Background: The complex CIED implant and follow-up service was started at Croydon University Hospital (CUH) in November 2012. The service is currently supported by 3 consultants, 2 arrhythmia nurse specialists and 4 specialised cardiac physiologists and received a favourable report following an accreditation visit by NHS England in 2015.
We reviewed the complex CIED implantation service from April 1 2013 to March 31 2019 examining:
- rates of implantation;
- compliance with national and international guidelines; and
- mortality and complication rates at 12 months.
Methodology: Data was collated from prospectively collected records for all CIED cases implanted at CUH. Complex CIED implants were defined by new or upgrade ICD or CRT implants.
Results: From 1 April 2013–31 March 2019 120 ICDs & 230 CRT were implanted. An LV lead was successfully deployed in 227/230 cases (98%). The mean age at implantation was 72 years (range 24–95 years); the M: F ratio was 3:1.
The chart below illustrates the annual number of complex CIED implants and the overall rate of complications for the 5-year period from 1 April 2013–31 March 2018.
During this 5-year period, the all-cause 12-month mortality was 10% (29/283). Of the 350 cases in which the implantation of a complex CIED was undertaken, 339 (97%) met NICE, ESC or HRS guidelines (1, 2, 3, 4, 5, 6).
Conclusions/implications:
- Committed DGHs can establish and maintain high-quality complex CIED services, which meet the standards expected by national organisations such as NHSE and BHRS (7).
- Using compliance with Guidelines and 12-month mortality as surrogate markers of appropriate patient selection we demonstrated that a well-considered complex CIED service can be delivered in DGHs.
- It is recognised that complications after the implantation of complex CIED occur more frequently than is generally acknowledged, with figures quoted often being derived from randomised controlled trials. However, publications are emerging from registry data suggesting higher complication rates in the “real-world”. Our complication rate over a 5 year-period of 8.5% is in keeping with this published data (8). This issue is especially relevant in the current era of progressing towards Shared Decision Making and conveying information to our patients which accurately informs the conversation.
References
1. Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronisation therapy: the Task Force on cardiac pacing and resynchronisation therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34:2281–329.
2. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;37:2129–200.
3. Authors/Task Force members, Elliott PM, Anastasakis A, et al. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J. 2014,35:2733–79.
4. National Institute for Health and Care Excellence. Implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure. 2014. Available at: www.nice.org.uk/guidance/ta314 (accessed 13 August 2019).
5. Birnie DH, Sauer WH, Bogun F, et al. HRS expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis. Heart Rhythm. 11:1305–23.
6. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2018;72:e91–220.
7. British Heart Rhythm Society. Standards for implantation and follow-up of cardiac rhythm management devices in adults January 2018 revision. 2018. Available at: https://bhrs.com/wp-content/uploads/2019/03/180122-sp-BHRS-Standards-Implantation-and-Follow-Up-of-CRM-Devices-in-Adults.pdf (accessed 13 August 2019).
8. Kirkfeldt RE, Johansen JB, Nohr EA, et al. Complications after cardiac implantable electronic device implantations: an analysis of a complete, nationwide cohort in Denmark. Eur Heart J. 2014;35:1186–94.
