Arrhythmia Care in Tertiary Centres: What needs to be done?

What is a “Tertiary Centre”

• Distinction between DGH and Tertiary blurring

• Tertiary: complete range of arrhythmia services:

• Arrhythmia and syncope clinics

• Devices: implantation and follow-up

• Invasive Electrophysiology

Is the title

• What needs to be done IN tertiary centres?

• Or

• What needs to be done TO tertiary centres?

• Or

• What needs to be done BY tertiary centres?

What do tertiary centres do?

• All services supplied by DGH

and

• Advanced devices

– CRT /Bifocal: IMAGING

– Extraction: Cardiothoracic surgery

– ICD

What do tertiary centres do?

• All services supplied by DGH

and

• Invasive electrophysiology

– Basic

• Diagnostic /VT stimulation

– Therapeutic

• Radiofrequency /Cryo other energy sources

– Complex

• AF /GUCH /VT and non contact electro-anatomical mapping

What do tertiary centres do?

• All services supplied by DGH

and

• Variable “extras”

– SCD /genetics

– Syncope

– Screening

What is being done

Current status UK

• Pacing centres

– 206 total UK

– 32 major > 200 implants per year

– 100 intermediate 50-200 implants per year

– 71 minor <50 implants per year

• ICD centres

– 54 total UK

– 28 > 20 implants per year

– 25 < 20 implants per year

• CRT

– ? 23 data unclear: CMR 10-12 centres

• EP centres

– Limited database as above

– Approx 25 in UK

Service

• Advanced heart failure care

– CRTwhich involves

• Imaging

– Tissue Doppler Imaging / 3D Echo / MRI

• Electrophysiology

– Bradycardia support pacing

– Tachycardia devices: ICD

– Invasive EP

Bradycardia Pacing

• Established service at UHNS

– 250 implants (BPEG: 550/million)

– 120 box change

• Requires clinical lead

– Clinical: difficult cases/extraction

– Strategic developments

• Development

– Syncope service

– One stop arrhythmia clinics

– SCD clinics

– Outreach complex arrhythmia clinics

Pacemaker Implants

All UK Generator Implants

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Total

New

Replacement

60% Dual40% Ventricular1% Atrial

Pacemaker Total Implant Rate 2003

0 200 400 600 800 1,000 1,200

Scotland

UK

Western Europe

France

Belgium

Germany

USA

International Comparisons

Rationale for expansion of service

• Implant numbers should increase

• Follow-up numbers are increasing and are

unmanageable

– particularly ICD

• Postcode prescription: ? abolished

• Local service provision

– ↓ transport

– ↓ time delays

– local expertise

– local records/data

• At the moment demand outstrips supply, ignoring ICD and CRT

Pacing and CHF

UK Implants for Heart Failure

0

500

1,000

1,500

2,000

2,500

3,0001980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

CRT –International Comparisons

All CRT Implants 2003

0 5 10 15 20 25 30 35 40 45 50

Finland

Portugal

Spain

Switzerland

UK

Norway

France

Sweden

Denmark

Austria

Belgium

Germany

Netherlands

Italy

Survival after non-CRT pacing

• Significantly

poorer

with CHF,

up to age 70

• No difference for

age > 70

Cardiac Resynchronization Therapy- what is it?

• Pacing therapy which aims to reorganize the incoordinated

contraction of the Left Ventricle (i.e. systolic dyssynchrony)

• Need to implant 3 pacing leads: RA, RV and LV (?more)

• Dysynchrony : commonly manifest as wide QRS, but not

always equivalent

Cardiac Resynchronization Therapy- what is it?

Cardiac Resynchronisation Therapy: CRT

• Overlaps with CHF and VT

– Numbers enormous

– CHF incidence 10% aged > 80

– 20% will benefit from CRT

– CHF 0.1%

• 280 implant per year for North Staffs

– Dependent on NSF Arrhythmia and NICE

• Development

– Links with Imaging and CHF

– Funding/ Operators / Lab time

– Follow-up

Heart Failure and Ventricular Asynchrony

CRT: Echo assessment: 4D TSI

CMR: Scar

Demand vs Supply

• Implant

– CRT for CHF

– 1 x 106 CHF

– Exclude 50%: co-morbid/frail/poor prognosis

– 30-50% eligible for CRT: 500000 x 50%= 250000

– 100 CRT implanters: 2500 WL each: 10 week = 5 year WL

• FU

– even allowing for “attrition”: massive

• Answer

– Train SpR

– Train and recruit Technical Staff

– DGH expansion: ? Driven by PRP and tariffs

Actuator

Button

Thumbwheel and

Reference Hole

Malleable

Shaft

Tongs

gripping

Lead Model

5071

Note the lead wrap around the shaft (twice in a clockwise direction)

Epicardial LV Lead implantation

ICD

• Established but

– 50 cases cf 140 (NICE: 100 per million)

• Requires clinical lead

• Expand service

– lab space

– operator time: training implications

– finance from commissioners

– consequence on follow-up

• tech staff recruitment

• tech staff training

• Fulfilled NICE criteria: 106 /million/yr

– Received ICD: 30 /million/yr

– No ICD: 76 /million/yr

• MADIT-II criteria: 453 /million/yr

ICD Implants after Acute Coronary Admission in EnglandDavid Cunningham, John Birkhead, Janet McComb, Morag Cunningham and Tony Rickards

NASPE 2004

192acute receiving hospitals

133,000acute myocardial infarctions

> 9,300died

118,000no cardiac arrest

15,000cardiac arrests

5,637survived

4,719early arrest

918late arrest

ICD CANDIDATE (Sec Prev)

24 ICD centres

Implant rate 61%168 non-ICD centres

Implant rate 10%

192acute receiving hospitals

133,000acute myocardial infarctions

> 9,300died

118,000no cardiac arrest

15,000cardiac arrests

5,637survived

4,719early arrest

918late arrest

ICD CANDIDATE (Sec Prev)

24 ICD centres

Implant rate 61%168 non-ICD centres

Implant rate 10%

ICD Total Implant Rate

per million population

0

10

20

30

40

50

60

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

ICD New Implant Rate

NICE Guideline

Invasive EP: SVT

• SVT

– SVT rate : 300 per million

– Approx 440 cases/year for North Staffs

– Was 80 cases/year

– Now 200 cases/year

– Current UK rate : approx 100 per million

• Standard Atrial Flutter

– Flutter now approx 30-50% workload

– Approx 30 - 120 cases/year for North Staffs

Invasive EP: Atrial Fibrillation

• A Fib RFA

– First late 90’s

– Normal heart “lone Paroxysmal AF”

– Low success 20%

– Targetted frequent ectopics

• Now

– Indications clearer

– PAF and “persistent AF” /Structurally abnormal hearts

– New technologies: mapping and ablation energy

– Methodology settling

– Success 60% - 80% one year

Invasive EP: Ventricular Arrhythmia

• VT Ablation

– Normal heart = uncommon, good success

– Ischaemic = common, poorer success, adjunct to ICD

• VT assessment

– increasing for LVD (NICE:60 per million/year)

– 90 cases/year for North Staffs

• VF ablation

New Technologies

• EP

– AF Ablation

– Robotics/Stereotaxis

• Ultrafast CT / MRI

– Coronary angiography

– Cardiac anatomy for RFA

• Surgical Advances

– Video-thorascopic LV pacing

– Mediastinoscopic RFA for AF

Objectives

• Immediate

– Raise awareness

• Public

• Medical and allied staff

– Expand Resource

• Lab space and time

• Technical and medical Staff

– Update technology

• Mapping

• Non-contact mapping

Objectives

• Long term

• Subspecialisation of EP services

• Device / Tachy EP

• Further consultant appointments

Summary

• Arrhythmia Care in Tertiary Centres: What needs to be done?

• Consolidate

– Links

– Referral pathways

• Expand

– Facilities

– Staffing

• Expand and Provide the service in DGH’s

Summary

• Arrhythmia Care in ALL Centres: What needs to be done?

FUNDING

• Thanks to

• AA

• All sponsors

Recruitment/Teaching/Training

• Integral learning opportunities

– “On the job” training

• Formal training modules

– Undergraduate and Postgraduate

• Undergraduate Medical School

General

• Identify local need

• Quantify population demand

– NPDB: www.ccad.org: Dr A Cunningham

– Local Age/Depcat adjusted rates

– Population transients

• Identify resource demand

– Staff: medical/ technical/ nursing/ radiographer

– Equipment: lab space/ screening/ resus /disposables

– Hardware

• Identify key personnel

– Hospital trust management

– PCT commisioners

– Local tertiary centre

Generic Needs

• Lead clinician: ?2

– Interested and Enthusiastic

– Experienced ± time (optional extra?)

– Determined

• Team

– Motivated/enthusiastic Technical staff: an absolute

– Nursing/ radiographers

– Supportive management: Trust and PCT

• IT/Quality

– Data collection

– Audit

– Central cardiac audit database www.ccad.org

Specific Needs

• Lab/X ray/theatre etc

– good screening/ laterals etc/ road map/ storage and archive

– defib/ pacing defib

– O2 monitoring

– ?CO2 monitoring if conscious sedation

– 12 lead monitoring and hard copy/ PSA/ cables

– PC for CCAD

• Preop and post op care

– Beds : how long and where

– Monitoring

– Training and familiarity

Training Standards

• Number based accreditation

• Time based accreditation

• Competency based accreditation

• MMC Specialist Training Scheme

• ? specialist training

– clinical fellow

– specialist streaming final year

UK New Generator Implant Rate

100

150

200

250

300

350

400

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Pacemaker New Implant Rate

Sequence of Implementation

• Follow up first

– Familiarisation

• Devices

• Programmers

• Jargon

– Training

• Company support

• Local

• Tertiary centre

• Abroad

• IP with temp wire

• OP: new implants

• OP: box changes

FU resources: BPEG recommendation

• Level 1 follow-up at non-implanting centres*

– Medical staff: one cardiologist with an interest in and training in pacing

– Technical staff: one technician minimum grade mto2 (5)

– Training: technician has attended an approved course on pacing

– Quality control: monitored by cardiologist with involvement of the implanting centre when appropriate.

– Audit

– Equipment: sufficient for routine follow-up and troubleshooting

• Level 2 follow-up at implanting centres* as above

but

– 2 dedicated cardiologists

– 2 dedicated technicians

CRT Implants in patients with CHF needing PPM

CRT Pacing for Heart Failure

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Training

Competencies