Novel findings of an old algorithm: PVC response "Atrial Pace'' initiates atrial arrhythmias in Abbott ICD and CRT-D devices.

BACKGROUND: Many algorithms have been developed to ensure the safety and accuracy of cardiac implantable electric devices (CIED). A specific algorithm designed to prevent pacemaker induced tachycardia (PMT) after a premature ventricular complex (PVC response) is available in all Abbott (former St. Jude Medical) CIED. However, a few case reports suggest that this algorithm may be proarrhythmic when programmed to Atrial Pace (A-Pace on PVC). METHODS: We analyzed the data of all (n = 333) Abbot implantable cardioverter defibrillator (ICD) and cardiac resynchronization defibrillator (CRT-D) devices followed remote using the Merlin.net Patient Care Network in our institute in 2020. Status of the PVC response algorithm A-Pace on PVC or Off was collected, and all atrial mode switch (AMS) episodes longer than 30 s were thoroughly evaluated. Data on clinical characteristics of the patients was collect from the electronic patient records. RESULTS: A total of 173 patients had A-Pace on PVC and twenty-five of them (14%) had at least one atrial high rate episode (AHRE) >30 s (AHRE) triggered by the action of this algorithm. The median PVC count was higher in patients who had algorithm triggered AHRE than in those with no algorithm-triggered AHRE (1.7% [IQR 0-3.2] vs. 0% [IQR 0-1.1], p < .0001). The major clinical characteristics were comparable in the two groups. CONCLUSION: The A-Pace on PVC setting was frequently used in our patients. Our study shows that a considerable number of patients had at least one AHRE triggered by the algorithm. The use of this algorithm should be carefully reconsidered.

Real-life data on the workload of cardiac implantable electronic device remote monitoring in a large tertiary center.

BACKGROUND: Cardiac implantable electronic devices (CIED) and implantable loop recorders (ILR) are increasingly monitored by systems allowing remote transmission of data from the patient to the hospital. Remote monitoring (RM) has been shown to increase patient satisfaction and safety. However, real-life data on the number and causes of the RM transmissions, and actions initiated by them are scarce. METHODS: A total of 3446 patients with CIED and 92 patients with ILR were included in the study. Data on the number of alerts, scheduled and patient-initiated transmissions as well as the causes and actions initiated by the transmissions were systematically collected from March 1 to December 30, 2022. The data was subdivided by the device type. RESULTS: During the study period 7087 remote CIED and 1212 ILR transmissions were generated, (0.2 and 1.3 per patient per month), respectively. Of these transmissions 49% (4084) were automatic alerts, and 29% (2434) and 22% (1781) were scheduled and patient initiated, respectively. Most of the CIED alerts (73%) and the scheduled transmissions (90%) were nonactionable, and only 7% and 5% led to in-office follow-up, respectively. Off all ILR alerts (1011) PM implantation was scheduled to 11 patients. CONCLUSIONS: RM transmissions were common, but most of them were nonactionable. These real-life findings indicate that detailed analysis of the causes of the RM transmissions is important for optimization of the remote follow-up workload.

Background of fatal pulmonary embolism: an analysis of all diagnosed fatal pulmonary embolism in 2015-2018 from Hospital District of Helsinki and Uusimaa.

Pulmonary embolism (PE) mortality has decreased in the last decades but acute PE is still associated with significant fatality. Specific information on fatal PE patients could guide how to efficiently improve PE management but to date this information has been scarce. All the individuals with PE defined as an immediate or underlying cause of death were collected from the death certificate archive of the Hospital District of Helsinki and Uusimaa, Finland, including approximately 1.7 million inhabitants (2015-2018). Crude and age-adjusted mortality rates and proportional mortality were calculated, and the distribution of comorbidities at death and death location (in-hospital, palliative care, or out-of-hospital) was analyzed. In total, 451 individuals with fatal PE were identified (238 females) with a mean age of 72 years (SD 13.5 year). Most of the fatal PEs (n = 264, 54.5%) occurred out-of-hospital and surprisingly, 70 (26.5%) of these individuals s had a history of mental illness or substance abuse. The out-of-hospital resuscitation was attempted in 108 (40.1%) individuals but only 7 (6.5%) received thrombolysis during resuscitation. Fatal PE occurred during hospitalization in 98 individuals and in 54 (55.1%), the diagnosis was only made postmortem. Majority of the fatal PEs occurred out-of-hospital and were diagnosed postmortem whereas only small proportion of deaths occurred to in-hospital PE patients. The earlier diagnosis of PE, which may be accomplished by raising the general awareness of PE, is necessary to prevent these sudden deaths of whom many occurred to individuals with history of mental illnesses or substance abuse.

Evaluation of the impact of changes in the autopsy rate on mortality trend of pulmonary embolism, Finland, 1996-2017.

Pulmonary embolism is listed as a cause of death in fewer and fewer cases in the twenty-first century. Autopsies reveal undiagnosed pulmonary embolism at a significant rate, but fewer and fewer autopsies are being performed. It could be that deaths from pulmonary embolism are not decreasing, but are increasingly missed because of decreasing autopsy rate. Population-based registry data of all individuals with pulmonary embolism related death from the Finnish death certificate archive from 1996 to 2017 were collected. The pulmonary embolism mortality trend was analysed with linear regression and the association of pulmonary embolism mortality with the number of autopsies was also assessed. Deaths with pulmonary embolism as immediate, underlying and contributory cause of death were not only included, but also analysed separately. In addition, the estimated pulmonary embolism mortality when presumptively missed pulmonary embolisms are taken into account is presented. During 1996-2017, the pulmonary embolism related mortality rate decreased 28% from 25: 100 000 to 18: 100 000, if all pulmonary embolism deaths were analysed, and 51% from 21: 100 000 to 11: 100 000 if contributory pulmonary embolism deaths were excluded. From 1996 to 2009, autopsy rate in the population remained unchanged, but declined thereafter. In 1996, autopsy rate was 31.1% (15 319/49167) and in 2017 20.1% (10830/53 923). Our results suggest that there has been real improvement in the prevention of death from pulmonary embolism in Finland in the twenty-first century. However, due to the decreasing autopsy rate, the pulmonary embolism mortality trend after 2010 should be interpreted more carefully.

Pulmonary embolism location is associated with the co-existence of the deep venous thrombosis.

: Multiple studies have shown that in approximately half of individuals with pulmonary embolism (PE), the deep venous thrombosis (DVT) is not evident at the moment of PE diagnosis. The underlying factors and the origin of PE in these patients are not completely understood: missed DVT, embolization of DVT in its entirety, or de-novo PE being possible explanations. The aim of this study was to evaluate the differences in PE patient with or without co-existing DVT. Sixty-three consecutive PE patients were included. Whole leg bilateral Doppler compression ultrasound was performed to all patients. The PE location and extension, C-reactive protein, platelet count, hemostatic markers FV, FVIII, FXIIIa, Fibrinogen, von Willebrand factor antigen, thrombomodulin were assessed. Thorough clinical assessment including echocardiography and pulmonary function tests were performed upon arrival and seven months later. The mean age of the patients was 57 years (SD 17.3) and 33 (52%) were women. Thirty-one patients (49.2%) had co-existing DVT. The presence of DVT was associated with the proximal location of the PE (100%), whereas none of the patients (n = 10) with exclusively peripheral PE had co-existing DVT. The PE extension, the measured hemostatic and inflammatory markers or the patient characteristics did not statistically differ between patients with isolated PE and PE with co-existing DVT. In roughly half of the PE patients no DVT could be detected. The location of the PE was associated with the presence of co-existing DVT. There were no differences in the PE extension, hemostatic markers or in the patient characteristic between patients with isolated PE or PE with co-existing DVT.