threshold after revision of the intracardiac Electrogram (EGM) by the physician. All battery issues consisted of low battery voltages without ERI alert encountered. Five device/lead anomalies were identified: two were ventricular farfield on the atrial lead, one was atrial noise without evidence of lead fracture or any lead integrity concern, one was low LV pacing percentage, and one was ineffective ventricular autocapture threshold (Table 3) . In group 2, eight clinically significant arrhythmias occurred; all were atrial arrhythmias (new-onset atrial fibrillation, atrial flutter, and atrial tachycardia). One patient had an inappropriate antitachycardia pacing in response to an atrial tachycardia. Five battery issues consisting of low battery voltages were reported, requiring early follow-up. Two lead anomalies were noted: one was a transient high left ventricular lead impedance, while the other consisted of persistent high atrial and ventricular thresholds (Table 3 ). Nineteen patients in each group required a physician intervention (14.5% in group 1 vs 9.6% in group 2, P = .22). All interventions were in response to clinical events identified by remote monitoring. Interventions were performed remotely in eight patients in both groups (6.1% in group 1 vs 4.0% in group 2, P = .14). Early in-person visit was organized in two patients in group 1 and in four patients in group 2 (1.5% vs 2.0%, P > .99). Nine patients in group 1 and seven patients in group 2 had an intervention postponed to their next in-person visit, all nonurgent programming changes (6.9% vs 3.5%, P = .20) (Table 2) . Overall, 90% of interventions in group 1 and 80% in group 2 were managed without requiring an in-person visit (Figure 1 ). Physicians' interventions in each group are listed in Device/lead anomalies, n (%) 5 (3.8%) 2 (1.0%) P = .12 Abbreviation: ERI, elective replacement indicator. in primary prevention by current guidelines. In group 2, elective cardioversion was organized during the pandemic for one patient with persistent atrial flutter and in another patient with persistent atrial fibrillation. Atrioventricular node ablation was planned for one patient with rapid atrial fibrillation and intolerance to medication. Finally, one patient was scheduled for lead extraction (debulking), reimplantation, and generator change due to low battery voltage and elevated atrial and ventricular thresholds. Nonurgent changes of device programming were recommended for the next in-person visit in five patients in both groups to update ventricular tachycardia detection zones as recommended in primary prevention by current guidelines. In group 1, a suggestion was made in one patient to lower ventricular tachycardia detection zone to ensure good ventricular tachycardia detection. It was suggested to prolong post ventricular atrial blanking (PVAB) in one patient to reduce farfield on the atrial lead and in another patient, a suggestion to enable AV search mode to reduce ventricular pacing was made. Finally, it was suggested to disable ventricular autocapture in one patient due to device incapacity to perform ventricular threshold. In group 2, a suggestion was made in one patient to modify antitachycardia therapies in the ventricular tachycardia zone. It was also suggested in one patient to modify pacing mode since he developed permanent atrial fibrillation. An inappropriate antitachycardia pacing was reported in a patient with recurrent atrial tachycardias in group 2. No intervention was made since subsequent atrial tachycardias were well discriminated by the device. This is the first study to report real world data on remote monitoring during the COVID-19 pandemic. In 131 patients whose in-person Phone call to patient, n (%) 3 (2.3%) 6 (3.0%) P > .99 Change in medication, n (%) 1 (0.8%) 3 (1.5%) P > .99 Recommendation to the primary physician, n (%) 4 (3.0%) 1 (0.5%) P = .08 Early in-patient follow-up, n (%) 2 (1.5%) 0 P = .16 Early remote device monitoring follow-up, n (%) 2 (1.5%) 4 (2.0%) P > .99 Planned device replacement, n (%) 0 1 (0.5%) P > .99 Planned procedure (ablation, cardioversion), n (%) 0 3 (1.5%) P = .28 Suggested programming change at the next visit, n (%) 10 (7.6%) 7 (3.5%) P = .13 F I G U R E 2 Central illustration. Clinical events and physicians' interventions during remote monitoring of implantable cardioverter defibrillators in the COVID-19 pandemic. Group 1 shows patients whose in-person annual visit was substituted for a remote monitoring session; group 2 shows patients who underwent remote monitoring sessions as scheduled in their usual device follow-up. 1 While remote monitoring is a class 1 recommendation for routine follow-up of CIEDs, an annual in-person visit is still proposed due to the lack of evidence on safety with longer interval between visits. 4 Thus, recommendations during the pandemic in favour of remote monitoring for every patient irrespective of the delay since their last in-person visit are only supported by expert consensus. 1 The low burden of clinical events was observed in our study, and the relevant physicians' interventions reassured us on the management of our patients with exclusive remote monitoring during the pandemic. Also, the absence of significant difference between groups suggests that remote monitoring with longer in-person visit interval is comparable to the Guidance for cardiac electrophysiology during the coronavirus (COVID-19) pandemic from the Heart Rhythm Society COVID-19 task force; electrophysiology section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology HRS/EHRA/APHRS/ LAHRS/ACC/AHA worldwide practice update for telehealth and arrhythmia monitoring during and after a pandemic Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic HRS expert consensus statement on remote interrogation and monitoring for cardiovascular implantable electronic devices The relationship between level of adherence to automatic wireless remote monitoring and survival in pacemaker and defibrillator patients Investigators T. 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