Journal of Arrhythmia 29 (2013) 314–319

Contents lists available at ScienceDirect

Journal of Arrhythmia
journal homepage: www.elsevier.com/locate/joa

Review

Implantable sensors for heart failure monitoring

P. Shasha Liu, Hung-Fat Tse n
Cardiology Division, Department of Medicine, Queen Mary Hospital, Hong Kong, Hong Kong Special Administrative Region

art ic l e i nf o a b s t r a c t

Article history: Over the last decade, there has been a surge in the implantations of devices for cardiac resynchronization
Received 28 May 2013 therapy (CRT), with increasing recognition of their value in the management of medically refractory heart
Accepted 7 June 2013 failure (HF). With this exponential growth, the need to offer the best quality of care after implantation
Available online 30 July 2013
has entailed an increase in healthcare spending. Frequent in-office follow-ups are limited by the
Keywords: immense healthcare cost, while emergency hospitalizations for acute decompensation of HF further
Sensor contribute to the burden.
Heart failure Implantable sensors in the CRT device offer a unique opportunity for continuous monitoring of a
patient's clinical HF status by measuring cardiac rhythm, intracardiac pressures, cardiac events, and
physical activity, as well as detecting any device malfunction. Detecting early signs of a deteriorating
clinical condition allows prompt preemptive medical intervention to optimize HF management. As a
result, not only healthcare professionals will benefit from a reduction in hospitalizations and routine
in-office follow-ups, but also patients will benefit from efficient management of their HF. This review
highlights the latest available device-based remote monitoring systems and the most up-to-date
evidence for the use of remote monitoring in CRT.
& 2013 Japanese Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
2. Concept of remote monitoring for heart failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
3. Evidence of effectiveness of remote monitoring of heart failure using CRT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
4. Components of a remote monitoring system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
4.1. Device sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
4.2. Types of electrical sensor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
4.2.1. Hemodynamic sensors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
4.2.2. Biochemical sensors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
4.2.3. Electrical parameter sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
4.2.4. Arrhythmia sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
5. Which parameters to monitor?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
6. Future trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Conflict of interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

1. Introduction

With the aging of the world's population and the consequent

increasing prevalence of major cardiovascular risk factors, heart failure
n
(HF) has become an important medical problem, one that imposes a
Correspondence to: Cardiology Division, Department of Medicine,
The University of Hong Kong, Hong Kong, Hong Kong Special Administrative
great economic burden on healthcare [1]. The worldwide prevalence
Region. Tel.: +852 22554694x3598; fax: +852 28186304. of HF has been estimated at 2–3% of the adult population [2]. With a
E-mail address: hftse@hkucc.hku.hk (H.-F. Tse). mortality rate as high as 50% in 4 years [2], the long-term prognosis

1880-4276/$ - see front matter & 2013 Japanese Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.joa.2013.06.003
 P.S. Liu, H.-F. Tse / Journal of Arrhythmia 29 (2013) 314–319
for patients with symptomatic HF appears to be even worse than for
those with certain major types of cancer. Patients with HF have a poor
quality of life, and suffer from high mortality resulting from progres-
sive HF or sudden death associated with arrhythmias [3]. In 2010, the
estimated direct cost of care for HF in the United States alone was
$39.2 billion, while in-patient treatment costs accounted for more
than half of this total cost [4]. Improvements in the outpatient
management of patients with HF are needed in order to reduce the
burden of hospital admissions.
First introduced approximately 30 years ago, cardiac resynchro-
nization therapy (CRT) has emerged as an attractive therapeutic
intervention for patients with medically-refractory New York Heart
Association (NYHA) classes III–IV HF and wide QRS duration [5].
Various studies have shown that, through synchronization of right
ventricular (RV)–left ventricular (LV) (interventricular) or intraven-
tricular contraction and optimization of atrioventricular (AV) tim-
ing, CRT facilitates reverse modeling of the LV, resulting in an
increased LV ejection fraction (LVEF), reduced mitral regurgitation,
and reduced heart size [6–9]. This translates to a clinical improve-
ment in the patient's functional status, as determined by NYHA
class, peak oxygen uptake, and exercise tolerance, better quality of
life scores, and reduced all-cause mortality [10–13].
The concept of CRT is a simple yet elegant one. The reality,
however, has exposed uncertainties in the efficacy of CRT, as several
studies have reported that up to 25–30% of patients show no benefit
from it [14–16]. Much emphasis in CRT-related research has been
focused on the identification of suitable candidates with ventricular
dyssynchrony. In contrast, guidelines for device follow up and
troubleshooting in the event of a suboptimal response after implanta-
tion have been lacking. To maximize the potential of resynchroniza-
tion therapy, CRT settings need to be monitored and titrated accor-
dingly [17]. This involves addressing issues such as device optimiza-
tion, management of arrhythmia and comorbidities, and, importantly,
HF monitoring and treatment. It has been shown that a multi-
disciplinary care plan involving frequent follow up and HF monitoring
at pre-discharge, 1 month, 3 months, and 6 months after implantation
leads to a significant improvement in event-free survival in compar-
ison to conventional care, up to 2 years after implantation [18]. By this
rationale, the ideal minimum frequency of follow up of CRT is every
1–3 months [19]. However, in view of the exponential growth in CRT
implantations over the past decade, the benefits of frequent in-office
follow ups are limited by the immense healthcare cost.
Vigilant HF surveillance and device monitoring after implanta-
tion are also important for detecting any early signs and symptoms
of impending decompensated HF. An aggressive surveillance
strategy would allow for earlier interventions, decrease morbidity
and mortality, and cut down on the healthcare costs of hospita-
lization. However, frequent in-office physician visits are limited by
resource availability. Thus, the concept of continuous remote
monitoring via intracardiac devices has become an enticing one.
Remote monitoring offers ongoing opportunities for manage-
ment from three perspectives:
1. Patient: continuous monitoring of the patient's HF and arrhythmia
status. This allows physicians to anticipate impending decompen-
sated HF and to implement timely medical treatment accordingly.
2. Device: sensors of device performance aid the hemodynamic
optimization of device timings, such as AV or LV–RV intervals.
They also allow the detection of device complications, such as
device malfunction and lead fractures.
3. Public health: decreasing the need for emergency hospitaliza-
tions for HF will be likely to alleviate the heavy healthcare
burden on the cardiovascular community.
This paper reviews the most up-to-date research efforts in the
field of remote monitoring of intracardiac devices, including a
315
discussion of the latest sensing technology, principles, implemen-
tation, and effectiveness of remote monitoring versus conventional
follow-up approaches, as well as the future outlook.
2. Concept of remote monitoring for heart failure
Most HF-related hospitalizations are due to fluid accumulation,
and careful surveillance of a patient's fluid status and symptoms is
important [20]. To effectively prevent HF-related hospitalizations, one
needs to detect early clinical deterioration and initiate earlier inter-
vention to avert acute decompensated HF. However, the clinical
difficulty lies in the fact that early signs and symptoms of HF, such
as dyspnea and decreased exercise tolerance, are nonspecific, whereas
more specific signs, such as lower limb edema and pulmonary
congestion, occur late. The traditional telemonitoring parameters, such
as body weight and natriuretic peptides, have poor sensitivities in
predicting impending decompensated HF; they did not confer any
survival advantage, nor a reduction in the number of hospitalizations
when compared to usual care [21,22]. Implantable sensors offer a new
means for the early detection of deteriorating HF in a way that has not
been possible before.
The concept of remote/home monitoring of patients is not a new
one; it was first established in patients with implanted pacemakers
in the 1970s. Historically, these sensors were developed to allow
rate-adaptive pacing during exercise and hemodynamic optimiza-
tion (AV interval, LV–RV timing). A newly emerging and arguably
more important role for such sensors is in continuous HF monitor-
ing. Nowadays, various companies are establishing novel interface-
linking systems that allow remote monitoring by transmitting data
from continuous home monitoring to a service center via a cellular
network or web application. From these centers, the physician and
nursing team can access and review the monitored parameters, and
can initiate interventions accordingly [23]. Acute deviations from
established trends—e.g., heart rate, atrial and ventricular high-rate
episodes, and the percentage of pacing and arrhythmias—can be
detected early, in contrast to the traditional in-office routine device
interrogations. This allows a physician to reprogram device settings
(e.g., AV timing changes) in case of suboptimal device efficiency,
treat arrhythmias (e.g., in the event of detection of new-onset atrial
fibrillation, or frequent ventricular ectopy that causes o100%
biventricular pacing) [24], and start medical treatments to prevent
hospitalization for acute decompensated HF.
When designing which parameters to monitor, one must take into
consideration the mechanism and natural disease progression of HF.
The reduction of cardiac output following myocardial injury sets into
motion a cascade of hemodynamic and neurohormonal derangements
that trigger the activation of neuroendocrine systems. The time
sequence of events begins with hemodynamic changes, followed by
a neurohormonal response, and finally the clinical manifestations.
Thus, changes in hemodynamic parameters and biochemical markers
precede changes in electrical parameters. Detecting parameters that
change at different time points in the HF course allows physicians to
adopt a proactive intervention style that aims at early prevention.
3. Evidence of effectiveness of remote monitoring of heart
failure using CRT
Two large-scale studies have shown a beneficial impact of
remote monitoring systems. The Lumos-T Safely RedUceS Routine
Office Device Follow-up (TRUST) multicenter study [25] was a
prospective study that compared automatic remote home mon-
itoring with conventional in-office interrogation and follow ups.
Varma et al. showed that a remote monitoring system allowed
earlier detection of clinically important events (both silent and
316 P.S. Liu, H.-F. Tse / Journal of Arrhythmia 29 (2013) 314–319
symptomatic), as well as device or lead malfunction and lead
fractures, thereby allowing timely interventions. Home monitoring
reduced the median time between detection of an arrhythmic
event and physician evaluation from 35.5 days in the conventional
group to o2 days in the home-monitoring group. Furthermore,
85.8% of all 3-monthly follow-ups were done remotely, without
compromising morbidity.
The Evolution of Management Strategies of Heart Failure
Patients with Implantable Defibrillators (EVOLVO) study [26]
showed that remote monitoring was able to reduce emergency
department and urgent in-office visits from 52% to 34%, while
decreasing in-person office follow ups by half. This translated to a
reduction in total healthcare utilization in patients with implan-
table cardioverter defibrillators (ICDs). Again, the lapsed time
between an ICD alert status and data review was reduced from
24.8 days in the standard arm to 1.4 days in the remote arm.
Furthermore, patients' quality of life scores were found to be more
favorable amongst patients in the remote arm.
4. Components of a remote monitoring system
The components constituting a remote monitoring system [27]
consist of:
1. CRT device.
2. Programmer: manufacturer-specific devices that receive and
transmit information via telemetry from CRT devices. Operators
are able to reprogram CRT devices via the programmer to alter
their behavior.
3. Home monitor/communicator: a remote telemetry device used
for transmitting sensed data from the patient's home to a
service center via telephone lines or cellular technology.
4. Remote monitor system: employs wireless/web technology to
allow near-continuous surveillance of the device and patient-
sensing parameters. Alerting events may be transmitted imme-
diately and flagged for attention. Examples of such systems
include Medtronic Care-Link, Boston Scientific Latitude, Biotro-
nik Home Monitoring, SorinSmart View, and St Jude Merlin.net.
4.1. Device sensors
Through CRT sensors, three major categories of parameters can be
monitored remotely to reflect a patient's hemodynamic and fluid
status: (1) hemodynamic parameters whose changes occur earlier on
in the disease process, including cardiac chamber pressures,
pulmonary arterial pressure and measures of cardiac contractility;
(2) biochemical parameters, such as oxygen saturation; and (3)
electrical parameters, e.g., intrathoracic impedance reflecting thoracic
fluid content, heart rate variability, and the patient's physical
activity level.
4.2. Types of electrical sensor
4.2.1. Hemodynamic sensors
4.2.1.1. Right ventricular pressure. A patient's RV pressure can be
serially measured using a piezoelectric crystal incorporated at the
tip of a pacing lead in the RV outflow region [28]. Subsequently,
the pulmonary arterial (PA) diastolic pressures can be estimated by
taking the RV pressure at the time of dp/dtmax [29]. The Chronicle
Offers Management to Patients with Advanced Signs and
Symptoms of Heart Failure (COMPASS-HF) study showed a
statistically non-significant reduction in HF hospitalization and a
21% decrease in the need for intravenous diuretics in the RV
pressure-guided treatment group [30]. A post-hoc analysis showed
a 36% prolongation in the time to HF-related hospitalization in the
access arm, occurring mostly in patients with NYHA Class III HF
but not in those with Class IV. The same trial also found that RV
monitoring in patients with diastolic HF led to a non-significant
20% reduction in HF events. Moreover, elevated RV pressure was
associated with an increased risk of ventricular tachyarrhythmias
[31]. However, the use of CRT with RV pressure sensors is limited
by the need for a specialized RV lead, with a high risk of lead
failure [32], and RV pressure monitoring is also influenced by the
presence of mitral valve disease, tricuspid regurgitation, and high
PA vascular resistance.
4.2.1.2. Left atrial pressure. Left atrial (LA) pressure reflects LV
filling pressure. An LA pressure sensor, such as the HeartPOD
device (St Jude Medical), is comprised a sensor lead placed at the
intra-atrial septum and attached to a coil antenna for telemetry of
sensor signals from the LA. In the Hemodynamically Guided Home
Self-Therapy in Severe Heart Failure Patient (HOMEOSTASIS) trial
[33], the use of LA pressure monitoring was associated with a
more favorable clinical course compared to the control group.
Moreover, LA pressure-guided medical therapy in Class III/IV HF
patients resulted in a fall in LA pressure and improved NYHA class
and LVEF. However, further prospective randomized trials are
needed to confirm the efficacy, stability, and safety (potential
risk of pulmonary embolism) of LA pressure sensors.
4.2.1.3. Pulmonary arterial pressure. Various studies have shown
that increases in intracardiac and PA pressures precede the onset
of HF decompensation by days to weeks. A PA pressure transducer
(Champion, CardioMENS, Atlanta, GA, USA) can be deployed in a
branch of the PA. The CardioMEMS Heart Sensor Allows Monitoring
of Pressure to Improve Outcomes in NYHA Class III Heart Failure
Patients (CHAMPION) trial [34] showed that daily measurement of
PA pressures in addition to standard care led to a 39% reduction in
HF-related hospitalization and improved quality of life scores
compared with the control group, while the duration of in-patient
stay was significantly shortened from 3.8 to 2.2 days.
4.2.1.4. Heart sound: peak endocardial acceleration. The peak
endocardial acceleration signal measures the mitral valve closure
sound and can be recorded using a piezoelectric sensor placed at
the tip of the lead in the RV apex or right atrium. In patients with
CRT, peak endocardial acceleration area has been shown to reflect
cardiac contractility [35]. However, further studies are required to
evaluate the use of this novel technology in the monitoring of HF.
4.2.2. Biochemical sensors
4.2.2.1. Mixed venous oxygen saturation. A specialized lead that
incorporates a venous saturation sensor and an RV pressure sensor
in the RV allows for measurement of mixed venous oxygen saturation
as well as RV pressure. This system has been shown to correlate well
with the current standard invasive assessments in HF patients [36,37]
and may thus be a potentially important parameter to use for conti-
nuous monitoring of HF patients after CRT implantation. Again, the
need for a specialized lead, with a high risk of lead-related compli-
cations, as well as the long-term stability of the measurement are
major limitations.
4.2.3. Electrical parameter sensors
4.2.3.1. Heart rate variability. Heart rate variability (HRV) is
measured as the standard deviation of atrial cycle length for
sensed atrial beats. HRV is an indirect measure of autonomic
function and thus neurohormonal activity [38]. It has been shown
that setting a cutoff for the standard deviation of 5-min median
sensed atrial–atrial intervals is useful for the prediction of both
 P.S. Liu, H.-F. Tse / Journal of Arrhythmia 29 (2013) 314–319
mortality risk and acute decompensated HF in patients with CRT,
with a sensitivity of 70% [39]. An HRV “footprint” (Boston
Scientific) can be generated by plotting HRV over a 24-h period
to provide a graphical representation that allows healthcare
professionals to assess any changes in HRV parameters. Potential
problems exist when using HRV for the monitoring of HF, as
measurement of HRV is not feasible during atrial pacing or atrial
tachyarrhythmias and may be affected by the use of cardiovascular
medications.
4.2.3.2. Physical activity monitoring. Accelerometers allow for
detection of a patient's physical activity level, which is an
accurate reflection of a patient's exercise performance [40]. An
accelerometer can thus be a useful adjunct to other sensors for HF
monitoring.
4.2.3.3. Intrathoracic impedance for pulmonary fluid status. Dyspnea
due to pulmonary congestion is the most common presenting
symptom of acute decompensated HF. Studies in HF patients have
revealed that intrathoracic impedance starts to decrease, as a result of
an increase in fluid in the lungs, up to 2 weeks before the onset of
dyspnea and subsequent hospitalization [41]. The intrathoracic
impedance can be measured with a transthoracic impedance sensor
using non-stimulating currents delivered between bipolar electrodes
from defibrillation or pacing leads to the device can. Fluid-detection
algorithms employing intrathoracic impedance for HF monitoring
have been developed in CRT: e.g., Optivol™ (Medtronic), which is
coupled to an audible alert when daily impedance values consistently
fall below the reference. Adoption of an intrathoracic impedance
sensor has acceptable battery energy expenditure and no additional
leads are needed for instrumentation. The disadvantage is that the
sensitivity and specificity of intrathoracic impedance monitoring may
be affected by other medical conditions, such as pleural effusion and
pneumonia, which also decrease impedance. Interestingly, in contrast
to expectations, the multicenter, cross-continental, randomized
controlled Diagnostic Outcome Trial in Heart Failure (DOT-HF) trial
[42] showed that the use of Optivol™ did not improve outcomes in HF
patients with implanted CRT or CRT-Ds. Optivol™ reduced neither the
composite endpoint of all-cause mortality, nor HF hospitalizations,
while it increased the number of outpatient visits and hospitalizations
compared with conventional care. Furthermore, the largest study in
this field, the Sensitivity of the InSync Sentry Optivol™ Feature for the
Prediction of Heart Failure (SENSE-HF) [43], revealed a much lower
sensitivity for Optivol™ in predicting HF hospitalizations, especially
within the first 2 months after device implantation, although the
sensitivity increased to 42% after 6 months. Nevertheless, recent trials
adopting multi-vector impedance or using intrathoracic impedance
sensors in combination with other sensors have reported more
favorable sensitivity and specificity [44,45].
4.2.3.4. Intracardiac impedance for cardiac contractility. Injecting
non-stimulating currents and measuring the subsequent impedance
from the RV apex to the CRT casing samples a small region in the
cardiac apex and reflects regional contractility. As impedance drops
with decreased LV volume, this system allows the monitoring of LV
contractile function. Preliminary results from Bocchiardo et al. [46]
indicate that patients with CRT have a good correlation between
stroke impedance and measured stroke volume and pulse pressure.
4.2.3.5. Minute ventilation. When a patient is at rest, this will be
detected by the activity sensor described above, allowing the
measurement of respiratory parameters such as minute ventilation.
An inappropriate increase in minute ventilation may suggest
compensatory hyperventilation, which in turn may reflect HF [47].
317
4.2.4. Arrhythmia sensors
CRT also allows continuous home monitoring and the detection
of atrial arrhythmias. Two studies using continuous device diag-
nostics in patients with CRT implants have demonstrated a higher
incidence of HF hospitalizations among patients with a high
burden of atrial tachycardia or atrial fibrillation when compared
to patients without atrial tachyarrhythmias [48]. It is likely that
both the rapid ventricular rate and the loss of CRT during atrial
tachyarrhythmias lead to a worsening of HF in these patients
[17,24]. On the other hand, other studies using routine device
interrogation did not demonstrate a significant difference in
primary outcomes between patients in sinus rhythm and those
with newly detected paroxysmal atrial fibrillation [49]. These
findings highlight the possible importance of earlier detection of
atrial tachyarrhythmias via remote monitoring to allow for earlier
intervention. Similarly, frequent sustained or non-sustained ven-
tricular tachyarrhythmias can also cause worsening of HF and
clinical outcomes due to the loss of CRT [17,24].
5. Which parameters to monitor?
The above is an overview of the currently available sensors for CRT.
As can be seen from previous studies, not all of these sensors will lead
to favorable clinical outcomes. For example, the DOT-HF trial [42],
which involved monitoring of intra-thoracic impedance by OptiVol™
(an electrical parameter), showed a possible wastage of healthcare
resources by increasing the rate of hospitalization and in-office visits
by up to three times, without conferring any benefit in terms of
mortality. Interestingly, trials that aimed to detect hemodynamic
parameters (whose changes occur earlier on in the course of HF)
showed a significant decrease in hospital admissions and mortality: e.
g., the HOMEOSTASIS (LA pressure sensor) [33] and CHAMPION
(wireless PA pressure sensor) [34] trials. A trend can be seen, where
the detection of hemodynamic parameters may have a more positive
impact in reducing future hospitalizations due to HF, as these
hemodynamic changes occur earlier in the stages leading to HF
decompensation. Only beyond a critical RV pressure would intrathor-
acic impedance begin to increase. Therefore, parameters that reflect
late changes in decompensated HF, i.e., pulmonary congestion, will not
be as effective, as they will not allow so much time for earlier medical
intervention.
6. Future trends
Researchers are investigating ways to optimize the limited
sensitivity and specificity of current HF sensors by using a combina-
tion of sensors to predict HF events. In the Program to Access and
Review Trending Information and Evaluate Correlation to Symp-
toms in Patients with Heart Failure (PARTNERS HF) study, research-
ers achieved an improved predictive value for acute decompensated
HF by utilizing multiple arrhythmic and sensor parameters, includ-
ing atrial fibrillation with a long duration and rapid ventricular rate,
an increase in Optivol fluid index, low patient activity, and abnormal
autonomic tone [45]. Another study that combined RV pressure and
intrathoracic impedance monitoring also showed improved accu-
racy [50]. Future directions in the field of sensor technology lean
towards the miniaturization of sensors and possible biologic
energy-capturing technology to minimize battery consumption.
7. Conclusion
Device-based ambulatory remote monitoring in patients with
CRT implants offers several advantages that could lead to a
reduction in healthcare resource utilization, while providing
318 P.S. Liu, H.-F. Tse / Journal of Arrhythmia 29 (2013) 314–319
essential and timely information about a patient's clinical status. It
has also been shown to be an effective tool for aiding the
optimization of CRT programming, guiding anti-arrhythmic ther-
apy, and detecting device/lead malfunction, while allowing health-
care workers to continuously monitor the progression of a
patient's HF status. Ambulatory monitoring in CRT is a promising
strategy for improving HF outcomes by allowing for earlier
interventions in patients with evidence of clinical deterioration.
However, more work remains to be done to fine tune this
technology, including the identification of effective sensing para-
meters and the optimization of sensor and lead technology.
The concept of an individualized sensor system, which takes into
account the patient's heart rhythm, the presence of arrhythmia,
and other medical co-morbidities such as pulmonary diseases,
may further optimize post-CRT implantation care for HF patients.
Moreover, the future faces further challenges in areas such as
identifying the most representative sensing parameters, technical
sensor and battery optimization, and the programming and data
flow of retrieved monitored data. These issues will need to be
addressed in order to achieve an efficient and effective remote
monitoring system for HF patients after CRT implantation.
Conflict of interest
None.
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