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Next Generation cardiac implantable electronic devices

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SGH guide for Healthcare workers in use of LVAD

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In singapore settings:
1.  Are there any criteria on when this device should be deactivated?
2. Is signed consent (written) needed to deavtivate it?

Christian..

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Is there a risk and benefits of ICD (Implanted Cardioverter Defibrillator) following LVAD implantation? I understand that ICD need to reactivate for LVAD patients.

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Is there a risk and benefits of ICD (Implanted Cardioverter Defibrillator) following LVAD implantation? I understand that ICD need to reactivate for LVAD patients.

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-KRIS

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Most LVDs patients cause of death is due to cardiovascular issues likely due complication of LVAD. Patients with LVAD who died within 1 month post implant most commonly died due to multi system organ failure.

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Most LVDs patients cause of death is due to cardiovascular issues likely due complication of LVAD. Patients with LVAD who died within 1 month post implant most commonly died due to multi system organ failure.

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-KRIS

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Why do LVAD patient have no pulse / measurable blood pressure? in this case how to determine their vitals? -Prema-

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Why do LVAD patient have no pulse / measurable blood pressure? in this case how to determine their vitals? -Prema-

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we need with respect to patient autonomy, they have the right to choose which treatments to undertake and which to be with-held.  Medical team need to assess whether patient has the mental capacity to make decision and need to explain to them if not go for battery replacement what will happen and the estimated  prognosis.  -Jin

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we need with respect to patient autonomy, they have the right to choose which treatments to undertake and which to be with-held.  Medical team need to assess whether patient has the mental capacity to make decision and need to explain to them if not go for battery replacement what will happen and the estimated  prognosis.  -Jin

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one of my patient with peacemaker in SGH, not sure about whether is the new Gen type. The battery is wireless like our handphone. we need to charge the portable battery and place near the patient, it will auto charge for the peacemaker. Besides, the peacemaker will auto send heart function report to NHCS  for detecting any abnormalities.- JIN 

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one of my patient with peacemaker in SGH, not sure about whether is the new Gen type. The battery is wireless like our handphone. we need to charge the portable battery and place near the patient, it will auto charge for the peacemaker. Besides, the peacemaker will auto send heart function report to NHCS  for detecting any abnormalities.- JIN 

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any home team from national heart center/device vendor go to pt's house for deactivation if pt is nearing end of life......?

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any home team from national heart center/device vendor go to pt's house for deactivation if pt is nearing end of life......?

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-christine Loh-

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-christine Loh-

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LVAD complications such as bleeding, stroke, infection and death wherein serious infections and sepsis were identified as the most common complications post LVAD implantation.
(Gordon et al, 2006)

-Lio

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End-of -life care and cardia implantable  devices, however  patient and family  understanding of CIED function and expected consequences  of   de-activation, after done , if patient is suffering the worst very important to support  patient ,care giver and family.

Marlar

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The patient need to take  a long term for aspirin and warfarin.
They have to do daily dressing  to the driveline. The batteries last  up to 8 hours and to carry spare batteries if they go out. They can only shower with an adequate protection  of the driveline exit site and electrical equipment. They cannot swim.

Marlar

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patient's rights to deactivate pacemaker/ICD therapy

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patient's rights to deactivate pacemaker/ICD therapy

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Overall, we will accede to the patient's requests so that ethical and legal considerations practised here. Ensure patient and family members are being informed and clear to make decisions at this palliative phase. We will respect and be comfortable towards their decision.
-Siti Radiah-

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does pacemaker increase life expectancy?

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does pacemaker increase life expectancy?

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is pacemaker that effective till can increase life expectancy even though doctor informed patient has poor prognosis?
-Siti Radiah-

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hope it also has other benefits at the same time which can treat and resolve the heart issues like example, wearing glasses to correct myopia?
-Siti Radiah-

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Noted that for new ICD, there is no need to go through central venous access and this reduces systemic infection.
-Siti Radiah-

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most common complication associated with implanted LVAD

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most common complication associated with implanted LVAD

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BLEEDING. Patient may stay alive for 5 and a half years with LVAD (Kilic, 2015).
-Siti Radiah-

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QOL can be affected. Presence of serious infections, neurologic complications (stroke, cognitive dysfunction) and device malfunction. Caregivers will experience significant burden, depression, anxiety and post-traumatic stress (Rizzieri et al, 2008).
-Siti Radiah-

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The next gen cardiovascular electronic device (if done well) appears to be useful in terms of looking at the hospital workload. With a shorter surgical time, hopefully it would also translate into shorter hospital in-flight days. In addition, if proven to reduce infections, it would also reduce the number of admissions and/or complications related to pacemaker-related infections which again translates to lesser hospitalisations. Infections resulting from the pacemaker sounds fatal, seeing as it is placed right into the right ventricle, where any bacterial growth can rapidly result in a systemic infection  - Cass

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patient on end of life in practical, we do not deactivate the pacemaker function with vendor (when pt agreed for DNR) to stop to shock pt when the heart stops. This actually triggers me thinking the effectiveness of pacemaker for EOL patient. because the patients actually still RIP, then we have to use a magnet to disrupt the impulses sent by pacemaker during LO, to get an asystole ECG reading so as to certify death. So, is deactivating the function of pacemaker necessary?

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Dilemma with pacemaker deactivation in terminally ill destitute patient who has lack of mental capacity.

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Dilemma with pacemaker deactivation in terminally ill destitute patient who has lack of mental capacity.

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This is a real case scenario that I encountered. Based on patient's poor prognosis with multi-factorial competing risk, the agent with enduring power of attorney, together with EOL/Palliative Team have to carefully decide on the termination of the pacemaker, in the best interest of patient's comfort care and non-active management of the dying patient.

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In the event of patient become unconscious, the tendency that CPR ( not suppose to do CPR when the pump is still on operating mode), would likely to be performed if healthcare worker or passer-by who attended to the patient is unaware of the function of LVAD. Cardiac compression should only be performed when there is no signs of life. Hasliza.

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Discussion on issues of battery replacement to end of life issues 

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Discussion on issues of battery replacement to end of life issues 

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Currently  there are no national guideline and specific set of consensus on deactivating of CIED.
Generally accepted that withdrawal of extraordinary measures at the end of life as do not prolong the dying process, but that will raise legal and moral issues.
Patient's autonomy , capacity and understanding of CIED function and consequences of de-activation are key.
Physician have right to decide and if felt uncomfortable with these decision , should consider referral to another physician comfortable to provide  the management of request.

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Need to respect patient last wishes and autonomy on end of their life limited time if they are still have capacity and able to make decision. 

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Need to respect patient last wishes and autonomy on end of their life limited time if they are still have capacity and able to make decision. 

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Patient have the right to choose treatment to continuous or to be withheld for their poor prognosis and terminal illness.
Physician need to document the discussion clearly that what have been discussed, what have been decided, who was informed  and who have involved during discussion to avoid euthanasia .

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This next generation of cardiovascular electronic device is better than old pacemaker.

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This next generation of cardiovascular electronic device is better than old pacemaker.

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This device is leadless pacemaker, most suitable for older patient who required only Right Ventricular pacing or patient with bilateral occluded subclavian veins.
-implanted time is short (about 30 mins)
-no longer leave a scar/ unsightly bulge over the chest
- reduce the risk of systemic infection and eliminates the needed for central venous access.
-some ICD have battery life is more than 10 years.
- Monitor heart rhythm all the time and detects VF and delivers a life saving shock automatically.

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Personal thoughts related to the device.

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Personal thoughts related to the device.

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My personal thoughts on this are that since the patient will still die even if the device is not deactivated, I will keep the device until it serves its purpose, unless the device hastens the patient's death due to complications.

Deactivation of the device, in my opinion, is equivalent to euthanasia, even if this device is a foreign body, but I believe it was invented for a greater purpose to every individual who chose to have this device in their body.

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- Need to be long term for aspirin and warfarin, must carry out daily dressing, battery only last up to 8 hour and need to carry spare batteries if they go out, only can shower with an adequate dressing to protective line exit site and electrical equipment, cannot swim .
-Travelling oversea is inconvenient as need to carry extra batteries and charger.
-Difficulty assess for no sign of life  when need for initiate to perform cardiac compression due to no pulsation.
-Some complication are stoke, pump thrombosis, RVF , GI bleeding ,Pump pocket infection, kidney failure.
- Need one of caregiver who have known how to change her controller when patient become unconscious due to device malfunction and who need to contact for getting instructions.

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Some differences to this new device compare to existing device

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Some differences to this new device compare to existing device

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- Leadless pacemaker, implanted short time , no longer leave scar, unsightly bulge, minimizing infection, eliminate the needed for central venous access.
-battery life 0f more than 10 years
-monitor heart rhythm all the time and detects VF and delivers a life saving shock automatically.
-most suitable for older patient who required only Right Ventricular pacing or patient with bilateral occluded subclavian veins.

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End of life concerns with LVAD patient- 

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End of life concerns with LVAD patient- 

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-Difficulty to assess vital sign to patient with no pulse at all time and management will be confused when patient become unconscious condition or unresponsive ( need to contact controller or to be continuous as treatment plan )
-Extra treatments and care will be add for complications eg; GI bleeding, kidney failure, stoke ,pump thrombosis ,pump pocket infection, depression

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If the LVAD were to suddenly fail, then the heart has to be strong enough to push the blood through the device and out to the body.

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I think the most common issues patient with LVAD face is coping with the inconveniences like the daily dressing to the driveline, must cover the driveline and electrical equipment properly so it won't get wet during shower, need to carry spare batteries as it only last for 8hours. - Faith

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I think the most common issues patient with LVAD face is coping with the inconveniences like the daily dressing to the driveline, must cover the driveline and electrical equipment properly so it won't get wet during shower, need to carry spare batteries as it only last for 8hours. - Faith

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As with any surgical procedure, LVAD implantation is associated with an adverse event profile. Such complications of LVAD therapy include bleeding, infection, pump thrombosis, right heart failure, device malfunction, and stroke.           -KRIS

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As with any surgical procedure, LVAD implantation is associated with an adverse event profile. Such complications of LVAD therapy include bleeding, infection, pump thrombosis, right heart failure, device malfunction, and stroke.           -KRIS

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For patients with LVAD who are deteriorating, quality of life is affected. LVAD is considered life-support, but when patient is deteriorating, discussion on whether to keep LVAD activated or not is very important, will it still be beneficial to patient? These issues must be discussed with family. -Faith

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For patients with LVAD who are deteriorating, quality of life is affected. LVAD is considered life-support, but when patient is deteriorating, discussion on whether to keep LVAD activated or not is very important, will it still be beneficial to patient? These issues must be discussed with family. -Faith

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For many patients with advanced heart failure, LVADs as destination therapy improve survival and quality of life. However, LVADs can be associated with complications, new comorbidities or worsening of previous conditions, resulting in decreased quality of life and limited prognosis, raising the need for planning palliative and end-of-life care. Open communication addressing the consequences of the LVAD implantation for daily life and the future (including advance directives) is advised in different stages of the treatment, involving a multidisciplinary team taking care of these complex patients and their caregivers.Healthcare professionals treating patients before and after LVAD implantation need to take an active role in end-of-life discussions and be able to communicate information regarding expected complications, quality of life and prognosis to the patients and caregivers. Research is needed addressing optimal ways and timing of communication with LVAD patients and families. (Tuvia Ben Gal et al. Curr Opin Support Palliat Care. 2013 Mar.). -KRIS-

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from my understanding, physician and team will discuss on PPC and consequences of de-activation of CIED.

lijiao

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just wonder, what is duration for device check scan for leadless pacemaker

li jiao

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concern: can do CPR for patients with LVAD

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concern: can do CPR for patients with LVAD

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If someone with LVAD turn unconscious in public/ hospital and require CPR, can we still do CPR ?

lijiao

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It’s really hard for home care to tell family to deactivate CIED when primary consultants did not suggest.

Nicole

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Does patient have to go back to hospital for deactivation? Do they look for the vendor or primary cardiologist? What if they do not want to go back to hospital. How to deactivate?

Nicole

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getting pregnant is considered hazardous for a woman with LVAD :( - candy

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Battery replacement is still recommended for patients who have a prognosis in months but still have good ECOG status. If they deteriorate rapidly, Dr will discuss with the family. Once agreed, Dr will reach out to the Cardiologist who inserted the device to contact the vendor accompanied by the home care Dr to deactivate it (for home care setting) - Doreen

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Glad LVAD has bought hopes and buying times for some of them. Some of the complications are expected, as mentioned. I'm thinking more about day-to-day living, such as showering and abstaining from some activities (swimming or causing sweating +++). Otherwise, they are living their normal active lifestyle ; )

Doreen

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Deactivated CIED is it reused for other patients?
-Prema-