signs warning people with cardiac pacemakers and defibrillators, and cardiac contractility modulation patients are therefore advised to present their device ID. In these cases, the security check will typically continue with the use of a hand-held metal detector or by physical inspection. Sports: All sports associated with increased stress on the arms or the chest, such as body building, martial arts or tennis, are usually not permitted. Diving is only permitted up to a depth of 5 meters due to the high pressure at greater depth. Magnetic Resonance Imaging (MRI): Similarly to other electrical stimulation devices, such as pacemakers, cardiac contractility modulation therapy is a contraindication for MRI, a medical imaging technique. Mechanism of action The mechanism of action of cardiac contractility modulation has been subject to continuous research since its initial discovery. Based on animal testing and experiments on human myocardial tissue obtained by biopsies, essential parts of the mechanism of action have been identified. According to current understanding (as of February 2015), the mechanism of action of cardiac contractility modulation may be summarized in the following manner: The signals applied during the electrical non-excitatory state of the cardiac muscle cells (the absolute refractory period) cause an increase in myocyte calcium in the cytosol during systole. This increases the muscle contraction strength. Additionally, within minutes, cell metabolism and gene expression, which are typically abnormal in heart failure, improve towards their normal state. This beneficial effect occurs initially only in the area adjacent to the electrodes, but with time also spreads to remote areas of the cardiac muscle. Cardiac contractility modulation therefore restores the structure and function of damaged cells back towards their normal state. In some cases, disease-related changes in the ventricular heart structure can be partially reversed by cardiac contractility modulation through a process known as reverse remodeling of the heart. History Development of cardiac contractility modulation began in the late 1990s. Studies on individual cardiac muscle cells using a patch-clamp technique had already shown, in 1969, that a voltage applied during the absolute refractory period through leads between the interior of the cell and its outside environment increased the calcium influx through the cell membrane and improved the contraction of cardiac muscle cells. In 2001, scientists observed that a similar effect occurs even if the voltage is applied exclusively outside the cardiac muscle cells.[48] Additionally, it was observed that therapeutically useful effects on the cardiac muscle were