Pacemaker recycling: A notion whose time has come

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.

Longevity and potential reusability of cardiac implantable electronic devices explanted in funeral homes

BACKGROUND

While in high-income countries (HICs) the implantation of cardiac implantable electronic devices (CIEDs) is common, in certain low- and middle-income countries (LMICs) access to devices is limited and insufficient to meet the demand. Between 17% and 30% of CIEDs explanted post-mortem in HICs appears to have enough battery life to be reused but devices are not routinely programmed to no pacing output and continue to consume battery after the patient's death. Therefore, we conducted a prospective analysis of CIEDs collected from funeral homes, controlling variables such as the date of explantation and limiting the time until the date of interrogation to 6 months. The objective was to perform an accurate analysis of the reusability of post-mortem explanted CIEDs to assess the possibility of implementing a local effort of CIED reuse in LMICs.

METHODS

A descriptive study of post-mortem explanted CIEDs in funeral homes was conducted. Participating centers stored all devices explanted between December 2020 to December 2021 for collection and interrogation.

RESULTS

The participating centers attended 6472 deaths (28.05% of total deaths registered in the region). Two hundred fourteen CIEDs were collected (90.2% pacemakers and 9.8% defibrillators). Of the 214 collected devices, 100 CIEDs (46.7%) had >4 years or >75% battery remaining, preserved external integrity, and no evidence of malfunction and therefore were considered reusable.

CONCLUSIONS

Based on stablished criteria 46.7% of recovered devices were considered reusable. Therefore, recovery from funeral homes of HICs comprises a potential source of reusable devices for LMICs.

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.

Battery life of cardiac implantable electronic devices explanted in funeral homes: a potential resource for underserved nations

INTRODUCTION

Cardiac implantable electronic devices (CIEDs) could still have adequate battery life and functionality when they are explanted after the death of the carrier, supposing an important resource for low- and middle- income countries where patients cannot afford new devices.

OBJECTIVE

The aim was to analyse the remaining battery life and reusability of CIEDs recovered from funeral homes.

METHOD

A descriptive study of postmortem explanted CIEDs was conducted. Devices were collected from three funeral homes in the Spanish region of the Basque Country (participation rate 33.3%). Devices with a remaining battery life of >75% or > 4 years, preserved external integrity and no evidence of malfunction were considered reusable.

RESULTS

A total of 188 CIEDs were collected (175 pacemakers and 13 defibrillators). Of the total number of devices, 95 (50.5%) had enough battery to be interrogated. Among the interrogable devices, a total of 20 pacemakers (22.4%) had an estimated battery life of more than 4 years, as well as preserved integrity and no record of malfunction.

CONCLUSIONS

A non-negligible number of postmortem explanted devices had battery life, external integrity and functionality to be considered reusable. Postmortem CIED donation could provide treatment to patients unable to afford new devices.

Spanish Rhythm Association member´s perspectives on cardiac implantable electronic device reuse in low- and middle-income countries

BACKGROUND

Postmortem explanted cardiac implantable electronic devices (CIEDs) from developed countries could provide patients unable to afford new devices in low- and middle-income countries (LMIC) a treatment they lack. This study describes the preferences of electrophysiologists and device implanting cardiologists from Spain on the management of explanted CIEDs and opinions and concerns regarding reuse in LMIC.

METHODS

A nationwide self-administered questionnaire was sent to members of the Spanish Rhythm Association (n = 1110), between December 2020 and January 2021.

RESULTS

Forty-two physician responses were obtained (response rate 5%). There was a strong preference to donate explanted devices for reuse in humans (61.9%) or animals (31%). The vast majority of the participants thought device reutilization was safe, ethical, and a reasonable alternative if a new device is not accessible. Moreover, they indicated they would be comfortable asking patients to consider post-mortem donation, and willing to implant post-mortem explanted and resterilized devices if they were unable to obtain new ones. 57.1% of respondents considered it would be beneficial for patients to have a document so they could reflect their wishes regarding device handling after their death. The most mentioned concerns regarding device reuse were malfunction (57.1%) and infection (54.8%).

CONCLUSIONS

The majority of respondents support reusable CIED donation to LMIC. It would be interesting to study the feasibility of a nationwide device reutilization program.

Reuse of cardiac implantable electronic devices in developing countries perspectives: A literature review

INTRODUCTION AND OBJECTIVES

Access to cardiac implantable electronic devices (CIEDs) is limited in developing countries. Postmortem CIED donation from developed countries to developing countries could be an important resource for those who cannot afford a new one. The objective of this paper was to identify and synthesize the perspectives on the donation of CIEDs for potential reuse in patients without resources living in developing countries.

METHODS

A bibliographic review was carried out in the PubMed, Web of Science and Scopus databases. The search strategy was limited to articles published in English or Spanish.

RESULTS

Eight publications were analyzed. The main results were grouped into two large frameworks on perceptions, preferences, attitudes and opinions of developed countries and developing countries towards the donation and reuse of CIEDs. Positive perspectives were identified towards the donation of CIEDs for their reuse in the majority of patients with a CIED, relatives, funeral homes and physicians of developed countries, as well as in physicians and potential recipient patients of developing countries.

CONCLUSIONS

This review highlights the positive perspectives on CIED donation from developed countries to patients in need of developing countries among all studied groups. In view of the feasibility of collecting postmortem devices, we advocate studying the feasibility of more local CIED donation initiatives.

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.

A Systematic Review of the Spectrum of Cardiac Arrhythmias in Sub-Saharan Africa

Major structural cardiovascular diseases are associated with cardiac arrhythmias, but their full spectrum remains unknown in sub-Saharan Africa (SSA), which we addressed in this systematic review. Atrial fibrillation/atrial flutter (AF/AFL) prevalence is 16-22% in heart failure, 10-28% in rheumatic heart disease, 3-7% in cardiology admissions, but <1% in the general population. Use of oral anticoagulation is heterogenous (9-79%) across SSA. The epidemiology of sudden cardiac arrest/death is less characterized in SSA. Cardiopulmonary resuscitation is challenging, owing to low awareness and lack of equipment for life-support. About 18% of SSA countries have no cardiac implantable electronic devices services, leaving hundreds of millions of people without any access to treatment for advanced bradyarrhythmias, and implant rates are more than 200-fold lower than in the western world. Management of tachyarrhythmias is largely non-invasive (about 80% AF/AFL via rate-controlled strategy only), as electrophysiological study and catheter ablation centers are almost non-existent in most countries.

Highlights

- Atrial fibrillation/flutter prevalence is 16-22% in heart failure, 10-28% in rheumatic heart disease, 3-7% in cardiology admissions, and <1% in the general population in sub-Saharan Africa (SSA).- Rates of oral anticoagulation use for CHA2DS2VASC score ≥2 are very diverse (9-79%) across SSA countries.- Data on sudden cardiac arrest are scant in SSA with low cardiopulmonary resuscitation awareness.- Low rates of cardiac implantable electronic devices insertions and rarity of invasive arrhythmia treatment centers are seen in SSA, relative to the high-income countries.

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.

Ablative neurosurgery and deep brain stimulation for obsessive-compulsive disorder

Despite advancements in pharmacotherapeutic and behavioral interventions, a substantial proportion of patients with obsessive-compulsive disorder (OCD) continue to have disabling and treatment-refractory illness. Neurosurgical interventions, including ablative procedures and deep brain stimulation (DBS), have emerged as potential treatment options in this population. We review the recent literature on contemporary surgical options for OCD, focusing on clinical aspects such as patient selection, presurgical assessment, and safety and effectiveness of these procedures. Given the invasiveness and limited evidence, these procedures have been performed in carefully selected patients with severe, chronic, and treatment-refractory illness. Along with informed consent, an independent review by a multidisciplinary team is mandated in many centers. Both ablative procedures and DBS have been found to be helpful in around half the patients, with improvement observed months after the procedure. Various targets have been proposed for either procedure, based on the dominant corticostriatal model of OCD. There is no strong evidence to recommend one procedure over the other. Hence, the choice of procedure is often based on the factors such as affordability, expertise, and reversibility of adverse effects. Surgery is not recommended as a standalone treatment but should be provided as part of a comprehensive package including medications and psychotherapeutic interventions. Available evidence suggest that the benefits of the procedure outweigh the risks in a treatment-refractory population. Advances in neurosurgical techniques and increasing knowledge of neurobiology are likely to bring about further progress in the efficacy, safety, and acceptability of the procedures.

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.

Increasing Medical Trainees' Empathy Through Volunteerism and Mentorship

BACKGROUND

Within medical education, there have been recent calls for increased understanding and exposure to poverty to increase trainees' empathy toward the underserved. Students participating in Michigan Cardiovascular Outcomes Research and Reporting Program research program volunteered at World Medical Relief (WMR) in Detroit, Michigan, a nonprofit organization which recycles medical equipment for developing countries and within greater Detroit. Participants' perceptions of the underserved were measured before and after the experience.

METHODS

Preliminary questionnaires were given to participants prior to and after exposures at WMR. Questionnaires examined participants' attitudes toward the underserved, knowledge of medical supply reuse, and their perceived ability to impact change. P values of <.025 were considered significant.

RESULTS

A total of 39 participants completed the survey, 77% previously volunteered, 33% had volunteered internationally. Participants were >4× more likely than previously to have knowledge of the variety of recycled medical supplies at WMR. Prior to volunteering, 48.7% of participants gave little thought to how excess medical supplies could be collected versus 0% after exposure. Participants were 1.5× more likely to agree that the experience was enhanced working with their peers and 2.7× more likely to consider starting their own organization/intervention for medical supply donations. Those participants that never previously volunteered were 1.3× more likely to do so with encouragement from a mentor.

CONCLUSIONS

Encouraging exposure to such service programs resulted in enhanced knowledge of community resources and increased motivation to participate in outreach and belief of individual responsibility to care for the underserved. Incorporating volunteerism into traditional education programs offers the opportunity to build awareness and interest in students reaching out to the underserved.