| BackgroundChronic heart failure (CHF) is the terminal phase of heart disease due to various causes; is a complex clinical syndrome characterized by cardiac dysfunction, neuroendocrine activation, and abnormal peripheral blood flow distribution, and resulted from ventricular filling and ejection disturbance due to changes to myocardial structure and function caused by any reason; is the severe stage of cardiovascular disease due to kinds of causes. It has high prevalence and death rates, and its survival rate is similar with that of malignant tumor. It seriously threatens the lives of the patients and affects their life quality. With the increase of the aging population and the survival rate of acute myocardial infarction, the number of chronic heart failure patients increases rapidly, and the number of hospitalization for decompensated heart failure increases correspondingly. Epidemiology shows that the incidence of chronic heart failure has been rising year by year in recent decades. In the beginning of the century, a survey of15,518cases with the age ranging from35to74in ten provinces in our country has shown that our country’s adult prevalence of symptomatic heart failure is0.9%and the annual medical cost is huge.The fundamental mechanism for the occurrence and development of CHF is ventricular remodelling that is due to a complex series of molecular and cellular mechanisms leading to the changes of cardiac structure, function and phenotype. The neuroendocrine system activates while CHF occurs, which is mainly reflected in the over activation of sympathetic and rennin-angiotensin-aldosterone system (RAAS). In the early time, the activations of both systems can contribute to compensatory increase in cardiac output, promote vasocomstriction, maintain blood pressure, and ensure the perfusion of important viscera. However, their long-term excitement instead can increase myocardial energy consumption, accelerate cardiac death, and cause ventricular remodelling. Currently, the key to heart failure treatment is to block the activation of nerve-endocrine system, to prevent and delay the ventricular remodelling. Large-scale clinical trials proves that angiotensin converse enzyme Inhibitor (ACEI), angiotensin receptor blockers (ARBs), aldosterone antagonist, and β-blockers can block the activation of the neuroendocrine system, and reverse the ventricular remodelling, decreasing the death rate of chronic heart failure patients. With the widespread use of these drugs, the treatment of chronic heart failure has made tremendous progress. Whereas for the chronic heart failure patients who have not responded to medication, or whose treatment effects are not obvious, cardiac resynchronization therapy (CRT) is a new treatment superior to artificial heart implantation and heart transplantation. By using CRT, atrioventricular sequential pacing can be provided, and ventricular synchronization can be achieved. Many large-scale international clinical trials confirm that cardiac resynchronization therapy (CRT) can improve heart function, reverse myocardial remodelling, improve the life quality of the patients, and reduce mortality rate. However, the latest research shows that the proportion of the patients who do not get effective CRT fluctuates between18%and32%. Moreover, the patients with CHF have very high incidence rate of atrial/ventricular arrhythmias, which seriously affect the longevity and life quality of the patients. There come the problems on how to have the best management of the patients, and especially on how to optimize medical treatment and other treatments of CHF.With the development of bioengineering technology, more and more implantable cardiac electronic devices with different functions have been launched on the market. The devices’performance has been improving gradually, and can store huge amount of valuable material, such as the equipment’s setting parameters, functional status, and patients’hemodynamic changes. The devices bring a new strategy for the mechanotherapy of cardiovascular disease, and expand the therapies and the indications. They are applied more widely in the field of CHF, which brings enormous medical and economic burden to the follow-up visits after the implantation. There are many problems in the traditional follow-up visits. For example, the problems happening between two visits cannot be found in time, thus the doctors cannot adjust the treatment program anytime according to the changes in patients’ condition. Once the best timing of treatment is missed, more medical cost will be paid. Researches show that67%of the follow-up visits are normal. Follow-up visits occupy the time of patients and doctors. In order to solve these problems, remote monitoring technology has been also applied to implantable cardiac electronic devices, and has been developed rapidly in recent few years. The remote monitoring system home monitoring (HM) launched by the Biotronik Company in2001was the first one to enter China’s market. At present, some large multicenter studies about HM are underway in China. Home monitoring system is consisted of the followings:(1) devices with built-in antenna (for data transfer);(2) mobile data transmitter (Cardio Messenger):it is used in vitro for the patients. It receives the information from pulse generator and transfer the information to the information processing center through data network.99%of the event records can be transferred completely within five minutes. This process is fully automatic without any operation from the patients. It just needs them to keep the mobile data transmitter on the side;(3) information processing center:it manages the data via network anytime and anywhere, and can view the real-time data through network. The information processing center receives the material of the patients wirelessly, analyzing and storing it, or sending it directly to the doctor. The doctor can read the information stored in the information processing center or receive the material in urgent situations, and then make quick diagnosis for the function of the equipment and the disease of the patient, making appropriate interventions if necessary. Besides, when cardiac events and equipment’s major failure occur, for example, the battery level of pulse generator reaching ERI, pacing electrode impedance being too low or too high, perception amplitude being too low, CRT pacing percentage being too low, high frequency of atrial and ventricular events, AF burden being too high, electric-shock events and some indicators of heart failure set (such as the average heart rate, the mobility of the patients, the changes of heart rate, and the variability, etc.), it can start the sending way triggered by those events on its own. The information processing center can monitor the details of the events, and make the corresponding reaction quickly. Home monitoring system can monitor the followings:(1) the integrity of the equipment itself, like if the impedance of the wire is in the normal range, the remaining life of the battery, and the time of changing the equipment;(2) the performance status of the equipment, such as the various setting parameters of the equipment, the pacing of the pacemaker and if the perceptive function is normal or not, whether ICD has the ATP treatment and discharge, the CRT pacing percentage and the synchronization sequence;(3) whether there is occurrence of arrhythmias, like if there is ventricular premature beat, the frequency and duration of NSVT, ventricular tachycardia, ventricular fibrillation, atrail flutter, atrial fibrillation and arrhythmias, whether the equipment intervenes the arrhythmias, whether the intervention is appropriate, and if there is any unreasonable discharge;(4) the hemodynamics indicators:such as blood pressure and thoracic impedance, etc.;(5) the heart failure monitor:the mobility of the patients, the variability of heart rate, the average heart rate at rest, the average heart rate, the ventricular premature beat per hour, biventricular pacing percentage%, left ventricular threshold, and atrial fibrillation burden.CRT with Home Monitoring (HM) can be used to monitor cardiac arrhythmias and other heart physiological indexes such as intrathoracic impedance and hemodynamics. Through wireless satellite, the data from the patients are sent to a monitor center, analyzed and processed. Doctors can read information stored in the monitoring center, receive emergency information directly, and make a rapid diagnosis. CRT with Home Monitoring can also interpret the function of the equipment status, the working state and the parameters of the program-controlled (PC). The system’s validity and reliability has been verified and it appears to be a valid method to be used to optimize drug treatment of individual parameters.ObjectiveBased on the advantages of CRT-P/D with home monitoring function, we evaluate its clinical guiding significance to patients with chronic heart failure after CRT treatment,through analyzing the data received from internet, and the data related to the alarm events.MethodsPatient population and Selection CriteriaWe reviewed39patients who had received CRT-P/D treatment due to chronic heart failure from August2008to October2012in our center. Nineteen cases had CRT-P/D with HM function (Biotronik, Germany) and20cases were treated with ordinary CRT-P/D (Medtronic, St Jude, USA). The selected were in accord with the CRT-P/D implant indication:they were all ischemic and non ischemic chronic heart failure patients. After drug treatment, New York Heart Association (NYHA) functional class of III-IV, QRS duration≥120ms and echocardiographic signs of inter-or intraventricular dyssynchrony and ejection fraction≤35%. The selected patients were divided into home monitoring group and non-home monitoring group. No clinical discrimination criterion was used to select patients to be remotely controlled with HM.Follow-upAll patients, within1week after the operation, conducted individual pacemaker parameters optimization under ultrasound guidance. The non-HM group, were scheduled to visit their physicians3and6months after the operation. The program information, according to the event, PC information, clinical signs and symptoms adjustment of clinical drug use were recorded. According to the heart failure monitor statistics and early-warning, HM group were prompted to be admitted to perfect the related inspection, and then the clinical drug use was adjusted.Observation indexesAll patients’ left ventricular ejection fraction (LVEF) preoperative and6months postoperative respectively, vital signs, NYHA functional class, PC information, atrial/ventricular arrhythmias events, biventricular pacing percentage, mean heart rate at rest and under activity. A "low biventricular pacing" was defined as biventricular pacing percentage<85%.Medicine treatmentAll patients regularly used beta-blockers, ACEI, diuretics, aldosterone receptor antagonists. Positive inotropic drugs were not used. Four cases of patients with ischemic cardiomyopathy regularly used aspirin after reconstruction of coronary blood supply. Diabetic patients took oral hypoglycemic drugs to control stable blood sugar state. Hypertension patients adjusted the ACEI dose. Atrial arrhythmia patients took amiodarone. Patients with ventricular arrhythmia increased beta-blockers dose. Statistical analysisStatistics were performed using SPSS13.0for Windows. Quantitative data are presented as mean values±standard deviation (SD) and compared using students t test. Qualitative data are presented as frequencies and were compared using the Pearson chi-square test or Fisher’s exact test. A p-value of<0.05was considered statistically significant.ResultsClinical informationWithin the first three months, the home monitoring group recorded40events among which2cases (10.5%) were the diagnosis of paroxysmal atrial fibrillation,10cases (52.6%) of non-sustained ventricular tachycardia,17cases (89.5%) of frequent ventricular premature beat,12cases (63.2%) of biventricular pacing less than95%, and mean heart rate more than80bpm at rest in10cases (52.6%). Ventricular arrhythmias were found basically consistent with baseline data. All19patients were scheduled to follow-up through telephone intervention (an average of5.05±0.97times/6months), perfecting the relevant inspection, changing the therapeutic schedule, and adjusting drug doses. Three cases of patients reset pacemaker parameters. After3months and6months, cardiac function in one patient showed no improvement from the previous, and on the basis of heart failure monitor the physiological parameters was provided, with drug-therapy optimization, heart failure with no progressive deterioration. None of the patients was recalled to hospital again.In the non-home monitoring group, when recalled for being Program-controlled3months after the operation, paroxysmal atrial fibrillation was found in2cases (10%), frequent premature ventricular contractions in18cases (90%), biventricular pacing rate less than85%in10cases (50%), mean heart rate more than80bpm at night in13cases (65%), the drug doses changing in18cases (90%), and readmission to the hospital in3cases (15%)Arrhythmias and cardiac function changes after drug treatment Six months after drug treatment, for all patients in the home monitoring group biventricular pacing was greater than95%. Fits onset atrial fibrillation frequency decreased significantly. The improvement rate of frequent premature ventricular contractions was88.2%and that of non-sustained ventricular tachycardia was80%. Mean heart rate at rest was62.68±1.70bpm. While in the non-home monitoring group, the improvement rate of low biventricular pacing was50%. Fits onset atrial fibrillation frequency decreased significantly. Frequent premature ventricular contractions was improved by55.6%and the average heart rate at night was67.30±3.29bpm. Six months postoperative LVEF (40.42±3.73)%in HM group, LVEF (35.85+5.71)%in non-HM group, which indicated that the two groups had significant difference (P<0.01).ConclusionsWith HM directed clinical treatment the chronic heart failure atrial/ventricular arrhythmia events and cardiac function can be improved significantly. |
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