Surveillance and Follow-up of Patients with Implanted Cardiac Pacemaker by Telephone Transmission

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1 Surveillance and Follow-up of Patients with Implanted Cardiac Pacemaker by Telephone Transmission Takeo SAKURAI, M.D., Shuichi TOKUTSU, M.D., Osamu NISHIMUR M.D., Yutaka TAGAMI, M.D., Motoyuki TAKIMOTO, M.D., Hisao OHTA, M.D., Yoshiyuki YAMAOKA, M.D., Kazuo OKADA, M.D., Yoshio SUZUKI, M.D., Hideki YOKOI, M.D., Katsumi ENOMOT M.D., Naniwa OKADA, M.D., Hirotomi TANAKA, M. Sc.,* and Keiji MURAKAMI, M. Eng.* SUMMARY A follow-up study on pacemaker function in 15 patients with implanted cardiac pacemaker has been performed by telphone transmission. The transmitting set consisting of electrocardiograph, pacemaker pulse modulator and acoustic coupler was manipulated by the patients themselves. ECG, pacemaker pulse, and pulse rate were simultaneously transmitted through 1 channel to the receiver in our clinic. Of 56 patients with pacemaker, 15 patients were surveyed by telephone transmission. In these patients battery exhaustion was detected in 3, competition in 2, and lead fracture in 1. The fact that surveillance and follow-up of the patients with implanted cardiac pacemaker could be carried out by telephone transmission as well as by clinic visitation tells us that the telephone transmission is a useful method and plays an important role in a pacemaker clinic. Moreover our study established its further usefulness in the patient's preference due to difficulties in travelling to the pacemaker clinic and in reducing patient's anxiety. Additional Indexing Words: Acoustic coupling Pacemaker clinic Battery exhaustion Competition Lead fracture RTIFICIAL cardiac pacemakers with long-life-batteries are now widely implanted in patients for treatment of atrio-ventricular block, sick sinus syndrome, bradycardia with atrial fibrillation and so forth. Of patients with implanted cardiac pacemaker, there are many aged patients and many physically handicapped. Some of them live in unpopulated moun- From the Department of Thoracic Surgery, Wakayama Medical College, Wakayama, Japan. * Research Institute for Medical Sciences, Wakayama Medical College, Wakayama. This paper was presented at the 13th International Cardiovascular Society in August, 197Add ress for reprints: Shuichi Tokutsu, M.D., Department of Thoracic Surgery, WakayamM edical College, 7-Bancho-1, Wakayama-shi 640, Japan. Resceived for publication May 25,

2 830 SAKURAI, ET AL. J ap. Heart J. November, 1978 tainous areas and in the district where no doctor lives. Nevertheless, precise follow-up of patients is required, and therefore, studies on surveillance methods enabling long-term follow-up are very important. In the past few years there have appeared several reports on follow-up of patients with pacemaker.1)-3) Furman and others for the first time tried to survey patients with implanted cardiac pacemaker via telephone in ) The authors tried an improvement of telephone transmission techniques in order to transmit 2 signals of ECG and implanted pacemaker pulses simultaneously through 1 channel, and have surveyed the patients with implanted cardiac pacemaker since June It is the purpose of this report to evaluate our experiences regarding the surveillance of patients with pacemaker by telephone transmission. MATERIALS AND METHODS Between April, 1970 and April, 1977, 56 patients underwent implantation of pacemaker for complete atrio-ventricular block, sick sinus syndrome, incomplete atrio-ventricular block, bradycardia with atrial fibrillation, and atrio-ventricular block after cardiac surgery. The average age at the time of first implantation was 58.3 years with a range of 5 years to 88 years, and 57% were over 60 years of age (Fig.1). Between 1970 and 1974, only 28% of the patients in this study received implantation. During the 2.5 years after 1975, the remaining 72% received implantation. The number of patients had a tendency to increase rapidly (Fig.2). Of all 56 patients, 15 patients with difficulties in visiting our pacemaker clinic were surveyed by telephone transmission. Telephone transmission was performed in the 3 months following the first implantation either once a month or every 2 weeks depending upon the patient's conditions. After that it was done once every 2 months or more frequently in abnormal cases or on approach of battery exhaustion. Fig.1. Age distribution of patients with implanted cardiac pacemaker.

3 Vol.19 SURVEILLANCE OF PACEMAKERS BY TELEPHONE 831 No.6 Fig.2. Increase of number of patients. Telephone transmission system: The applicable device of the telephone transmission system consists of ECG apparatus (0-150Hz (-3dB)), a pacemaker pulse modulator (Sensitivity: pulse height>2mv, AM: 106Hz), and an acoustic coupler (FM: 1,700 }250Hz). The Fig.3. Diagram of the system.

4 832 SAKURAI, ET AL. Jap. Heart N ovember, 1978 acoustic coupling transmission method was used to convert signals into frequency. The signals of ECG and the implanted pacemaker were transmitted through channel by public telephone. The transmitted information received through the acoustic coupler was accurate and highly reproducible. At the same time transmitted data were recorded and pulse rate were printed out in the receiver. Changes in battery voltage, pacemaker pulse rate, pulse duration, and pulse configuration were analyzed from the transmitted information (Fig.3). RESULTS An example of ECG and pulse rate transmitted by telephone over a distance of about 190Km is shown in Fig.4. A in Fig.4 shows the ECG transtmited from a patient. B shows the ECG with pacemaker pulse received in the pacemaker clinic. C shows the ECG after filtration, reproduced in the clinic. D shows pulse rate. Since the received ECG was exactly the same as the transmitted ECG, the received ECG and pulse rate were reliable. Some cases in which complications were detected by use of the telephone Fig.4. ECG and pulse transmitted.

5 Vol.19 No.6 SURVEILLANCE OF PACEMAKERS BY TELEPHONE 833 transmission are presented below. Premature battery exhaustion: Due to old age, telephone transmission was done in a patient with a demand pacemaker (Starr-Edwards 8114) (Fig.5). Twenty months after implantation the pacemaker pulse rate decreased unexpectedly from 68.1 } 0.5 to 66.4 beats/min and further decreasted to 65.8 beats/min 11 days later. At that time the battery was judged to be exhausted and the generator was replaced. Successive measurement of the pulse rate in the removed generator revealed decreases in the rate. Fortunately, by telephone transmission, we were able to detect the premature battery exhaustion that had occurred before the normal life span. Competition: Because of complete artio-ventricular block a fixed-rate pacemaker (Medtronic 5910) was implanted in a 67-year-old woman. Transmitted electrocardiograms of the patient are shown in Fig.6. A in Fig.6 shows the transmitted ECG with normal pacing. B shows the ECG 13 months after implantation of the pacemaker. The normal conduction of the heart has recovered and sinus rhythm is seen. As ventricular fibrillation might be induced by a spike on T-wave, the pulse generator was replaced with a new demand pacemaker. C shows the transmitted ECG after replacement. Because both ECG and pacemaker pulse were simultaneously transmitted, it could be easily evaluated whether the pacemaker pulses were effective or not. Lead fracture: Transmitted electrocardiograms of a 51-year-old woman with a demand pacemaker and myocardial bipolar electrodes are shown in Fig.7. One and a half years later the patient felt dizzy. As shown in A and B in Fig.7, polar change of pacemaker pulses in lead II and irregular pacemaker pulses and pacing failure in lead V6 were found and fracture of electrodes was suspected. Consequently electrodes and a pulse generator were newly implanted. As seen in C in Fig.7, the ECG after replacement shows normal pacing - Table I represents reasons why pacemaker generators have been replaced. In 15 patients who were surveyed by telephone transmission, battery exhaustion was detected in 3, competition in 2, and lead fracture in 1.

6 834 SAKURAI, ET AL. NJap. Heart ovember, 1978 Fig.5. Change of pacemaker pulse rate in a 74-year-old woman. Fig.6. Transmitted ECG in a case of competition.

7 Vol.19 No.6 SURVEILLANCE OF PACEMAKERS BY TELEPHONE 835 Fig.7. Transmitted ECG in a case of electrode malfunction. Table I. Reasons for Pacemaker Replacement Numbers in parentheses are those detected by telephone transmission DISCUSSION Since the first permanent pacemaker was implanted in 1958 by Senning,5) the number of patients requiring pacemaker has increased yearly, with a rapid acceleration in the past several years. In order to follow up and manage these patients satisfactorily, the pacemaker clinic should be organized to examine the patient's general condition, ECG, X-ray film, site of implantation, and to analyse pulse generator impulses. Thus, replacement of

8 836 SAKURAI, ET AL. Jap. Heart N ovember, 1978 Fig.8. Reasons of preference for telephone transmission. the pulse generator can be postponed to the ultimate terminal and various complications can be also detected. However some patients have difficulties in travelling to the pacemaker clinic. Fig.8 represents various reasons why patients could not frequently travel to the pacemaker clinic. Thirty-five percents of all our 56 patients are at long distances; 4 patients have to travel over 3 hours to the pacemaker clinic and 5 patients over 2 hours. Since Furman and others for the first time tried to survey patients with implanted cardiac pacemaker via telephone in 1970,4) several surveillance methods by telephone transmission have been reported.6)-10) In areas where telephone service is ubiquitous, patients can be surveyed as frequently as necessary and they need not come to the pacemaker clinic unless X-ray or more exact electronic analysis is required, or unless intervention is indicated. Accordingly, if telephone transmission enables an examination and exact diagnosis equal to those in the pacemaker clinic, it is a useful method and plays an important role. As signals capable of being transmitted through telephone, there are pacemaker rate, ECG, digital plethysmography, and electronic parameters. Transmission of electronic parameters is the most sophisticated system of data transmission and the technique and transmitter are too complex. Transmission of pacemaker rate and ECG is widely used. Pulse rate is used as an indicator of battery depletion and ECG is used as an indicator of ventricular capture and cardiac activity. The authors have used a combination of these 2 methods to survey the patients' pacemakers. On the other hand, there are 2 methods of telephone transmission; direct wire coupling and acoustic coupling. After consideration of regional peculiarity, movability of the device, simplification of manipulation, and simplicity of setting, acoustic coupling was adopted for both transmitting and receiving. By this method pacemaker rate and ECG are simultaneously

9 Vol.19 No.6 SURVEILLANCE OF PACEMAKERS BY TELEPHONE 837 transmitted to the receiver through 1 channel. Accuracy of pacemaker rate via telephone was less than }0.1 pulse per minute and telephone line loss was less than 14dB. In 15 patients transmission was performed more than 300 times. Three battery exhaustion, 2 competition and 1 lead fracture were detected and there were no errors. An old woman who consulted a home-doctor due to difficulty in walking and was not surveyed by telephone transmission by her choice underwent emergency replacement twice for premature battery exhaustion. If the patient had been surveyed by telephone transmission when the patient first experienced abnormal feelings or anxiety, an accurate diagnosis with ECG could have been made and the abnormality of the pacemaker could have been detected in an earlier stage. At the beginning of our study, selection of patients to use the telephone transmission system was done on a random basis for patients with the greatest difficulty in travelling to the clinic. We found at the conclusion of the study that 72% of the total 56 patients (including 15 patients who used this method) would prefer to use the telephone transmission method of surveillance not only due to difficulties of travelling to the pacemaker clinic but also in reducing anxiety of patients and their families. They worried about being unable to visit the pacemaker clinic easily when abnormal feelings occurred. Therefore, by using telephone transmission for the surveillance of patients with implanted cardiac pacemaker the function of the pacemaker clinic can be further extended. CONCLUSION 1. Patients with implanted cardiac pacemaker could be surveyed by telephone transmission using the ubiquitous telephone service. 2. ECG and pacemaker pulse were simultaneously transmitted through 1 channel. 3. The information transmitted by the telephone was accurate and highly reproducible. 4. Complications in the patients could be detected and treated at an early stage. There were no errors in the telephone transmission. 5. Patients who had difficulties in frequent travels to the pacemaker clinic could be fully surveyed. 6. Both the patients and their families were reducted from the about being unable to visit the pacemaker clinic easily when abnormal feelings occurred.

10 838 SAKURAI, ET AL. Jap. Heart N ovember, 1978 REFERENCES 1. Parsonnet V, Myers GH, Gilbert L, Zucker IR: Prediction of impending pacemaker failure in a pacemaker clinic. Am J Cardiol 25: 311, Mantini EL, Majors RK, Kennedy JR, Lebo GR: A recommended protocol for pacemaker follow-up: an analysis of 1705 implanted pacemakers. Ann Thorac Surg 24: 62, Stoney WS, Finger FE III, Alford WC Jr, Burrus GR, Frist RA, Thomas CS: The natural history of long-term cardiac pacing. Ann Thorac Surg 23: 550, Furman S, Parker B, Escher DJW: Pacemaker clinic via telephone. Bull Heart Inst Jap 14: 1, Senning ð: Discussion of Stephenson SE, Edwards WE, Jolly PC, Scott HW: Physiologic p-wave cardiac stimulator. J Thorac Cardiovasc Surg 38: 604, Furman S, Parker B, Escher DJW.: Transtelephone pacemaker clinic. J Thorac Cardiovasc Surg 61: 827, Parsonnet V, Myers GH, Gilbert L, Zucker IR, Shilling E: Follow-up of implanted pacemakers. Am Heart J 87: 642, Sakurai Y, Aoki E, Terashima M, Asano K, Takeuchi Y, Hattori J: Pacemaker clinic by telephone transmissisn. Artificial Organs 4: 357, Furman S: The future utility of transtelephone pacemaker monitoring. J Electrocardiology 9: 199, Furman S: Cardiac pacing and pacemakers VIII. The pacemaker follow-up clinic. Am Heart J 94: 795, 1977

Transtelephone Pacemaker Monitoring

Transtelephone Pacemaker Monitoring Five Years Later Seymour Furman, M.D., and Doris J. W. Escher, M.D. ABSTRACT Six hundred nineteen patients have been followed by remote monitoring of pacemaker function