I implant fewer pacemakers for sick sinus syndrome. More post-atrial fibrillation (AF) conversion pauses are treated with primary therapy of the AF, rather than with pacing and more drugs—especially in the non-elderly. Successful rhythm control can occasionally supplant the need for a chronic indwelling pacing device. In the non-elderly, this strategy of addressing the root cause (AF) seems much more elegant than having a chronic device, which in and of itself does not preclude the need for lifelong medical treatment.
In the elderly patient with permanent AF recently validated strategies of less vigorous rate control have resulted in fewer cases of bradycardia and thus fewer single lead ventricular pacemakers. Additionally, the detrimental effects of right ventricular apical pacing have further lessened pacing enthusiasm.
I am seeing fewer patients with ischemic cardiomyopathy, the reason of which may be multi-factorial. First, in Louisville’s fairly stable population, many patients with heart damage from remote heart attacks have already been referred for an ICD. Second, it seems possible that the now widespread acceptance of aborting heart attacks by stenting culprit blockages within 90 minutes may have decreased the incidence of persistently damaged hearts.
Pre-ICD implant meeting
Not only do there seem to be fewer ischemic cardiomyopathy patients in the ICD pool, the pre-implant meeting has resulted in a small, but finite, number of patients who decline the shock-only, non-ejection fraction-improving ICD. Years ago, I dismissed the idea of meeting the patient just prior to the implant in the pre-op holding area. Like a dinosaur, I cling to the poorly compensated and often emotionally draining pre-ICD meeting in the office. We discuss all aspects of the ICD, such as longevity after a shock, and potentially trading a painless peaceful death for the more drawn out heart failure death. Also, I would take the time to explain that ICDs do not help with symptoms like dyspnea, chest pain or fatigue. Often, this information is new to the patient.
Referral bias also could play a role in my changing ICD practice. In a small medical community, one’s ICD philosophy becomes known quickly, and referring doctors have options. It seems possible that referring cardiologists who deem an ICD necessary may be more likely to refer to a like-minded electrophysiologist, who is less encumbered by the complexities of the ICD implant decision.
CRT vs. ICD
While the quantity of life-enhancing prophylactic ICDs becomes less prevalent in my practice, the quantity and quality of life-enhancing cardiac resynchronization therapy (CRT) devices are on the rise. When applied to the appropriate patient, these CRT devices can improve cardiac output—often dramatically. Implanting a CRT device that improves both the quality and quantity of one’s life is a much less complex decision. That said, our device companies have rightly given us the choice of implanting a three-lead synchronizing CRT device that also shocks or paces.
This choice of CRT with or without a shocker adds yet another layer of complexity to the decision-making process. That the only trial showing superiority of a CRT-defibrillator compared with a CRT-pacemaker barely reached statistical difference—but is quoted as if it were a landslide win—makes CRT device choice even more complex.
Dr. Mandrola is a cardiac electrophysiologist in private practice with Louisville Cardiology in Louisville, Ky., and blogs at drjohnm.blogspot.com.