Critical appraisal of cardiac implantable electronic devices: complications and management

Abstract

Population aging and broader indications for the implant of cardiac implantable electronic devices (CIEDs) are the main reasons for the continuous increase in the use of pacemakers (PMs), implantable cardioverter-defibrillators (ICDs) and devices for cardiac resynchronization therapy (CRT-P, CRT-D). The growing burden of comorbidities in CIED patients, the greater complexity of the devices, and the increased duration of procedures have led to an augmented risk of infections, which is out of proportion to the increase in implantation rate. CIED infections are an ominous condition, which often implies the necessity of hospitalization and carries an augmented risk of in-hospital death. Their clinical presentation may be either at pocket or at endocardial level, but they can also manifest themselves with lone bacteremia. The management of these infections requires the complete removal of the device and subsequent, specific, antibiotic therapy. CIED failures are monitored by competent public authorities, that require physicians to alert them to any failures, and that suggest the opportune strategies for their management. Although the replacement of all potentially affected devices is often suggested, common practice indicates the replacement of only a minority of devices, as close follow-up of the patients involved may be a safer strategy. Implantation of a PM or an ICD may cause problems in the patients’ psychosocial adaptation and quality of life, and may contribute to the development of affective disorders. Clinicians are usually unaware of the psychosocial impact of implanted PMs and ICDs. The main difference between PM and ICD patients is the latter’s dramatic experience of receiving a shock. Technological improvements and new clinical evidences may help reduce the total burden of shocks. A specific supporting team, providing psychosocial help, may contribute to improving patient quality of life.

Palliative care for people living with cardiac disease

“…That is why discontinuing pacing cannot be considered a PC intervention in a dying person. [37][38][39][40] In patients responding to CRT and showing improvement of HF symptoms, even an accidental loss of effective stimulation leads to the abrupt deterioration of cardiac function and may precipitate fulminant, acute HF symptoms like dyspnea or acute pulmonary edema. Device reprogramming, which stops resynchronizing stimulation, would evoke similar acute HF symptoms.…”

“…Therefore, it should be strongly discouraged and cannot be regarded as a PC intervention. [38][39][40] Implantable cardioverter -defibrillators and CRT -D devices deliver low -voltage therapies (antitachycardia pacing [ATP]) unnoticeable for patients or usually painful high -voltage interventions, ie, cardioversion and defibrillation. The modification of antitachyarrhythmia therapy in patients approaching death, in whom the underlying diseases cannot be successfully treated, aims to avoid suffering precipitated by the CIED interventions or to prevent prolongation of the dying process (futile therapy).…”

<div>Review of cardiac implantable electronic device related infection</div>

“…Pulmonary complications such as pneumonia, emboli, and abscesses can be secondary to septic emboli. 33 In rare cases, left-sided vegetations can also develop.…”

Knowledge expectations, self-care, and health complaints of heart failure patients scheduled for cardiac resynchronization therapy implantation

“…At first glance, CRT implantation might seem a rather simple surgical procedure but receiving the device may be a stressful experience for patients, especially for those with CRT-D devices who expect and may experience defibrillating shocks. 19 They have been found to suffer from psychological distress, depressive symptoms, and impaired quality of life, even though they experience physical improvement. 20 The Heart Failure Association of the European Society of Cardiology has recently urged policy makers to improve education and support for heart failure patients and their families.…”

“… 21 Implantation of a device increases educational needs even further, and emerging evidence suggests that education and psychosocial support play a fundamental part in patients’ adjustment to cardiac devices. 19 , 22 , 23 Individualized education, which starts with the assessment of learning needs, delivered in multiple doses and the use of multiple media is recommended for both heart failure patients 24 , 25 and surgical patients. 26 , 27 However, content analysis of all written educational material for recipients of implantable cardioverter defibrillators in Sweden has revealed that biophysical content dominates the material while other relevant contents are scarce or nonexistent.…”