Background Epicardial placement of the left ventricular (LV) lead via a video‐assisted thoracoscopic (VAT) approach is an alternative to the standard transvenous technique. Hypothesis Long‐term safety and efficacy of VAT and transvenous LV lead implantation are comparable. To test it, we reviewed our experience and we compared the outcomes of patients who underwent implantation with the two techniques. Methods The VAT procedure is performed under general anesthesia, with oro‐tracheal intubation and right‐sided ventilation, and requires two 5 mm and one 15 mm thoracoscopic ports. After pericardiotomy at the spot of the epicardial target area, pacing measurements are taken and a spiral screw electrode is anchored at the final pacing site. The electrode is then tunneled to the pectoral pocket and connected to the device. Results 105 patients were referred to our center for epicardial LV lead implantation. After pre‐operative assessment, 5 patients were excluded because of concomitant conditions precluding surgery. The remaining 100 underwent the procedure. LV lead implantation was successful in all patients (median pacing threshold 0.8 ± 0.5 V, no phrenic nerve stimulation) and cardiac resynchronization therapy was established in all but one patient. The median procedure time was 75 min. During a median follow‐up of 24 months, there were no differences in terms of death, cardiovascular hospitalizations or device‐related complications vs the group of 100 patients who had undergone transvenous implantation. Patients of both groups displayed similar improvements in terms of ventricular reverse remodeling and functional status. Conclusions Our VAT approach proved safe and effective, and is a viable alternative in the case of failed transvenous LV implantation.

Aims Implantable cardiac monitors (ICMs) can generate false-positive (FP) alerts. Although these devices have an extended programmability, there are no recommendations on their optimization to reduce not-relevant activations. We tested a strategic programming optimization guide based on the type of FP and investigated the safety and feasibility of the nurse-led insertion of ICMs with a long-sensing vector. Methods and Results Consecutive patients implanted by trained nurses with long-sensing vector ICM were enrolled in a one-month observational stage (Phase A). Patients who had ≥10 FP episodes underwent ICM reprogramming based on the predefined guide and were followed for an additional month (Phase B). A total of 78 patients had successful ICM insertion by nurses with a mean R wave amplitude of 0.96 ± 0.43 mV and an 86% P wave visibility. Only one patient reported a significant device-related issue, and nurse-delivered ICM was generally well accepted by the patients. During phase A, 11 patients (14%) generated most of FP (3,627/3,849; 94%) and underwent ICM reprogramming. In the following month (Phase B), 5 patients (45%) were free from FP and 6 (55%) transmitted 57 FP alerts (98% reduction compared with Phase A). The median number of FP per patient was significantly reduced after reprogramming (195 [interquartile range, 50-311] versus 1 [0-10], p = 0.0002). Conclusion A strategic reprogramming of ICM in those patients with a high FP alert burden reduces the volume of erroneous activations with potential benefits for the remote monitoring service. No concerns were raised regarding nurse-led insertion of ICMs with a long-sensing vector.

Aims Current guidelines recommend remote follow-up for all patients with cardiac implantable electronic devices. However, the introduction of a remote follow-up service requires specifically dedicated organization. We evaluated the impact of adopting remote follow-up on the organization of a clinic and we measured healthcare resource utilization. Methods In 2016, we started the implementation of the remote follow-up service. Each patient was assigned to an experienced nurse and a doctor in charge with preestablished tasks and responsibilities. During 2016 and 2017, all patients on active follow-up at our center were included in the service; since 2018, the service has been fully operational for all patients following postimplantation hospital discharge. Results As of December 2018, 2024 patients were on active follow-up at the center. Of these, 93% of patients were remotely monitored according to the established protocol. The transmission rates were: 5.3/patient-year for pacemakers, 6.0/patient-year for defibrillators, and 14.1/patient-year for loop recorders. Only 21% of transmissions were submitted to the physician for further clinical evaluation, and 3% of transmissions necessitated an unplanned in-hospital visit for further assessment. Clinical events of any type were detected in 39% of transmissions. Overall, the nurses’ total workload was 3596 h per year, that is, 1.95 full-time equivalent, which resulted in 1038 patients/nurse. The total workload for physicians was 526 h per year, that is, 0.29 full-time equivalent. After 1 year on follow-up, most patients judged the service positively and expressed their preference for the new follow-up approach. Conclusion A remote follow-up service can be implemented and efficiently managed by nursing staff with minimal physician support. Patients are followed up with greater continuity and seem to appreciate the service.

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