With modern advances in implantable technologies and telemedicine, patients are increasingly able to remain engaged with their healthcare providers regardless of their global location. Remote monitoring of cardiovascular implantable electronic devices (CIEDs) such as pacemakers, defibrillators, and implantable loop recorders has been increasingly integral to the practice of cardiovascular electrophysiology. Benefits of remote monitoring include reduced mortality and reduction in hospitalization, particularly for cardiac resynchronization therapy (CRT) devices.1-4 Earlier establishment of remote monitoring is associated with greater patient survival.5 Thus, all patients at NYU Langone Health undergoing CIED implantation are enrolled in remote monitoring and commonly discharged with a “paired” remote monitor. Current remote monitoring units come with either a cellular adapter or have a cellular component built into the device that the unit utilizes to transmit data securely to the remote monitoring portal (Table 1). Thus, adequate cellular service is critical to establishing remote monitoring. Figure 1 displays a sample of various monitors.
We present a case report illustrating present challenges and solutions related to remote monitoring of patients residing internationally.
A 71-year-old Ethiopian male with prior medical history of hypertension, dyslipidemia, diabetes mellitus, coronary artery disease, and three-vessel coronary artery bypass surgery presented for coronary angiography for workup of presyncope, and was noted to be in complete heart block (Figure 2). Transthoracic echocardiography was notable for a left ventricular ejection fraction of 45%. A dual-chamber pacemaker (Azure XT DR MRI, Medtronic) was implanted with a fixed-helix, lumenless lead (SelectSecure MRI SureScan Model 3830, Medtronic) into the basal interventricular septum for direct left bundle pacing, and inserted into the ventricular port of the device (post-operative ECG in Figure 3). Prior to discharge, he received a paired remote monitor (CareLink 24952, Medtronic). We explored availability of remote monitoring in Ethiopia with all available PPM manufacturers prior to implant, and were unable to confirm availability with any vendor. We proceeded with the plan to reach out to local technical support after the patient’s return to Ethiopia in order to establish remote monitoring.
Post-operative appointment revealed a well-functioning device and a well-healed surgical site. Shortly after the patient returned to Ethiopia, the remote monitoring clinic received a notification alert for disconnection due to his home monitor not communicating with his pacemaker in 14 days. The monitor was confirmed to be connected to power, but unable to connect to the local cellular connection. Further consultation and follow-up with Medtronic CareLink technical services confirmed lack of availability of the CareLink Network cellular coverage in Ethiopia, and local in-person follow-up was recommended. Two local hospitals with Medtronic programmers were identified, but it was determined that the implanted device would not be able to be interrogated due to local unavailability of the device. An adapter that would allow the CareLink Monitor to connect securely to a WiFi router was then identified. However, this required the patient to arrange for delivery due to the vendor’s international shipping regulations. Ultimately, the adapter was provided to a family member, who then sent the adapter to the patient. Figure 4 shows the setup for connecting to the router and home monitor. The patient successfully set up the unit, and is now actively participating in remote monitoring per our usual CIED follow-up protocol.
Remote monitoring of implanted CIEDs has become the standard of care. Increasingly mobile patient populations present technical and logistical challenges for implementation of remote monitoring. Our patient, whose primary residence is in Ethiopia but travels to the United States for advanced healthcare needs, is a prime example of one of these patients. Implantation of the latest model devices is typical at most U.S.-based medical centers, but can result in challenges for internationally-based patients due to geographic variability in device availability and local cellular availability for remote monitoring. CIED vendors have moved away from telephone landline remote monitoring in favor of direct cellular connection; however, geographic availability varies by vendor. In consulting with technical services for vendors with substantial U.S. market share, we were able to compile geographic availability of cellular remote monitoring (Table 2). Medtronic recently released a remote monitoring device with capability to connect to a patient’s WiFi network (24960 MyCareLink Relay, Medtronic), but at this time, this device is currently compatible with only the recent model pacemaker and CRT-P generator.12
In this case, our patient did not own a smartphone or tablet, which would have allowed utilization of a personal device-based app. However, since 2015, CIED vendors have increasingly incorporated use of personal devices such as smartphones and tablets for CIED management. For example, Medtronic has recently released personal device-based applications for both earlier (MyCareLink Smart) and newer (MyCareLink Heart) generations of pacemakers and CRT-Ps. Abbott has an insertable cardiac monitor that can utilize a smartphone for both symptom triggering and remote transmission (Confirm Rx with SharpSense Technology). Additionally, Boston Scientific released the MyLATITUDE Patient App, which provides patients with information about their implanted device’s battery status, whether their LATITUDE Communicator is plugged in and connected, and how to troubleshoot the monitor.13
Vendors provide a WiFi adapter for remote monitoring if cellular service is not available in the region of patient residence, but these adapters must be specifically requested. Given the increasingly global nature of patient populations, an industry-wide effort amongst CIED manufacturers to ensure global software availability for device interrogation will allow for improved care for patients when they are away from their implanting center. Increased awareness of the challenges faced by our patients as they travel across the globe can facilitate more optimal care.
Disclosures: The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Barbhaiya reports personal fees from Abbott, Ms. Smyth-Melsky reports honoraria from Medtronic, and Dr. Chinitz reports personal fees as a consultant for Abbott, Biosense Webster, BIOTRONIK, Boston Scientific, and Medtronic.
- Mittal S. Increasing role of remote monitoring of cardiac resynchronization therapy devices in improving outcomes. Card Electrophysiol Clin. 2019;11(1):123-130. doi: 10.1016/j.ccep.2018.11.011.
- Crossley G, Boyle A, Vitense H, Sherfesee L, Mead RH. Trial design of the clinical evaluation of remote notification to reduce time to clinical decision: The Clinical Evaluation Of Remote NotificatioN to rEduCe Time to Clinical Decision (CONNECT) Study. Am Heart J. 2008;156(5):840-846. doi: 10.1016/j.ahj.2008.06.028.
- Saxon LA, Hayes DL, Gilliam FR, et al. Long-term outcome after ICD and CRT implantation and influence of remote device follow-up: the ALTITUDE Survival Study. Circulation. 2010;122(23):2359-2367. doi: 10.1161/circulationaha.110.960633.
- Landolina M, Perego GB, Lunati M, et al. Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators. Circulation. 2012;125(24):2985-2992. doi: 10.1161/circulationaha.111.088971.
- Mittal S, Piccini JP, Snell J, Prillinger JB, Dalal N, Varma N. Improved survival in patients enrolled promptly into remote monitoring following cardiac implantable electronic device implantation. J Interv Card Electrophysiol. 2016;46(2):129-136. doi: 10.1007/s10840-016-0112-y.
- Available options for remote monitoring. Medtronic. Available at https://www.medtronic.com/us-en/healthcare-professionals/products/cardiac-rhythm/managing-patients/improved-outcomes/remote-monitoring-options.html. Accessed May 29, 2019.
- Merlin@home™ Transmitter: Abbott Cardiovascular. Abbott Cardiovascular. Available at https://www.cardiovascular.abbott/us/en/hcp/products/cardiac-rhythm-management/merlin-home-transmitter/ht-tab/overview.html. Accessed May 29, 2019.
- Merlin.net™ Patient Care Network: Abbott Cardiovascular. Abbott Cardiovascular. Available at https://www.cardiovascular.abbott/us/en/patients/living-with-your-device/heart-failure/remote-monitoring/merlin-patient-care-network/ht-tab/setup.html. Accessed May 29, 2019.
- LATITUDE™ Home Monitoring System. Boston Scientific Corporation. Available at https://www.bostonscientific.com/content/gwc/en-US/patients/about-your-device/latitude-home-monitoring.html. Accessed May 29, 2019.
- LATITUDE™ Communicator Patient Literature Supplement Model 6359 USB Cellular Adapter. Boston Scientific. Available at https://www.bostonscientific.com/content/dam/Manuals/us/current-rev-en/92185415-001_LATITUDE_Communicator_Supplement_multi-GLOBAL_S.pdf. Accessed May 29, 2019.
- CardioMessenger Smart. BIOTRONIK. Available at https://www.biotronik.com/en-us/products/crm/transmitter/cardiomessenger-smart. Accessed May 29, 2019.
- MyCareLink Relay Home Communicator - Remote Monitoring. Medtronic. Available at https://www.medtronic.com/us-en/patients/treatments-therapies/remote-monitoring/available-monitors/mycarelink-relay-home-communicator.html. Accessed May 29, 2019.
- MyLATITUDE™ Patient App. Available at https://www.bostonscientific.com/content/gwc/en-US/patients/about-your-device/latitude-home-monitoring/mylatitude.html. Accessed May 29, 2019.