Mark Dayer



Pacing Audit 2014

2014 has been a good, but not exceptional year. Although my complication rate has been acceptable, at least by Danish standards (the most comprehensive data on real-world complications) it has not been substantially better.

In 2014 I undertook 163 procedures. 105 were on men (64%). The mean age was 73.3±11.3 years. The oldest person was 96, the youngest 18. The mean weight was 81.6±18.7Kg and body mass index 28±5.1Kg/m2.

There were 92 new systems, 35 revisions and 31 box changes; 5 other procedures were undertaken. I implanted 211 leads in total. The majority were implanted via the cephalic, but I made 97 subclavian punctures nonetheless. There were 68 atrial leads, 74 pacing right ventricular leads, 37 right ventricular defibrillator leads and 32 left ventricular leads (Table 1)

Table 1

|Single Chamber Pacemaker (VVIR) |Box Change |1 |

| |New |18 |

| |Revision |2 |

|Dual Chamber Pacemaker (DDDR) |Box Change |6 |

| |New |39 |

| |Revision |7 |

|Cardiac Resynchronisation Therapy – Pacemaker (CRT-P) |Box Change |2 |

| |New |8 |

| |Revision |9 |

|Subcutaneous Implantable Cardioverter Defibrillator (ICD) |Box Change |0 |

| |New |1 |

| |Revision |0 |

|Single Chamber ICD |Box Change |2 |

| |New |9 |

| |Revision |2 |

|Dual Chamber ICD |Box Change |13 |

| |New |7 |

| |Revision |4 |

|Cardiac Resynchronisation Therapy – Defibrillator (CRT-D) |Box Change |7 |

| |New |10 |

| |Revision |11 |

|Other |Device Removal |1 |

| |Reveal |1 |

| |Haematoma Removal |2 |

| |Wound Revision - Infection |1 |

Complications

There were no particular changes to technique this year. I started to use Ioban drapes at the end of March in an effort to reduce infection. We also started to use the Plasma blade in selected cases. I have also begun to use quadripolar LV leads and there has been a definite learning curve associated with these.

Complications have been defined as those requiring re-operation, resulting in “downgrade” of a system, or any pneumothorax. In detail:

JP. Operation 08/01/14. VVIR box change. Developed post-operative infection requiring extraction and re-implantation. She had severe right sided heart failure and has now died (not related to pacing complication)

JL. Operation 10/01/14. DDDR pacemaker (new). Early A lead displacement. Not repositioned.

MS. Operation 29/01/14. DDDR pacemaker (new). Late RV lead displacement. New RV lead required. I wonder if I placed the lead in the coronary sinus. No obvious displacement of RV lead on X-ray, so exit block a possibility.

CD. Operation 19/02/14. CRT-D Box Change. INR 2.7. Wound haematoma requiring evacuation.

DM. Operation 11/06/14. New CRT-P. Lead fine when tested on table, but when sat up developed diaphragmatic pacing that could not be cured by reprogramming. Also subclavian vein thrombosis (warfarin). New LV lead at Bristol. The lead itself did not move.

VM. Operation 25/07/14. New CRT-D. LV lead displacement (early). Required repositioning.

BB. Operation 30/07/14. New single chamber ICD. INR 2.7. Wound haematoma requiring evacuation.

BK. Operation 06/08/14. Dual chamber ICD box change. Infection requiring extraction and re-implantation. Interesting. Immunosuppressed (methotrexate). Caseous material filling pocket when I opened the pocket. Elected to wash out and close. Re-presented with infection shortly after. I have had this once or twice before. I will not re-implant a device in this situation in future.

SC. Operation 05/09/14. Revision of single chamber ICD. INR 1.3. Required clexane as had mitral prosthetic valve and TV annuloplasty. Substantial haematoma that did not require intervention.

MW. Operation 03/12/14. New CRT-P. Small right-sided pneumothorax from left sided implant. Settled spontaneously. I am still not sure if I caused this or not. It is hard to work out how this could have happened.

In summary (Figure 1), there was one pneumothorax (possibly), two infections, one of which was probably pre-existing, three wound haematomas (two of which required extraction) and four lead displacements (one atrial, one right ventricular and two left ventricular leads).

Figure 1

[pic]

Standards

I normalised my data using published Danish complication rates. I would have expected 13 complications (8.5%) in the past year and experienced 10 (6.4%). One, possibly two or three might not have been included.

According to the NHS commissioning board 2013, the following standards should be met:

1. A total of 60 new implants per year (127)

2. A minimum of 30 new complex (CRT/ICD) device implants (61)

3. At least 20 should be CRT-P/D (32)

4. At least 10 should be ICDs (20)

New in practice equals revisions too – but an upgrade from a CRT-P to a CRT-D would be counted as a defibrillator not a CRT device. I am therefore comfortably within standards.

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