Optimizing the positioning of the implantable loop recorder

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Tracing N° 1
Medtronic Devices: ILR Field: Reveal DX / Reveal XT
Patient

Sixty-four year old woman with a history of myocardial infarction and a preserved ejection fraction (left ventricular ejection fraction: 58%); three episodes of abrupt syncope without clear context; the ECG in sinus rhythm shows an incomplete right bundle branch block associated with a sequel of inferior myocardial infarction; complementary exams, including an electrophysiological study with programmed ventricular pacing are negative; immediately before installation of the device (Reveal XT), optimizing of device position using the Vector Check.

Graph and trace

Four tracings are performed with the same level of detection and amplification.

  1. the device is positioned horizontally at the level of the fourth intercostal space on the first tracing (angle: 0°); the following tracings are obtained by progressively vertically rotating the device until 90° (last tracing); in the four tracings, ventricular activity is correctly detected and labeled by the device (VS); however, it is clear that, looking at the first tracing, the ventricular signals are small and that no P or T-waves can be distinguished.
  2. on the second tracing, the QRS amplitude is larger and small T-waves are identified;
  3. on the third tracing, the QRS amplitude is even larger but the P and T-waves remain difficult to analyze;
  4. the last tracing indubitably allows a better detection of the ventricular signal, and a clear identification of both the P and T-waves; ECG signals are stable with only few variations in morphology and amplitude; this last position has been preferred for this patient. 
Comments

Since its introduction fifteen years ago, the implantable recorder (ILR) has become one of the reference diagnostic tools in the context of unexplained syncope. Syncope represents a major public health problem since 40 to 50% of the general population has already experienced an episode of transient loss of consciousness, and this symptom represents 1 to 6% of hospital admissions. While medical history, anamneses and clinical examination yield the correct etiology in the vast majority of the patients with neurally-mediated syncope, the performance of this conventional strategy is disappointing in the setting of cardiac syncope. The correlation between a syncopal event and any alteration of the ECG is the “gold standard” for the clinician; however syncope rarely occurs during short-term monitoring. The implantable loop recorder is a small device inserted subcutaneously in the left pectoral region that allows for long-term ambulatory recording of a bipolar ECG. The device has a loop memory, which records and memorizes the electrocardiogram upon its activation by the patient or by a bystander following a symptomatic episode, as well as automatically on the basis of pre-programmed detection criteria. In the next tracings, we will describe

  1. the technological characteristics and the main current and future indications of this type of device,
  2. the broad principles of interrogation and programming of the Reveal DC and Reveal XT, using the analysis of representative recordings from device recipients,
  3. the specificities of the latest platform of insertable cardiac monitors (Reveal LINQ).

The implantation of an implantable loop recorder is usually performed under local anesthesia in the same operative theater as that used for pacemakers. After a large disinfection of the left thoracic region, the device is positioned between the first intercostal space and the fourth rib. The quality of the future recorded tracings, the ability to avoid artifacts and to discriminate between different types of arrhythmias critically depends on the optimization of the implant procedure. Two elements should be considered:

  1. the optimization of R-wave collection: the Reveal XT package contains a mapping tool (the Reveal Vector Check –RVC- attached to the blister package), which helps selecting the optimal implant site without desterilizing the device itself. The Vector Check has 2 electrodes that are approximately 4 cm apart, and which match the electrode spacing of the device. These electrodes make contact with the device electrodes at one end and with the patient’s skin at the other. The quality of the sensed signal can be checked with the programmer. Small variations in the orientation of the device may lead to significant changes in the amplitude and morphology of the R-wave. Optimal device positioning is associated with R-waves of large and stable amplitude (≥0.3 mV when viewed on the programmer strip chart), a stable R-wave morphology, a good visualization of both the R-wave and the P-wave with a R/T and R/P ratio sufficiently high to avoid any P and T-wave oversensing.
  2. reducing the risk of myopotential oversensing: to warrant good reliability of the automatic detection, it is important to reduce device movement within its subcutaneous pocket as much as possible. Accordingly, the pocket should not be too large. It also should not be too small to avoid the externalization of the device. The head of the device is equipped with 2 suture holes for securing the device to the subcutaneous tissue and minimize the risks of rotation and migration of the device after implant.     
    When the Reveal has been implanted, set up the device sensing and data collection, and instruct the patient in using the Reveal XT system.