Cardiac rhythm management devices (pacemakers) are being increasingly implanted worldwide not only for symptomatic bradycardia, but also for the management of arrhythmia and heart failure. Their use in more elderly patients with significant comorbidities is rising steeply and consequently long-term complications are increasingly arising. Such an increase in device therapy is being paralleled by an increase in the requirement for system extraction. Safe lead extraction is central to the management of much of the complications related to pacemakers. The most common indication for lead extraction is system infection Adhesions in chronically implanted leads can become major obstacles to safe lead extraction and life-threatening bleeding and cardiac perforations may occur. Over the last 20 years, specific tools and techniques for transvenous lead extraction have been developed to assist in freeing the lead body from the adhesions. This article provides a comprehensive review of the indications, tools, techniques and outcomes for transvenous lead extraction. The success rate largely depends on the time from implant. Up to 12 months from implant, it is rare that traction alone will not suffice. For longer lead implant duration, no single technique is sufficient to address all extractions, but laser provides the best chance of extracting the entire lead. Operator experience is vital in determining success as familiarity of a wide array of techniques will increase the likelihood of uncomplicated extraction. Long implantation time, lack of operator experience, ICD lead type and female gender are risk factors for life-threatening complications. Lead extraction should therefore, ideally be performed in high volume centres with experienced staff and on-site support from a cardiothoracic surgical team able to deal with bleeding complications from cardiovascular perforation.

Wellens' syndrome refers to specific ECG abnormalities in the precordial T-wave segment, which are associated with critical stenosis of the proximal left anterior descending (LAD) coronary artery culminating in an acute anterior wall myocardial infarction (MI) if the patient is not urgently revascularised. We describe the youngest reported presentation of Wellens' syndrome in a 24-year-old woman with unstable chest pain, characteristic ECG changes and slight troponin biomarker elevation. This was initially unrecognised by the emergency department as unstable coronary syndrome and she subsequently progressed to an anterior non-ST elevation MI (NSTEMI). Her coronary angiogram showed critical narrowing of the proximal LAD which was successfully treated with a drug-eluting stent.

SUMMARYA transradial arterial approach to coronary angiography and percutaneous coronary intervention has become increasingly embraced by cardiologists as it is associated with decreased vascular complications and allows early mobilisation of patients when compared with transfemoral arterial access. Major vascular complication post-transradial access is uncommon. We describe a very rare case of perforation of the costocervical trunk (a branch of the right subclavian artery at the site of the thoracic inlet) presenting shortly after percutaneous transradial coronary intervention. The resulting rapidly expanding cervical haematoma caused airway compromise necessitating emergent intubation in the catheter laboratory recovery area. Transfemoral catheter coil embolisation of the feeder artery was successful in obliterating blood flow to the perforated vessel with eventual resolution of the neck haematoma. BACKGROUND

Implantable cardioverter defibrillators (ICDs) save lives in selected patients at risk of sudden cardiac death. However, in patents suffering with terminal illness, ICD therapy could pose a risk of unnecessary futile shocks which could lead to undignified discomfort in their final days of life. National guidelines advise that patients approaching the end of their natural life should be offered a compassionate choice of having their defibrillator deactivated. Following an actual clinical incident involving a patient receiving avoidable ICD shocks in his final hours, we identified shortcomings in communication and gaps in knowledge about ICD management in end-of-life care. We developed a quality improvement programme targeting training and educational support to general physicians and nurses at our large District General Hospital. A series of interventions were delivered including Grand Round presentation, departmental seminars and publicity posters. In parallel, we introduced a local protocol for implementing ICD deactivation which was published on our intranet for Trust-wide accessibility. Following interventions, we examined the clinical notes of each end-of-life care patient who died with an ICD in situ over a 6-month observation period and recorded the proportion who received consent-guided ICD deactivation versus died with an active ICD in situ because no deactivation discussion had been offered. Before our interventions in 2015, 0 out of 10 eligible patients (0%) received consent-guided ICD deactivation. Six months into our campaign to encourage healthcare workers to undertake advance care planning discussion in 2016, 7 out of 13 eligible patients (54%) received consent-guided ICD deactivation and no patients received shocks in their final month of life. This programme was successful in raising awareness of this emerging issue, improving physician knowledge and delivering patient choice as well as contributing to safe and compassionate end-of-life care.