Injectable loop recorder (ILR): How to, where to, who to

Abstract

In this issue of PACE, Kipp et al. 1 present a provocative article describing their favorable experience with a simplified advance practice provider (APP) implant approach for implantable loop recorder (ILR) implantation.The method described amounts to a "no questions asked assembly line." For such an approach, Henry Ford was considered to be a villain in his time but he turned out to be correct. Initially. Everyone was invited to order any color Model T as long as it was black. We now know how many options can be ordered individually on an assembly line.The reviewers for this article were concerned about the options. Is the left sternal border optimal for everyone, or do some patients benefit or prefer an inframammary location? Are all skin and body textures such that a nonscalpel "injection" and medical adhesive (glue) closure would be optimal? Do such decisions benefit from expert electrophysiology (EP) physician input? Do the efficiencies and convenience of an office setting overbalance the resources of an EP lab?What is an acceptable complication rate, and how does this differ from an optimal rate? This editor has seen several extrusions and/or infections of ILRs, all in patients whose incisions were closed with medical adhesive (which allows the ILR to be squeezed close to the skin) rather than a stitch.Such events do not typically cause systemic infections, and the argument is therefore made that the risk:benefit ratio is acceptable. Kipp et al. have shown what can be done. Local circumstances may dictate actual practice. APPs (NPs, PAs) are valuable assets, and should be cherished for what they can do. Meanwhile, the challenge has been made.