Who are the main actors of cardiac device follow-up? Analysis of the super follow-up study.

To the Editor,

We read with great interest the excellent paper titled “Should physicians instead of industry representatives be the main actor of cardiac implantable electronic device follow-up? (Super Follow-up)” by Üreyen et al. (1) recently published in the Anatolian Journal of Cardiology 2017; 18: 23-30. The authors presented their work on the role of proper cardiac device follow-up performed by cardiologists. They commented that the errors made by representatives of industries are higher than expected—an interesting finding.

Although the study conducted by Üreyen et al. (1) is very beneficial to health professionals and individuals alike, some points warrant mention:

Üreyen et al. (1) did not mention the role of AF detection algorithms (automatic mode switches) to assess whether such patients were in need of anticoagulation. According to the litera-ture, greater than 5–6 min spent in AF is an important predictor of stroke, with such patients in need of anticoagulation therapy based on CHADS2 or CHA2DS2VasC scores (2). Industry representatives may not be aware of indications for stroke prevention in patients with cardiac devices, a limitation that can leave patients at risk. Hence, responsibility of device follow-ups have to be taken by physicians only.

The role of industry represantives is very crucial. Physicians work in tandem with industry representatives and without their efforts, physician’s quality of care would be reduced. However, due to technological improvements, it is becoming harder for physicians to acclimate themselves with improved medical technologies. During my fellowship training in Canada, there were some patients who required an industry representative to be present alongside the physician. For instance, there was a patient with inappropriate device treatments due to T-wave oversensing, which was resolved after decay delay adjustment (3). As cardiac electrophysiologists in North America, we are not allowed to change decay delay parameters in ICD patients without industry technical support.

Üreyen et al. (1) stated that cardiac implantable electronic devices (CIEDs) should be followed by medical doctors instead of industry representatives alone. We think that Üreyen et al. (1) meant that the efforts of cardiac rhythm device clinic specialists, including cardiac electrophysiologists and specialized trained device technicians (nurses), should be in tandem to provide patient care.

One of the overlooked issues is to assess percentage of biventricular pacing in patients with CRT. It is unreliable to determine this percentage according to the device calculation. Because device will show total percentage of both RV and LV pacing (only one manufacture shows RV and LV separately), however only 12-lead ECG will ensure biventricular pacing. As far as we know that industry representatives do not check 12-lead ECG in patients with CRT during the interrogation. This issue needs to be solved only by cardiac electrophysiologits and/or device specialists.

Another unmentioned issue is device recalls. Unfortunately, device recalls and advisories are not taken seriously in our country. Both companies and physicians should act together and keep the patients informed regarding device recalls (4).

Finally, we would like to provide solutions to improve device follow-up in developing countries:

a) Specialists specializing in rhythm disorders: Unfortunately, in developing countries, there are no fellowship programs; however, in North America (USA and Canada) and European countries, cardiac electrophysiology training (1–2 years) is essential to perform in- and outpatient arrhythmia service.

b) Dedicated Cardiac Rhythm and Device Management clinics (electrophysiologists and/or device technicians)

c) Implantation of more technologically advanced devices is also very useful because it will improve follow-up of patients with pacemakers and ICD/CRTD. Due to economic issues in developing countries, there are still big public centers that implant basic devices instead of new, smarter, MRI-compatible devices.

d) Trainings and educational courses offered by companies to health-care workers may prove invaluable.

In conclusion, we congratulate Üreyen et al. (1) for their insightful study. As a cardiac electrophysiologist trained in Canada, I am proud of my colleagues that they increased awareness of this important issue.