Reuse of pacemakers and defibrillators in developing countries: logistical, legal, and ethical barriers and solutions

[Senegal's experience with pacemakers re-use : about 161 patients at the Aristide Le Dantec university hospital center]

INTRODUCTION

The reuse pacemakers is a beneficial technique for patients in countries with a low economic standard of living where health care is almost non-existent. We offered to share the experience of Senegal on the reconditioning of pacemakers.

METHODOLOGY

We conducted a retrospective study over a period from January 2015 to December 2020 including all patients who benefited from a reconditioned pacemaker for primary implantation or reimplantation. The criteria for reconditioning pacemakers are the absence of dysfunction or damage and a residual battery life of more than 5 years of the pacemaker. Refurbished pacemakers are acquired either from deceased families or from extraction centers. Sterilization is carried out using phenoxypropanol + benzalkonium chloride solution, 70% ethanol and ethylene oxide.

RESULTS

We collected 161 patients during the study period, including 77 men (48%) and 84 women (52%), i.e. a M/F sex ratio of 0.94. The average age of the population was 65 years. Functional symptomatology was dominated by syncope in 54%. Electrocardiographically, 72% of patients were in complete atrioventricular block. A primary implantation was noted in 91.5% of patients. The vascular approach most used during implantation was cephalic in 49.5% of cases. In our series, we noted that 58% of patients had benefited from temporary stimulation before implantation. At implantation, single-chamber stimulation was used in 60% of patients and 46.5% of patients had programming in VVI mode. We had 5.5% major complications with 3% box infection occurring between 3 and 6 months post-implantation and 2.5% pacemaker syndrome. We noted 1 case of death linked to underlying heart disease.

CONCLUSION

Reconditioning of cardiac pacemakers is a safe and beneficial therapeutic strategy for patients. In Senegal, reconditioning has shown satisfactory results. In our countries this technique can be an alternative for certain patients.

Postmortem Protocols of Implantable Neurosurgical Devices: A Cross-Sectional Survey

BACKGROUND

Implantable devices are increasingly more common for management of movement disorders, pain, and epilepsy. These devices are often complex and constructed of nonbiodegradable or hazardous materials. Therefore, proper postmortem handling of these devices is exceedingly important. Unfortunately, there is no consolidated resource available for postmortem neuromodulation device protocols. Thus, we surveyed and catalogued the protocols for implantable devices to summarize proper postmortem device protocols for implantable neurosurgical devices currently on the market.

METHODS

We performed a cross-sectional study of companies producing commonly implanted neurosurgical devices. Using information from company websites, user manuals, and catalogs we categorized devices into 3 groups: A (formal recommendation for explantation), B (recommendation for explantation without formal company protocol), and C (explantation is not necessary). We then compiled the data into a stoplight diagram, providing a clear postmortem disposal algorithm for each device category.

RESULTS

Twelve companies were queried regarding 46 devices. Postmortem protocols were available for 50% (23/46) of devices; the remaining devices did not have formal recommendations. Overall, 50% of devices were classified as category A "red light" on the stoplight diagram based on recommendations, 10.9% as category B "yellow light," and the remaining 39.1% were classified as category C "green light" indicating they are safe to bury or cremate.

CONCLUSIONS

Evolution in therapies and growth in functional neurosurgery has expanded the range of implantable neurosurgical devices. We provide an educational document summarizing their postmortem protocols. This resource aims to aid health-care providers and encourage proper disposal practices during burial or cremation.

Deactivation of Left Ventricular Assist Devices at the End of Life: Narrative Review and Ethical Framework

Left ventricular assist devices (LVADs) have become an increasingly common advanced therapy in patients with severe symptomatic heart failure. Their unique nature in prolonging life through incorporation into the circulatory system raises ethical questions regarding patient identity and values, device ontology, and treatment categorization; approaching requests for LVAD deactivation requires consideration of these factors, among others. To that end, clinicians would benefit from a deeper understanding of: 1) the history and nature of LVADs; 2) the wider context of device deactivation and associated ethical considerations; and 3) an introductory framework incorporating best practices in requests for LVAD deactivation (specifically in controversial situations without obvious medical or device-related complications). In such decisions, heart failure teams can safeguard patient preferences without compromising ethical practice through more explicit advance care planning before LVAD implantation, early integration of hospice and palliative medicine specialists (maintained throughout the disease process), and further research interrogating behaviors and attitudes related to LVAD deactivation.

Reimplantation of Implantable Cardiac Devices-An Ethical Controversy?

BACKGROUND

Cardiovascular diseases are an important public health problem, the main cause of death in both men and women, with a continuous increasing prevalence and consequences upon morbidity in economic, physical, and psychological terms.The new technology have made possible the development of innovative devices, which have increased the possibility of therapeutic interventions today, extending the life of the population with cardiovascular pathology, transforming the patient care, and providing a complex, personalized therapeutic approach.

FIELDS OF UNCERTAINTY

The aim of the study was to evaluate from an ethical perspective the need, feasibility, and safety of reusing cardiac pacemakers to revise the legal terms and requirements.In recent years, the problem of accessibility to cardiovascular drugs has been increasingly accompanied by the accessibility to technology, interventional cardiology advancing recently, and becoming an increasingly important standard of care.

DATA SOURCES

A review of the specialized literature was performed in March 2023, using keywords such as implantable cardiac devices, reuse, ethics from PubMed, Scopus, Web of Science, and Google Scholar, as well as official documents issued at the international level (World Health Organization).

ETHICS AND THERAPEUTIC ADVANCES

An ethical analysis assesses the extent to which a medical act (PM reimplantation) is covered by the 4 universally accepted principles: nonmaleficence, beneficence, autonomy (respect for the person), and social justice, the analysis addressing to the risk-benefit ratio based on studies that analyzed the phenomenon over the past 50 years. The ethical analyzed issues start from the fact that although 80% of pacemakers, most of them working perfectly, with a battery life of more than 7 years are buried with their owners, while approximately 3 million patients die annually due to the lack of access to these devices in undeveloped and developing countries.But beyond the ethical issues, legal practice has meant that in many countries, reusing of these devices is prohibited, mostly being single-use devices. Low-income countries continue to accept this practice as the only one economically accessible to them, considering the prohibition of reusing them to be an economic rather than a medical issue.

CONCLUSIONS

Reusing implantable cardiac devices is of great interest because of the costs, being in certain situations, the only possibility that certain people can have access to a therapeutic method that ensures their health recovery and increases their quality of life. But this is not possible without clear procedures, without clear criteria on how sterilization should be performed, how the technique should be performed, without obtaining a truly informed consent, and especially without a proper patient's follow-up.

Global Variations in Heart Failure Etiology, Management, and Outcomes

Importance

Most epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries.

Objective

To examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development.

Design, Setting, and Participants

Multinational HF registry of 23 341 participants in 40 high-income, upper-middle-income, lower-middle-income, and low-income countries, followed up for a median period of 2.0 years.

Main Outcomes and Measures

HF cause, HF medication use, hospitalization, and death.

Results

Mean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a β-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper-middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower-middle-income countries (39.5%) (P < .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper-middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower-middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper-middle-income countries (ratio = 2.4), similar in lower-middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper-middle-income countries (9.7%), then lower-middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower-middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies.

Conclusions and Relevance

This study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally.

Pacemaker Reuse in Portuguese Speaking Countries: A Clinical Reflection

There is a gap between high-income countries and others in terms of access to medical cardiac devices, such as pacemakers and implantable cardioverter defibrillators. Costs are one of the main barriers to the use of cardiac devices in these countries. There are international initiatives that aim to reduce the gap. The reuse of pacemakers has been discussed as a possible alternative to this problem. The concept of reusing pacemakers is not new; however, recent studies have proven to be safe, ethical, and effective for those who need cardiac implantable electronic devices and cannot afford them. Part of the Portuguese-speaking countries, especially in Africa, need an immediate response that benefits their countless patients who suffer from treatable arrhythmias.

Electrophysiology practice in low- and middle-income countries: An updated review on access to care and health delivery

Concurrent with the epidemiological transition to cardiovascular diseases in low- and middle-income countries (LMICs), the burden of arrhythmias is increasing significantly. However, registries of electrophysiological disorders and their management in LMICs are limited. The advancement of telemedicine technology can play a distinctive role in providing accurate diagnoses in resource-limited settings. The estimated pacemaker implantation requirements (1 million per year) demand an alternate source of pacemakers, including reused permanent pacemakers and implantable cardioverter-defibrillators. In addition, the majority of supraventricular tachycardias and atrial fibrillation can be managed with radiofrequency ablation, which not only is cost-effective but is curative for most patients.

Evaluation of reused orthodontic mini-implants on stability: An in-vivo study

INTRODUCTION

During treatment, some patients may need to change the location of mini-implants (MIs). This study investigated the stability of MIs relocated to another position in the same patient using the periotest and torque device.

METHODS

Twenty-nine MIs were applied randomly to 1 side of the maxillary region, and torque and periotest values were recorded. The patients were followed-up at 4-week intervals, and periotest measurements were performed at each session. After recording the torque and periotest values in the fourth session, the MIs were removed. After applying the appropriate sterilization procedure, the same MIs were relocated to the contralateral side of the patients' jaw, and distalization was achieved using a similar procedure for the group of as-received MIs.

RESULTS

Negative correlations were obtained between the torque meter and periotest data for both MI groups. We observed no significant effect of the MI group on periotest measurements (P >0.05). The effect of the MI group on torque values and the interaction effect of the MI group and torque values were not statistically significant (P >0.05).

CONCLUSIONS

It is possible to achieve similar stability values with as-received and retrieved MIs when appropriate cleaning and sterilization protocols are performed.

Safety and Efficacy of Submuscular Implantation With Resterilized Cardiac Implantable Electronic Device in Patients With Device Infection: A Retrospective Observational Study in Taiwan

Background

Reuse of cardiac implantable electronic devices (CIEDs) can reduce the cost of using these expensive devices. However, whether resterilized CIEDs will increase the risk of reinfection in patients with previous device infection remains unknown. The aim of the present study is to compare the reinfection rates in patients who had initial CIED infection and underwent reimplantation of resterilized CIEDs or new devices.

Methods

Data from patients with initial CIED infection who received debridement of the infected pocket and underwent reimplantation of new or resterilized CIEDs at MacKay Memorial Hospital, Taipei, Taiwan, between January 2014 and June 2019 were retrospectively analyzed. Patient characteristics, relapse rates of infection, and potential contributing factors to the infection risk were examined.

Results

Twenty-seven patients with initial CIED infection and reimplanted new CIEDs (n = 11) or resterilized CIEDs (n = 16) were included. During the 2-year follow-up, there were 1 (9.1%) and 2 (12.5%) infection relapses in the new and resterilized CIED groups, respectively. No relapse occurred for either group if the lead was completely removed or cut short. The median duration between debridement and device reimplantation in patients with infection relapse vs patients without relapse was 97 vs 4.5 days for all included patients, and 97 vs 2 days and 50.5 vs 5.5 days for the new and resterilized CIED groups, respectively.

Conclusions

Subpectoral reimplanting of resterilized CIEDs in patients with previous device infection is safe and efficacious. With delicate debridement and complete extraction of the leads, the CIED pocket infection relapse risk can be greatly decreased.

The ethics of explantation

BACKGROUND

With the increased use of implanted medical devices follows a large number of explantations. Implants are removed for a wide range of reasons, including manufacturing defects, recovery making the device unnecessary, battery depletion, availability of new and better models, and patients asking for a removal. Explantation gives rise to a wide range of ethical issues, but the discussion of these problems is scattered over many clinical disciplines.

METHODS

Information from multiple clinical disciplines was synthesized and analysed in order to provide a comprehensive approach to the ethical issues involved in the explantation of medical implants.

RESULTS

Discussions and recommendations are offered on pre-implantation information about a possible future explantation, risk-benefit assessments of explantation, elective explantations demanded by the patient, explantation of implants inserted for a clinical trial, patient registers, quality assurance, routines for investigating explanted implants, and demands on manufacturers to prioritize increased service time in battery-driven implants and to market fewer but more thoroughly tested models of implants.

CONCLUSION

Special emphasis is given to the issue of control or ownership over implants, which underlies many of the ethical problems concerning explantation. It is proposed that just like transplants, implants that fulfil functions normally carried out by biological organs should be counted as supplemented body parts. This means that the patient has a strong and inalienable right to the implant, but upon explantation it loses that status.

Infections Associated with Resterilized Pacemakers and Defibrillators

BACKGROUND

Access to pacemakers and defibrillators is problematic in places with limited resources. Resterilization and reuse of implantable cardiac devices obtained post mortem from patients in wealthier nations have been undertaken, but uncertainty around the risk of infection is a concern.

METHODS

A multinational program was initiated in 1983 to provide tested and resterilized pacemakers and defibrillators to underserved nations; a prospective registry was established in 2003. Patients who received reused devices in this program were matched in a 1:3 ratio with control patients who received new devices implanted in Canada. The primary outcome was infection or device-related death, with mortality from other causes modeled as a competing risk.

RESULTS

Resterilized devices were implanted in 1051 patients (mean [±SD] age, 63.2±18.5 years; 43.6% women) in Mexico (36.0%), the Dominican Republic (28.1%), Guatemala (26.6%), and Honduras (9.3%). Overall, 85% received pacemakers and 15% received defibrillators, with one (55.5%), two (38.8%), or three (5.7%) leads. Baseline characteristics did not differ between these patients and the 3153 matched control patients. At 2 years of follow-up, infections had occurred in 21 patients (2.0%) with reused devices and in 38 (1.2%) with new devices (hazard ratio, 1.66; 95% confidence interval, 0.97 to 2.83; P = 0.06); there were no device-related deaths. The most common implicated pathogens were Staphylococcus aureus and S. epidermidis.

CONCLUSIONS

Among patients in underserved countries who received a resterilized and reused pacemaker or defibrillator, the incidence of infection or device-related death at 2 years was 2.0%, an incidence that did not differ significantly from that seen among matched control patients with new devices in Canada.

Worldwide pacemaker and defibrillator reuse: Systematic review and meta-analysis of contemporary trials

BACKGROUND

Patients go without pacemaker, defibrillator, and cardiac resynchronization therapies (devices) each year due to the prohibitive costs of devices.

OBJECTIVE

We sought to examine data available from studies regarding contemporary risks of reused devices in comparison with new devices.

METHODS

We searched online indexing sites to identify recent studies. Peer-reviewed manuscripts reporting infection, malfunction, premature battery depletion, and device-related death with reused devices were included. The primary study outcome was the composite risk of infection, malfunction, premature battery depletion, and death. Secondary outcomes were the individual risks.

RESULTS

Nine observational studies (published 2009-2017) were identified totaling 2,302 devices (2,017 pacemakers, 285 defibrillators). Five controlled trials were included in meta-analysis (2,114 devices; 1,258 new vs 856 reused). All device reuse protocols employed interrogation to confirm longevity and functionality, disinfectant therapy, and, usually, additional biocidal agents, packaging, and ethylene oxide gas sterilization. Demographic characteristics, indications for pacing, and median follow-up were similar. There were no device-related deaths reported and no statistically significant difference in risk between new versus reused devices for the primary outcome (2.23% vs 3.86% respectively, P = 0.807, odds ratio = 0.76). There were no significant differences seen in the secondary outcomes for the individual risks of infection, malfunction, and premature battery depletion.

CONCLUSIONS

Device reuse utilizing modern protocols did not significantly increase risk of infection, malfunction, premature battery depletion, or device-related death in observational studies. These data provide rationale for proceeding with a prospective multicenter noninferiority randomized control trial.

A Community Level Sample Survey to Determine CurrentUnderstanding About Medical Recycling of Cardiovascular ImplantableElectronic Devices

Background

Medical recycling and reutilization of cardiovascular implantableelectronic devices (CIEDs) have a significant impact not only in patientsof low-income countries but may also in certain patients in the UnitedStates who do not have sufficient medical insurance coverage. Themain determining factor for future utility and popularity of recycledmedical devices is thorough understanding about this topic amongstpublic and healthcare professional. To the best of our knowledge,there has been no study conducted so far at a community level to determinethe understanding in public and healthcare personnel about recyclingof medical devices including CIEDs. We sought to determine existingknowledge and attitude about recycling of CIEDs amongst representativesample population in a community.

Methods

A questionnaire was sent for online completion to multiple peoplein the community, healthcare and funeral home in Lehigh Valley, Pennsylvania,USA. The questionnaire was designed in order to assess three maincategories; knowledge, attitude and practice. We called this a KAPstudy which is an acronym for knowledge, attitude and practice survey.

Results

We got 117 responses to our questionnaire from community members(55.45%), 89 responses (42.18%) from the healthcare personnel andfive responses (2.37%) from funeral homes. About 30.77% communityparticipants had heard about medical devices recycling compared to57.30% participants from healthcare sector. A total of 88.64% of medicalprofessionals were aware that there are people in the world who diebecause they cannot afford CIEDs while 73.50% of community participantswere also found to be aware of this fact. Higher percentages of healthcareprofessionals were found to be willing to personally consider a decisionabout medical device donation compared to community participants.

Conclusions

CIED reutilization can improve quality of life among many patientswith low or medium socioeconomic status. People should be made moreaware about the benefits of CIED reutilization. Concerns about device-relatedinfections, complications and law suits should be addressed to helpimprove their utility.

Remaining longevity and evidence of failure of cardiac implantable electrophysiology devices recovered from funeral homes

BACKGROUND

Given the prohibitive cost of pacemakers and defibrillators for medically underserved patients in low-income countries, these devices are sometimes recovered from funeral homes for charitable reimplantation. Many devices are implanted near the end of the patients' lives, meaning that recovered devices from funeral homes have the potential for significant remaining longevity.

METHODS

After sending letters asking funeral directors in the Philadelphia area to donate explanted pacemakers and defibrillators, 78 devices were recovered. Sixty-seven of these devices were successfully interrogated, and 64 devices reported estimates of remaining battery life in years. Twenty-one defibrillators were also interrogated for evidence of failure.

RESULTS

Twenty-two percent of the 64 devices had greater than 4 years of longevity. Fourteen percent of the devices had between 1 and 4 years of longevity, and the remaining 64% had less than 1 year of remaining battery life. We found no evidence from 21 recovered defibrillators that the patient's cause of death was because of defibrillator failure. In almost half (10/21) of the defibrillators, however, the arrhythmia logs were nondecipherable given the entire log was replaced by episodes of signal noise likely occurring after death.

CONCLUSIONS

A significant percentage of devices explanted in funeral homes have suitable remaining battery life for reuse. While no evidence of defibrillator device failure could be found, the analysis was limited by postmortem signal artifact, which may preclude accurate assessment of rates of failure in devices explanted postmortem.

Pacemaker recycling: A notion whose time has come

The purpose of this paper is to summarize the need, feasibility, safety, legality, and ethical perspectives of pacemaker reutilization in low- and middle-income countries (LMICs). It will also describe, in-depth, Project My Heart Your Heart (PMHYH) as a model for pacemaker reuse in LMICs. The primary source of the discussion points in this paper is a collection of 14 publications produced by the research team at the University of Michigan and its collaborative partners. The need for pacemaker reutilization in LMICs is evident. Numerous studies show that the concept of pacemaker reutilization in LMICs is feasible. Infection and device malfunction are the main concerns in regard to pacemaker reutilization, yet many studies have shown that pacemaker reuse is not associated with increased infection risk or higher mortality compared with new device implantation. Under the right circumstances, the ethical and legal bases for pacemaker reutilization are supported. PMHYH is a proof of concept pacemaker donation initiative that has allowed funeral home and crematory directors to send explanted devices to an academic center for evaluation and re-sterilization before donation to underserved patients in LMICs. The time is now to pursue large-scale studies and trials of pacemaker reuse for the betterment of society. PMHYH is leading the way in the effort and is poised to conduct a prospective randomized, non-inferiority, multicenter study to confirm the clinical efficacy and safety of pacemaker reuse, for clinical and legal support.

Guidance on reuse of cardio-vascular catheters and devices in India: A consensus document

Reuse of medical device is accepted worldwide. Benefits of reuse include not only cost saving but a favorable impact on environment. However, certain requirements should be met for reuse to be safe and effective. The devices, which can be reused, should be clearly defined, a meticulous process for dis-infection and sterilization followed and its functionality ascertained before use. Further, an appropriate consent should be obtained where necessary and the cost saving entailed should be directly passed on to the patient.

Safety and feasibility of biventricular devices reuse in general and elderly population--a single-center retrospective cohort study

Introduction

Cardiac resynchronization therapy (CRT) is known to have very important beneficial effects on heart failure patients. Unfortunately, biventricular implantable cardiac devices (CRT devices), through which this therapy is implemented, are very expensive and sometimes hard to achieve, especially in underdeveloped/developing economies, making this an important problem of public health. As a possible solution, CRT reuse is of great interest nowadays, but unlike simple devices, data in the literature are scarce about biventricular device reuse.

Aim

To address safety concerns, we aimed to analyze infection burden in the general and elderly population and also early battery depletion and generator malfunction of resterilized biventricular devices compared to new devices.

Methods

A cohort of 261 CRT patients (286 devices), who underwent implantation between 2000 and 2014, was retrospectively analyzed. The study group included 115 patients and 127 resterilized devices, that was divided into a subgroup of 69 elderly patients (≥60 years) and 74 devices and a subgroup of 47 younger patients (<60 years) and 53 devices, and the control group included 146 patients and 159 new devices. The groups were compared using a multivariate logistic regression model.

Results

A number of 12 (4.2%) infectious complications were encountered, five (3.9%) in the study group and seven (4.4%) in the control group (odds ratio, 2.83 [0.59–13.44], P=0.189), one (1.3%) in the elderly and four (7.5%) in the younger subgroup (odds ratio, 3.80 [0.36–40.30], P=0.266), with no statistically significant difference between them. There was only one case of early battery depletion, after 17 months, in one study group patient. No generator malfunction was detected.

Conclusion

Reuse of biventricular cardiac implantable electronics seems feasible and safe in both the general population and the elderly population, and it could be a promising alternative when new devices cannot be obtained in a safe period of time.

Performance of re-used pacemakers and implantable cardioverter defibrillators compared with new devices at Groote Schuur Hospital in Cape Town, South Africa

OBJECTIVES

Little is known about the performance of re-used pacemakers and implantable cardioverter defibrillators (ICDs) in Africa. We sought to compare the risk of infection and the rate of malfunction of re-used pacemakers and ICDs with new devices implanted at Groote Schuur Hospital in Cape Town, South Africa.

METHODS

This was a retrospective case comparison study of the performance of re-used pacemakers and ICDs in comparison with new devices implanted at Groote Schuur Hospital over a 10-year period. The outcomes were incidence of device infection, device malfunction, early battery depletion, and device removal due to infection, malfunction, or early battery depletion.

RESULTS

Data for 126 devices implanted in 126 patients between 2003 and 2013 were analysed, of which 102 (81%) were pacemakers (51 re-used and 51 new) and 24 (19%) were ICDs (12 re-used and 12 new). There was no device infection, malfunction, early battery depletion or device removal in either the re-used or new pacemaker groups over the median follow up of 15.1 months [interquartile range (IQR), 1.3-36.24 months] for the re-used pacemakers, and 55.8 months (IQR, 20.3-77.8 months) for the new pacemakers. In the ICD group, no device infection occurred over a median follow up of 35.9 months (IQR, 17.0-70.9 months) for the re-used ICDs and 45.7 months (IQR, 37.6-53.7 months) for the new ICDs. One device delivered inappropriate shocks, which resolved without intervention and with no harm to the patient. This re-used ICD subsequently needed generator replacement 14 months later. In both the pacemaker and ICD groups, there were no procedure-non-related infections documented for the respective follow-up periods.

CONCLUSION

No significant differences were found in performance between re-used and new pacemakers and ICDs with regard to infection rates, device malfunction, battery life and device removal for complications. Pacemaker and ICD re-use is feasible and safe and is a viable option for patients with bradyarrhythmias and tachyarrthythmias.

Critical appraisal of costly therapy modalities for heart failure in a developing country

Contemporaneous challenges in heart failure management include strategies to rationally use health economic resources and relative donor shortage to adequately offer electric devices (cardiac resynchronization therapy [CRT] and implantable cardioverter defibrillators [ICD]), ventricular assist devices (VADs) and heart transplant, respectively. These issues are particularly important in countries with middle-income rates and limited structured heart transplant centers, such as Brazil. Use of CRT and ICDs need to follow strict guidelines, further customized to public financial health conditions. Experience with VADs in is the early days in Brazil and will require extreme caution to allocate health public resources to develop VAD programs in highly selected centers. Chagas' disease is epidemiologically important in Brazil; outcomes of patients with Chagas' on electric devices are unclear while these patients fare better post-transplant than non-Chagas' patients. Thus, heart transplant remains an attractive option regarding both favorable outcomes and resource allocation for advanced heart failure patients in Brazil.

Heart Rhythm Society members' views on pacemaker and implantable cardioverter-defibrillator reuse

BACKGROUND

Reuse of cardiac implantable electronic devices (CIEDs) may help address the unmet need among patients in low- and middle-income countries (LMICs).

METHODS

To examine Heart Rhythm Society (HRS) physicians' opinions regarding CIED reuse, an online survey eliciting attitudes toward CIED reuse was sent to all 3,380 HRS physician members.

RESULTS

There were 429 responses (response rate 13%). A large majority of respondents agreed or strongly agreed that resterilization of devices for reimplantation in patients who cannot afford new devices may be safe (370, 87%) and, if proven to be safe, would be ethical (375, 88%). A total of 340 (81%) respondents would be comfortable asking their patients to consider donating their device, and 353 (84%) would be willing to reimplant a resterilized device if it were legal. The most commonly cited concerns about device reuse were infection (270, 64%) and device malfunction (125, 29%). Respondents from the United States and Canada had more favorable impressions of device reuse than respondents from other high-income countries (P < 0.05 for three of five positive statements regarding reuse), and were less likely to cite ethical concerns (P < 0.001). However, when responses from all high-income countries were compared with lower- and upper-middle income countries, there were no significant differences in the rates of approval.

CONCLUSIONS

HRS survey respondents support the concept of CIED reuse for patients in LMICs who cannot afford new devices. Studies are needed to demonstrate the clinical efficacy and safety of this practice and to identify potential barriers to adoption among physicians.

Patient preferences regarding device reuse and potential of devices for reuse - a study in a veteran population

BACKGROUND

Many cardiac patients need and undergo device implants. Veterans' preferences regarding post-mortem handling of devices are not known. Cardiac patients in low- and middle-income countries who need but cannot afford devices rely on donations. Charitable organizations have successfully provided devices for reuse to such patients.

OBJECTIVE

We estimated the number of devices with potential for possible reuse in a veteran population.

METHODS

Between January and December 2008, at a tertiary medical center, veterans with implanted cardiac devices were surveyed using a questionnaire for their preferences regarding post-mortem handling. One choice was donation to charity for reuse. Although altruistic, it is unclear what percent of such devices have reuse potential. Retrospective chart review of veterans who underwent device implants between 1992 and 2007 identified a cohort of patients with Implantable Cardiac Defibrillators (ICDs) who had died by April 31st 2009. In this cohort, ICDs implanted in the year preceding the patient's death were counted as having reuse potential.

RESULTS

94 of 97 veterans completed the survey. 56% were unaware of how devices are handled after death. The top three preferences for postmortem handling were: return to manufacturer, return to hospital and donation for reuse. 88% were willing to sign an advance device directive. Retrospective review identified 161 veterans who had received 301 ICDs. Of these, 77 ICDs (25%) had median reuse potential of 3.1 years.

CONCLUSION

In a VA cohort of deceased patients a substantial proportion of devices had reuse potential. Further research is needed to direct health policy.

Reuse of pacemakers: comparison of short and long-term performance

BACKGROUND

In developing economies, there are patients in whom pacemaker implantation is delayed because they cannot afford one. Reused devices have been a solution. To address concerns about safety, a cohort of consecutive patients implanted with a reused pacemaker was compared with a control group.

METHODS AND RESULTS

A cohort of 603 consecutive patients from 2000 to 2010 was studied in an ambispective noninferiority study. The study group patients (n=307) received resterilized pacemakers, and the control group patients (n=296) received a new pacemaker. A combined end point of 3 major outcomes-unexpected battery depletion, infection, and device dysfunction-was analyzed. A total of 85 pacemakers had to be explanted, 31 in the control group (10.5%) and 54 in the study group (17.6%; relative risk, 1.68; 95% confidence interval, 1.1-2.5; P=0.02). Forty-three reached the primary end point, 16 in the control group (5.5%) and 27 in the study group (7.2%; relative risk, 1.3; 95% confidence interval, 0.70-2.45; P=0.794). In terms of individual outcomes, 5 new pacemakers (1.7%) and 11 resterilized pacemakers (3.6%) had unexpected battery depletion (relative risk, 2.12; 95% confidence interval, 0.75-6; P=0.116); 3.7% new pacemakers and 3.2% reused pacemakers had a procedure-related infection (relative risk, 0.87; 95% confidence interval, 0.38-2.03; P=0.46); and 1 pacemaker in the study group malfunctioned.

CONCLUSIONS

Pacemaker reuse is feasible and safe and is a viable option for patient with bradyarrhythmias. Other than the expected shorter battery life, reuse of pacemaker generators is not inferior to the use of new devices.

Reuse of explanted permanent pacemakers donated by funeral homes

Poor patients in developing countries may not receive permanent pacemakers (PPMs) even as lifesaving measures because of their high cost. In this report we examined whether PPMs that were explanted and donated by funeral homes in the United States could be safely and effectively reused in indigent patients in India. With permission from the deceased patients' families, 121 PPMs were explanted and donated by funeral homes for reuse. These PPMs were sterilized and sent for implantation in needy and indigent patients at a charity hospital in Mumbai, India. From the pool of donated 121 PPMs, 53 (88%, 11 single-chamber PPMs, 21%, and 42 dual-chamber PPMs, 79%) were acceptable for reuse and implanted (37 new implants, 70%, and 16 for battery/generator replacement, 30%) in 53 patients (mean ± SD 64 ± 10 years old, 28 women, 53%). Indications for PPM implantation were complete heart block (n = 27, 51%) and sick sinus syndrome (n = 26, 49%). All patients were alive and well postoperatively. No significant complications including infections or device failures occurred over 19 to 1,827 days (mean 661) of follow-up. Of 40 patients (75%) who were followed locally, 4 (10%) died because of nonpacemaker-related causes; time to death was 121 to 750 days (mean 430) after PPM implantation. All except 2 patients (5%) reported marked improvement in their symptoms. There were only 4 patients (8%) who were previously employed, and all were able to resume their manual labor work. Also, of the women, 27 patients (96%) reported improvement in symptoms enabling them to resume regular household chores as housewives after PPM implantation. In conclusion, with proper device sterilization and handling protocols, reuse of explanted PPMs in poor patients in developing countries is safe and effective. Implantation of donated PPMs can not only save lives but also improve quality of life of needy poor patients.

Societal views of pacemaker reutilization for those with untreated symptomatic bradycardia in underserved nations

PURPOSE

Significant healthcare disparities exist between the developed world and low and middle income countries (LMIC), specifically in the field of cardiac electrophysiology. As a result, pacemaker reutilization has been proposed as a viable option for those in LMIC and no other means of obtaining a device. Little data exist regarding the feasibility of establishing a reuse program in addition to understanding the views of society on device reutilization. This study investigated the views of funeral directors, patients with cardiac devices, and members of the general population regarding reutilization of previously implanted pacemakers.

METHODS

Ninety funeral directors in Michigan were surveyed regarding current practice as well as preferences for post-mortem device disposal. One hundred and fourteen patients with devices and 1,009 members of the general population were surveyed regarding post-mortem device handling.

RESULTS

Funeral directors had an average of 21 years of experience with an annual volume of 120 deceased persons per year, with a cremation rate of 35%. When asked about disposal methods of explanted devices, the majority of devices (84%) were discarded as medical waste or stored with no intended purpose, with a total of 171 devices currently in possession at the funeral homes. Eighty-nine percent of funeral directors expressed a desire to donate devices for reuse in LMIC and 10% acknowledged previous device donation. Eighty-seven percent of device patients and 71% of the general population also expressed a desire to donate devices.

CONCLUSIONS

The results of our survey show that a large percentage of funeral directors, patients with implantable devices, and members of the general population support a pacemaker reutilization initiative. This study lends further evidence that collection of devices for reuse is feasible and that establishing a framework for regional pacemaker reutilization program is warranted. If successful, the feasibility of this model should be investigated in other parts of the country in order to alleviate the burden of untreated symptomatic bradycardia in our world.