1. Alireza Heidari Bakavoli, MD. Cardiology department Qaem medical center Mashhad University of Medical Science Role of ICD and CRT devices in Heart failure monitoring

2. Introduction Heart failure is a major public health concern A goal of HF management is reduction of hospital admissions rates. While optimal medical therapy favorably impacts the natural history of the disease, devices such as CRT and ICDs have added incremental value in improving HF outcomes.

3. CRT/ICD as a guide for heart failure management It may be possible to improve prognosis of HF by CRT and ICD, beyond their directly therapeutic effect, by following existing or novel diagnostic parameters (shared by many ICD devices) to guide therapy. For example monitoring the Af burden, percent of biventricular pacing may be predictors of worsening HF.

4. Many parameters can be monitored by ICD/CRT devices Remote patient monitoring. Device based monitoring of physiological parameters:  patient activity level  Intrathoracic impedance  HR variabillity Using these data for direct day-to-day management of HF patients can significantly reduce hospitalization rates.

5. Optivol Transthoracic Ω Patient activity Average Ventricular rate HR variabillity Percent of pacing

6. Intrathoracic impedance monitoring Intrathoracic Impedance and fluid accumulation are inversely related(less transthoracic impedace means more wet lungs) Trans thoracic Impedance inversely correlated with pulmonary capillary wedge pressure and net fluid loss

7. Transtoracic impedance monitoring

8. Optivol basics

9. Thranstoracic Impedance monitoring

10. Clinical evidence for usfullness of thransthoracic impedance monitoring

12. Predictive values of parameters obtained at device in HF patients

13. Heart rate variability Continuous HRV can be derived from implanted devices and remote patient monitoring systems. HR variability is a marker of cardiac autonomic control, describing the balance between sympathetic and parasympathetic activity. Increased sympathetic and decreased parasympathetic activity in HF is associated with worse outcomes. HR variability can be defined as the standard deviation of 5 min median atrial-to-atrial intervals (SDAAM). In one study, SDAAM,50 ms when averaged over 4 weeks was associated with a > 3-fold mortality risk Lower HRV higher mortality

18. ICD memory is a mirror of heart failure condition AVN ablation Possible worsening of HF due to increased RV pacing Possible worsening of HF due to increased RV pacing

19. Remote monitoring

20. Remote Device Monitoring 20 Remote Device Monitoring Systems Systems commonly available in the US:  Medtronic Carelink ®  St. Jude Merlin™@Home and HouseCall Plus™  Biotronik CardioMessenger ®  Boston Scientific LATITUDE ® system

21. Remote Device Monitoring 21 Remote Monitoring Systems Medtronic CareLink Network The patient monitor enables you to “connect” your implanted device to your clinic via a standard phone line. Available for Medtronic ICDs, CRT, pacemakers and implantable cardiac monitors in the United States. www.carelinknetwork.com/

22. Remote Device Monitoring 22 Remote Monitoring Systems St. Jude Merlin@Home The patient monitor enables you to “connect” your implanted device to your clinic via a standard phone line. For use with Current TM RF ICD and Promote TM RF CRT-D devices. St. Jude Housecall Plus The patient monitor enables you to “connect” your implanted device to your clinic via a standard phone line. For use with Atlas TM and Epic TM ICDs and Atlas HF and Epic HF CRT devices. www.sjm.com/

23. Remote Device Monitoring 23 Remote Monitoring Systems Biotronik CardioMessenger A portable unit that receives data from the implanted device. It is the link that connects you to the Biotronik service center. Available for Biotronik ICDs, CRT and pacemakers in the continental United States and in over 50 countries. www.biotronik.com/en/us/

24. Remote Device Monitoring 24 Remote Monitoring Systems Boston Scientific LATITUDE System The patient monitor enables you to “connect” your implanted device to your clinic via a standard phone line. Available for Boston Scientific ICDs and CRT devices in the United States, Puerto Rico and the Virgin Islands. www.aboutlatitude.com

25. Remote monitoring

27. Key messages Diagnostic data derived from ICD/CRT memories are useful in HF management Clinical evaluation and the use of multiple diagnostics saved in Device memory are most efficacious EP and HF clinicians will need to work together to improve overall patient care