Europace EHRA SURVEY doi:10.1093/europace/euab215 The use of remote monitoring of cardiac implantable devices during the COVID-19 pandemic: an EHRA physician survey Stefan Simovic 1,2*, Rui Providencia3,4, Sergio Barra 5,6,Bratislav Kircanski7,8, Jose M. Guerra9, Giulio Conte 10,David Duncker 11, Eloi Marijon 12,13,14, Ante Anic 15, and Serge Boveda 14,16,17 1 Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69, 34000 Kragujevac, Serbia; 2Clinic for Cardiology, University Clinical Center Kragujevac, Kragujevac, Serbia; 3St Bartholomew’s Hospital, Barts Heart Centre, Barts Health NHS Trust, London, UK; 4Institute of Health Informatics, University College of London, London, UK; 5Cardiology Department, Hospital da Luz Arrabida, V. N. Gaia, Portugal; 6Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK; 7University Clinical Centre of Serbia, Pacemaker Centre, Belgrade, Serbia; 8School of Medicine, University of Belgrade, Belgrade, Serbia; 9Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Universidad Autonoma de Barcelona, CIBERCV, Barcelona, Spain; 10Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland; 11Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany; 12University of Paris, Paris, France; 13European Georges Pompidou Hospital, Cardiology Department and Cardiovascular Research Center, Paris, France; 14Institut National de la Sante et de la Recherche Medicale U970, 75908 Paris Cedex 15, France; 15Department for Cardiovascular diseases, University Hospital Center Split, Split, Croatia; 16Heart Rhythm Department, Clinique Pasteur, 31076 Toulouse, France; and 17Universitair Ziekenhuis Brussel—VUB, Heart Rhythm Management Centre, Brussels, Belgium Received 16 July 2021; editorial decision 20 July 2021 Abstract It is unclear to what extent the COVID-19 pandemic has influenced the use of remote monitoring (RM) of cardiac implantable electronic devices (CIEDs). The present physician-based European Heart Rhythm Association (EHRA) survey aimed to assess the influence of the COVID-19 pandemic on RM of CIEDs among EHRA members and how it changed the current practice. The survey comprised 27 questions focusing on RM use before and during the pandemic. Questions focused on the impact of COVID-19 on the frequency of in-office visits, data filtering, reasons for initiating in-person visits, underutilization of RM during COVID-19, and RM reimbursement. A total of 160 participants from 28 countries completed the survey. Compared to the pre-pandemic period, there was a sig- nificant increase in the use of RM in patients with pacemakers (PMs) and implantable loop recorders (ILRs) during the COVID-19 pandemic (PM 24.2 vs. 39.9%, P = 0.002; ILRs 61.5 vs. 73.5%, P = 0.028), while there was a trend to- wards higher utilization of RM for cardiac resynchronization therapy-pacemaker (CRT-P) devices during the pan- demic (44.5 vs. 55%, P = 0.063). The use of RM with implantable cardioverter-defibrillators (ICDs) and CRT- defibrillator (CRT-D) did not significantly change during the pandemic (ICD 65.2 vs. 69.6%, P = 0.408; CRT-D 65.2 vs. 68.8%, P = 0.513). The frequency of in-office visits was significantly lower during the pandemic (P < 0.001). Nearly two-thirds of participants (57 out of 87 respondents), established new RM connections for CIEDs implanted before the pandemic with 33.3% (n = 29) delivering RM transmitters to the patient’s home address, and the remain- ing 32.1% (n = 28) activating RM connections during an in-office visit. The results of this survey suggest that the cri- sis caused by COVID-19 has led to a significant increase in the use of RM of CIEDs. 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 Keywords Remote monitoring • Cardiac implantable electronic devices • COVID-19 • EHRA survey Introduction monitoring of CIEDs reduces the number of scheduled in-office visits Remote monitoring (RM) of cardiac implantable electronic devices and leads to early detection of events, such as atrial fibrillation and (CIEDs) was initially introduced for complementary evaluation of de- ventricular arrhythmias, inappropriate shocks, lead failure, premature vice function but now represents the standard of care and is recom- battery depletion, loss of biventricular capture, and mortality.3,4 mended by major cardiology societies worldwide.1,2 Remote However, despite the international guidelines’ recommendations * Corresponding author. Tel: þ381 64 4111120. E-mail address: simovicst@gmail.com C The Author(s) 2021. For permissions, please email: journals.permissions@oup.com. Published on behalf of the European Society of Cardiology. All rights reserved. V Page 2 of 8 EHRA survey based on these numerous benefits, its use in the routine clinical set- for implantable cardioverter-defibrillators (ICDs) did not change sig- ting remains modest.1,2,5 nificantly during the pandemic [ICD: 65.2% before vs. 69.6% during Although the COVID-19 pandemic caught us unprepared, it facili- the pandemic, P = 0.408; cardiac resynchronization therapy- tated and accelerated the use of telemedicine and digital solutions.6 defibrillators (CRT-D): 65.2% before vs. 68.8% during the pandemic, Remote monitoring and teleconsultations, new digital tools, mobile P = 0.513]. There was a trend for a higher utilization of RM for CRT- health apps were available to replace traditional clinician-patient, face- pacemakers (CRT-P), with 44.5% of devices with RM before and 55% to-face interaction, and enabled the follow-up and treatment of patients of devices with RM during the pandemic (P = 0.063). during the lockdown.7 Although it is clear that the COVID-19 pan- The majority of the respondents declared willingness to increase demic has expedited the utilization of digital tools, it remains unclear to the use of RM of all CIEDs after the pandemic: 53.7% for PM, 80% for what extent the pandemic has influenced the use of RM of CIEDs. ICD, 71.5% for CRT-P, 80.5% for CRT-D, and 81.8% for ILR. The aim of this physician-based survey, disseminated by the Scientific Initiatives Committee of the European Heart Rhythm Association New RM connections for pre-COVID (EHRA), was to evaluate and describe the impact of the COVID-19 implanted CIEDs and adherence to the pandemic on the use of RM of CIEDs among EHRA members. official guidance Nearly two-thirds of participants (57 out of 87 respondents), estab- lished new RM connections for CIEDs implanted before the pan- Methods demic with 33.3% (n = 29) delivering RM transmitters to the patient’s An online survey was prepared and disseminated by the EHRA Scientific home address, and the remaining 32.1% (n = 28) activating RM con- Initiatives Committee to the EHRA Scientific Research Network mem- nections during an in-office visit. bers, national electrophysiology working groups, and social media plat- More than half of the respondents (54.1%) stated that recent guid- forms (Twitter, LinkedIn and Facebook), with the help of the EHRA e- ance by the European Society of Cardiology (ESC)8 and Heart Communication Committee. The survey was conducted between 17 Rhythm Society (HRS)9 on management of cardiovascular disease March 2021 and 30 April 2021. It was designed after reviewing the litera- during the COVID19 pandemic did not lead to any significant changes ture and using expert opinion to examine the changes in RM practice in- on their management of CIED patients. Up to 42.2% acknowledged duced by COVID-19 pandemic, and comprised a total of 28 questions some degree of modification in practice, and only 3.7% stated that it distributed in four blocks focusing on the impact of COVID-19 on the fre- ‘absolutely changed’ their practice during the pandemic. quency of in-office visits, data filtering, reasons for initiating in-person vis- its, underutilization of the RM during the pandemic and RM reimbursement (Supplementary material online, Table S1). Frequency of in-person visits of RM Participants who disagreed with GDPR compliance were excluded patients from the analysis. Of 109 responses, respondents stated that 57.4% of all CIEDs in- clinic follow-ups were delayed due to the pandemic. The mean pe- Statistical analysis riod between face-to-face appointments for RM patients with an Mean and standard deviation were used to present continuous variables, implanted PM changed from 10.3 ± 5.4 months to 16 ± 12.5 months while categorical variables are expressed as numbers and percentages. during the pandemic (P < 0.001). For patients with an ICD, this Student’s t-tests, Mann–Whitney U tests and one-way analysis of variance, changed from 8.6 ± 5.8 months to 15.1 ± 13.9 months during the as appropriate, and Chi-square test (v2) for categorical variables were COVID-19 pandemic (P < 0.001), and for CRT patients, it increased used to compare groups. Statistical analysis was performed using SPSS from 8.3 ± 6 months to 14.3 ± 14 months (P < 0.001). Implantable 25.0 for Macintosh (SPSS Inc., Chicago, IL, USA). P-values of <0.05 were loop recorder were checked in person every 11.1 ± 11.9 months be- considered statistically significant. fore vs. 17.6 ± 17.2 months during the pandemic (P = 0.002) (Figure 2). Results Remote monitoring data filtering The survey was completed by 160 participants from 28 countries The COVID-19 pandemic did not significantly impact on the recruit- [mean age 45.5 ± 11 years, female 28.3% (n = 37)] (Table 1). The ma- ment and organization of the RM data filtering personnel (P = 0.818) jority of survey participants (76%) stated that their hospitals were (Figure 3). In most cases, a specialized nurse or physician assistant was partially turned into COVID-19 centres, while 16% declared that the in charge of data filtering (56.1% before vs. 55.9% during the pan- entire hospital was converted into a COVID-19 centre at some point demic), followed by doctors (33.3% vs. 31.2%) and allied professio- during the pandemic. nals (6.1% vs. 5.5%, respectively). Remote monitoring before, during, and Clinical impact of RM during the after the COVID-19 pandemic pandemic Remote monitoring was used in 24.2% of pacemaker (PM) patients The clinical impact of RM findings did not significantly differ before before the COVID-19 pandemic. The percentage of PM patients with and during the COVID-19 (P = 0.687). Of 114 responses, participants RM increased significantly during the pandemic to 39.9% (P = 0.002). replied that the need for phone calls (64% vs. 64.2%) or in-office visits Similarly, usage of RM for implantable loop recorders (ILRs) in- (12.3% vs. 15.6%) following significant RM findings was similar be- creased from 61.5% to 73.5% (P = 0.028) (Figure 1). Utilization of RM tween the pre-and post-pandemic period. EHRA survey Page 3 of 8 (P = 0.048). The main reasons for underutilization of RM before the Table 1 Basic characteristics of the respondents (full list of responding countries available from pandemic were lack of personnel (46.5%) and lack of reimbursement Supplementary material online, Table S2) (50.9%). Interestingly, during the pandemic, these percentages dropped to 34.7% (P = 0.053) and 40.4% (P = 0.085) (Figure 6). Mean age (years) 45.55 ± 10.62 Female respondents 28.31% (n = 37) Current working po- EP specialist 77.34% Discussion sition (n = 152) Cardiologist 8.67% EP fellow 4% The main findings of this survey are: (i) use of RM increased during Cardiology fellow 3.33% COVID-19, and a further increase may be expected after the pan- Nurse 5.33% demic; (ii) the pandemic significantly reduced the frequency of face- Allied professional 1.33% to-face appointments of RM patients with CIEDs; (iii) the reasons for Main working envi- University hospital 58.67% in-office visits of RM patients during the pandemic were similar to ronment (n = 152) Specialized public cardiol- 7.33% those prior to it; and (iv) COVID-19 did not change the RM data fil- ogy centre tering personnel profile. Public hospital 16% Private hospital 16% Use of RM of CIEDs pre-, during, and Private practice 2% planning for the post-COVID period Country (top 5, total France 32.67% Even though RM had been available for two decades before the pan- 28) (n = 152) Spain 18% demic and international guidelines recommend its use since 2015, the Poland 11.33% full capacities of RM had not been fully exploited, with a low adoption Serbia 6.67% rate across European centres.2,4,10 The measures of physical distancing Italy 4.67% implemented in many countries during the COVID-19 created a The hospital turned Yes, the entire hospital 16% broader and urgent need for a wider adoption of digital solutions, among in the COVID-19 Yes, part of the hospital 76% them, RM. Indeed, the wEHRAbles survey-II showed an increased use of centre (n = 152) No 8% teleconsultations during the pandemic, while the HRS survey showed al- most a 10-fold higher adoption of routine use of video-telehealth.6,11 The results of our survey confirm the greater use of RM in patients with CIEDs, particularly with PM and ILR, and, to a less extent, CRT-P. According to the responses, the most frequent reasons for face-to- Remote monitoring of high-energy devices was adopted in a larger num- face visits before and during the pandemic were inappropriate ICD ber of centres during the pandemic but differences were not significant. therapies (69.3% vs. 64.2% responses, respectively, P = 0.321), followed These findings are in concordance with the results of the 2015 EHRA by appropriate ICD therapies (64% before vs. 56.9% during the survey on the RM implementation across Europe, which showed a very COVID-19; P = 0.242). Even though no significant differences in reasons high rate of RM use in ICD and CRT devices, comparable to the rate in for initiating in-office visits for RM patients when comparing before and our survey.4 Additionally, in Italy, there was no significant increase in the during pandemic were reported (Figure 4), there was a trend towards use of RM for ICD and CRT devices from 2012 to 2017, although there fewer face-to-face appointments for all indications during COVID-19, was a significantly higher use of RM for ILR, as we have seen in our except for ventricular arrhythmias (61.4% vs. 62.4%, P = 0.424). study.12 Unlike the wEHRAbles survey-II results, which showed that the same level of telemedicine use is expected after the COVID-19 pan- Reimbursement for RM of CIEDs demic, our survey shows that a further increase of RM use after the pan- Of 114 respondents, 57% (n = 65) did not receive any reimburse- demic is likely and is planned by the majority of physicians.11 ment for RM of CIEDs, before the pandemic. Reimbursement of RM before the pandemic was declared by 25.4% of the respondents for Frequency of in-office visits of RM PM, 41.2% for ICD, 29% for CRT-P, 37.7% for CRT-D, and only 8.8% patients, changes introduced by ESC and of the centres received reimbursement for RM of ILR. Additional re- HRS guidance and establishment of new imbursement for RM of CIEDs was declared by 7.3% respondents for RM connections for pre-COVID PM and ICD during the COVID-19 pandemic of 109 respondents. A implanted CIEDs 5.5% increase in respondents receiving reimbursement for RM of To reduce transmission of the SARS-CoV-2 virus, ‘lock-down’ meas- CRT-P and CRT-D was observed during the pandemic. Only 1.8% of ures were put into practice worldwide. In addition, the ESC and HRS participants received additional reimbursement for RM of ILR during guidance for cardiac electrophysiologists during the COVID-19 pan- the COVID-19 (Figure 5). demic recommended the postponement of elective or in-person vis- its for CIED routine follow-up.8,9 Our findings revealed a significantly Reasons for underutilization of RM lower frequency of in-office visits of RM patients with CIEDs during Out of 114 respondents, only one-quarter of the participants (24.6%) the pandemic, showing an adjustment of the clinical practice to the considered RM sufficiently utilized prior to the pandemic. During the emerging epidemiological situation. Despite the application of meas- pandemic, this proportion has significantly increased to 35.8% ures presented in the ESC and HRS guidance, more than half of the Page 4 of 8 EHRA survey 100% Before COVID-19 During COVID-19 90% * 80% 73.5% 69.6% 68.8% 70% 65.2% 65.2% 61.5% 60% 55.0% * 50% 44.5% 39.9% 40% 30% 24.2% 20% 10% 0% PM ICD CRT-P CRT-D ILR Figure 1 Question: ‘What percentage of implanted CIEDs before/during COVID-19 had remote monitoring?’ Total number of respondents 114. *P < 0.05. CIED, cardiac implantable electronic device; CRT-D, cardiac resynchronization therapy-defibrillator; CRT-P, cardiac resynchronization therapy-pacemaker; ICD, implantable cardioverter-defibrillator; ILR, implantable loop recorder; PM, pacemaker. respondents stated that such guidance did not lead to any significant mortality of these patients, mainly by earlier recognition and manage- changes in their clinical practice. Reasons for this lack of change in be- ment of arrhythmias, device malfunction and heart failure.3,4,15 Our haviour remain to be clarified, and we consider these results as a call survey shows that despite COVID-19, there were no changes in the for action for further official guidance promotion. clinical value of the data received via RM before and during the pan- Controversially, the approach for establishing new RM connec- demic. However, the volume of transmissions is increasing alongside tions for pre-COVID implanted CIEDs was equally split between de- the alerts. In a recent study, 40% of all RM transmissions were alerts, livering an RM transmitter to the patient’s home address and in-office with 50% of all alerts being produced by ILR, even though these only RM connection activation. Noteworthy, one-third of centres did not accounted for 18.8% of all followed devices.16 This represents a con- offer RM connections to patients with CIEDs implanted prior to the siderable burden, and therefore, efficient data filtering is a crucial part pandemic. This discrepancy in the respondents’ answers to this sur- of RM by reducing data overload. In our survey, no changes were ob- vey, and non-compliance with the advice of the practice document served in the RM data filtering personnel. Surprisingly, in 2.6% of the responding centres in pre- and 1.8% during COVID-19, no one fil- proposed by the ESC and HRS should be indicative, and eventually tered the data. Despite the tiny percentage of respondents for whom helpful for further recommendations or consensus documents. no one filters the data, concerns and encouragement for organizing Recent studies on patients that received RM devices at home teams for RM data filtering, according to the guidelines, must be addresses show that the majority of patients were able to successfully expressed.2 In addition to data filtering, RM teams’ crucial tasks are activate the transmitter, and experienced higher degree of satisfac- timely recognition and initiation of in-person visits. In this survey, rea- tion, as well as a reduced anxiety levels when compared to the face- sons for initiating an face-to-face visits did not differ before and during to-face activation of RM connection.13,14 This increase in RM utiliza- the COVID-19. Despite the lock-down measures, recent research in- tion, even for CIEDs implanted before the pandemic, was in accor- vestigating data from RM transmissions during COVID-19 showed a dance with the ESC and HRS guidance for COVID-19.8,9 significant increase in thoracic impedance, decreased physical activity and a 33% increase in atrial fibrillation episodes in patients with RM data filtering and initiation of in- CIEDs.17,18 In contrast, during the pandemic, a 32% reduction in ven- office visits of RM patients tricular arrhythmias requiring device therapies was observed with a RM is an efficient and safe method of monitoring patients with CIEDs, more pronounced reduction in areas with a greater prevalence of while simultaneously reducing the number of in-office visits and COVID-19 infection.19 EHRA survey Page 5 of 8 Months Before COVID-19 During COVID-19 20.0 * * 18.0 17.6 * 16.0 * 16.0 15.1 14.3 14.0 12.0 11.1 10.3 10.0 8.6 8.3 8.0 6.0 4.0 2.0 0.0 Pacemaker ICD CRT ILR Figure 2 Question: ‘How frequent were in-person checkups with your remotely monitored patients, before/during COVID-19?’. Total number of respondents 114. *P < 0.05. CIED, cardiac implantable electronic device; CRT, cardiac resynchronization therapy; ICD, implantable cardioverter-defi- brillator; ILR, implantable loop recorder. 60% 56.1% 55.9% Before COVID-19 During COVID-19 50% 40% 33.3% 31.2% 30% 20% 10% 6.1% 5.5% 3.7% 2.6% 1.8% 0.9% 0.9% 0.9% 0% Specialised Doctor External RM centre Alied professional No one Resident nurse/Physician assistant Figure 3 Question: ‘Who was in charge of filtering remote monitoring data of CIEDs before/during COVID-19?’ Total number of respondents 114. CIED, cardiac implantable electronic device; RM, remote monitoring. Page 6 of 8 EHRA survey 80% Before COVID-19 During COVID-19 69.3% 70% 64.0% 64.2% 61.4% 62.4% 60% 57.9% 57.0% 56.9% 54.4% 55.1% 56.0% 50.0% 50% 48.6% 46.5% 44.0% 44.0% 40% 30% 20% 10% 0% Sensing and Battery Lead Appropriate Inappropriate Atrial Ventricular Heart failure pacing issues depletion malfunction therapy ICD therapy arrhythmias arrhythmias worsening Figure 4 Question: ‘Please specify the main reasons for initiating in-clinic visits of remotely monitored patients before/during COVID-19 pandemic’. Total number of respondents 114. ICD, implantable cardioverter-defibrillator. 60% Additional reimbursement during COVID19 Before COVID19 50% 7.3% 40% 5.5% 5.5% 30% 7.3% 20% 41.2% 37.7% 29.0% 25.4% 10% 1.8% 8.8% 0% Yes for PM Yes for ICD Yes for CRT-P Yes for CRT-D Yes for ILR Figure 5 Question: ‘Did you receive any reimbursement for remote monitoring before/during COVID-19? If yes, please specify for which devices’. Total number of respondents 114. CRT-D, cardiac resynchronization therapy-defibrillator; CRT-P, cardiac resynchronization therapy-pacemaker; ICD, implantable cardioverter-defibrillator; ILR, implantable loop recorder; PM, pacemaker. EHRA survey Page 7 of 8 60% Before COVID-19 50.9% During COVID-19 50% 46.5% 40.4% * 40% 35.8% 34.9% 35.1% 30% 26.6% 24.6% 20% 14.7% 13.8% 13.8% 13.8% 14.0% 11.4% 9.2% 10.5% 10% 7.9% 7.3% 2.6% 0.9% 0% ns es n ns t l ad s ed it e ne en ue un tio bl l tio er lo is ac la on em pa ss il 9 er nc i ita ut va t rs -1 bs li ci ov rs co r im pe ta na D r ti de bu lo VI a l pa cy no io un at of im ga al O at iva D ic nt C re ck s Le ot iz og ce ie Pr in La an N of at ol vi d rg ck de hn tp ne lo La c en M ur Te ta R lt ci pi ffi ta of os su pi n H os In tio H bu tri is D Figure 6 Question: ‘If you consider that remote monitoring was underutilized before/during COVID-19, please specify the main reasons’. Total number of respondents 114. *P < 0.05. RM, remote monitoring. Reimbursement of RM during the having reduced the legal and privacy concerns or (ii) as an improve- ment and a greater adherence to the GDPR during the crisis. pandemic The results of the 2015 EHRA survey showed that 80% of the Limitations respondents did not receive reimbursement for RM of CIEDs and Considering that 50% of the answers to the survey came from France that the lack of reimbursement was the most significant barrier for and Spain, the results of this survey may not necessarily be generaliz- implementation of RM of CIEDs.4 However, results from our survey able to the whole of Europe. Additionally, the voluntary nature of show that the number of centres not receiving reimbursement for surveys like this one adds uncertainty to the estimates and raises RM of CIEDs before the COVID-19 was now more than 50%, dem- questions whether these results represent a realistic reflection of the onstrating a significant increase in the rate of reimbursement. actual situation. The lack of space for additional questions in the sur- Additionally, our results show an increase in the rate of participant vey prevented a more detailed investigation of the observed changes, centres being reimbursed during the COVID-19 pandemic across all and further research is needed. devices. These results are promising, but it must be borne in mind that a large number of participants still do not receive reimbursement for RM preventing its wider use. Conclusions Reasons for underutilization of RM The results of this survey highlight the impact of COVID-19 on the in- during COVID-19 creased use of RM of CIEDs, leading to a reduction of unnecessary Besides increased use of RM of CIEDs during COVID-19, a significant in-office visits. The pandemic did not change RM data filtering person- nel and the reasons for in-office visits of RM patients were similar to number of respondents expresses additional reasons for the relative those prior to it. Further implementation of RM use after the pan- underutilization of RM. Despite not achieving statistical significance, it demic is warranted and planned by the majority of physicians. is essential to note a declining trend of reasons, such as lack of reim- bursement, personnel and hospital organizational issues during the COVID-19. Moreover, as a reason for the underutilization of RM in Supplementary material our survey, privacy concerns and legal obstacles represented an insig- nificant proportion. It can be interpreted either as: (i) the pandemic Supplementary material is available at Europace online. Page 8 of 8 EHRA survey Acknowledgements 5. Braunschweig F, Anker SD, Proff J, Varma N. Remote monitoring of implantable cardioverter-defibrillators and resynchronization devices to improve patient out- The production of this document is under the responsibility of the comes: dead end or way ahead? Europace 2019;21:846–55. Scientific Initiatives Committee of the European Heart Rhythm 6. Han JK, Al-Khatib SM, Albert CM. Changes in the digital health landscape in car- diac electrophysiology: a pre-and peri-pandemic COVID-19 era survey. Association: Serge Boveda (Chair), Giulio Conte (Co-Chair), Ante Cardiovasc Digital Health J 2021;2:55–62. Anic, Sergio Barra, Julian K.R. Chun, Carlo de Asmundis, Nikolaos 7. Varma N, Marrouche NF, Aguinaga L, Albert CM, Arbelo E, Choi JI et al. HRS/ Dagres, Michal M. Farkowski, Jose M. Guerra, Konstantinos E. EHRA/APHTS/LAHRS/ACC/AHA worldwide practice update for telehealth and arrhythmia monitoring during and after a pandemic. Europace 2021;23:313. Iliodromitis, Kristine Jubele, Jedrzej Kosiuk, Eloi Marijon, Rui 8. ESC Guidance for the Diagnosis and Management of CV Disease during the Providencia, Frits Prinzen. COVID-19 Pandemic. https://www.escardio.org/Education/COVID-19-and- The authors acknowledge the EHRA Scientific Research Network Cardiology/ESC-COVID-19-Guidance (10 June 2020, date last accessed). 9. Lakkireddy DR, Chung MK, Gopinathannair R, Patton KK, Gluckman TJ, Turagam centres participating in this survey. A list of these centres can be M et al. Guidance for cardiac electrophysiology during the coronavirus (COVID- found on the EHRA website. 19) pandemic from the Heart Rhythm Society COVID-19 Task Force; The authors are deeply thankful to Vanessa Meyen for her sup- Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical port in coordinating the project. Cardiology, American Heart Association. Heart Rhythm 2020;17:e233–41. Conflicts of interest: S.S. has received speaker honoraria from 10. Marinskis G, van Erven L, Bongiorni MG, Lip GYH, Pison L, Blomström-Lundqvist Bayer. R.P., S.B., and B.K. have nothing to declare. J.M.G. has served C. Practices of cardiac implantable electronic device follow-up: results of the European Heart Rhythm Association survey. Europace 2012;14:423–5. as a consultant for Medtronic, Boston Scientific, Microport and 11. Manninger M, Zweiker D, Svennberg E, Chatzikyriakou S, Pavlovic N, Zaman JAB Abbott, received speaker fees from Medtronic, Boston Scientific and et al. Current perspectives on wearable rhythm recordings for clinical decision- Abbott and received a research grant from Abbott. G.C. has nothing making: the wEHRAbles 2 survey. Europace 2021;23:1106–13. 12. Palmisano P, Melissano D, Zanotto G, Perego GB, Toselli T, Landolina M et al. to declare. 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