Good morning, everyone. Thank you so, so much for coming Sunday morning, last day of HRS. We appreciate you being here. There will be prizes for everyone later. My name is Martha Ferraro. I'm a family nurse practitioner and the assistant director of EP services at White Plains Hospital in New York. I'm sitting here with the unbelievably fantastic Dr. Sam Sears. I know he didn't ask me to say that, but I'm going to say it anyway because I love him. Our session today is Detecting Deaths of Patients with CIEDs on Remote Monitoring. Without further ado, we are going to get started. Dr. Sears, did you want to say anything else? Good morning, everybody. I think we have a great session. Chris? Please send us your questions on the QR code. We would appreciate the questions. First up, we have Christopher Monkhouse from the Barth Hart Center. You know how to do that, right? You have to hit on your name, start, and then wait about 10 seconds because the disclosures will come up. Beautiful. Lovely. Hello, everybody. My name is Chris. I work at St. Bart's Hospital in London, England, and I'm really glad to have this as a part of the sessions for Heart Rhythm because I've been, this has been a bit of a passion of mine for the last sort of six or seven years, and I'm hoping we can all learn something today. There are my disclosures. Now, we have, for remote monitoring, it's obviously expanding across the whole world. We're using more remote monitoring and enrolling more and more patients and probably thousands across the world every day. And I just want to sort of like put, make you sort of think about how many remote monitoring transmissions that you're going through and how many everybody is going through. And you get combinations of different alerts continuously and all of your scheduled transmissions if people haven't moved over to just alert-based monitoring. And in how many patients and how many transmissions you have, when you receive a transmission, there is always an assumption that the patient is alive when that is sent. So, I'd like to ask you all to wave at me right now. So, if everybody can do this. Lovely. You're all awake. Great. Sweet. All right. So, one of the benefits of, well, that's what remote monitoring feels like. If you were to see me, for us on the panel, sat up here, everybody's waving, saying, give me attention. Please look at my remote monitoring download. And what you have to do is pick out the one person whose hand is actually down, but they've sent you the transmission. So, that's what we're going to try and pick out today. Because you're going to have thousands of these transmissions. And there we go. I've got Mr. Bean. So, that's the British contingent. So, yeah. The question of are they alive is what I'm going to try and come with the answer for you today. And I don't know how many of you use this system of PBL stop in your analysis of devices and when you look through transmissions. And I thought that I would, well, this is a fundamental that we do for everyone that we teach. So, I thought let's give a bit of structure to it. So, what parts of PBL stop here can be helpful for us to be able to detect these? So, I'm going to start with P, the presenting rhythm. So, the presenting rhythm is probably the most helpful thing that we have. But importantly, it's not there on every single manufacturer that comes through every single time there's a transmission. Now, what can you see on these presenting rhythms can vary between the devices. But I want to sort of break it down with this example here. So, we've got all of the different recording channels. We've got our integrated. We have almost too many channels, don't we? We have the unipolar, another unipolar, and the bipolar, and then the marker channel. And importantly, one of the first things that I'm going to highlight to you, I'll put it in red to try and make it really obvious, is our amplifiers. So, the amplifiers, because there is a systole underlying, the amplifiers will be gained all the way up. So, you start to see some baseline noise, which is a systole, but the amplifier gains will go absolutely to the max. And sometimes you can just have really small signals, and maybe that is just because the patient does have small signals. But that's the first clue. And not everybody always looks at these. I don't know if everybody does. First thing to do, check what channels you have, then check what the gains are, because you want to know what you're looking at. And then if you've got a transvenous device, you'll just see pacing. So, this example of this biventricular pacing. However, I've definitely presented this trace many, many times. And people will say, well, it's bivy pacing, and you can't always tell it about response, right? Sometimes it's really quite hard to tell whether it's capturing or not. Well, the benefit here is we've got the unipolar channels. And one of the things that we use to try and determine whether somebody is deceased or not is you're looking for the absence of a T-wave. So, you should see a T-wave. If there's depolarization, there should be repolarization. So, there's a QRS, there should be a T-wave. So, there's no T-waves here whatsoever. Which is the first marker to say that this patient has sadly passed away. So, P is our first port of call. Then we've got our lead tests. And this is one of the common reasons why you'll get the transmission come through in the first place. And I'll zoom in a little bit here on this example, which kindly has all of the different types on it. So, we've got the automatic tests that have been done by the device. And the first one that calls out is the automatic capture threshold test. Which obviously, as the patient is deceased, has gone up to max. So, we've got a high threshold. And the device is auto-adapted to push the outputs really high. The sensing, the sensing will disappear. You won't get any sense star waves. Now, if you've got a dependent patient, that might not be obvious because they're dependent already. So, there might not be a sense star wave. But if you've got a patient that's had an R-wave and had intrinsic rhythm, then they would suddenly start not having their sensed R-wave. And then your impedances. So, you get an impedance rise post-mortem. But it isn't just straight to 2,000. Actually, the rise can be subtle. It will be a significant change. So, if you have auto-adapted or adjusted your lead impedance thresholds. I don't know how many people do that where they move them 200 ohms above, 200 ohms below. You will probably pick this up a bit sooner. But if we had this impedance alert set at 2,000, we're not getting an impedance alert for this. Particularly, how soon the transmission comes through post-mortem. If you're immediately after post-mortem or in some situations during the process of death, you might have an impedance that can be completely normal. So, it's always important to have that in the context of the trend. So, we have L, S, and T that can all indicate this and can be the cause of the transmission coming through. Another common cause of the transmission coming through is VT slash VF events. And one of the things that I'm going to try and focus on here is about the definitions between successful shocks and unsuccessful shocks. And one of the reasons why this has been so important for us to define is we've had to go to the equivalent in the U.S. is, I think, an inquest. So, we have a lawyer's inquest into the cause of death. And we're trying to find out why the patient has died. And we've had to present this in the U.K. That's called a coroner's court. So, they have the full autonomy of a normal court. And we will have to then explain why the patient has died. And we've had to do this and effectively defend that the device has worked. So, here we've got effectively VTVF. One bad sign, I think, if anyone is a little bit of an electrogram nerd, when you start seeing an atrial electrogram with asystole, this patient is not doing well. When you start seeing sinus brady and VTVF, they are generally really not doing well hemodynamically. So, in this VF episode, we can see that the shocks come in. And we do have a brief reversion with maybe one intrinsic, maybe an escape beat or a sinus. But it's not a sinus because there's no P wave. But before we get VF recurring. So, you get recurrent VTVF with successful shocks. It's very easy to say the device didn't work, the shocks didn't work. Well, actually, the shock worked. But the patient is going back into VF. So, that's not where the device has had a fault. So, important thing to define for when you put it into your report. But there are times where the devices won't necessarily deliver therapy. And we looked through a portion of ICD patients who we detected this. And you can have some episodes where the VTVF is incredibly slow detected on the RV channel. So, you can have in the left ventricle, you can be going 200, 250 beats a minute. And in the right ventricle, there is the conduction across of that VF is not as fast. And that was defined by a group over in London from Imperial where they described them as dissimilar rhythms. And I'll focus on this channel here where we've got the intracardiacs of the right ventricle and the left ventricle. And you can see that the right ventricle is in VF. Though we've got the far field, they're clearly in VF. The right ventricle is conducting the VF faster than the left ventricle. And if you're just looking at this left ventricular channel, how would you even tell that that's VF? How is the device going to be able to tell that this is VF? So, particularly if you have somebody who has VTVF in their process of dying. Some of you may have seen this during an acute myocardial infarction, maybe when the patient is passing away. You start seeing really agonal, horrible looking VTVF. This is when you're getting to that point. So, we want to try and get to treat the patients before this. But if they are going through pump failure and then will have VTVF, it can be really, really slow. And the devices can undersense this. And who's going to be programming a VTVF zone at 140 beats a minute? You're not going to be able to do this. And there are algorithms from some manufacturers like the ones from Abbott for VFT therapy assurance that might hopefully alleviate this by comparing the far field and the near field. But there are also events that we necessarily didn't know about where the devices were at fault. And this is an example of the onset discriminator that we had programmed on for many, many years before this event had occurred. Where the onset discriminator had withheld the detection and the patient sadly passed away. If we hadn't have had the remote monitoring data, we would not have known this had happened. And I think that we don't necessarily get all of the information post-mortem. I think this is an international situation that we don't check all of our cardiac devices after any patient has just died. So you start to get a sense of extra data that we see and we wouldn't normally have detected. So from this, we can tell from the presenting rhythm, the battery generally isn't going to be causing you an alert. Impedance, sensing, threshold, and observations. They're going to be all of the different mechanisms in which you could detect this. And we looked at the prevalence of these different causes for transmission. And VTF events was the most common. But the easiest way to detect this is on the presenting rhythm. Now, one question that I would ask you is if you have somebody who's presented with this, is there a differential diagnosis? And there's always a differential diagnosis. So we had one patient who had an implantable loop recorder who we thought might have passed away. It wasn't passed away. The device had self-explanted. So it was just present. It was sat on their bedside table and transmitted. And we phoned them up. We panicked. We also had another patient where we were very panicked who had a CRTD, who had gone and had a transplant at another center and been given the device. So it was in their cupboard. We phoned them up saying, is this person dead? No, I'm actually great. I'm going for a run. How are you going for a run? I've got a new heart, actually. But thanks. We didn't let you know. So there is a differential diagnosis. And understanding then what to do when you detect this I think is what we're going to sort of be alluding to. And we came up with a management plan that we now use as a standard of practice if you do detect somebody who you think has deceased. And it can be a real challenge when you're making that call to be able to find out if somebody knows whether they've passed away and where they are. We did have one patient who was staying around his friend's house, had taken his remote monitor with him, and we sent police and an ambulance to his home address and he was not there. So the police broke down his door hoping to find him there. He wasn't there. And none of his neighbors knew where he was. And it took us two weeks to find him, which was really sad. But it was really quite a lot of detective work that we had to do to be able to quite literally follow his friends to figure out where he was. So there's a lot. And we're going to move into all the different factors that do this. But for conclusion for how you detect this, presenting rhythm. Report and look at every single presenting rhythm you see or have transmitted come through to you. That is the wave. That's the easiest way to detect it. There is a differential diagnosis and have a plan. And if you have not seen this or your center has not seen this and you do remote monitoring, you will see this. This is a matter of time when you will see it. It is not will it happen to you. If you'd like to read any more, feel free to read our article that was published a few years ago in Heart Rhythm. And thank you very much. It was wonderful. Thank you. Thank you. Please send your questions. It was a wonderful presentation, Christopher. Next we have Monique Young. Good morning, everyone. I'm Monique. I work with the University of Tulane, and I'm going to talk today about how the clinicians should respond when reviewing transmissions such as Chris has just talked about. One disclosure. So remote monitoring, although it's been around for a really long time, for about 20 years, we've noticed that we've been able to avert the episodes that Chris has talked about the death. So they have, because of remote monitoring, there's been a reduction in supraventricular arrhythmia deaths, or not even deaths, but treatments of them, that 77% of people did better because of the remote monitoring and because of the technologies that have evolved and are evolving. And this study was specifically in patients with ICDs. This means that our patients, they have two-thirds of a lower risk from supraventricular arrhythmias if they are monitored. Then the survival benefits. The survival benefits have also been showed as a reduction in all-cause mortality in patients who have heart failure. If they're being monitored, we are saving their lives. These people who are monitored, we all know what they can do. The PBL stop, it works wonderful, and it's a standard tool. So we're not only reducing the supraventricular arrhythmias, we're also reducing heart failure admissions and comorbidities associated, and hopefully not even, hopefully not death. So with all this reduction in death arrhythmias, it also comes to what we do with remote monitoring. We have a, it's a burden. I don't want to use the word burden. I don't like it. However, it is a, it's a volume. And yesterday I heard a speaker talk about, should we do alert-based, or should we just, or go to alert-based only? Because reports from mine, which doesn't seem like a lot, is about 40 a day for part of my team. And that's just scheduled. That's not unscheduled. There's, the urgent detection could be as much as 20 percent. I'm, excuse me, 20 per day. So then we move into what is the hidden burden of remote transmission. For my staff and for remote staff, this takes up about 32 percent of the clinical workload. That's a lot. In my, at least I think it's a lot. One transmission, and this is what goes along with that. There's telephone work, there's clinical action, there's scheduling, patient communication, such as, and I'm keep referring back to Chris, but he did such a great job of what it is. But all that work and all those steps take time. It's not just one step. And you have to have the team to support it and to go with it so you don't have mistransmissions that result in death. So alert notifications could be many different, different types, such as an elective replacement indicator, into service on a device, ventricular tachycardia, bradycardia, asystole, well, an agonal rhythm as well. So then there's a stepwise approach that we take. Obviously there's critical alerts. With these critical alerts, they take up a different priority. There's an immediate action. We usually like to try to get these as soon as possible within less than 24 hours. And these alerts generally are between the patients who are having ventricular tachycardia. And what do we do with this? This is a wellness check, calling the patient, seeing what's going on, if they're okay, if they're taking their medicines. Device integrity. It's an urgent review. What if you have somebody that has a lead integrity issue and can't, and the device is not going to deliver therapies appropriately? Again, going back to how we assess each transmission, each time, each day. Heart failure trends. We need to monitor and adjust the therapies. This takes a team approach. Again, it's not just one person. It's multiple people that's involved in this. And it's to prevent patients from having decompensated episodes. And then there's still the non-urgent. There's still an urgency to look at these. However, it takes up time from more urgent episodes or transmissions. And then, of course, documentation. Everything comes with documentation. So this is how we approach each day. Wouldn't we love to see zero transmissions assigned to you? I would, but this is truly not a true morning that I wake up and look at my remote transmissions. However, they are with remote platforms. Instead of going into each one, this is very helpful for our team to look at. Red alerts, yellow alerts, blue, and all green. So now we're going to move into alerts that we see from patients. So this is patient one. This patient is not pacer-dependent, but his ERI was reached. And you can see it right here, 16%. So my team actually sent me this alert. And what do we do with this? Again, it's a multidisciplinary approach. We don't just, my team just doesn't send the reports to me. They're going to tell me, they know I need to know, is this patient dependent? What's going on with it? And gives me a lot more detail to the transmission. So there's not back-and-forth communication taking up their time or my time. So we looked at this patient, and you can see from December of 22 through February, that the patient's trend was starting to go down. So this is just a routine. This patient actually had a follow-up in two months. There wasn't much to do besides to have them make sure that they're coming into the clinic and be aware that at some point in the near future, this person would need a generative change. So here's another transmission. And why did I give you another ERI transmission? Because this one holds a little bit different priority. This patient has actually a CRT, and the ERI was reached. And so what goes in my mind when I see this, is that if this patient gets into the EOS, they won't have the ability to buy V-PACE as much, or they will lose that ability, as well as lose the ability for therapies to be delivered if they have a sustained ventricular event. So this patient was brought in a little bit earlier to discuss when we would get their device changed as well. This is patient number three. So this patient actually is a 70-year-old male who had a loop recorder for AFib monitoring. He was on propafinone and, as needed, pill-in-the- pocket metoprolol for elevated heart rates. As we see, this patient had one episode recorded on December of 24, and at 8 a.m. he went into a sinus bradycardia followed by a 27-second pause. And then it went into a junctional rhythm, and then the following tracings showed that the patient had a sinus rhythm. The patient was called by my team, and actually the man took two propafinones. And this is why he had such a sustain. There wasn't other episodes, but he also lived in Puerto Rico. So just like you had someone that it took you two weeks, unfortunately, to find him, this man lived in Puerto Rico. So it was to coordinate his care coming in, and also some teaching that, you know, be mindful of your propafinone and don't double-take it. Patient number four. So this is a patient who has a CRT, and as you see on here, this patient's in this October of 2024. His CRT pacing started to go down. His PVC started to go up. His thoracic impedance also started to go down. We called the patient, seeing how he's doing. He's like, I don't feel any different. Verified that he was taking his medication as prescribed, and he was. So my team just knew to be on a higher alert. It was on the higher priority for us to keep looking at it. So if you see, in November, he still stayed. Well, here in December of 2024, two months later, he was still sustained. So we called the patient, asked him how he was doing. He actually said he was having some shortness of breath. He wasn't feeling as well. We wound up getting another echo, looking at him, adjusted his medications. He still did not feel well. His EF dropped to about 50%, and then saw him back in follow-up and actually did a PVC ablation on him. He is now doing well. Feels great. EF came back up, and PVCs are gone. So these interventions on these patients are really important, and it's not that it needs immediate action, but it may take a long-term, you know, two to three months follow-up on these people with good care and coordination through the team. So this patient, this patient was a VTVF episode. He was lucky. He went into this atrial tachycardia. I'm missing a slide. One of my slides is gone. Okay. Anyway, he was in here. He actually did have therapies delivered to him. This was after hours, so the after-hours team was called. The patient was sent to the emergency room. He was actually fine. It was just he missed some medications. He said it's a double take, and he missed them, and the patient was then seen in clinic. We did adjustments of his device as well, and he's doing fine now. This is patient number six. So as you see, November of 2024, we had some yellow alerts. There was a rapid ventricular and atrial episodes that happened, and it's this December 5th. Remember this time right here, because December 18th, there was no alerts between here. However, there was a red alert that came back that therapies were disabled. Well, to my team, they were looking at the history and saw that this patient had some ventricular, because it was a primary prevention ICD. When we called the patient and looked through the chart, the patient actually went to an outside facility. His therapies were disabled because he was changed into hospice. So my takeaway from this slide is that we have to have good communication with the patients, with the teams, including outside facilities as well. So this poor little guy, he was really nice. So as we talked about alerts and how much we save patients with heart failure, these patients with heart failure and having devices, there was a study that showed that one alert transmission, that 30% of people died within five years. Even more scary, the median time from the last transmission to death was 10 days. So when you think that transmission is not important or that these patients may not expire, 10 days, that's a really powerful number for myself. So then we get into the ethical considerations, which is what I think of, and the end-of-life planning. I think these end-of-life transmissions and life plannings need to come out before the patient gets the device and to keep on educating them. Because we all know we sit in these clinical visits, we see these patients, and we tell them, this is what can happen down the way. But this patient's device was implanted maybe five years ago, 10 years ago, and then their health has changed over time. So when we do these discussions, it has to be up to date. Keep their advanced directives up to date and respect their autonomy. Also, the psychological and logistical changes in healthcare, the rates of burnout. When we're talking about dealing with patients who are sick, who we become very close to. Because if you have a patient that is coming back into the clinic often, or they've been in the monitoring, we get close to these people. We start to know them, we become friendly with them. And so cardiology burnout's about 27%, and cardiac electrophysiology's at 36%. With this burnout, we know if you get tired, there's increased healthcare costs, medical errors, patient outcomes, and patient satisfaction. So what do we do? Let's wrap this up in a sense of monitoring and preventing burnout. There's low-priority alerts. Again, going back to alert-based and not scheduled transmissions. Should we do this so we can better assist the care of the patients? Automated dashboards from my own team definitely significantly help us. And we rotate staff responsibility. We provide cross-coverage. So if my team sends out an alert to me to look at and to see, we send it to the on-call person as well as the attending, who is the main person of, the main providers, electrophysiologist, cardiologist. We try to keep a team approach so everyone is involved in that care and it has worked out quite well. Because if the electrophysiologist is in the procedure or the on-call is in the procedure, that transmission response may be delayed. So paths to better outcomes, structured workflow, patient engagement, alert prioritization, support staff, interdisciplinary collaboration, technological advancements, these all go into what we all need to take into consideration when looking and dealing with these patients. This is my team and I couldn't do it without them. Thank you very much. Thank you. Thank you. Thank you very much, Monique. That was a great presentation. Next up, we have Machi Derbis from the University of Celestia. Yes, it is. It's kind of tricky when you come from Poland. Yeah. Okay, so first of all, I'd like to thank the organizers for inviting me to participate in both the HRS and this very interesting session. Today, I have a difficult task of magic, of predicting something that is gonna come. And first of all, when talking about heart failure, Monique has already stated that it's one of the most difficult tasks for us to cope with heart failure and heart failure worsening is associated with the worst long-term survival. And in this context, an appropriately conducted remote monitoring has been shown to improve prognosis in patients with heart failure. And so in both the European Society of Cardiology guidelines for cardiac pacing or resynchronization therapy, as well as in the guidelines for the prevention of sudden cardiac death, remote monitoring has been given class one or two A indication depending on the clinical scenario. The consensus document of the HRS and the sister societies on remote monitoring also gives the class one A indication for remote monitoring itself, emphasizing that it's the continuous connectivity with the possibility of delivering the alert transmissions that matters the most. And so of the three possible schemes of care that we have, it's actually the continuous or the alert based that actually make a difference to the patient's outcomes. Of course, when analyzing the causes of the transmissions, there are plenty of them. And even though there may be some subtle differences between the manufacturers as has been elegantly stated, for instance, in the study that has been already discussed by Chris with some subtle differences between both manufacturers and the devices itself, in general, we can say that the majority of the transmissions that are delivered and then are analyzed by us would be either because of the arrhythmias or the patient related factors, including, for instance, patient trigger transmissions or device hardware or software issues. Are these transmissions frequent? Well, it depends and obviously, it will depend both on the programming and also on the patient population. In our analysis of more than six year follow up of all the patients, the rate of patients experiencing, for instance, appropriate shock therapies was approximately 26% with approximately 10 to 12% experiencing inappropriate therapies. In regards to patients with cardiac resynchronization therapy, please take into consideration that approximately 50% of those patients do experience at least one alert associated with low percentage of biventricular pacing. Naturally, the number of transmissions that are delivered will be dependent on the way we program the devices and we program also the indications for those transmissions and the office of the consensus document do recommend that we should program the transmissions according to the patient's indications with one exception, in patients in whom any ICD or CRTD shock therapy occurs, this should be mandatorily reported as an alert transmission with all the others being turned on and off according to the treating team's discretion. The consensus document prioritizes the ICD shocks, the battery parameters and the possible lead integrity alerts as the most prioritized ones with the thresholds or delivery of ATP being of the second however high priority. However, do any of those transmissions actually have message giving us an indication that this patient is at higher risk of death? And when looking at the long-term data, we know for instance from the combined analysis of the MATIC trials that the ICD shocks delivered due to VF or fast VT are associated with a higher risk of death and similarly we can say that in the MATIC trial the inappropriate shocks delivered were also associated with a higher risk of death. Also in patients with cardiac resynchronization therapy, the more pacing we get, the better outcomes of these patients and for instance in the MATIC CRT trial, patients with a low biventricular pacing percentage had a higher risk of death. In the real world study, for instance the one on the right side that has been conducted in our center, patients who had a lower percentage of biventricular pacing on a day-to-day basis also had a higher risk of death. Multiparametric algorithms that are being more and more frequently utilized in this population also enable us to predict not only heart failure worsenings but also identify patients at a higher risk of death and when you look for instance into the data on the heart logic algorithm, you see that patients in the alert had a substantially higher risk of death. In the heart insight algorithm, patients with the higher baseline heart failure score were also identified at those with the higher risk of dying. However, the question, the practical question would be, can we identify patients, not only those ones who are gonna likely die in the long-term but also in the short-term perspective? In the study of Chris that he has already discussed in detail, I would just like to emphasize that of more than 7,000 patients monitored remotely, the study population focused on 28 patients which is a relatively low number. Monique has also cited our work from 2022 in which we have analyzed more than 1,000 patients monitored remotely and I would like to emphasize a few points because I think that those refer to the subject of this presentation. First of all, 85% of our patients with an ICD or CRTD do experience at least one alert and when you look at the mortality of those populations, they are substantially different which is also clinically explicable I think with the mortality in patients with the alerts of approximately 30% and in those without any alerts of approximately 12%. When you look at the data on the last before death transmission of those patients, not all of them are alert at all and approximately 50% of patients with ever an alert have the last before death transmission as the planned one and when you look in details into the causes of those alerts, they're actually kind of replicable and also very often reproducible and were probably occurring in those patients before. When we look at the causes of those last transmissions, please have a look that 39% of those are caused by atrial fibrillation or flutter. You would have approximately 25% of patients with a VT or VF and also a high proportion of patients whose last transmission was caused by low percentage of biventricular pacing. When we looked at the number of such transmissions occurring in those patients before, more than 90% of those patients had a similar transmission before so it's usually not a new event that was this last cause of transmission. When we were analyzing why so little percentage of patients were actually had the last transmission before death caused by ventricular tachyarrhythmias, we came back to the pivotal studies on heart failure and heart failure management and when you look, for instance, into the causes of death of patients regarding to the New York Heart Association class and in our study, approximately 50% of patients were implanted already in New York Heart Association III. When you look at those patients, the proportion of subjects who died due to sudden death was substantially lower the more progressed heart failure was and for instance, when you look at the data from the DENISH trial which demonstrated no substantial benefit of an ICD in patients with non-ischemic cardiomyopathy, you could have reproducible results with patients in the more progressed heart failure with higher baseline anti-prop BNP not deriving that much benefit from an ICD. So ladies and gentlemen, in conclusion, I would love to say that there are many useful tips for identifying patients at a higher risk of death but unfortunately, I get to say that specific remote monitoring alerts, including shocks, including biventricular pacing percentage or multi-parametric algorithms are associated with increased risk of mortality in the long-term perspective. However, the last before death transmissions are alerts only in a limited percentage of patients probably highlighting the multi-morbidity and often the non-cardiac nature of the terminal events in this population and with this, I would like to thank you for your attention. Thank you. Thank you so much, Maciej. That was a wonderful presentation. Next presenter is Nairi Sencion-Akhtar from Westchester Medical Center. Hi, I'm Nyree from West Chester Medical Center, New York. My piece today is a little bit different from everyone else. It's the emotional response by clinicians to observing death on remote monitoring. And thank you for having me here today. Okay here we go. I have no disclosures. This is my team from Westchester Medical Center New York. Now we all know that remote monitoring you know allows for the oversight of cardiac implantable devices and is considered a standard of care. While observing or you know overseeing remote monitoring however device clinic staff have witnessed end-of-life arrhythmias and depending on the timing of the event an intervention may be made to save a life or we're too late to help the patient. And if the patient cannot be saved you know the result can have psychological implications on the staff who have witnessed this event. I'd like to present a case of a patient that we took care for many many years. Oh I forgot this guy sorry. The patient was a 67 year old trans-female. You know she had hypertension, COPD, congenital heart disease, valvular surgery. She had persistent AFib. She had heart blocks. She had a you know pacemaker and she had a relay monitor at home. On the day of this event the APP logged into the remote monitoring platform around 730 a.m. and got a yellow alert for this patient and the patient's transmission was sent around 717 a.m. which recorded seven episodes of high ventricular rate including a prolonged episode. As you can see the presenting EGM has like this wide complex tachycardia with you know variable cycle length which you can see some undersensing from the pacemaker as well. So this was classified as you know non-sustained episode. So she had seven episodes. We looked at all of them. You can see the first one was around 710. The prolonged one was around 711 and when we reviewed everything we concluded that this probably was a sustained episode which was undersensed by the pacemaker. So you know we made multiple phone calls to the patient and the family you know with no response. We called the local police department and about approximately an hour later the police officer confirmed that the patient was found in cardiac arrest and they were trying to you know resuscitate her. They brought her to the local emergency room and unfortunately you know she was deceased and the patient probably at the time of this event was near her monitor and some of the monitors actually immediately will push you know high ventricular rate alerts. So although you know remote monitoring isn't real-time the timing of this event from receipt of this transmission was coincidental and despite activating you know EMS the likelihood the likelihood of her survival was low. You know remote monitoring provides abundant information which can be challenging for centers due to the data volume and also the nature of information being received you know and for detecting a patient's death. So because we couldn't help this patient we couldn't save her this was emotionally you know distressful for the staff. There was a long-standing relationship with this patient and then compounded by the receipt of this transmission almost simultaneously to the initiation of her VT. With the patient staff with the with the staff's emotional reaction be different if there was no relationship with the patient. So how did the staff cope? So instinctively you know we spoke to the patient's family. We talked about memories you know about taking care of the patient in the office. How many years we took care of them. We offered our condolences. You know we discussed with the patients attending. We discussed with each other. We talked about our feelings. I know this sounds really mushy but this works. You know we debriefed. You know we talked about how can we do things better. We also discussed with our families and yes we were HIPAA compliant. So how many device clinics have seen a patient's device on remote monitoring? How many have agonized over not being able to help the patient promptly? Could the patient have been saved if there was a more rapid response to this event? How many you know health care providers have felt sad and or guilty helpless or upset? So I was curious so I sent out a very small survey just to get an idea of what other clinics have experienced and how they've coped. And these are some of the questions that were on that survey. Does your office do remote monitoring? And a hundred percent answered yes. Does your office outsource remote monitoring? And 42% answered yes. Does your office have designated staff to review you know the remote monitoring transmissions? And a hundred percent answered yes. Do your patients come in for annual visits? A hundred percent answered yes. Have you ever received or reviewed a transmission with a lethal arrhythmia? And 88% said yes. Was the patient deceased? And out of that group 95% answered yes. All right so how did that make you feel? And the options were angry, sad, frustrated, tearful, guilty, helpless, okay it's part of my job, none of the above, all of the above, some of the above, and there was a spot for other. And if they selected you know any of the emotions from above well then how did you cope emotionally? And some of the options were to breathe with colleagues and attending, you know discuss with co-workers, discuss with family and friends or other. About 57% of the respondents responded they discussed with their co-workers. However three of the respondents did answer that they used all of the above. So this survey demonstrated that you know the clinical staff have experienced symptoms of grief such as sadness or helplessness, guilt, indifference. Others you know responded feeling really upset. So it also demonstrated how you know the staff try to cope with the event which they used you know debriefing with colleagues and attendings, you know discussing with co-workers and family and friends. Some use some of these interventions and some used just one. So when you look at the literature on this topic literature does not exist specific to this subspecialty you know pertaining to the psychological and emotional response to death witnessed on remote monitoring. You know many of, I'm sorry, many of the available recommendations however of coping with death were from different specialties like pediatrics, oncology, you know COVID. You know so therefore there's you know research is needed to help develop interventions for addressing this need in EP. You know there's several articles from other specialties that have provided useful strategies for coping with death and from these you know available studies several interventions can be applied to help EP staff cope with dealing with you know death's witness on remote monitoring. Some of these studies actually had shown that as health care professionals we try to continue to perform our duties while dealing with these emotions. So what interventions you know can be used from other specialties to help the EP staff deal with their grief? What can we do to help? Well from the literature there are many useful interventions and recommendations. At the end of this I'll let Dr. Sears you know be the judge of that. One of the things that we can do is have awareness. You know be aware of what the staff may experience. They can experience you know disbelief, guilt, anger, ambivalence, indifference, denial. You know health care workers may experience different reactions to the loss depending on the relationship with the patient. You know we also need to be aware of that frequent exposure to loss and stressful work setting can pose significant stress and impact the health care's professionals well-being. Communication. Open communication. Asking the staff how are they doing? How are they feeling? Active listening. Peer support. Looking to each other for support. That has deemed to be the most beneficial. Have staff gatherings with other team members. You know reminisce about the patient after the patient dies. Provide you know staff with the opportunity for personal closure. Having you know discussions with other health care professionals. Attending support staff. Anyone that was involved in the patient's care. Debriefing. Debriefing debriefing you know provides staff the opportunity to discuss death. Reflect on care activities. Review what went well and what could have been done differently. You know we actually after we debriefed we changed some of our remote monitoring protocols because of this event. Other things we can do. You know attend the patient's funeral. You know go to their memorial service. Make phone calls. Condolence cards. These are simple things that you know we can do and if we need you know more support then we can you know send someone to EAP or you know bereavement counselor. So many of these interventions can be applied to help staff or the EP staff dealing you know with death witness on remote monitoring and several of these strategies have been utilized in our practice and have been you know proven to be beneficial. There is an identifiable gap within literature on the psychological and emotional responses to dealing with death witness on remote monitoring. So you know there is research needed to help develop interventions that address this need specific to EP. If we're not able to manage our grief in healthy ways it can potentially affect our personal lives and professional lives and you know resulting in less than optimal care to our patients and our families and we are at risk for burnout. We need to focus on building resilience within healthcare to enable us to deliver the highest quality care to our patients and ourselves. Thank you. Thank you Neri. That was a wonderful emotionally powerful presentation. So we have many many questions from the audience. Thank you for sticking with us. You know this is a subject that is very very tough to tackle and we hardly ever talk about it because we just have so much work to do and we keep moving on. So I'm glad that this session is being attended by so many of you today. There was some questions that I wanted to address first and get those out of the way. The one that somebody sent out was it's ERI and RRT. Can this be used interchangeably? So everyone here knows that ERI is the elective replacement interval and RRT is the recommended replacement time. You know that is what the interoperability group at HRS of which I'm a part of is trying to do because too many terms, too many this, too many that. Let's just be cohesive with what we're talking about. And that would be like the mechanical question that I'm going to you know focus on for this moment. But I think that the bulk of this presentation is where is the emotionality of what we do every day. Every single one of the scenarios these presenters alluded to and spoke about during their presentations, I've experienced every single one of them. And I can tell you that in order to protect yourself, you start to build a chaos around your emotions. And I have termed that and there was an article that Sam just recently published. But what I like to just share with all of you is that it feels like my empathy is being punched out of me. And that is real and I'm truly truly sad about that because the relationship that we have with patients even though it's remote monitoring, it's really real. You speak to these people every single time. You speak to their daughters, their sons, their family members, their spouses. So it's a real relationship and it's so new, so new. So maybe Sam can talk to us about is this PTSD for me that it feels like I'm my empathy is being punched out of me. I'm an old woman trying to do good in the world, Sam. You're doing it. You're doing it. So empathy is our secret power, right? Empathy is the power that drives relationships. There's high stakes on both sides of that interaction. There's high stakes as a pro. That's what we do. We're pros. On the other side, this patient needs safety in this interaction. And so callousness is a reasonable response to something that is very difficult to manage. In addition, all of us are high achievers. We're used to winning. And when we lose, we don't always know what to do with that. I mean, if you think across your life, you don't get to this stage because you lose a lot. You get to this stage because you win a lot. So coping with the emotions, particularly negative emotions, and in our world where mental health stigma or being emotional is somehow made fun of, then caring about a patient, having your heart broken, and building these relationships makes us human. So I don't think callousness is so much the, callousness is a symptom. But the root cause is that we have empathy. There are negative emotions. And we don't have good avenues of addressing it in this highly cognitive world. I mean, you guys are experts at looking at these rhythms. But what happens when you feel guilt? And it's in part because we have delusions of control and illusions of control. Just because that rhythm was there and it had the coincidental time to time, the chances were low in the best case. And so we replay that back in some sort of false set of probabilities and create different emotions. So I could go a long time about this. I mean, I think your question is, is that PTSD? I would simply say that rather than call it PTSD, which is a formal diagnosis, I would say that our brains put ourselves on alert. That when bad things happen, we try to forecast them happening again and conjure up the memory, the reminder, to try to prevent that emotional negative response again. So it's the processes of PTSD, perhaps. But I would shun the idea that it's PTSD per se. But the characteristics are there and the symptoms are. It's more just a nomenclature and a formality that I'm trying to separate here. I just think that's important. I think the processes remain the same. Does anybody have any questions? We're going to address some of the questions that were asked on the app. But if anybody feels compelled to stand up to the mic and ask a question. I actually asked one on the app as well. But I'm from New Zealand. And I just found out how much remote monitoring you guys do. And I don't know how you cope. We basically set our patients up to see them in the clinic once a year. And we do a remote monitor once a year as well. So every six months. Patients know that they can ring us if they want. If they feel there's any change and we can send one through. We say to them, the idea of putting this device is so you can live your life and not focus on your condition. And I just wondered with the frequency of the remote monitoring that you do. So I believe it's every 31 days for ICD patients and 91 days for pacemaker patients. We don't remote monitor any of our pacemaker patients. We mainly only do ICD patients. And we tailor the alerts, tighten them in so that they alert us and have a good relationship with the patients. And I don't know how you guys cope. But I just wondered from a patient perspective, does that make them feel safer? Or does it make them kind of focus on their condition? Yeah, good question. So that study is underway to kind of look at the impact. There have been multiple studies that look at remote monitoring, which have been generally halo type effects. People benefit from both the technical and perceived protection that goes with remote monitoring. So it's quite broadly a positive effect. In Nova Scotia, there's some larger. And Canada has been focused on a number of the impacts of remote monitoring. In general, remote monitoring has a very positive effect on patients. We worried about that a lot early on. We know that the relationship has changed as a result of less human eye-to-eye contact. But in the post-COVID world, we're all a lot more comfortable with these more, I don't know, technical connections, if you will. I think you can coin the phrase technical connections. Yeah. Yeah, I mean, I think it's kind of, it is. It's a technical connection, because we do. I mean, think about it in a way. You look at someone's rhythm, but you also conjure up in your mind's eye that human, right? I mean, we really do know these humans. And we have this incredible narrative. It's almost a story. I'm being a little facetious here. But you have this narrative about a human's life. In their medical record. So even if you didn't have a relationship, we create or conjure who this person is based on their medical record and the things they've gone through. So in general, the question is remote monitoring is quite desirable all around. It's just the issues that this, by the way, I think these were four fantastic presentations. I've been coming to HRS since it was nasty. And these were fantastic presentations. You guys are doing a great job. These were fantastic presentations. You guys were doggone pros up here. But I think that we can reassure ourselves that the technical side does seem to have a positive patient benefit. I agree with that. Just to answer the question from us, I consider myself a boots on the ground remote monitoring soldier, because it really does make the patient feel safe. I can tell you that that technical connection really is real. And the reason, I'm not sure why, I guess different payer systems in different countries are different, but I can tell you that the reason why you probably look better than I look is because I do remote monitoring more. She also lives in New Zealand. It's also one of the most beautiful places in the world. But sure, yeah. So did you want to look at the questions that come? Sure. So let's see if we can answer some of these questions that are same theme. So one of the questions here is, does the high frequency of remote monitoring in the US have an impact on how the patient perceives their condition? You probably are the one that asked that question. But I would say in the US, they do. Patients are very, very attached to that monitor. And obviously, there have been many, many trials that show that remote monitoring does save lives, does keep you out of the hospital. Some of the presentations that you all did here attest to that. So I'd like for each panelist to share their experience. But I would say for patients, and I've been doing remote monitoring for a very long, long time, hence the way I look. But I would say that they have, especially post-COVID, they have looked at that monitor as a lifesaving device, as a lifesaving connection. And our aging population holds onto that very, very much every single day. Why did you not see that? Did you not see that I had this? Why didn't you call? So they are holding us accountable to that. There's not enough money in the world that we can get paid for what we do, because patients do make, they do transfer that real connection, that connection that they feel. It isn't mechanical for them. It's like Martha's watching. So anyway, share. And they'll be watching the best we can do to help them. So I don't know where to start. Will the panelists be able to answer? I'd probably just expand a little bit further on that line of thought. I think one of the biggest misconceptions of remote monitoring from a patient perspective is that it is alive, particularly with remote monitoring apps. And it's one of the main reasons we've had queries with lawyers within our own trust when we presented these cases, because the question is always asked, why didn't you save my brother? Or why didn't you save my son? And you go, well, I didn't get the transmission until 2 o'clock in the morning. And I wasn't there looking at it at 2 o'clock in the morning. It was also seven hours or too late. So these sort of situations with understanding that communication and being able to make sure that the patients are aware of that, I think, are a key fundamental. I think that the different structures for payment are probably the main reason why the services are different. We don't do transmissions every three months or every 30 days. But I think one of the benefits of that is you end up having a different disconnected rate. If you're checking whether the patient has a transmission every 30 days, they're going to be connected. If we're doing it once a year, the patient gets disconnected. Are you going to be following that up after two weeks? We might not. And if we're not necessarily having a payment incentive, you might not have enough resource to be able to sort that solution out. But I think, fundamentally, the alerts are where a lot of the mortality and the benefit for remote monitoring is from the alerts, necessarily the schedules. You pick stuff up on the schedules, but the vast majority are alerts. So I'm going to kind of go back to a little bit further back. I think we get desensitized. I don't know if it's PTSD. I think we become desensitized when we have these alerts. And I know I'm kind of going back a few, but I wanted to kind of amplify that. I think it's more desensitized than PTSD. But I also think, just like we're getting alerts and saying that this is there, I also have patients that will say, hey, did you see anything? And I think it's also a comfort, hey, there's nothing there. So I think we have to look at the other spot. Do we see alerts? Yeah, but we also can comfort the patients, maybe post-ablation, post this, what you're feeling is not there. So it's not always the negative. It's also the positives and saying, go live your life. So I think it has both sides of that. That's wonderful. Well, if I could contribute a little bit to the sense of the need for remote monitoring and also the patient's desire to that. In Poland, we have initiated reimbursement of remote monitoring only two years ago. So before that, it was not reimbursed. And there was a short period of time when we, as the hospital, supplied every patient with remote monitoring just from our own resources. Then this period has ended. And in the period between being given reimbursement and giving the transmitters to all the patients with the ICDs and CRTDs, we were very often forced during the device replacement because, again, of the reimbursement of the supplies for the hospital to say to the patient, sorry, you're getting a new device, but it's not going to come with remote monitoring. And there came a huge disappointment, which we basically couldn't do anything without that. And we also saw many of the patients trying to even commercially get remote monitoring for us so that we could continue this care. So that also shows you how much these patients attach to this kind of surveillance that they get and the better care that they also perceive from their perspective. So because we usually transition from no monitoring to monitoring, but the reversal transition is kind of very critical when it occurs. It's a great anecdote. Thank you. Well, let's see. I have patients that I think it's the older patients that weren't used to being remotely monitored. They wanted to come into the office to get checked because they felt safer that way. So those we had to work on a little bit more. I still have patients that are on remote monitoring, and they still come into the office, but that's OK. And then touching on your point about reimbursement and remote monitoring, that's another issue as well with patients. They don't want to get the co-pays if they have co-pays. If you have an ILR, and it's monthly, or if it's an ICD, and it's every three months, and then you also have the heart failure monitoring. So I think that's another problem or another issue that patients might have with remote monitoring is the financial aspect of being remotely monitored. Yes, they feel comfortable and safe being monitored, but then they're worried about, well, how am I going to afford to pay these co-pays every month? The American problem. Yes, it is. I think we're a little over time, right, are we? OK, so unless it's a burning question, everyone, thank you so, so much for coming, and safe travels, everyone. See you next year.

Cardiac Implantable Electronic Devices

remote monitoring

patient safety

healthcare efficiency

CIEDs

structured workflows

ICD shocks

emotional impact

healthcare providers

mortality prediction