These are the options?

It's no secret what my stance on women's reproductive issues are. Again, I am flabbergasted by the BS that is shoveled out by the pro-life movement. Here is another rebuttal about one of their "alternatives" to abortion. Adoption. "Oh dear, you need to love your child so much you are willing to give it life then give it up for adoption into a loving home". Ah yes, a loving home, with a dog, a cat and rich, white parents with the matching white picket fence. However, to get there dear children you'll hang out in the system for a while. The adoption process takes YEARS and MONEY - and lots of it; think $30 000 of it. And, if you happen to be less than the adorable, wide eyed, cherub cheeked child, well, you'll be on the shelf a lot longer sweet one. The adoption agencies are impenetrable walls. I myself have looked into adoption. I meet the requirements. No problem right? Wrong. I DON'T have to $5000 up front cost to OPEN a file. Oh yes just to OPEN a file. Shit and I do that for free daily! Then we have visits, more cash, and a long waiting period. If the agency doesn't think a particular child I have chosen to be a "fit" they turn me down. The autistic child for example or the diabetic child; I'll need a degree in ECC and an RN certification to get one of them. This is just the domestic adoption agency. The foreign one is much more complicated. You will need to attend classes where they teach you how to make sure your child stays connected to their heritage and doesn't turn around and say that you were a shitty parent because you treated them like a Canadian child with no roots - God forbid!! Well if you can wade through that swamp and actually get assigned (literal - you don't choose) a child, you must then go to the country where they live and spend two weeks there with them; great idea, makes sense; but wait, you're not done cousin! If your child is deemed medically unfit to be let into Canada, you put the child down, walk away, board your plane and start again - FROM THE BEGINNING - which means, all together now, MORE MONEY! So the child whose mother so selflessly and lovingly gave her up to the system, may very well languish there amid other children whose fate is similar or bounce from foster home to foster home until they are either adopted or become of age. I think we need a better Plan B.

The Future of ICD's?

Returning from a weekend conference, I am feeling refreshed from professional discourse, idea sharing and not a little merriment. One of the most interesting presentations (for me at least), was an intriguing talk given by Dr. Riccardo Cappato on the initial patient experience with the still investigational subcutaneous ICD's. The positives of this novel approach to CRM device implantation were immediately apparent namely the following:

• Fluoroscopy is not required intraop


• risk of complications such as pneumothorax, hemothorax, myocardial perforation and lead dislodgement are completely removed


• No introduction into the vascular system - especially useful in pediatric patients and patients with difficult or not vascular patentcy


• No risk of SVC vein occlusion or need for possible laser lead extraction for subsequent lead revision


• lower risk of lead dislodgement

These risks are minimized or bypassed due to the fact that the lead system is implanted entirely subcutaneously. The defibrillation coil runs parallel to the left aspect of the sternum and the lead body is then tunneled along (approximately) the 6th intercostal space to the device which is implanted parasternally (approximately 5 inches inferior to traditional placement and slighly more lateral).

The initial experiences that were reported described a virtually equivalent tolerance to alternate device placement, and not perceived increased patient discomfort when compared with traditional placement. DFT's were also successful at 65 joules or less allowing for a safety margin of at least 15J, given the devices maximum output at ~80 joules. This method of course is contraindicated in those who DO have an underlying pacing indication. That being said, the investigators did note that success of the post-shock pacing at higher than traditional values.

I personally am cautiously optimistic about the early success of this approach to implantation. I would like to see how the lead behaves chronically while it is in perpetual contact with subcuticular tissue. How will the leads perform chronically? How (if at all) will lead maturation manifest? Can the defibrillation coil become indurated with scar tissue? Will weight changes or either a decrease or increase in fat affect DFT's? How will that impact the leads efficacy? Only time will tell.

Discuss...

Arrhythmia Device Follow-up 101

I have been encouraged to share the meager knowledge I have of arrhythmia devices for those who may be interested. A brief background of my involvement in these devices: I trained in Diagnostic Cardiovascular technology both on the electrophysiologic and imaging level. I began my arrhythmia device training (moving forward I will use the industry accepted acronym CRM - Cardiac Rhythm Management) at a university hospital in downtown Toronto back in early 2003. I currently run a pacemaker clinic at a different Toronto hospital. I wrote two exams, both the Canadian CRM specialty exam in 2006 and the IBHRE (International) exam in 2007. My posts will tend to run on the side of generality, but I hope even veterans in the industry may glean some benefit from this and future posts on the subject. I do not endeavor to insult any one's intelligence, nor is this an instructional post per say. I merely wish to share my experiences to either the benefit or amusement of my fellow cohorts. So, enough about me and on with the show so to speak.

It may sound a tad hokey but the greatest tool (usually) you have in your arsenal for following and troubleshooting CRM's is definitely your patient. Unless the patient is clearly a veterinary historian or otherwise inclined to vague and non-specific symptom relation, they are your best jumping off point. I can illustrate this with a very good example I recently encountered. A patient of mine, Mr. P, came to clinic for his annual check up. His original implant indication was sick sinus syndrome and for the past 5 years has had a total pacing percentage of no more than <0.1%.>30 bpm. He indeed after 5 years of almost no pacing, became fully pacemaker dependent. This is not an unusual occurrence as ~15-25% of SSS patients will develop varying degrees of AV block.
Mr. P was programmed to a rate responsive mode with a conservative rate response curve and performed a hall walk. In comparison with his marked shortness of breath walking 20 feet from the waiting room to the clinic versus the hallwalk totalling 60 feet, he was totally relieved of his symptoms with the new parameters.
I was quite lucky to have such a diligent and observant patient to aid me in programming his appropriately. More often than not, you will be met with stoicism or vague reporting of symptoms and parameters will by and large become trial and error.
The take home message here is listening to your patients can make your job easier.