Pacemaker and ICD Re-use in AFRICA the Cape Town experience

Transcription

1 Pacemaker and ICD Re-use in AFRICA the Cape Town experience Ashley Chin MBChB, FCP(SA), MPhil, FHRS Cardiologist/Electrophysiologist Groote Schuur Hospital University of Cape Town South Africa PASCAR 2015, Mauritius

2 Outline Current Status of Pacing and ICD use in AFRICA 2014 PASCAR Survey of Pacing and ICD use in Africa Pacemaker and ICD re-use in Groote Schuur Hospital, Cape Town, South Africa PASCAR fellowship in cardiac pacing

3 Permanent pacing remains one of the... Still unavailable to many patients living most cost effective treatments in Africa today... available in modern medicine Activitrax MicroMinix Thera EnPulse First External Pacemaker Pediatric Asynchronous Pulse Generator Rate response Radically smaller size First Microprocessorbased, Mode switching Full automaticity First Leadless Pacemaker est 1960 First Implantable Pacemaker Chardack-Greatbatch 1979 Byrel 1989 Dual chamber rate response Synergist 1991 Elite 1998 Rate response via activity & minute ventilation Kappa 2006 MVP, Full automaticity Adapta R Sutton, The foundation of Cardiac Pacing 1991

4 Brignole et al, 2013 ESC pacing guidelines PM implantation rate in EUROPE

5 Mond et al, PACE, August 2011 PACING in AFRICA 11 th World Survey of Cardiac Pacing and ICDs in 2009 included 2 African countries POPULATION (million) PM CENTRES 2009 PM IMPLANTS 2009 SOUTH AFRICA SUDAN PM (Units per million) SPAIN PM implantation rates are very low in 2 African countries compared to other European countries with a similar population

6 2014 PASCAR SURVEY on PACING and ELECTROPHYSIOLOGY in AFRICA ACKNOWLEDGEMENTS: Bongani Mayosi (PASCAR President) Aime Bonny (Chair PASCAR Task Force on Sudden Cardiac Death) PARTICIPANTS: Ashley Chin (South Africa), Isaac Kofi Owusu (Ghana), Adama Kane (Senegal), Houenassi (Benin), Jeilan (Kenya), A Gehani (Libya), Diakite Mamadou (Mali), Toure Ali Ibrahim (Niger), Sonia Marrakchi (Tunisia), Kamilu Karaye (Nigeria), Maiduguri (Nigeria), Anastaze Dzudie (Cameroon), Tantchou Cabral (Cameroon), Ouankou Debozard (Cameroon), James Russel (Sierra Leone), Icham Bouzelmat (Morocco), Brahim Hamdaoui (Morocco), Awad Mohamed (Sudan) 14 African countries

7 PACING in AFRICA in 2014 COUNTRY PM CENTRES PM DOCTORS PM/CENTRE (2013) PM (2013) SOUTH AFRICA Yes TUNISIA No MOROCCO SUDAN 517 KENYA NIGERIA 5 3 Re-used PM SENEGAL Yes (22%) CAMEROON No LIBYA GHANA BENIN MALI NIGER SIERRA LEONE Severe shortage of PM centres exist in all countries surveyed Severe shortage of PM doctors Mostly lowvolume implanters PM implantation rate is very low UGANDA Yes 2014 PASCAR SURVEY on PACING and EP in AFRICA

8 PACING in SOUTH AFRICA PM (Units per million) Increase in PM implants over time but rates are still low compared to Europe Increase in PM doctors: 112 PM doctors (31 centres) in PM doctors (54 centres) in 2014 Scott Millar, S Afr Med J 2001

9 PACING in SOUTH AFRICA Large geographic and racial discrepancies Few PM doctors in 4 provinces in SA in 2014 ( people) 3700 patients/year may have AV block without a PM (1998) Scott Millar, S Afr Med J 2001

10 Mond et al, PACE, August 2011 ICDs in AFRICA 11 th World Survey of Cardiac Pacing and ICDs in 2009 included 2 African countries POPULATION (million) ICD IMPLANTS (2009) SOUTH AFRICA SUDAN 39 2 <1 ICD (Units per million) SPAIN

11 2014 PASCAR SURVEY on PACING and EP in AFRICA ICDs and CRT in AFRICA in 2014 COUNTRY ICD CENTRES ICD DOCTORS CRT CENTRES SOUTH AFRICA TUNISIA KENYA MOROCCO N/A 7 N/A 2 CAMEROON LIBYA SENEGAL NIGERIA 1 or 2? 0 0 GHANA BENIN MALI NIGER SIERRA LEONE CRT DOCTORS ICDs and CRT are available in a few centres Few in sub-saharan Africa except South Africa

12 ICDs and CRTs in SOUTH AFRICA ICDs and CRTs (per million) ICDs CRT-P Increase in ICD implants over time but rates are still low compared to Europe 40 ICD centres (70 implanters) in ICD centres (68 implanters) in 2014

13 Outline Current Status of Pacing and ICD use in AFRICA 2014 PASCAR Survey of Pacing and ICD use in Africa Pacemaker and ICD re-use the Cape Town experience PASCAR fellowship in cardiac pacing

14 Safety of Pacemaker Re-use Baman et al. Circ Arrythm Electrophysiol, 2011

15 Baman et al. Circ Arrythm Electrophysiol, 2011 Safety of Pacemaker Re-use INFECTION (3%) No difference in infection rates between re-used and new pacemakers DEVICE MALFUNCTION (1%) Increase in pacemaker malfunction in re-used group: abnormalities in set screws and technical abnormalities

16 Pavri et al. Ann Intern Med, 2012 Safety of ICD Re-use 81 patients No infectious complications No control group

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18 Cadaveric donors Visual inspection Battery>2 years 24 hrs 9 hrs

19 Re-used pacemakers were implanted in elderly patients with co-morbidities with poor level of functioning

20 No device infections No device malfunction No premature battery depletion

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22 Outline Current Status of Pacing and ICD use in AFRICA 2014 PASCAR Survey of Pacing and ICD use in Africa Pacemaker and ICD re-use the Cape Town experience PASCAR fellowship in cardiac pacing

23 PASCAR fellowship in cardiac pacing Fellowship directors: Bongani Mayosi Ashley Chin (Andrzej Okreglicki) Aim: Train one team/country at Groote Schuur Hospital 6 month practical training in cardiac pacing for a cardiologist or a specialist physician with an interest in cardiology 3 month practical training for support staff Pilot phase Industry-funded

24 PASCAR fellowship in cardiac pacing Selection of candidate: (1) a track record of service and commitment to developing health services in their institution, (2) support from their institutions for the development of a cardiac pacing service, (3) plans for establishment of the cardiac pacing service upon completion of the programme. Training: To achieve a minimum of 30 single chamber pacemakers and 5 dual chamber pacemakers implants as 1 st operator First two fellows have been selected: Dr Akwanalo from Tanzania (due to start October 2015) Dr James Russel from Sierra Leone

25 Summary There is a severe lack of pacemaker implanters and pacemaker centres in Africa ICDs and CRTs are not available in almost all sub- Saharan countries (except South Africa) Pacemaker and ICD re-use is safe and feasible PASCAR fellowship in cardiac pacing will address the absence of clinical expertise

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