How Often Does My Pacemaker Monitor Read My Pacemaker

Europace. 2009 Jun; 11(6): 701–709.

Remote monitoring and follow-up of pacemakers and implantable cardioverter defibrillators

Received 2008 Dec 30; Accepted 2009 Apr 12.

Abstruse

In the era of communication technology, new options are at present available for following-up patients implanted with pacemakers (PMs) and defibrillators (ICDs). Most major companies offering devices with wireless capabilities that communicate automatically with home transmitters, which so relay data to the physician, thereby assuasive remote patient follow-upwardly and monitoring. These systems are beingness widely used in the USA for remote follow-up, and have been more recently introduced in Europe, where their adoption is increasing. In this article, nosotros depict the currently existing systems, review the bachelor prove in the literature regarding remote follow-up and monitoring of PMs and ICDs, and finally discuss some unresolved issues.

Keywords: Pacemaker, Implantable cardioverter defibrillator, Telemedicine, Remote monitoring, Remote follow-upwardly

Introduction

With increasing awareness of indications for pacemakers (PMs) and especially implantable cardioverter defibrillators (ICDs), the number of patients with implantable devices has been growing steadily. According to the recent ACC/AHA/HRS guidelines,^ane patients with a PM should be followed-up every 3–12 months, and those with an ICD every 3–6 months (with more frequent follow-ups as the battery approaches elective replacement, Tableane ). Birthday, this implies frequent visits for the patient, and for the outpatient clinic a significant increase in workload. Transtelephonic monitoring has been bachelor for many years, but provides only basic information on bombardment status and capture thresholds, and is limited to follow-up of PMs. More recently, dwelling transmitters are available from most major device companies that are able to interrogate the device, either manually by the patient using a telemetry wand or automatically using wireless technology. The data downloaded from the device by the transmitter is and then sent to the physician, using either the landline phone or the GSM network. Many electric current PMs and ICDs are able to automatically execute the tests that are performed manually at the outpatient dispensary, such as battery status, atomic number 82 impedances, or sensing and capture thresholds. Information caused automatically on a pre-defined periodic basis by the device can then be sent from the patient's home to the physician using the transmitter (thus avoiding an unnecessary in-clinic visit), hence the term remote follow-up. Another aspect is remote monitoring, which concerns data acquired automatically on a daily ground by the device, with unscheduled transmission of any pre-defined alerts to the physician. These alerts may involve device integrity (e.thousand. bombardment condition, lead impedance), programming issues (e.g. disabling of ventricular fibrillation therapy, bereft safety margins for sensing or capture), or medical data (due east.g. arrhythmias, indication of lung fluid accumulation). Therefore, remote monitoring has the potential to offer improved patient prophylactic and quality of care. A comprehensive review on remote monitoring and follow-up of implantable devices has been published last year.² Our aim is to provide an update on this rapidly evolving topic by presenting new data and describing the currently available technology.

Tabular array 1

Minimum frequency of pacemakers/implantable cardioverter defibrillator/cardiac resynchronization therapy monitoring and possibilities of remote follow-upward

	Straight follow-up	Remote follow-up
Within 72 h of implantation	Ten	—
2–12 weeks mail-implantation	X	—
Every 3–12 months (PM/CRT-P)	X	X
Every iii–6 months (ICD/CRT-D)	X	X
Annually until battery depletion	X	—
Every 1–3 months at signs of battery depletion	Ten	X

Existing remote monitoring systems

Most major PM/ICD manufacturers have introduced their version of remote monitoring organization (Figure1 and Tabular array2 ):

1. Habitation Monitoring™ (Biotronik, Berlin, Deutschland)

2. CareLink Network™ (Medtronic, Inc., MN, USA)

3. Latitude Patient Management system™ (Boston Scientific, St Paul, U.s.)

4. Merlin.net™ (St Jude Medical, Sylmar, Us).

Currently available transmitters from different device manufacturers.

Table 2

Comparison of different remote monitoring systems

	Biotronik Home Monitoring™	Medtronic CareLink™	Boston Scientific Breadth™	St Jude Merlin.cyberspace™
Wireless communication with implanted device	Radiofrequency	Radiofrequency	Radiofrequency	Radiofrequency
Data transmission	GSM network	Counterpart phoneline	Analogue phoneline	Counterpart phoneline
Transmitter	Mobile	Stationary	Stationary	Stationary
Frequency of transmissions	Daily FU; Alert events	Scheduled FU; Warning events	Scheduled FU; Alarm events	Scheduled FU; Alert events
Remote follow-up	Yes	Yes	Yes	Yes
Remote monitoring	Yes	Yep	Aye	Yes
Physician notification	SMS, email, fax	SMS, e-mail	Fax, phone	Fax, east-mail, SMS
Feedback to patient via transmitter	LED indicating normal condition or call to clinic	LED indicating normal condition or phone call to clinic	Automatic text and audio messages	LED indicating telephone call to dispensary, automated telephone calls
IEGM (real-time at remote follow-up)	30 s (monthly periodic EGMs)	10 south	10 south	thirty s
IEGM (arrhythmic episodes)	All memorized episodes	All memorized episodes	All memorized episodes	All memorized episodes
Special features	Alerts fully configurable online	Automatic RA, RV and LV (merely Consulta) pacing thresholds	Optional wireless weight scales and BP cuffs	Alerts fully configurable online
	Automatic RV and LV thresholds (but Lumax 500/540)	Optivol® lung fluid condition alarm	Configurable data transmission to associated caregivers	Possibility of sending automated phone calls to patients
	Wireless PMs	Configurable carmine and yellow alerts	Configurable red and xanthous alerts	Automatic RA, RV, and LV pacing thresholds (next generation of ICDs)
			Electronic wellness tape data export adequacy

All electric current models of PMs and ICDs from these manufacturers are able to exist manually interrogated by the patient using a telemetry wand incorporated in the dwelling transmitter and are thus able to perform remote follow-ups. However, automatic wireless interrogation of the device is preferable, as information technology depends less on patient compliance and allows frequent transmissions, which is mandatory for effective remote monitoring. Automatic wireless interrogation requires that the implanted device is equipped with a micro-antenna for communication with the transmitter located close to the patient. Data are then sent to a cardinal database using either the analogue landline phone system and a toll-free number (Boston Scientific, Medtronic and St-Jude Medical systems) or via the GSM network (Biotronik). The information are processed and made accessible to the physician on a secured webpage. The doc is informed past east-post, SMS, fax, or phone letters whenever disquisitional data are available for consultation. The types of events which trigger an alert can exist customized for each patient. None of the systems currently allows remote device programming (although this is technically feasible), essentially for safety problems.

Biotronik (Habitation Monitoring^®)

This company is the pioneer in the field of remote PM/ICD follow-up and monitoring, with FDA approving of their starting time organization in 2001. The transmitter (CardioMessenger^®) is a little bigger than a jail cell telephone and communicates wirelessly with the implanted device within a radius of 2 yard. Information technology sends the retrieved data to a middle in Germany using the GSM network, which is the main advantage of the system. This is an important consequence today, as the patient may non have a landline phone connexion (due to increased use of cell phones) or may have a digital landline connexion (currently incompatible with all device systems) or a DSL/VOIP connection that requires special filters and converters. It also ways that the patient can exist monitored continuously around the clock, as the CardioMessenger has a rechargeable battery that allows it to exist carried around past the patient. Furthermore, the patient can continue to be monitored while travelling abroad with the CardioMessenger, as the system is compatible with almost bachelor GSM networks throughout the earth. Parameters for the alerts can be fully configured on the secured webpage, without having to bring the patient into the clinic for a manual transmission (Figure2 ). EGMs of 30 s duration are sent periodically that may assistance with data interpretation (Figurethree ). Biotronik is the only company today that offers PMs with wireless technology for remote monitoring (other manufacturers are also going to offer wireless PMs in the future).

Remote monitoring parameters (print screens) for CRT-D devices bachelor at the Academy Hospital of Geneva at the time this manuscript was submitted. The Biotronik Lumax-540 CRT-D (left) can be fully configured online. Parameters of a Medtronic Consulta CRT-D (right) can be defined as red or yellow alerts (or website warning only) that trigger different urgencies of notification.

(A) Biotronik Home Monitor showing trends of Every bit–VS events (black dots) and As–Vp events (bluish diamonds). Alerts of reduced (< 85%) CRT delivery are indicated ('CRT low' arrows) and coincide with increased percentage of Equally–VS events (blackness dots). This would advise that the AV interval is programmed too long. (B) The real-time EGM strip available past remote monitoring nonetheless shows that the AS–VS events are due to premature atrial beats (red asterisks) with a brusque intrinsic AV interval (most probably due to proximity of the ectopic focus with the AV node). Doses of beta-blockers were increased, with improvement in CRT delivery.

Medtronic (Carelink Network™)

The system has been introduced in Europe in a pilot study in 2005.ⁱⁱⁱ The ICD communicates with a wireless transmitter (Home Monitor) within a radius of three m, which is usually placed in proximity to the patient'south bed. Data are sent via an analogue telephone landline, which can but be used in the patient's country of residence (a carrier-independent, international solution is being developed). Pre-scheduled remote follow-upwardly transmissions (that take place at 03:00) may exist programmed remotely, but can exist executed only later 21 days. In addition, for remote monitoring purposes, detection of an event (e.chiliad. abnormal lead impedance etc.) will immediately trigger the ICD to attempt advice with the Dwelling Monitor (with repeated attempts every 3 h during 3 days in instance of inability to establish advice, and and so by audible alerts). The parameters for remote monitoring can exist configured individually in each patient, with pre-defined degrees of urgency ('red' and 'yellow' alerts, Figuretwo ), which helps with data triage. However, the threshold settings for each alert require in-clinic programming of the device. An reward with the latest generation of Medtronic implantable devices is the ability to automatically perform a wide range of tests, including automatic atrial, right ventricular, and left ventricular capture thresholds, which facilitates full remote follow-up. A unique feature with Medtronic dual-chamber and biventricular ICDs is the Optivol^® algorithm that monitors transthoracic impedance for detecting lung fluid accumulation, which may exist potentially useful for remote monitoring of patients with heart failure.

Boston Scientific (Latitude Patient Management system™)

This system is to be introduced in Europe in 2009. The transmitter besides uses an analogue landline for data manual, which may be configured for use in various countries (but may crave plug adapters). A unique feature of the system is the possibility to connect wireless weight scales and blood pressure cuffs for remote monitoring of heart failure status (Effigy1 ). As well, the patient tin self-written report heart failure symptoms into the organization on a weekly basis (such equally fatigue, ankle swelling, orthopnea etc.). Event notifications tin be configured individually in each patient based upon 'crimson' and 'yellow' alerts. Furthermore, the organisation allows customizable data manual to different physicians (for instance to the general practitioner or full general cardiologist in addition to the center rhythm specialist), which improves networking of middle failure direction.

St Jude Medical (Merlin.net™)

The wireless transmitter (emoh@nilreM) has been introduced in Europe in 2008 at airplane pilot centres. The system communicates automatically by radiofrequency with the implantable device and sends data to the physician using the counterpart landline system (a cellular adapter card is planned for 2009). Every bit with the other available systems, remote monitoring is possible with alerts being sent by e-mail, fax, or SMS to notify the dr. of events. A useful characteristic is the ability for the physician to betoken alerts or reminders of scheduled in-office visits on the patient's transmitter, and to ship automated telephone calls to patients indicating the results of the remote follow-up (e.g. that everything is normal). The next generation of ICDs volition likewise take capture thresholds for all leads, which volition facilitate full remote follow-upward.

Potential benefits and existing prove of utility

Reduction of in-dispensary visits

In a study by Brugada,⁴ 271 patients with a Biotronik ICD and Home Monitoring ^® organization were followed for 12 months with routine follow-upward every iii months. Retrospective assay of the Biotronik Dwelling Monitoring ^® information showed that as many equally half of the regular scheduled visits may take been skipped, without impairing patient safety.

More recently Heidbuchel et al.^five retrospectively analysed information from 1739 in-clinic ICD visits in 169 patients. The authors establish that merely half dozen% of scheduled in-clinic visits resulted in device reprogramming or patient hospitalization. Thus, in 94% of all scheduled visits, remote follow-upwardly would have sufficed. Furthermore, they estimated that ICD remote monitoring could potentially diagnose > 99% of arrhythmia- or device-related bug, if combined with clinical follow-upwardly by the local full general practitioner and/or the referring cardiologist.

Preliminary results of the TRUST (Lumax-T/Lumos-T safely RedUceS rouTine office device follow-up) study were recently presented.⁶ Information on 1312 patients with a Biotronik VR/DR ICD were randomized to standard (3 months) in-office visits vs. remote monitoring (with in-part visits at iii and 15 months). Remote monitoring and follow-up resulted in a 43% relative reduction in visits (from 3.0 to 2.5 visits/patient-year, P < 0.001) with a amend adherence to the scheduled follow-up timetable. The trial demonstrated also similar condom (death, stroke, or result-related surgery) past remote monitoring compared with in-dispensary control group.

In addition to reducing scheduled in-clinic visits, remote follow-upwards may avoid unscheduled visits following an ICD shock.^7,8 Afterwards such an result, the patient may perform transmission interrogation to upload data to the physician for determining if the daze was appropriate or non, and it may and then be decided whether the patient should be seen for device reprogramming or modification of drug therapy.

Patients with cardiac resynchronization therapy (CRT) may require special consideration, as they are commonly sicker and accept more complex devices with specific bug (e.1000. requirement for atrio-ventricular interval optimization, greater variations in left ventricular thresholds, phrenic nerve capture etc.). Thus frequency of follow-up and requirement for in-function device reprogramming may be greater than in patients with standard PMs or ICDs. In a report from the Insync ICD Italian Registry,^ix there was a marked reduction in number of interrogations requiring reprogramming between the beginning six months of follow-upward and subsequent periods, as pacing and CRT delivery parameters were usually optimized relatively rapidly after implantation and maintained unmodified thereafter. This means that remote follow-up is an adequate alternative in these patients, peculiarly with the advent of algorithms that automatically adjust device settings such as left ventricular pacing output based upon daily threshold measurements.^ten

Even though remote device monitoring and interrogation has the potential to reduce numbers of in-clinic visits, it does not entirely supercede straight contact (that is valued by many patients). According to current guidelines, in-role visits need to take place at least yearly (Tableone ), but this may change in the future for subsets of patients (e.g. master prevention ICD patients without clinical events or elderly/disabled patients etc.).

Improved patient safe

Figure4 shows an example of a patient in whom remote follow-upward proved to exist life-saving.

A 66-year-old patient with a Medtronic Concerto CRT-D for primary prevention of sudden death phoned the dispensary complaining of fatigue since ii days, without any angst or ICD shocks. (A) Remote interrogation of the device with the real-fourth dimension 10 s rhythm strip (partly displayed) showed slow irregular VT (a ventricular far-field is seen in the atrial EGM). No episodes of SVT or ventricular arrythmias (faster than 140 b.p.chiliad.) were recorded by the device. On the basis of the EGM findings, the patient was asked to come directly to the dispensary. (B) Immediately upon arrival in the clinic 15 min after, the patient complanate due to rapid incessant ventricular tachycardia (VT) that led to 22 ICD shocks. Injection of amiodarone resulted in slowing and finally disappearance of the VT. The patient developed multiorgan failure, but recovered later and was seen in-office 1 month later, with no events. (C) Impress screen of the CareLink website of remote interrogation of the device 6 months after the arrhythmic storm (asterisk) showing no arrhythmia (faster than 113 b.p.m.), with improvement of the patients' physical activity (arrow).

In a recent study by Nielsen et al.,¹¹ patients with a Biotronik ICD and Habitation Monitoring™ organization were prospectively enrolled in a registry for a mean follow-up of 10 months. At least i Home Monitoring outcome occurred in 41% of patients, consisting mostly of clinical events (such as arrhythmias). Technical events (inappropriate shock, lead impedance issues etc.) occurred in ∼3% of patients. The temporal distribution of home monitoring events is interesting, as over lx% occurred during the starting time month following the last visit. In some other study using the Biotronik Home Monitoring organization with over 3 meg transmissions in > 11 000 patients,¹² the mean interval between last follow-upward and occurrence of events notified by home monitoring was 26 days. This represented a temporal proceeds of 154 days for event notification in patients usually followed at 6 months intervals and of 64 days in patients usually followed at three months intervals. This has implications for diagnosing technical issues such as lead fracture, device malfunction,¹³ or clinical events such as onset of atrial fibrillation (AF). Continuous monitoring for AF is peculiarly interesting, equally information technology offers new treatment strategies for anti-arrhythmic drug therapy and anticoagulation. In a report by Ricci et al.¹⁴ of 166 patients implanted with a Biotronik PM or ICD using the Home Monitor system during a mean follow-up of sixteen months, remote monitoring alerts for AF were triggered in 25% of patients, with an unscheduled follow-upwardly (in-office or past phone) resulting in interventions involving anti-arrhythmic drug therapy, anticoagulation, or antiplatelet drug initiation, external cardioversion, or device reprogramming, in 17% of all patients.

Remote monitoring may be particularly useful in patients with CRT, every bit they are nearly likely to have transmissions of medically related events.¹² A number of different randomized trials are currently underway to assess the utility of monitoring lung fluid overload in patients with heart failure (Table3 ).

Tabular array three

Ongoing multicentre randomized studies on remote device monitoring and follow-up registered on www.clinicaltrials.gov

Report	Sponsor	Device	Projected size	Primary result measures	Status
CONNECT28,29	Medtronic	CRT-D, ICD-DR	2000	Reduction in fourth dimension to clinical decision for arrhythmias, cardiovascular disease progression, and organisation issues	Active, not recruiting
issue30	Biotronik	CRT-D	300	Bloodshed and morbidity in patients with AF	Recruiting
EuroEco31	Biotronik	ICD-VR, ICD-DR	312	Costs	Recruiting
EVATEL32	French Ministry of Health	ICD-VR, ICD-DR	1600	Safety and cost-effectiveness	Recruiting
HomeCARE 233	Biotronik	CRT-D, ICD-VR, ICD-DR	300	Operation of intrathoracic impedance for monitoring centre failure	Recruiting
IMPACT34	Biotronik	CRT-D, ICD-DR	2718	Thromboembolic events and bleeding in patients with AF managed past pre-defined anticoagulation programme.	Recruiting
IN-Time35	Biotronik	CRT-D, ICD-VR, ICD-DR	620	Mortality, hospitalization for heart failure, clinical status	Recruiting
OptiLink-HF36	Medtronic	CRT-D, ICD-VR, ICD-DR	1000	Intrathoracic impedance monitoring for reducing expiry or cardiovascular hospitalization	Recruiting
Quantum37	Biotronik	ICD-VR, ICD-DR	150	Psychosomatic evaluation	Recruiting
TRUSTvi,38	Biotronik	ICD-VR, ICD-DR	1516	Number of ICD follow-ups and safety	Active, not recruiting

Failure of ICD leads is a major result and has been highlighted by the Fidelis atomic number 82 recall. The Medtronic atomic number 82 integrity alert algorithm has been shown to give a alarm of impending inappropriate shocks by at least 3 days accelerate in 76% of patients,¹⁵ and triggers an audible alarm that may prompt the patient to seek attention. However, these audible alerts may not exist heard by the patient in time, resulting in inappropriate shocks.^xvi,17 Detection of lead failure may therefore be enhanced by remote monitoring. In a report of 54 patients with an ICD lead failure, remote monitoring by the Biotronik Home Monitoring organization resulted in a significant reduction in the incidence of inappropriate shocks and symptomatic pacing inhibition compared with those without remote monitoring (27.3 vs. 53.4%, P = 0.04).¹⁸ Inappropriate shocks occur for a variety of reasons other than pb dysfunction. In a recent written report on 35 patients with Brugada syndrome implanted with a Biotronik ICD followed by Home Monitoring,^nineteen identification of bug by remote monitoring such as T-wave oversensing, external electromagnetic interference and sinus tachycardia led to device reprogramming that may have prevented shocks.

Remote follow-up and monitoring can also exist used for tracking product performance in a large number of patients, and may permit earlier identification of issues with specific models. The large corporeality of data gathered in a consistent mode besides has the potential to facilitate medical research.

Increased patient satisfaction

The showtime studies evaluating patient satisfaction by remote follow-up of ICDs were published in 2004 using the Medtronic Carelink system^xx and the St Jude Medical HouseCall II™.²¹ Patient satisfaction with the systems was high in both studies. In an Italian study, 67 patients implanted with a Medtronic CRT-D were followed remotely using the CareLink™ arrangement.^viii,22 Remote follow-ups were preferred to in-clinic visits by 78% of the patients. Satisfaction by the physicians was likewise very favourable. Likewise, in some other study using the Medtronic CareLink™ conducted in Finland,²³ the patients' and physicians' level of satisfaction with the organization was high. Our own experience is that most patients readily take remote monitoring, and feel secured by the employ of this applied science to amend their healthcare.

Potential cost savings

In that location are a few studies that assess the potential price/benefit of remote monitoring-assisted intendance compared with conventional follow-upward, and all are based on the fact that remote data access may decrease the charge per unit of inhospital patient visits. Using a French database of 502 ICD-patients followed in third care hospitals, Fauchier et al.²⁴ estimated a subtract in costs for follow-upward visits of as much as $2149 over a five years device lifespan. Nonetheless, savings were closely related to the distance betwixt abode and medical facilities. It is noteworthy that this study did not include reimbursement for the time spent reviewing remote monitoring data.

Recently, an interesting Finnish written report²³ replaced standard ICD follow-upwards at 3 and 6 months after implantation, by remote data manual using the Medtronic CareLink™ organisation. This was safe, reduced fourth dimension burden for patient and inhospital staff, and was also toll-constructive. Yet, one should note that the economic impact of remote follow-upward may not be the same in all countries, due to the fact that indirect costs (such as travel expenses and sickness assart) played a major role.

Specific problems

Optimal workflow

Even though reports suggest that the physician is unlikely to exist submerged by incoming information from his patients (for example, the mean numbers of events per patient per month reported in the largest report to engagement¹² was only 0.six), this will probably depend to a large extent on programming of the alerts and data triage. Ricci et al.²⁵ have described a system whereby a specialized nurse connects to the home monitoring website for checking data from all their 117 patients at least every 15 days and whenever an event report was received. Only half dozen% of events were and so relayed to the physician for further evaluation. This workflow resulted in a mean of 59 min/week for the nurse and 12 min/week for the physician to analyse home monitoring data. A well-organized clinic will also ensure that alerts are responded to in a timely manner.

Several companies are working on compatibility of their systems with electronic medical records for exporting remote follow-up data. This will considerably alleviate the dispensary's workload and help streamline workflow.

Legal aspects

The patient needs to exist informed of the purpose and limitations of remote monitoring, such as the fact that information technology does not supervene upon an emergency service or absence of dealing with alarm events outside office hours. Earlier initiating remote monitoring and follow-up, the patient may be requested to sign a written informed consent stating these points and authorizing transmission of personal data to third parties, respect of privacy, and confidentiality of patient data past device companies should be subjected to strict rules, described in contracts.

Patient privacy and security

In order to examination the vulnerability of security breaches by hackers accessing devices with wireless capability, Halperin et al.²⁶ performed laboratory tests on a Medtronic Maximo DR ICD. After having partially reversed the ICD's communications protocol with an oscilloscope and a software radio, they performed several software radio-based attacks that were able to retrieve uncrypted personal patient data, every bit well every bit change device settings (including commanded shocks). This written report triggered considerable media coverage, although it is believed that the run a risk of unauthorized access to an ICD is unlikely, given the considerable technical expertise required.²⁷ There accept been no reports to appointment of hacking of implantable devices. Some other consideration, withal, is hacking of the internet server database.

Reimbursement

In the Usa, Medicare and Medicaid have expanded reimbursement for remote device monitoring for all states since 2006. Reimbursement rates vary from state to land, and in some instances are the same as an in-role visit without device programming. In the United kingdom, Federal republic of germany, and Portugal, reimbursement for remote monitoring is similar to that offered for standard follow-up visits.

Conclusions

Remote monitoring and follow-up are likely to become the standard of care for patients with PMs and ICDs, as they take the potential to better patient safety and satisfaction, to support efficient employ of resources, and to reduce costs. Existing data show that current applied science for remote monitoring is reliable and that information technology is readily accepted past patients and their physicians. Big randomized trials are underway that will hopefully evidence that remote monitoring improves patient outcome. Specific issues such as reimbursement demand to exist dealt with by the authorities, in order to ensure that this solution is a viable one.

Conflicts of interest: D.S. is a member of the Boston Scientific fellowship programme. H.B. receives enquiry grants from Medtronic, Boston Scientific, and St Jude Medical, has been on the speakers' bureau for Medtronic and Boston Scientific, and is a member of the Breadth advisory lath.

Funding

H.B. was supported in part by a enquiry grant from the Foundation for Cardiovascular Research of the Hôpital de la Tour, Meyrin, Switzerland. Funding to pay the Open Admission publication charges for this article was provided equally by Biotronik, Boston Scientific, Medtronic and St. Jude Medical.

Acknowledgements

The authors would similar to thank Mr Tim Montgomery (Biotronik), Mr Matthias Wollenstein (Boston Scientific), Mr Bertjo Frick (Medtronic), Mrs Severine Pradere (Sorin), and Mr Blaise Sahli (St Jude Medical) for their kind assist and technical review of the manuscript.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686319/

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