Defining the incidence of complications and associated costs from contemporary cardiac electronic device utilisation in the united kingdom

Abstract

The population of patients living with a cardiac implantable electronic device (CIED) continues to expand. In 2016, 1,006 per million CIEDs were implanted in the United Kingdom (UK) and 37,288 per million across European Society of Cardiology (ESC) member countries.1 Routine procedures beyond the de novo implant are not recorded, yet CIEDs have limited longevity. Generator and lead replacements are to be expected during a patient’s lifetime and similarly, the health status of patients does not remain static. Progression of cardiac pathology brings the potential requirement to increase CIED complexity and weight loss or intervening co-morbidities can mandate device reburial.

Complications can occur with every intervention, resulting in morbidity, mortality and financial cost. Extraction of CIEDs presents the greatest risk, with demand speculated to be rising.2

At the commencement of this project, reporting of complications and transvenous extractions within the UK was not mandatory. The contemporary incidence of complications, trends in extraction and associated costs was therefore unknown. A single centre, retrospective evaluation of 10,125 consecutive CIED operations confirmed complication rates of 4.0 - 22.8%, dependant on index procedure. Morbidity at one year was 5.7 - 34.6%, with an estimated cost of £416,770 per annum in resolving complications. Analysis of 646 transvenous extraction procedures between 2006 – 2016, demonstrated demand peaked in 2010 –11. The cost of extraction during a single year was £682,892 (£1,300,509 including re-implantation), equating to £5 million and £9 million respectively when extrapolated to the UK.

I hope the work within this thesis will provide physicians with insight into contemporary complication rates and encourage scrutiny of operative technique and outcomes. For patients, the informed consent process may be enhanced and realistic expectations of life with an implant achieved. Strategies to prevent complications will produce significant cost savings, whilst national tariffs representative of expenditure, will ensure the viability of hospitals to deliver optimal care.