Left Bundle Branch Area Pacing From a Femoral Approach in a Patient Without Superior Access.

Limited venous access and lateral left ventricular scar are impediments to traditional cardiac resynchronization therapy. We present a case where placement of an implantable cardioverter-defibrillator from a femoral approach while using left bundle branch area pacing led to clinical improvement. (Level of Difficulty: Intermediate.).

The modern EP practice: EHR and remote monitoring.

Cardiac implantable electronic devices (CIEDs) store clinically valuable, time-sensitive information regarding system integrity, arrhythmias, and heart failure parameters. Remote monitoring has impacted clinical practice by reducing scheduled office visits, providing protocols for device recalls and advisories, and facilitating the management of unscheduled encounters. The successful implementation of remote monitoring into clinical practice requires a new work flow and additional staff; the use of the electronic medical record to manage the data emanating from CIEDs poses an additional challenge. Solutions to these issues are discussed, and projections are made regarding the management of CIEDs in a modern electrophysiology practice.

Remote patient management using implantable devices.

Remote patient management utilizing the Internet is a milestone in the management of patients with an implantable cardiac device. Pacemakers and implantable cardioverter-defibrillators (ICDs) store diagnostic information about device and lead integrity, the occurrence of atrial and ventricular arrhythmias, and parameters that may reflect on a patient's heart failure status. Previously, these data could only be retrieved with a programmer at an in-person office visit. The introduction of remote follow-up and monitoring has changed the paradigm for the management of patients with implanted devices. Remote follow-up has been shown to be superior to traditional transtelephonic monitoring for the detection of clinically actionable events in pacemaker patients. Remote monitoring using ICDs with wireless technology has been demonstrated to result in detection of lead malfunction and atrial and ventricular arrhythmias while reducing the need for in-office evaluations without compromising patient safety. Studies are underway to evaluate the clinical utility of identification of atrial high-rate episodes and to identify patients at risk for exacerbation of heart failure. Remote monitoring technology has yet to be universally adopted by patients or physicians. Impediments to the implementation of remote monitoring including issues related to work flow and data management are explored.

Ambulatory external electrocardiographic monitoring: focus on atrial fibrillation.

There has been progressive development in ambulatory external electrocardiogram (AECG) monitoring technology. AECG monitors initially consisted of 24- to 48-h Holter monitors and patient-activated event and loop recorders. More recently, several ambulatory cardiovascular telemetry monitors and a patch-type 7- to 14-day Holter monitor have been introduced. These monitoring systems are reviewed along with their utility and limitations, with particular emphasis on their role in the diagnosis and evaluation of patients with atrial fibrillation (AF). AECG monitoring is necessary when asymptomatic AF is suspected (as in patients presenting with cryptogenic stroke) or when an ECG diagnosis of unexplained arrhythmic symptoms is warranted. In addition, AECG plays an important role in patients with known AF to guide ventricular rate control and anticoagulation therapy, and assess the efficacy of antiarrhythmic drug therapy and/or ablation procedures. Finally, we outline areas of uncertainty and provide recommendations for use of available AECG monitors in clinical practice.