Short- and long-term survival in patients over 90 years old undergoing pacemaker implantation.

AIMS: In Italy, 12-month survival in the general population between 90 and 94 years old is 26%. In very old patients, the benefit of pacemaker implantation in terms of quality and duration of life is unclear. The aim of our study was to analyse clinical characteristics, outcome and factors associated with survival in patients at least 90 years old at the time of the first pacemaker implant. METHODS: Clinical parameters, device characteristics, survival and predictors of outcome in patients at least 90 years old treated with a pacemaker in our centre in 2019-2020 were evaluated. RESULTS: Among the 554 patients undergoing pacemaker implantation in our centre during the study interval, 69 (12%) were at least 90 years old; a complete/advanced atrioventricular block was present in 65%. A cardiological comorbidity (excluding atrial fibrillation) was present in 22 patients (32%). Oncological, pulmonary and neurological comorbidities were present in 12 (17%), 19 (28%) and 32 (46%), respectively. Renal impairment was present in 25 patients (36%). After pacemaker implantation, a pneumothorax developed in two patients and lead dislodgment in one. During follow-up (median 17 months, interquartile range: 13-24), 32 patients died (46%), with a 12-month mortality probability of 24.6%. At multivariate analysis, the presence of oncological (hazard ratio (HR) 5.31; P < 0.001) and neurological (HR 6.44; P < 0.001) comorbidities was associated with mortality. Truncating the outcome at 6 months, renal impairment (HR 8.01; P = 0.003), anticoagulant therapy (HR 8.14; P = 0.003), oncological comorbidities (HR 14.1; P < 0.001) and left ventricular function (5% increase of left ventricular ejection fraction: HR 0.66; P < 0.001) were significantly associated with outcome. CONCLUSION: At our centre, patients at least 90 years old underwent pacemaker implantation mainly for advanced atrioventricular block. One-year survival was excellent, even better than expected in the general population.

Long-term patient satisfaction with implanted device remote monitoring: a comparison among different systems.

AIMS: Remote monitoring is an effective strategy to improve patients' outcomes and reduce hospitalization in patients with cardiac implantable electronic devices. However, data on patients' satisfaction are scarce. The aim of the current study was to assess patients' satisfaction, ease of use and impact on daily activities of the remote monitoring and to investigate whether there are differences among different devices and different manufacturers. METHODS: A modified Home Monitoring Acceptance and Satisfaction Questionnaire telephone survey on the perceived quality of the different systems was performed with all patients followed with remote monitoring for at least 3 months. RESULTS: Among 604 patients with remote monitoring screened by telephone, 466 patients (77%) answered the questionnaire [142 patients (30.5%) had a pacemaker, 317 patients (68%) had an implantable cardioverter defibrillator, and seven patients (1.5%) had an implantable loop recorder]. Ninety-seven percent of patients were satisfied by the remote monitoring system during the entire follow-up and found it easy to use. Similarly, 85% of patients did not experience any restriction in daily activities, and for 99% of patients it did not affect their privacy. Importantly, for the vast majority of patients, remote monitoring gave a great (56.7%) or moderate (33.4%) sense of security. CONCLUSION: Daily impact of cardiac implantable electronic devices still remains a challenging issue for caregivers. The introduction of remote monitoring allowed closer follow-up and improved outcomes. Our results highlighted patients' satisfaction, who also felt safer, with the remote monitoring, its ease of use, and the absence of any disturbances in patients' everyday activities or in their privacy.

Malfunction of cardiac devices after radiotherapy without direct exposure to ionizing radiation: mechanisms and experimental data.

AIMS: Malfunctions of cardiac implantable electronical devices (CIED) have been described after high-energy radiation therapy even in the absence of direct exposure to ionizing radiation, due to diffusion of neutrons (n) causing soft errors in inner circuits. The purpose of the study was to analyse the effect of scattered radiation on different types and models of CIED and the possible sources of malfunctions. METHODS AND RESULTS: Fifty-nine explanted CIED were placed on an anthropomorphous phantom of tissue-equivalent material, and a high-energy photon (15 MV) radiotherapy course (total dose = 70 Gy) for prostate treatment was performed. All devices were interrogated before and after radiation. Radiation dose, the electromagnetic field, and neutron fluence at the CIED site were measured. Thirty-four pacemakers (PM) and 25 implantable cardioverter-defibrillators (ICD) were analysed. No malfunctions were detected before radiation. After radiation a software malfunction was evident in 13 (52%) ICD and 6 (18%) PM; no significant electromagnetic field or photon radiations were detected in the thoracic region. Neutron capture was demonstrated by the presence of the (198)Au((197)Au + n) or (192)Ir((191)Ir + n) isotope activation; it was significantly greater in ICD than in PM and non-significantly greater in damaged devices. A greater effect in St Jude PM (2/2 damaged), Boston (9/11), and St Jude ICD (3/6) and in older ICD models was observed; the year of production was not relevant in PM. CONCLUSION: High-energy radiation can cause different malfunctions on CIED, particularly ICD, even without direct exposure to ionizing radiation due to scattered radiation of neutrons produced by the linear accelerator.