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Boosting telemedicine through remote monitoring of cardiac electronic devices during the Italian COVID-19 outbreak.

Remote monitoring of cardiac implantable electronic devices (CIEDs) affords an alternative to the one-on-one interaction required in traditional outpatient visits, and provides access to complete information on device performance [1]. The principal purposes of remote monitoring are: to reduce face-to-face hospital visits; ensure continuous follow-up and early detection of device malfunctions and subsequent clinical problems; and provide superior information processing [2]. On 31 December 2019, China reported a cluster of pneumonia cases with unknown etiology to the World Health Organization (WHO), the causative pathogen later being identified as a novel coronavirus (SARS-CoV-2) [3]. On 11 March 2020, WHO declared the pandemic phase of the outbreak [4]. On 20 February 2020, a male admitted to hospital in Codogno (Lombardy, Italy) was confirmed as the first Italian citizen with COVID-19 [5–7]. The following day, a second outbreak was detected, in the Veneto region (Padua). The Government quarantined these two “red” areas by closing schools and commercial activities, and cancelling events. Our public hospital is located west of Vò Euganeo and east of Codogno; i.e., between the two outbreaks. COVID-19 patients at highest risk for more severe complications and death include people aged > 60 years and people with comorbidities. Mortality increases with age, with the highest rate among individuals over 80 years of age. Furthermore, mortality is higher among males compared with females. Patients with CIEDs followed by our clinical center are of advanced age (mean age 78.5 ± ± 10.6 years), with more than half (53.8%) 80 years of age or older (Table 1); most have cardiovascular disease; and there was a higher prevalence of men (62.7%; n = 570). Because the duration of this medical emergency was unknown and the above mentioned clinic population was largely at higher risk of serious consequences from COVID-19 (Table 1), the aim was to check cardiac devices of patients using a home-monitoring system as much as was feasible, thereby reducing outpatient visits and decreasing infection risk for these fragile patients. While the Government was gradually extending restrictions outside of the two red areas, our unit quickly established a new procedure optimizing the management of CIED follow-ups. Overall, the remote monitoring system covered 909 CIEDs including 678 pacemakers (PMs), 198 implantable cardioverter-defibrillators (ICDs) and 33 loop recorders. The following measures were introduced: first, patients previously refusing device remote monitoring were contacted and strongly encouraged to accept this system. Should they accept, the telemonitoring system was dispatched and activated through a phone-mediated technical support system. Second, all devices without auto-thresholds (i.e., patients without PM-dependency) were exclusively checked through remote monitoring. Third, the new procedure required a mandatory attempt to solve all device alarms via phone communication. From 3 February to the day preceding the Italian outbreak, 40 patients had CIED monitoring transmissions checked remotely (26 PMs and