Author + information
- Received November 4, 2016
- Revision received February 13, 2017
- Accepted February 15, 2017
- Published online April 17, 2017.
- Sylvain Ploux, MD, PhDa,b,∗ (, )
- Niraj Varma, MD, PhDc,
- Marc Strik, MD, PhDa,b,d,
- Arnaud Lazarus, MDe and
- Pierre Bordachar, MD, PhDa,b
- aIHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, Bordeaux, France
- bBordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, Bordeaux, France
- cHeart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
- dPhysiology and Cardiology Department, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
- eInParys, A. Paré Private Hospital, Neuilly sur Seine, France
- ↵∗Address for correspondence:
Dr. Sylvain Ploux, Service Pr Haïssaguerre, Hôpital Cardiologique du Haut-Lévêque, Avenue de Magellan, 33600 Pessac, Bordeaux, France.
Remote monitoring (RM) receives a Class I: Level of Evidence: A recommendation for the follow-up of patients with implantable cardioverter-defibrillators, positioning the technology as standard of care. RM is often seen and sold as a plug-and-play technology, whereas fundamental differences exist in the philosophy and conception of the 5 main RM systems. The capabilities and limitations of the different RM systems need to be understood and taken into account when the decision is made to remotely manage an individual patient. The purpose of this review is to provide to the cardiologist practical information about RM systems’ specificities with respect to the different technical and clinical alerts. Clinically based indications and programming suggestions are provided.
A recent international consensus statement recommended that all patients with implantable cardioverter-defibrillator (ICD) should be offered remote monitoring (RM) as part of the standard follow-up management (1). This Class I recommendation was delivered with the highest level of evidence originating from multiple randomized controlled trials (2–5). A step upstream from the clinician, the cardiovascular implantable electronic device manufacturers have progressively implemented RM capabilities in their most recent platforms. Although the different systems share a common principle, they differ significantly in philosophy and practical application, the type and number of programmable alerts, and some proprietary algorithms. For example, the Biotronik system (Biotronik, Berlin, Germany) proposes 42 alerts for the monitoring of cardiac resynchronization therapy (CRT)-defibrillator versus 16 for the LivaNova system (LivaNova, London, United Kingdom). Nowadays, cardiologists are encouraged to implement RM in their clinical practice for better efficiency and quality of patient care. This transition implies major organizational changes with the replacement of routine appointments to a system of nearly continuous monitoring, with most visits initiated in response to alert notiﬁcations communicated by the RM system. The machine is invited to play a major role in the patient care, formerly performed solely by the clinician. The authors recognize that not only may this paradigm shift be daunting, but selection and activation of any particular RM system may be confusing to any clinician wishing to adopt RM for patient care. This may account for the fact that only 50% of devices implanted in the United States are RM capable, and of those, only 50% are activated (6,7). The capabilities and limitations of the different RM systems need to be understood and taken into account when the decision is made to remotely manage an individual patient. These may determine selection before implantation, so that RM may be enabled soon post-implantation, because this carries benefits and conforms with recommendations (1). The purpose of this review is to provide to the cardiologist practical information about RM systems’ specificities.
Radiofrequency transmissions are sent from the implanted device wirelessly to a transceiver that must be in proximity to the patient at the time of transmission. Size, portability, and need for patient operation of the transceiver vary considerably among the manufacturers. Initiation of the connection is either achieved by the transceiver or by the device, 2 strategies that may affect battery longevity differently. Transmission to the manufacturer’s data repository is achieved using either analog or digital landlines, or wireless data networks. Remote monitoring of the ICD couples remote systematic interrogations with continuous surveillance of device functionalities and clinical events. Automatic remote interrogations are performed daily by the Biotronik system but at longer pre-specified intervals by the other systems (usually every 3 months, and this may be programmable). A variety of “alerts” can be programmed, either via the programmer (Biotronik, LivaNova, Medtronic [Dublin, Ireland], and St. Jude Medical [St. Paul, Minnesota]) or the website (Biotronik, Boston Scientific [Natick, Massachusetts], and St. Jude Medical), and these define the framework to operate the remote monitoring function per se. The capability to switch on/off or change the range of alerts remotely from the website avoids alert redundancy and the need for an in-clinic device reprogramming (inconvenient to patient and clinic alike). Some alerts are linked to transmission of related stored electrograms (EGMs) (e.g., ventricular fibrillation [VF]/ventricular tachycardia [VT]/atrial fibrillation [AF] episodes). The EGM transmission capabilities vary from 1 EGM per session (Biotronik) to the complete EGM folder (Boston Scientific, Medtronic, and St. Jude Medical). A limit to the number of EGMs transmitted when multiple events occur the same day incurs a loss of information and may be problematic. The systems are designed to communicate at night (usually between 1:00 am and 4:00 am), however, 2 manufacturers (Biotronik and Medtronic) maintain unrestricted transmission of critical alerts (with the corresponding EGM) when the patient is close enough to the transmitter. These so called “direct” transmissions may reduce the time to medical intervention (for a VT storm or a lead alert). Transmission on patient demand (for symptoms) are allowed for Boston Scientific, LivaNova, Medtronic, and St. Jude Medical devices. The Biotronik system is entirely automatic and transmits daily, eliminating dependency on patient activation.
The main technical features are shown in Table 1.
ICD Lead–Related Alerts
The essential function of an ICD system depends on its sensing and defibrillation capabilities. These functions rely on lead integrity, which is known to be the weakest part in all ICD systems (8). Lead failure may lead to loss of bradycardia pacing, missed treatment of ventricular arrhythmias (antitachycardia pacing [ATP] or defibrillation), or to inappropriate therapies caused by oversensing. Inappropriate shocks decrease the quality of life and probably the life expectancy of the ICD recipients (9). Two manufacturers (Medtronic and St. Jude Medical) have developed dedicated algorithms for lead failure detection in response to the recall of the Sprint Fidelis and Riata leads (10,11). These algorithms integrated to their respective RM system confer significant advantage over the conventional impedance monitoring. A large part of the RM alert portfolio is commonly devoted to the ICD lead surveillance (Table 2), which includes:
1. A daily check of the pacing and shock impedances. An alert is triggered for each impedance out of the lower and upper bounds (which can remotely be changed through the Biotronik website). Medtronic and St. Jude Medical provide dedicated impedance alert for the superior vena cava coil.
2. Boston Scientific also checks for lead impedance variations and sends an alert when 3 large variations have been detected in a 7-day rolling window, this alert is available for Wave communicators (models 6288 to 6290) and must be individually programmed on the website.
3. More sophisticated proprietary algorithms have been introduced to detect lead-related oversensing without interfering with treatment delivery. Boston Scientific tracks short RR intervals (≤160 ms) within detected episodes, whereas LivaNova sends an alert for accumulation of untreated VF episodes (Online Appendix). Medtronic provides a lead integrity alert (LIA) that is triggered by a combination of: 1) relative changes in impedance; 2) transient short RR intervals; and 3) nonsustained VT (NSVT). This latter algorithm has been proven to significantly increase the detection rate of lead failure compared with conventional impedance monitoring (12).
4. Medtronic and St. Jude Medical provide noise discrimination algorithms that differentiate ICD lead noise from VT/VF by comparing a far-field EGM signal to near-field sensing. Once lead noise is identified, VT/VF detection is withheld, and an alert is triggered (Figure 1).
5. Biotronik and Boston Scientific only provide specific alerts for right ventricular (RV) intrinsic amplitude out of range <2 mV and ≤3 mV, respectively. These warnings allow early diagnosis of loss of sensing, ICD lead dislodgment, and paradoxically oversensing (Figures 2 and 3⇓⇓).
NB: Following a first impedance alert (either sensing or shock), the RM systems behave differently. These specificities are important to know for those who would prefer to wait for a recurrence (which is not advised).
Biotronik: An alert will be sent for any new abnormal measurement (pending that the impedance recovers in between). However, if the impedance is continuously out of range, the alert will only be repeated after 21 days.
Boston Scientific: Latitude delivers a first and unique alert, whatever the number of subsequent abnormal measurements. There will not be any recurring alerts until the device has been interrogated with a programmer. One exception is the alert for “lead impedance abrupt change,” which can be retriggered without a programmer interrogation.
LivaNova: After a first impedance alert, a 1-week inhibition period is applied during which no alert can be sent. In case of recurrence, the system will deliver a second and last alert (until the device has been interrogated with a programmer).
Medtronic: A new alert is sent for every new impedance out of range.
St. Jude Medical: Merlin delivers a first and unique alert, whatever the number of subsequent abnormal measurements. That alert will not repeat until the device has been interrogated with a programmer.
▪ Turn ON all the ICD lead–related alerts that do not interfere with therapy. Boston Scientific “Right ventricular non-physiologic signal detected” and “Right ventricular pacing lead impedance abrupt change” are nominally OFF and must be activated individually on the Latitude website because they do not respond to the patient group default settings.
▪ Program noise detection alert that may inhibit the therapy (lead noise discrimination algorithm for Medtronic, and SecureSense for St. Jude Medical).
▪ The St. Jude Medical SecureSense trigger alert for nonsustained RV/ventricular oversensing must be set to 1 (number of episodes needed before triggering and sending the alert).
▪ Attention must be paid to the scheduled reports on RV lead impedance and R-wave sensing trends, especially in LivaNova, Medtronic, and St. Jude Medical devices, in order to detect a sudden drop in R-wave amplitude or abrupt impedance changes (Figure 2).
▪ At the time of generator change, the preferred RM systems for surveillance of leads under advisory are Medtronic and St. Jude Medical, which provide active and passive noise detection algorithms and alerts.
▪ Patients subjected to a decrease in R-wave amplitude (arrhythmogenic RV dysplasia) would benefit from a Biotronik system, which has alerts for changes in sensing (13).
Right Atrial, Left Ventricular Lead–Related Alerts
Although less critical than ICD RV lead failure, a right atrial (RA) or left ventricular (LV) lead malfunction may have clinical consequences. A RA lead malfunction may favor pacemaker-mediated tachycardia, loss of CRT, or supraventricular tachycardia (SVT)-VT discrimination errors. An LV lead failure would interfere with CRT delivery either by loss of capture or oversensing (for Biotronik and Boston Scientific only). Biotronik and Boston Scientific are the most sensitive in atrial and LV lead failure detection (Table 3).
Ventricular Arrhythmia–Related Alerts
Ventricular arrhythmia–related alerts are driven by different manufacturer philosophies. Biotronik and St. Jude Medical offer the highest sensitivity with the possibility to transmit the range of ventricular arrhythmia episodes (from nonsustained, events treated with ATP, to shocked), whereas Boston Scientific and Medtronic mostly restrict the alert to shocked arrhythmia episodes (Table 4). The rationale for adopting a high sensitivity in arrhythmia diagnosis is as follows:
1. NSVT events are a common source of noise/oversensing identification. Their early notification by RM may prevent inappropriate shocks and reduce patient morbidity (14). In fact, NSVT is the most sensitive of the 3 LIA criteria (impedance change + NSVT + sensing integrity counter) and is present in 96% of the LIA alerts, which have been found to be very effective in lead failure detection, especially in combination with remote monitoring (8,12).
2. Non-shocked episode alerts allow reduction in time to medical evaluation for VT and VF events, as shown in the TRUST (Lumos-T Safely Reduces Routine Office Device Follow-Up) trial (2).
3. Non-shocked VT and VF episodes may relate to SVT, P/R/T-wave oversensing, noise oversensing, or lead dysfunction. Boulé et al. (15) demonstrated that RM systems that generate alerts following ATP delivery could reduce emergency presentations for ICD shock by 24%.
4. Asymptomatic cancelled shock therapy (whether for actual VT or noise) may reduce battery longevity. Their early identification provides an opportunity for prevention of therapy and battery preservation (16).
To date, no study has shown the ability of RM to reduce appropriate shocks in comparison to standard follow-up. However, early RM notification of ventricular arrhythmia episodes enables preemptive action to avoid further inappropriate shock therapy and/or aborted shocks, which affects the battery longevity. The ECOST (Benefits of Implantable Cardioverter Defibrillator Follow-Up Using Remote Monitoring) trial involving Biotronik devices has reported a 50% reduction in the proportion of patients who received inappropriate shocks (17). In contrast for those systems that restrict the alert to the shocked episodes (Boston Scientific and Medtronic), the time to diagnosis is delayed and necessitate a careful examination of the arrhythmia logbook at the time of the scheduled transmission (Figures 4, 5, and 6⇓⇓⇓).
▪ Analyze all transmitted ventricular arrhythmia tracings in order to detect potential sources of inappropriate shock, or unnecessary shock/aborted shock.
▪ Biotronik and St. Jude Medical are the preferred systems to monitor VT burden (e.g., arrhythmogenic RV dysplasia, ablated VT, history of VT storm).
▪ Medtronic ICDs should be programmed with the CareAlert “Number of Shocks Delivered in an Episode” ON and set to 1.
▪ LivaNova ICDs should be programmed “all shocks” instead of “Inefficient Max shock.” “ATP delivered” is available since the Platinum series and should be programmed ON.
▪ In order to shorten the time to medical intervention, we advise reducing the remote interrogation interval of the Boston Scientific, Medtronic, and LivaNova devices (<3 months) with careful examination of the VT/VF counters and EGM library (18).
▪ Patient-initiated transmission should be allowed for Boston Scientific, LivaNova, and Medtronic systems in order to access nontreated, but symptomatic, arrhythmic events.
Atrial Arrhythmia–Related Alerts
Current dual-chamber and CRT-ICD RM systems provide alerts for AF episodes and/or AF burden (Table 5). Likewise, the new Biotronik Dx and Medtronic single-chamber ICD also provide alerts for excessive AF burden. RM outperforms standard follow-up in AF detection because: 1) a large proportion of AF episodes are asymptomatic; 2) RM shortens the time to detection of AF (1 to 5 months earlier); and 3) an EGM of an AF episode that has been teletransmitted may be absent from the ICD records if overwritten by more recent episodes (that may not be AF, but rather are noise, for example) (2,3,19). Early detection of AF is an important assignment of RM that may help to prevent clinical complications:
1. Recognizing AF is important to avoid inappropriate ICD therapies, since AF is responsible for the majority of them. The ECOST trial showed a 74% reduction in the number of inappropriate shocks related to SVT in the RM arm compared with standard follow-up (17).
2. AF may trigger hemodynamic instability and worsen congestive heart failure, especially by loss of CRT. The InTIME (INfluence of home moniToring on mortality and morbidity in heart failure patients with IMpaired lEft ventricular function) study showed more favorable outcomes and survival in patients with heart failure and RM of their ICD. Interestingly, patients with a history of AF beneﬁted more from RM than did the patients without AF. It is also noteworthy that AF was the RM alert that most often led to patient contact. These observations suggest a link between AF management and the RM benefits observed (5).
3. Early detection of AF (sometimes in real time) provides the opportunity to consider whether to initiate anticoagulation therapy. In the ASSERT trial (Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial), AF episodes as short as 6 min have been shown to be associated with an increased risk of stroke (20). The benefit of treating these with anticoagulation is currently being evaluated in the ARTESIA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation) trial.
It is the authors’ opinion that AF detection thresholds should be programmed at their lower values (from the programmer, for LivaNova, Medtronic, and St. Jude Medical; from the website, for Biotronik and Boston Scientific) in patients with no history of AF (21). The default value for AF detection is 3 h for St. Jude Medical devices, compared with 6 h for other companies. The lowest threshold for AF detection is 30 min for LivaNova, Medtronic, and St. Jude Medical, and can be lowered in Biotronik and Boston Scientific devices to >0 h or 0% (Table 5). In patients with known AF, this detection threshold can be increased and/or replaced by a high ventricular rate alert. The AF episode and AF burden alerts are delivered with an EGM, which allows confirmation of the diagnosis. Due to memory size limitation, the transmitted EGMs are the latest, not necessarily the longest, episodes. Furthermore, because atrial undersensing is common in AF, a continuous, clinical AF episode may be stored as multiple shorter, sequential device-defined episodes. Thus, the health care provider should scrutinize the AF burden graph or log and the atrial-mode switch table (if any) to determine the duration of the clinical AF episodes before deciding about anticoagulation. Additional AF-related alerts are proposed for Biotronik and St. Jude Medical devices.
▪ Program the AF detection threshold at their lowest value in patients free of AF.
▪ Increase the threshold for an AF alert in patients with known AF (AF burden >50%, for example) or replace it with the alert of high ventricular rate during atrial burden (>110/min during 10% of the day, for example).
▪ When an AF/mode switch EGM is delivered, always pay attention to AF burden/24 h because the transmitted EGM may not be the longest, but rather the last. This is particularly true for Biotronik and LivaNova devices.
▪ Apart from the EGM library, duration of the longest atrial episode can be found under “Atr. Arrhythmia” for Biotronik, “Atrial arrhythmia history” for LivaNova, “Clinical status” for Medtronic, and “Diagnostics summary” for St. Jude Medical.
▪ LivaNova ICDs send a maximum of 2 AF burden alerts between 2 programmer interrogations.
▪ Be aware that a teletransmitted episode loses its priority in the LivaNova device storage library.
Heart Failure–Related Alerts
ICD recipients may be subjected to acute decompensated heart failure (especially CRT patients). With the exception of Medtronic, all systems can be programmed to deliver a “low CRT” alert, with a programmable %CRT threshold). With the exception of Biotronik, this alert is delivered with an EGM that can reveal the cause of the lack of CRT (e.g., atrial undersensing, T-wave oversensing). Biotronik provides alerts for high ventricular rate and high premature ventricular contraction burden. Medtronic and St. Jude Medical can provide alerts for a decrease in the thoracic impedance (OptiVol and Corvue, respectively). Though expected to be related to heart failure decompensation, this was not borne out by the recent Optilink (Optimization of Heart Failure Management using OptiVol Fluid Status Monitoring and CareLink) trial, raising doubts about coupling thoracic impedance changes to RM (22). Boston Scientific devices equipped with the weight scale can alert for sudden loss or gain in weight, if patients weigh themselves daily (Table 6). Finally, AF alerts may also identify risk of heart failure decompensation in CRT patients.
▪ The effectiveness of fluid status telemedicine alerts to manage congestive heart failure is currently uncertain (Class IIB recommendation in the recent guidelines) (1).
▪ For Biotronik and Boston Scientific, CRT% (CRT pacing percentage) includes LV pacing triggered by RV sensing, which is often higher than the biventricular pacing %. We therefore recommend using the BIV% (biventricular pacing percentage) alert instead of the CRT% alert in Biotronik devices (not available for Boston Scientific).
RM while travelling is only possible with transceivers carrying their own SIM card and depends on the availability of cellular roaming. Travelling is usually not an issue when the shift in time zones is <3 h; likewise, there is no issue with daylight savings time. The different manufacturers have specific contracts with different operating communicators all over the world. Some transceivers are more compact and portable (Table 1).
Biotronik: The ICD is programmed to transmit once a day between 01:00 am and 02:00 am. The transmission attempts will last 3 h. Therefore, it is advised to reprogram the transmission time if the shift in time zones is more than 3 h. Alternatively, the patient can carry the Cardiomessenger Smart transmitter to allow direct transmissions.
Boston Scientific: Before the use of the 6290 communicator (Autogen and after), RM was not possible from another continent. With the use of the Medical Implant Communication Service bandwidth, RM is ensured from most parts of the world. The communicator will try to reach the device between 00:00 and 05:00 am (original time zone) and repeat the search every 10 min during the day. This process is not supposed to affect the battery longevity.
LivaNova: The transmitter will try to reach the device at the programmed original time and continue the search 31 times during 3 consecutive nights. It is therefore advised to change the transmission time through the website (“Enable day time follow up”).
Medtronic: The transmitter will try to reach the device at the original programmed time and perform a new search every 3 h during 3 days.
St. Jude Medical: The transmitter will try to reach the device between 02:00 am and 04:00 am (original Merlin time zone) and continues the search until the transmission succeeds.
▪ Global availability of RM depends on the company and is subject to changes. Before implanting in a patient who plans to move abroad, it is advised to check with the manufacturer that RM is available in that country.
▪ For Biotronik and LivaNova, RM transmission requires that the cardiac implantable electronic device be reprogrammed according to the foreign time zone. This can be done remotely for LivaNova devices through the website. Of course, this time needs to be changed back when the patient returns home.
▪ Patient equipped with a Biotronik Cardiomessenger Smart transmitter may benefit from carrying it during the day to allow permanent transmission and avoid reprogramming the device.
Although RM has recently become a Class I recommendation for ICD follow-up regardless of the system used, major quantitative and qualitative differences exist between the 5 different RM systems. Equipping the patient with an automatic RM system must be the priority. However, the cardiac implantable electronic device specialist should be aware of the individual differences in RM systems, balance the relative beneﬁts/limitations for an individual patient, and consider the transmission loads that need to be handled. The higher the number of proposed alerts, the better the sensitivity in clinical/technical problems detection. On the other hand, focusing on a few alerts intends to decrease the noise and the consumption of scarce resources, for example, clinic manpower. For systems that provide a limited number of alerts, it is advisable to allow patient-initiated interrogation (for symptoms) and shorten the time between scheduled remote follow-ups (every month, for example). We have shown that a specific RM system may be preferred for a patient-specific condition (Table 7). Medtronic and St. Jude Medical systems are undoubtedly better equipped to detect lead failure and avoid unnecessary shocks. They are therefore particularly indicated for surveillance of leads prone to failure: under advisory or implanted in young and active patients. When a close monitoring of the VT burden is required, in an ischemic patient with history of VT storm, or a patient with arrhythmogenic RV dysplasia, the limitation of the Medtronic and Boston Scientific systems, which only alert for shocked episodes, must be borne in mind. One may argue that the occurrence of VT is expected in an ICD recipient; however, ignoring a VT storm may have adverse consequences (Figure 6). Similarly, the systems have different capabilities for transmitting NSVT detection episodes, which may enable reprogramming to avoid inappropriate therapy, such as for electromagnetic interference and T-wave oversensing. The 5 RM systems have the capability to detect and store AF episodes adequately. However, Biotronik and Boston Scientific have enhanced sensitivity and can be programmed to alert for a few seconds of rapid atrial rate. This specificity may be considered when implanting a patient with a history of embolic stroke of undetermined source. Biotronik and Boston Scientific also provide an attractive combination of alerts dedicated to CRT monitoring: RA and LV lead continuous check with CRT% alert. Additionally, the patient followed with Latitude can transmit at regular intervals weight and blood pressure using Boston Scientific–dedicated material. Finally, the compact size and the ability of the Biotronik transmitter to communicate any time in the day render this suitable for short and frequent trips, for example, for a commercial traveler (Central Illustration).
We would like to stress that the purpose of this document is not to compare and rate the different systems, but rather to optimize their use in clinical practice. Suggestions/advice reflect the authors’ clinical experience and opinions. It is the authors’ anticipation that these insights should reduce reluctance to adopt and maintain RM. The present review refers to the latest ICD version of each manufacturer.
The authors wish to acknowledge the kind collaboration of Xavier Laroche (Biotronik, France); Nicolas Charlier (Boston Scientific, Europe); Muriel Bon (LivaNova, France); Arthur Schmidt (Medtronic, France); Eve Clédat and Pierre Stiegler (St. Jude Medical, France). The authors are especially grateful for the expert opinions offered by Dr. C.D. Swerdlow (Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California).
This study received financial support from the French government as part of the “Investments of the Future” program managed by the National Research Agency (ANR), Grant reference ANR-10-IAHU-04. Dr. Strik has received grant support from the Dutch Heart Foundation and the Netherlands Heart Institute. Dr. Ploux is a consultant for Biotronik, Boston Scientific, LivaNova, Medtronic, and St. Jude Medical. Dr. Varma is a consultant for Biotronik, Boston Scientific, Medtronic, St. Jude Medical, and LivaNova; and has received research funding from Zoll, Medtronic, Biotronik, St, Jude Medical, and Boston Scientific. Dr. Strik has received a grant from Biotronik. Dr. Lazarus is a consultant for Biotronik, Boston Scientific, Medtronic, and LivaNova. Dr. Bordachar has reported that he has no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Abbreviations and Acronyms
- atrial fibrillation
- antitachycardia pacing
- implantable cardioverter-defibrillator
- lead integrity alert
- left ventricular
- nonsustained ventricular tachycardia
- right atrial
- remote monitoring
- right ventricular
- supraventricular tachycardia
- ventricular fibrillation
- ventricular tachycardia
- Received November 4, 2016.
- Revision received February 13, 2017.
- Accepted February 15, 2017.
- 2017 American College of Cardiology Foundation
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