612
`
`Brief clinical and laboratory observations
`
`The Journal of Pediatrics
`April 1979
`
`Diagnosis and management of cardiac rhythm disorders
`by transtelephonic electrocardiography in infants and
`children
`
`Macdonald Dick Il, M.D.,* Dena McFadden, M.D., Dennis Crowley, M.D., and
`Amnon RoSentbal, M.D., Ann Arbor, Mich.
`
`TRANSTELEPHONIC ELECTROCARDIOGRAPHY was
`initially developed for outpatient monitoring of pace-
`maker performance in adult patients.'-5 Subsequent
`reports describe its use in the management of paroxysmal
`arrhythmias.4-5 There has been little experience, however,
`with these devices in the diagnosis and treatment of
`cardiac rhythm disturbances in infants and children.
`Alternative methods of diagnosis are often unsatisfactory.
`An outpatient standard electrocardiogram in unlikely to
`record an episodic event of short duration. Hotter moni-
`tors used to obtain a 12- or 24-hour electrocardiographic
`tape recording are heavy and cumbersome and may be
`damaged when given to a child. Hospitalization for
`constant ECG monitoring is disruptive of family life and
`expensive. For these reasons we have explored the use of
`transtelephonic electrocardiography in the diagnosis and
`management of disorders of cardiac rhythm in children.
`The purpose of this report is to summarize the indications,
`resultS, advantages, and limitations of transtelephoriic
`electrocardiography in the pediatric age group.
`
`MATERIALS AND METHODS
`
`The transtelephonic ECG system consists of a battery-
`powered portable
`transmitter (Cardiotrack 2112 or
`Instromedix 9404 Pacer-Tracer), one side of which rests
`during transmission against the patient's chest with the
`other adapted to fit an ordinary telephone receiver (Fig.
`1). The patient's electrocardiographic signal modulates a
`constant 1900 Hertz transmitter audible output which is
`conducted via the telephone to a receiver (Cardiotrack
`2100) fOr translation into an ECG tracing. Recordings are
`received by a technician or physician during the day, and
`by the staff of the Intensive Care Unit or tape recording
`device during the night or weekends.
`From December I, 1977, through May 31, 1978, 18
`children ranging in age from one month to 19 years,
`transmitted 125 transtelephonic ECG recordings. Indica-
`
`From the Section of Pediatric Cardiology, C. S. Mott
`Children's Hospital, and the Department of Pediatrics,
`University of Michigan.
`•Reprint address: Section of Pediatric Cardiology, F-I I I7A
`C. S. Mott Children's Hospital, University of Michigan, Ann
`Arbor, MI 48109.
`
`tions for transmission were classified into three groups
`(Table): Group I included six patients with undocti-
`mented or undiagnosed cardiac complaints; three of these
`patients presented with palpitations, syncope, or chest
`pain, and three with poorly documented tachyarrhyth-
`mias. Group II: Transtelephonic contacts in this group
`were used to guide decisions to initiate, maintain, alter, or
`discontinue therapy. Group III: The transtelephonic
`system was used to monitor beat to beat heart rate (RR
`interval) to detect early pacemaker failure.
`
`Abbreviation used
`electrocardiogram
`ECG:
`
`An "abnormal" tracing was defined as a newly recog-
`nized disturbance of rate of rhythm. An "intervention"
`was defined as any change in drug regimen or manage-
`ment resulting from a transtelephonic transmission. The
`relative weight, size, and cost of the transtelephonic
`electrocardiography system were compared to those of a
`Holter monitor. Distances from the patient's homes to the
`C. S. Mott Children's Hospital in Ann Arbor were
`estimated.'
`
`RESULTS
`
`The Table summarizes the results of 125 transmissions
`received from the 18 patients. Eighteen percent of these
`tracings were abnormal; intervention occurred following
`26% of the recordings. The number of interventions
`exceeded the number of abnormal tracings because in one
`patient stable tracings permitted withdrawal of drug
`therapy.
`Two of the six Group I patients produced abnormal
`tracings. A 12-year-old boy presented with complaints of
`episodic dizziness, syncope, and chest pain. Transtele-
`phonic ECG tracings showed frequent premature ventric-
`ular beats, with a bigeminal and trigeminal pattern.
`However, there was no temporal relationship between the
`ectopy and the symptoms of faintness or dizziness; no
`therapy was initiated. Another 12-year-old boy com-
`plained of frequent and severe palpitations; a transtele-
`
`0022-3476/79/400612 + 04$00.40/0 © 1979 The C. V. Mosby Co.
`
`ALIVECOR - EXHIBIT 2016
`Apple Inc. v. AliveCor, Inc. - IPR2022-01186
`
`

`

`Volume 94
`Number 4
`
`Brief clinical and laboratory observations
`
`613
`
`at e
`
`ca
`
`r-r•?.
`
`S-rfr,z7
`
`Fig. 1. A, Transmitting technique. The transmitter rests on the anterior chest wall and the microphone
`end of the telephone receiver is placed over it. B, Transtelephonic receiver. The telephone receiver is
`inserted into the cradle of the recorder, and the audible signal is converted into an electrocardiographic
`tracing.
`
`Table
`
`Patients
`
`Tracings
`
`Age
`range Total Abnormal
`(yr) (No.)
`(No.)
`
`No.
`
`Inter-
`yen-
`tions
`(No.)
`
`14
`
`2
`
`1
`
`97
`
`21
`
`32
`
`6 10 to
`13
`
`9
`
`1/12
`to 15
`
`I. Diagnosis
`4
`PSVT
`1
`VT
`1
`NSHD
`II. Drug management
`PSVT
`5
`2
`VT
`JT
`Ventricular
`bigeminy
`
`1
`
`III. Pacemaker
`Congenital CHB
`Surgical CHB
`
`I
`2
`
`3
`
`2/12
`to 19
`
`14
`
`0
`
`0
`
`Total
`
`18
`
`125
`
`23
`
`33
`
`Abbreviations used: CHB = Complete heart block: JT = junctional
`tachycardia; NSHD = no significant heart disease; PSVT = paroxysmal
`supraventricular tachycardia: VT = ventricular tachycardia.
`
`phonic tracing, obtained during a symptomatic episode,
`demonstrated paroxysmal supraventricular tachycardia.
`Conversion to normal sinus rhythm was achieved with
`immersion of his face in cold water. Therapy with digoxin
`was begun, with a subsequent decrease in the frequency of
`paroxysmal episodes. The remaining three children with
`poorly documented arrhythmias have remained free of
`arrhythmias.
`Among the nine patients in Group II, premature atrial
`contractions were present in two tracings, premature
`
`• ..
`
`h.
`
`Fig. 2. These transtelephonic tracings illustrate paroxysmal
`supraventricular tachycardia in a 12-year-old boy. A. An abnor-
`mal broad QRS morphology. B, A few minutes later; the
`difference in QRS morphology, now more clearly indicating a
`supraventricular impulse, was obtained by changing the orienta-
`tion of the transmitter on the chest wall so that the lead system of
`the transmitter was more parallel to the QRS mean electrical
`axis.
`
`ventricular contractions in seven, and junctional tachycar-
`dia in one. During each of these observations there were
`no associated symptoms; thus no further control of the
`arrhythmias was considered necessary. Eleven tracings
`demonstrated supraventricular tachycardia; digoxin and/
`or propranolol dosage was increased with successful
`conversion to sinus rhythm in ten of these episodes. In one
`2-month-old infant, supraventricular tachycardia per-
`sisted for 36 hours despite increases in digoxin and
`propranolol, and hospitalization was advised. A 5-year-
`
`

`

`614
`
`Brief clinical and laboratory observations
`
`The Journal of Pediatrics
`April 1979
`
`old girl who had ventricular tachycardia associated with
`myocarditis was readmitted to the hospital when ventric-
`ular bigeminy returned while on propranolol therapy.
`No tracings requiring intervention were received from
`Group III (pacemaker) patients.
`Distance from the patient's home to the C. S. Mott
`Children's Hospital averaged 82 miles (range one to 450
`miles). The transmitter (Cardiotrack 2112) weighs five
`ounces and is eight cubic inches. Holter monitors vary in
`weight and size from 14 ounces, 22 cubic inches (Oxford
`Medilog) to 32 ounces, 50 cubic inches (ICR Dyna-Gram
`recorder). Another widely used Holter recorder is 26
`ounces, in weight and 43 cubic inches (Avionics Electro-
`cardiocorder MN 445). Purchase of the transmitter is
`borne by the institution, and charge to the patient or third
`party payer is initiated upon each transmission. After
`diagnosis or cessation of drug monitoring, the transmitter
`is returned. Pacemaker patients purchase ($100 to $200)
`and receive the transmitter at the time of pacemaker
`implantation. Comparison of relative cost at our institu-
`tion disclosed that one transtelephonic electrocardiogram
`cost approximately 75% of that of a 12-lead diagnostic
`electrocardiogram and 10% of that of a 24-hour Holter
`monitor or one day hospitalization. No complications
`related to the use of this technique occurred during the
`period of study.
`
`DISCUSSION
`Transtelephonic electrocardiography is a safe, useful,
`and economic procedure in the management of pediatric
`patients with disturbances of cardiac rhythm. In the six
`patients with cardiac symptoms, arrhythmias were identi-
`fied in two and a temporal relationship between symp-
`toms and cardiac rhythm established in one of these. In
`the nine patients monitored for drug management, inter-
`ventions were made in five patients; the remaining four
`had stable rhythms requiring no change. In the three
`children requiring pacemaker implantation, we anticipate
`that the system will detect early pacemaker failure, as it
`does in adults.'-3
`The use of this device permits rapid, accurate assess-
`ment of a symptom suggestive of a cardiac dysrhythmia.
`In the past, these patients would have to rush to an
`emergency room or physician's office to obtain an ECG,
`or receive a 24-hour Holter monitor. Holter monitoring,
`especially if done as an inpatient, is very expensive. The
`equipment is bulky, heavy, and subject to breakage,
`especially by the young child. The recording electrodes
`must be attached to the body surface, and the recorder
`carried from the shoulder or waist. Finally, Hotter moni-
`toring does not provide an instantaneously available
`method of correlating symptoms and cardiac rhythm. In
`
`the patients with implanted pacemakers, beat-to-beat
`analysis of pacemaker rate provides precise monitoring of
`pacemaker output, and diminishes the need for pulse
`checking. Symptoms suspected of pacemaker malfunction
`can be evaluated without travel to a medical facility. The
`management of recurrent or chronic arrhythmias requir-
`ing drug therapy can be achieved as an outpatient.
`Changes in drug regimen can be accomplished and
`monitored efficiently and effectively. The need for office
`visit or hospitalization for serum drug levels or other
`studies can be based on data obtained via the transtele-
`phonic ECG.
`The disadvantages of transtelephonic monitoring are
`few. Most commercially available systems transmit one
`lead; with the proper equipment one can obtain a 12-lead
`diagnostic electrocardiogram, increasing the likelihood of
`detecting obscure P waves and ST-T wave changes. The
`potential for artifacts was thought to be great, but, in fact,
`reliable recordings were obtained from all patients. Arti-
`facts from lead placement can be corrected by asking the
`patient to change the orientation of the transmitter on his
`chest so that the lead system is parallel to the P wave and
`QRS mean electrical axis (Fig. 2). The signal generated is
`recorded only as long as the transmitter is placed upon the
`chest wall; thus recording's of prolonged time periods (12
`to 36 hours as with Holter tapes) surveying the cardiac
`rhythm for very transient (single ectopic beats) events or
`asymptomatic alterations cannot be obtained by this
`method. At this time most transmissions are made during
`working hours; however, signals can be recorded on
`standard phone answering-recording devices and played
`back the next morning for analysis. Alternatively, a
`receiver may be placed in an area where there is a
`constantly manned telephone, such as in an intensive care
`unit.
`The transtelephonic system offers several intangible
`benefits for all patients. The instrument is lightweight and
`portable, so it can be carried to school and away from
`home during a family vacation. It can be returned by mail
`to the medical facility when no longer needed. It is simple
`and convenient to use, so a young patient can initiate the
`call. Outpatient management decreases travel time, incon-
`venience, and expense. Ready access to professional
`personnel relieves patient and family anxiety, allowing
`accurate observation of worrisome symptoms and provid-
`ing reassurance that medical care is available.
`
`ADDENDUM
`Since preparation of this manuscript 16 additional
`transmitters,
`transtelephonic
`received
`patients have
`initiating an additional 57 transmissions. Seven of these
`patients had permanent implanted pacemakers. One 18-
`
`

`

`Volume 94
`Number 4
`
`Brief clinical and laboratory observations
`
`615
`
`month-old boy with syncopal episodes was shown to have
`a prolonged QT interval and transient ventricular fibrilla-
`tion; further evaluation demonstrated the prolonged QT
`sydrome with congenital deafness. Propranolol was
`administered with virtual elimination of syncope (one
`undocumented 1- to 2-second episode without loss of
`consciousness occurred while on therapy).
`
`REFERENCES
`1. Furman S, Parkcr B, and Escher DJW: Transtelphone
`pacemaker clinic, J Thor Cardiovasc Surg 61:827, 1971.
`2. Furman S, and Escher DJW: Transtelephonic pacemaker
`monitoring: Five years later, Ann Thorac Surg 20:326,
`1975.
`
`3. Starr A, Dobbs J, Dabolt L, and Pierie W: Ventricular
`tracing pacemaker and teletransmitter follow-up system,
`Am J Card 32:956, 1973.
`4. Hasin Y, David D, and Rogel S: Diagnostic and therapeutic
`assessment by telephone electrocardiographic monitoring of
`ambulatory patients, Br Med J 2:609, 1976.
`5. Scheidt S. McGill J, Wilner G, and Killip T: Remote
`electrocardiography clinical experience with telephone
`transmission of electrocardiograms, JAMA 230:1293,
`1974.
`6. Williams RL: Use of transtelephonic electrocardiography in
`patients with symptoms suggesting cardiac arrhythmias,
`Pediatrics 61:493, 1978.
`7. Crippled Children's Representative Manual, Bureau of
`Personal Health Services, Regional Offices, Michigan De-
`partment of Public Health, Appendix, Exhibit 2, 1976, p 4.
`
`Premature ventricular contractions as the presenting
`feature of mitral valve prolapse in childhood
`
`Arthur S. Pickoff, M.D., Henry, Gelband, M.D., Pedro Ferrer, M.D., Otto Garcia, M.D., and
`Dolores Tamer, M.D.,• Miami, Fla.
`
`ALTHOUGH the association of various cardiac arrhyth-
`mias and mitral valve prolapse is well described in the
`adult literature,'• 2 little is known about this association in
`childhood. Most reports of children with arrhythmias and
`MVP have described patients with the typical auscultatory
`findings of MVP, specifically, nonejection systolic clicks
`or late systolic murmurs or both.2
`Although echocardiographic surveys have demon-
`strated findings of MVP in up to 6% of "normal" young
`women,' there is no doubt that there exists a definite
`population with the same echocardiographic findings who
`experience, in varying degrees of severity, symptoms that
`have been described frequently in the context of the MVP
`syndrome. These symptoms include chest pain, dizziness,
`palpitations, episodes of syncope, and, in a small number
`of cases, sudden death." Cardiac arrhythmias, which can
`be associated with MVP, may play a role in the genesis of
`some of these symptoms.'
`Over the past four years we have included an echocar-
`diogram as part of the evaluation of any child presenting
`with ventricular arrhythmias of undetermined etiology.
`During this time, we have examined 51 patients and
`encountered six patients with echocardiographic evidence
`of MVP.
`
`From the Division of Pediatric Cardiology, the
`Department of Pediatrics, University of Miami School
`of Medicine.
`•Reprint address: Pediatric Cardiology, Department of
`Pediatrics, P.O. Box 016820, Miami, FL 33101.
`
`0022-3476/79/400615 + 03$00.30/0 c9 1979 The C. V. Mosby Co.
`
`MATERIALS AND METHODS
`
`All patients were referred for cardiac evaluation of
`ventricular arrhythmias of unknown etiology. A multipo-
`sitional auscultatory examination of the heart was
`performed in all. The diagnosis of the arrhythmia was
`made by standard electrocardiographic criteria in all
`patients. The diagnosis of MVP in six patients was made
`according to previously published echocardiographics or
`angiocardiographic criteria.° Five of six patients had
`exercise stress testing using a treadmill and following the
`Bruce protocol for graded exercise. Three of the patients
`had 24-hour electrocardiographic Holter monitoring.
`
`Abbreviations used
`MVP: mitral valve prolapse
`ECG:
`electrocardiogram
`PVC:
`premature ventricular contraction
`
`RESULTS
`
`The group consists of five girls and one boy ages 6 to 16
`years (Table). Symptoms included nonspecific chest pain
`in three patients, fatigability in one, and palpitations in
`two patients; "dizzy spells" were encountered in one
`patient, and near or actual syncope in two patients. Only
`one patient (Patient 3) could be considered totally asymp-
`tomatic from the cardiovascular point of view.
`The family history revealed a sibling with documented
`MVP in one patient (Patient 51: in Patient 2 there was an
`
`