Jan 12, 2021
Paul J. Wang:
Welcome to the monthly podcast, On the Beat for Circulation, Arrhythmia and Electrophysiology. I'm Dr. Paul Wang, editor-in-chief with some of the key highlights from this month's issue.
In our first paper, Bruce Wilkoff and associates evaluated antibacterial envelope cost effectiveness compared to standard of care infection prevention strategies in the US healthcare system. Decision tree model was used to compare costs and outcomes of the antimicrobial envelope used adjunctive to standard of care infection prevention versus standard of care alone over a lifelong time horizon. The analysis was performed from an integrated payer provider network perspective. Infection rates, antimicrobial envelope effectiveness, infection treatment costs and patterns, infection related mortality and utility estimates were obtained from the WRAP-IT study. Life expectancy and long-term costs associated with device replacement, follow-up, and healthcare utilization were sourced from the literature. Costs and quality life adjusted years were discounted at 3%. An upper willingness-to-pay threshold of $100,000 per quality adjusted life year was used to determine cost-effectiveness in alignment with the American College of Cardiology and American Heart Association practice guidelines and as supported by the World Health Organization and contemporary literature. The base case incremental cost-effectiveness ratio (ICER) of the antibacterial envelope compared with standard-of-care was $112,603 per quality-adjusted life year. The ICER remained lower than the threshold in 74% of iterations in the probabilistic sensitivity analysis and was most sensitive to the following model inputs: infection-related mortality, life expectancy, and infection cost. The authors concluded that the absorbable antibacterial envelope was associated with a cost-effectiveness ratio below contemporary benchmarks in the WRAP-IT patient population, suggesting that the envelope provides value for the US healthcare system by reducing the incidence of CIED infection.
In our next paper, Peter Loh and associates in this study aim to investigate the feasibility and safety of single pulse irreversible electroporation (IRE) pulmonary vein (PV) isolation in patients with atrial fibrillation (AF). Ten patients with symptomatic paroxysmal or persistent AF underwent single pulse IRE pulmonary vein isolation under general anesthesia. Three-dimensional reconstruction and electroanatomical voltage mapping of the left atrium and pulmonary veins were performed using a conventional circular mapping catheter. Pulmonary vein isolation was performed by delivering nonarcing, nonbarotraumatic 6 ms, 200 Joule direct current IRE applications via a custom nondeflectable 14-polar circular IRE ablation catheter with a variable hoop diameter (16–27 millimeters). A deflectable sheath was used to maneuver the ablation catheter. A minimum of 2 IRE applications with slightly different catheter positions were delivered per vein to achieve circular tissue contact, even if pulmonary vein potentials were abolished after the first application. Bidirectional pulmonary vein isolation was confirmed with the circular mapping catheter and a post ablation voltage map. After a 30-minute waiting period, adenosine testing was used to reveal dormant pulmonary vein conduction. All 40 pulmonary veins could be successfully isolated with a mean of 2.4 IRE applications per pulmonary vein. Mean delivery peak voltage and peak current were 2154 volts and 33.9 amperes. No pulmonary vein reconnections occurred during the waiting period and adenosine testing. No periprocedural complications were observed. The authors concluded that in 10 patients in this first in-human study, acute bidirectional electrical pulmonary vein isolation could be achieved safely using single pulse IRE ablation.
In our next paper, Christian Sohns and associates studied the relationship between left ventricular ejection fraction (LVEF) New York Heart Association (NYHA) class on presentation and the end points of mortality and heart failure (HF) admissions in the CASTLE-AF study population. Furthermore, predictors for LVEF improvement were examined. The CASTLE-AF patients with coexisting heart failure and AF (n=363) were randomized in a multicenter prospective controlled fashion to ablation (n=179) versus pharmacological therapy (n=184). Left ventricular function in NYHA class were assessed at baseline after randomization and at each follow-up visit. In the ablation arm, a significantly higher number of patients experienced an improvement in their LVEF to greater than 35% at the end of the study (odds ratio, 2.17; P<0.001). Compared with the pharmacological therapy arm, both ablation patient groups were severe, less than 20% or moderate/severe, greater than 20% and less than 35% baseline LVEF had a significantly lower number of composite end points (hazard ratio 0.60; P=0.006), all-cause mortality (hazard radio 0.54; P=0.019), and cardiovascular hospitalizations (hazard ratio 0.66; P=0.017). In the ablation group, NYHA I/II patients at the time of treatment had the strongest improvement in clinical outcomes (primary end point: hazard ratio 0.43; P<0.001; mortality: hazard ratio 0.30; P=0.001). The authors concluded that compared with pharmacological treatment, AF ablation was associated with a significant improvement in LVEF, independent from the severity of left ventricular dysfunction, indicating that AF ablation should be performed at early stages of a patient’s heart failure symptoms.
In the next paper, Milena Leo and associates conducted a randomized study to compare risk of esophageal heating and acute procedure success of different LSI-guided ablation protocols combining higher or lower radiofrequency power or different target LSI values. Eighty consecutive patients were prospectively enrolled and randomized to one of 4 combinations of radiofrequency (RF) power and target LSI for ablation of the left atrial posterior wall (that is 20 watts LSI 4, 20 watts LSI 5, 40 watts LSI 4, and 40 watts LSI 5). The primary end point of the study was the occurrence and number of esophageal temperature alerts (ETAs) per patient during ablation. Acute indicators of procedure success were considered as secondary end points. Long-term follow-up data was also collected for all patients. Esophageal temperature alerts (ETAs) occurred in a similar proportion of patients in all groups. Significantly, shorter RF durations was required to achieve the target LSI in the 40 watt groups. Less than 50% of the RF lesions reached the target LSI of 5 when using 20 watts despite a longer RF duration. A lower rate of first-pass pulmonary vein isolation and a higher rate of acute pulmonary vein reconnection were recorded in the group 20 watts LSI 5. A lower AF recurrence rate was observed in the 40 watt groups compared with the 20 watts groups at 29 months follow-up. The authors concluded that when guided by LSI, posterior wall ablation with 40 watts is associated with a similar rate of ETAs and a lower AF recurrence rate at follow-up if compared with 20 watts. These data will provide a basis to plan future randomized trials.
In the next paper, Shohreh Honarbakhsh and associates in this study aimed to determine whether STAR mapping using sequential recordings from conventional pulmonary vein mapping catheters could achieve similar results. Patients with persistent AF less than 2 years were included. Following pulmonary vein isolation (PVI), AF drivers were identified on sequential STAR maps created with PentaRay, IntellaMap Orion, or Advisor HD Grid catheters. Patients had a minimum of 10 multipolar recordings of 30 seconds each. These were processed in real-time and AF drivers were targeted with ablation. An ablation response was determined as AF termination or cycle length slowing greater than or equal to 30 milliseconds. Thirty patients were included, 62.4 years old, AF duration 14.1 months, of which 3 had AF terminated on pulmonary vein isolation, leaving 27 patients that underwent STAR-guided AF driver ablation. Eighty-three potential AF drivers were identified 3.1 per patient of which 70 were targeted with ablation (2.6 per patient). An ablation response was seen at 54 AFDs, 77.1% of AF drivers with 21 AF termination and 33 cycle length slowing and occurred in all 27 patients. No complications occurred. At 17.3 months, 22 out of 27 or 81.5% of patients undergoing STAR-guided ablation were free from atrial fibrillation, atrial tachycardia off antiarrhythmic drugs. The authors concluded that STAR-guided AF driver ablation through sequential mapping with a multipolar catheter effectively achieved an ablation response in all patients. AF termination in a majority of patients, with a high freedom from atrial fibrillation atrial tachycardia off antiarrhythmic drugs at long-term follow-up.
In our next paper, Takashi Kaneshiro and associates sought to evaluate the characteristics of esophageal injuries in atrial fibrillation (AF) ablation using high power short duration setting. After exclusion of 5 patients with their esophagus at the right portion of left atrium and 21 patients with additional ablations such as box isolation and/or low voltage area in left atrium posterior wall, 271 consecutive patients, 62 years, 56 women, who underwent pulmonary vein isolation (PVI) by radiofrequency catheter ablation were analyzed. In the 101 patients, high power short duration setting at 45 to 50 watts with an Ablation Index module was used. In the remaining 170 patients, before introduction of the high power short duration setting, a conventional power setting of 20 to 30 watts with contact force monitoring was used, that is the conventional group. They performed esophagogastroduodenoscopy after pulmonary vein isolation in all patients and investigated the incidence and characteristics of esophageal thermal injury. Although the incidence of esophageal thermal injury was significantly higher in the high power short duration group compared with the conventional group (37% versus 22%, P=0.011), the prevalence of esophageal lesions did not differ between the groups (7% versus 8%). Multivariate logistic regression analysis revealed that the use of the high power short duration setting (odds ratio 6.09, P<0.001), and the parameters that suggest anatomic proximity surrounding the esophagus, were independent predictors of esophageal thermal injury. However, the majority of esophageal thermal injury in the high power short duration group was gastric hypomotility, and the thermal injury was limited to the shallow layer of the periesophageal wall using the high power short duration setting. The authors concluded that although the use of the high power short duration setting was a strong predictor of esophageal thermal injury, it could avoid deeper thermal injuries that reach the esophageal mucosal layer.
In our next paper, Prasongchai Sattayaprasert, Sunil Vasireddi and associates hypothesize that in disease the inflammatory secretome of cardiac human mesenchymal stem cells remodels and can regulate arrhythmia substrates. Human cardiac mesenchymal stem cells were isolated from patients with or without heart failure from tissue attached to extracted device leads and from samples taken from explanted donor hearts. Failing human cardiac mesenchymal stem cells or nonfailing human cardiac mesenchymal stem cells were cocultured with normal human myocytes derived from induced pluripotent stem cells. Using fluorescent indicators, action potential duration (APD), calcium alternans, and spontaneous calcium release, incidence was determined. Failing and nonfailing human cardiac mesenchymal stem cells from both sources exhibited similar trilineage differentiation potential and cell surface marker expression as bone marrow human cardiac mesenchymal stem cells. Compared to nonfailing human cardiac mesenchymal stem cells, failing human cardiac mesenchymal stem cells prolonged action potential duration by 24% (P<0.001, n=15), increased calcium alternans by 300% (P<0.001, n=18), and promoted spontaneous calcium release (SCR) activity (n=14, P<0.01) in human cardiac mesenchymal cells. Failing human cardiac mesenchymal stem cells exhibited increased secretion of inflammatory cytokines IL-1β (98%, P<0.0001) and interleukin-6 (460%, P<0.02) compared with nonfailing human cardiac mesenchymal stem cells. IL-1β or IL-6 in the absence of human cardiac mesenchymal stem cells prolonged action potential duration but only IL-6 increased calcium alternans and promoted spontaneous calcium release activity in human cardiac myocytes, replicating the effects of failing human cardiac mesenchymal stem cells. In contrast, nonfailing human cardiac mesenchymal stem cells prevented calcium alternans in human cardiac myocytes during oxidative stress. Finally, nonfailing human mesenchymal stem cells exhibited greater than 25 times secretion of IGF-1 compared to failing human mesenchymal stem cells. Importantly, IGF-1 supplementation or anti–IL-6 treatment rescued the arrhythmia substrates induced by failing human mesenchymal stem cells. Conclusions: The authors identified device leads as a potential novel source of cardiac human cardiac mesenchymal stem cells. Their findings show that cardiac human cardiac mesenchymal stem cells can regulate arrhythmia substrates by remodeling their secretome in disease. Importantly, therapy inhibiting anti–IL-6 or mimicking IGF-1 the cardiac human mesenchymal stem cells secretome can rescue arrhythmia substrates.
In the next paper, Atsushi Suzuki and associates conducted this study to use scanned proton beams for ablation of cardiac tissue, investigate electrophysiological outcomes, and characterize the process of lesion formation in a porcine model using particle therapy. Twenty-five animals received scanned proton beam irradiation. ECG-gated computed tomography (CT) scans were acquired at end-expiration breath hold. Structures, the atrioventricular junction (AV junction), or left ventricular myocardium (LV), and organs at risk were contoured. Doses of 30, 40, and 55 gray were delivered during expiration to the AV junction (n=5) and left ventricular myocardium (n=20) of intact animals. In this study, procedural success was tracked by pacemaker interrogation in the AV junction group, time-course magnetic resonance imaging (MR) in the left ventricular group, and correlation of lesion outcomes displayed in gross and microscopic pathology. Protein extraction (active caspase-3) was performed to investigate tissue apoptosis. Doses of 40 and 55 gray caused slowing and interruption of cardiac impulse propagation at the AV junction. In 40 left ventricular irradiated targets, all lesions were identified on magnetic resonance imaging after 12 weeks, being consistent with outcomes from gross pathology. In the majority of cases, lesion size plateaued between 12 and 16 weeks. Active caspase-3 was seen in lesions 12 and 16 weeks after irradiation but not after 20 weeks. . The authors concluded that scanned proton beams can be used as a tool for catheter-free ablation, and time-course of tissue apoptosis was consistent with lesion maturation.
In the next paper, Philippe Maury and associates sought to study surface ECG waveforms and effect of ablation in long-lasting ventricular fibrillation (VF) in patients with left ventricular assist devices. Continuous 12-lead ECG of 5 episodes of long-lasting VF occurring in 3 patients with left ventricular assist devices were analyzed. Spectral analysis (dominant frequency or DF) and quantification of waveform amplitude regularity (URI), and complexity (NDI) were performed over a median of 24 minutes of VF. Radiofrequency (RF) ablation was performed during VF in 2 patients. There was a significant increase in dominant frequency between VF onset and termination but none of the other parameters significantly changed. Some VF parameters varied from patient to patient and from lead to lead. DF decreased after RF ablation in both cases and VF terminated spontaneously shortly after ablation in one case. The previously incessant VFs in these 2 patients did not recur afterward. The authors concluded that VF rate increases over time with left ventricular assist devices and is lowered by ablation. Long-lasting VF may be modified or even terminated by ablation.
In the next paper, Taisuke Ishikawa and associates aim to determine the prevalence of nonsyndromic forms of emerinopathy, which may underlie genetically undefined isolated cardiac conduction disturbance, and the etiology of thromboembolic complications associated with Emery-Dreifuss muscular dystrophy (EMD) mutation. Targeted exon sequencing was performed in 87 probands with familial sick sinus syndrome (n=36) and a progressive cardiac conduction defect (n=51). The authors identified 3 X-linked recessive EMD mutations (start-loss, splicing, missense) in families with cardiac conduction disease. All 3 probands shared a common clinical phenotype of progressive atrial arrhythmias that ultimately resulted in atrial standstill associated with left ventricular noncompaction, but they lacked early contractures and progressive muscle wasting and weakness characteristic of Emery-Dreifuss muscular dystrophy. Because the association of left ventricular noncompaction and Emery-Dreifuss muscular dystrophy has never been reported, they further genetically screened 102 left ventricular noncompaction patients and found a frameshift EMD mutation in a boy with progressive atrial standstill and left ventricular noncompaction without complications of muscular dystrophy. All six male EMD mutation carriers of 4 families underwent pacemaker or defibrillator implantation, whereas two female carriers were asymptomatic. Notably, a strong family history of stroke was observed in these patients was probably due to the increased risk of thromboembolism attributed to both atrial standstill and left ventricular noncompaction. The authors concluded that cardiac emerinopathy is a novel nonsyndromic X-linked progressive atrial standstill associated with left ventricular noncompaction and increased risk of thromboembolism.
In our next paper, Min Gu, Hongxia Niu, Yiran Hu and associates in their study aim to compare his bundle pacing (HBP) implantation with a novel imaging technique versus the standard implantation technique. This study included 50 patients with standard pacing indications randomized to HBP with visualization of the tricuspid valve annulus (n=25, the visualization group) or with the standard method (n=25, the control group). In the visualization group, the tricuspid valve annulus (TVA) was imaged by contrast injection in the right ventricle using fluoroscopy. The site of HBP was identified in relationship to the tricuspid septal leaflet and interventricular septum. Permanent his bundle pacing was successful in 92% in the visualization group and 88% in the control group. The fluoroscopic time in his bundle lead placement was significantly shorter in the visualization group (7.1 minutes) compared to control group (10.1 minutes, P=0.03). Total procedural and fluoroscopic times were also significantly shorter in the visualization group (91 minutes and 9.6 minutes) than the control group (104 minutes and 12.7 minutes, P=0.01 and P=0.04, respectively). There was no significant difference in capture threshold between the groups. In the visualization group, there was a quantitative association between the his bundle pacing site and the tricuspid valve annulus. The authors concluded that visualization technique shortens the procedural and fluoroscopic times for his bundle implantation. Moreover, anatomic localization of his bundle pacing sites is strongly associated with physiological characteristics of pacing, which can help optimize lead placement.
In our next paper, Ethan Rowin and associates study cohort comprises 207 consecutive hypertrophic cardiomyopathy (HCM) patients with primary prevention implantable cardioverter defribillators (ICDs) implanted prior to 2008 and followed for 10 years or more (mean 12 years; range to 31). Patients were 38 years at implant and 45 or 21% experienced appropriate interventions terminating ventricular tachycardia (VT) or ventricular fibrillation (VF). The majority of ICD discharges occurred 5 years or more after implant (29 patients or 64%), including 10 or more years in 16 patients (36%). Initial device therapy increased in frequency from 2.3% of patients at less than 1 year to 8.5% of patients at 10 years or more post implant (P=0.005). Inappropriate ICD shocks in 39 patients occurred most commonly less than 5 years after implant (54%) and decreased in frequency with increasing time from implant from 9.7% of patients at less than 5 years to 3.8% at 10 years or more, P=0.02). Other major device complications including infection and/or lead fractures and dislodgement occurred in 27 patients (12%) but did not increase in frequency over follow-up (P=0.47). There were no arrhythmic sudden death events among the 217 ICD patients. The authors concluded that HCM primary prevention ICD therapy increased progressively over time after implant including substantial proportion with prolonged periods of device dormancy including two thirds of patients five years or more and 10 years or more in one-third. Frequency of inappropriate shocks decreased over follow-up, likely reflecting changes in device programming, while occurrence of device complications, such as lead fractures or infection, did not increase over follow-up.
In the next paper, Alexander Zolotarev, Dmitry Dylov, Vadim Fedorov and associates hypothesize that application of machine learning (ML) to electrogram frequency spectra may accurately automate driver detection by multielectrode mapping (MEM) and add some objectivity to the interpretation of MEM findings. Temporally and spatially stable single atrial fibrillation (AF) drivers were mapped simultaneously in explanted human atria (n=11) by subsurface near-infrared optical mapping 0.2 mm2 resolution and 64-electrode multielectrode (higher density [HD] or lower density [LD] with 3 mm2 and 9 mm2 resolution, respectively). Unipolar MEM and near infrared optical mapping recordings (NIOM) were processed by Fourier transform analysis into 28,407 total Fourier spectra. Thirty-five features of ML were extracted from each Fourier spectrum. Targeted driver ablation and NIOM activation maps efficiently defined the center and periphery of AF driver preferential tracks and provided validated classifications for driver versus nondriver electrodes in MEM arrays. Compared with analysis of single electrogram frequency features, averaging the features from each surrounding 8 electrodes neighborhood, significantly improved classification of AF driver electrograms. The classification metrics increased when less strict annotation, including driver periphery electrodes, were added to driver center annotation. Notably, f1-score for the binary classification of HD catheter data set was significantly higher than that of the LD catheter (0.81 versus 0.66, p<0.05). The trained algorithm correctly identified 86% of driver regions with HD but only 80% with LD MEM arrays (81% for low density and high density arrays together). The authors concluded that ML model pretrained on Fourier spectrum features allows efficient classification of electrograms recordings as AF driver and non-AF driver compared to NIOM gold-standard. Further application of NIOM-validated ML approach may improve the accuracy of AF driver detection for targeted AF ablation in treatment in patients.
In our next paper, Deborah Friedman and associates provide data regarding any potential fetal/neonatal cardiotoxicity, leveraged an opportunity that is unique in which neonatal electrocardiograms (ECGs) and hydroxychloroquine (HCQ) blood levels were available in a recently completed study evaluating the efficacy of HCQ 400 mg daily to prevent the recurrence of congenital heart block associated with anti-SSA/Ro antibodies. Forty-five ECGs were available for QTc measurements, and levels of HCQ were assessed during each trimester of pregnancy and in the cord blood, providing unambiguous assurance of drug exposure. Overall, there was no correlation between cord blood levels of HCQ and the neonatal QTc (R=0.02, P=0.86) or the mean of HCQ values obtained through each individual pregnancy and the QTc (R=0.04, P=0.80). In total 5 (11%) neonates had prolongation of the QTc>2 standard deviations above historical healthy controls (2 markedly and 3 marginally) but ECGs were otherwise normal. The authors concluded that in aggregate, these data provide reassurance that the maternal use of HCQ is associated with a low incidence of infant QTc prolongation. However, if included in clinical COVID-19 studies, early postnatal ECGs should be considered.
In a research letter, James Hummel and associates sought to examine the time course of QTc prolongation in their database of COVID-19 patients treated with hydroxychloroquine. This study demonstrates that QTc prolongation in hospitalized patients with COVID-19 infection is common and can occur very late, well after the initiation of therapy. Vigilance to minimize multiple concurrent drugs and careful monitoring of renal function and cardiac rhythm are required for hospitalized COVID-19 patients. This, however, should not be extrapolated to non-COVID-19 patients with no comorbidities and who are not using concurrent QT-prolonging medications.
In a research letter, Melissa Moey, Prasanna Sengodan and associates aim to characterize the electrocardiographic characteristics and incidents of patients admitted with SARS-CoV-2. Their study had several limitations. It was a single study observational retrostudy of a small population of patients with SARS-CoV-2 without a comparison group. Data are limited to index hospital admission followup data to see whether EKG electrocardiogram intervals revert to baseline following recovery from infection are lacking. Approximately 70% of patients in their study received hydroxychloroquine (HCQ) and/or azithromycin. However, the latest data have shown ineffectiveness and possible harm with these drugs in treatment of SAR-CoV-2. QRS widening has been previously documented in critically ill intensive care unit ICU patients. Hence, this finding may not be specific to SARS-CoV-2. Additional prospective studies with a larger population and longer follow up period are recommended to validate and further elucidate their findings.
In a research letter, Hikmet Yorgun and associates aim to report their experience in patients with mechanical aortic mitral prosthesis who underwent endocardial ventricular tachycardia (VT) ablation as an index or redo procedure. The author's findings expand the literature regarding the safety and efficacy of transapical approach with limited left ventricular (LV) access, and emphasize the importance of close collaboration between cardiac electrophysiologist and surgeons during the procedure. Limitations include small sample size and short follow-up duration, as well as lack of pre-procedural magnetic resonance imaging, mainly due to the presence of implantable cardioverter defibrillator.
In a research letter, Bradley Peltzer and associates sought to define the incidence and risk factors for arrhythmias among patients hospitalized with COVID-19 and to evaluate associated arrhythmias with outcomes, including mortality. The authors studied all patients with COVID-19, who were admitted consecutively to New York Presbyterian Weill Cornell medicine and New York-Presbyterian Lower Manhattan hospital between March 3rd and April 6th, 2020. The primary outcome of the study was a 30 day all cause mortality. Arrhythmias were identified by review electrocardiograms and telemetry data obtained during hospitalization. There were several limitations to this study. This was a retrospective study with data obtained via chart abstraction, which may be subject to error or misinterpretation. Variation telemetry monitoring systems across hospital units may have led to possible underdetection of arrhythmias in some cases. Because this study focuses on hospital outcomes. Out of hospital deaths following discharge of COVID-19 were not examined. In this analysis of rhythmic complications of over a thousand consecutive patients hospitalized with COVID-19, atrial fibrillation flutter was seen in over 15% and more than 60% of these occurring in patients without any prior history of atrial fibrillation while ventricular tachycardia ventricular fibrillation occurred in less than 3% of patients. Age, male, sex and hypoxia and presentation were independently associated with the occurrence of arrhythmia. The presence of arrhythmia is tracked with markers of disease severity and elevated markers of myocardial injury, inflammation, and fibrinolysis. While there are likely myriad factors that lead to COVID-19 associated arrhythmias, their findings suggests that arrhythmias may predominantly be a marker of COVID-19 severity. Further studies to elucidate the mechanism COVID-19 associated arrhythmias and assess whether treatments targeting SARS-CoV-2 infection and its associated inflammatory response can reduce arrhythmia occurrence or warrant.
In a perspective, Bryce Alexander and Adrian Baranchuk discuss that in the current area of medicine, many patients with terminal illnesses have preexisting cardiac disease that required implantable cardioverter (ICD) placement. The world is currently in the midst of an unprecedented COVID-19 pandemic. While data are still being collected and analyzed, there appears to be significantly increased mortality in older and more comorbid patients with current process of deactivation, the requirement for the physical presence of the electrophysiology (EP) team with the patient may disrupt the dying process and may serve as a vector for transmission of infection back into the community or hospital. Most modern ICDs currently have the ability of unidirectional communication through remote monitoring network. These allow for followup of patients through interrogation device independent of a physical program. Currently there is no capacity for bi-directional remote communication of a program or implanted device. The potential perceived barrier to implementation to strategies, concerns related to cybersecurity of implantable electronic devices (CIECD). While cyber security threats from any network connected medical device cannot be eliminated, the benefits of the features provided may outweigh the possible dangers. In the case of remote deactivation of ICDs, there are several important benefits. For patients, benefits will include preservation of the dying process without outside interruption, as well as possible faster deactivation of the ICD eliminating unwanted shocks. For healthcare providers, this approach could eliminate barriers to ICDs deactivated early in terminal patients and help to develop a structured approach to routine deactivation. On a system level, this approach may reduce costs and allow for less utilization of hospital or clinic space. Given the benefits of remote monitoring and the increased demand to transform practice into tele-health, the authors propose a stepwise approach to remote programming capability, starting with remote deactivation. If able to be accomplished, the inactivation of ICD's at Distance for Dignity of Dying project, the 4D project, will allow for a less interrupted dying process in the palliative patient. And it reduced the risk of infection transmission in the setting of ongoing or future pandemic. If this approach were to prove feasible, it could potentially open the door for future applications of remote reprogramming, including, but not limited to: 1) allowing increased input in the case of loss of capture, 2) adjusting sensitivity, 3) reprogramming to the MRI magnetic resonance imaging mode, 4) asynchronous pacing, tachy detection off prior to electric cardiac response, and 5) lower rate cutoff for slow ventricular tachycardia.
That's it for this month. We hope that you'll find the journal to be the go-to place for everyone interested in the field. See you next time. This program is copyright American Heart Association, 2020.