arrhythmia care in tertiary centres: what needs to be done? · fu resources: bpeg recommendation...
TRANSCRIPT
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