Patient work up – the arrhythmia nurse perspective

Hilary Bugden RN, MScPapworth Hospital

Cambridge

• Proof of concept 2000• Commenced my role in 2003• Patients enrolled in the feasibility study• Initially attracted to the simple, not-in-heart

approach• Concerns regarding comfort and reliability

The early days

• Patient acceptance• Comfort• Effective• Safe removal• Evolving design

Today

Transvenous issues

InfectionLead failure/damageExtraction risksInappropriate therapy (AF)

• 45yr old male with Brugada syndrome• ICD implanted 2006 for primary prevention• No therapies delivered in 9 years• Now presents with Riata lead externalisation• SVC occlusion• Lead extraction with complications

Case study

• Offers protection without those risks• Initially considered only for young people• Now recognised as appropriate for other age

groups• Not only for primary prevention• Either may be suitable

S-ICD

• If either is suitable, they should both be considered and discussed with the patient (if appropriate)

• Principles of the ICD• Pros and cons of each

Patient involvement

• Lead into the heart• Pacing capability• ATP• Smaller device• Lower energy• More widely used

(tried and tested)• Complications more

widely known

Transvenous vs S-ICD

• Lead not touching the heart

• No pacing capability • No ATP• Different position• Unlikely to be awake for

appropriate therapy• Numbers increasing• Still evolving

• Provide information• Be honest and open• Allow discussion• Use resources (booklets, internet, other

ICD patients)• Discuss the role of screening

New technology

• Why not S-ICD?• ‘Might need pacing’• ‘Might benefit from

ATP’• ‘My patient has HCM’• Brugada • ARVC

ICD or S-ICD?

• 47yr old, with HCM• Brother had tranvenous ICD• Implanted in 2010, first DFT successful• Lung surgery• EUR

HCM

• First implant 2009, 63yr old, family history of SCD, Brugada ECG, EUR 2014

• 30yr old with syncope with febrile illness, found to have Brugada ECG

Brugada

• 45yr old recurrent VF arrest on haemodialysis, implanted 2010. Appropriate therapy, recent EUR, good quality of life.

• 22yr old OOHCA probably due to myocarditis, implanted 2010.Fully recovered in 3 years.

Patient progress

• Valuable alternative when seeking a less invasive device

• Avoids the risks associated with leads in the heart

• Suitable for more than just the very young or very sick

• Appropriate as first line therapy option

Conclusion

Thank you