Enhancing longevity of pacemakers through reprogramming. Underutilization and cost-effectiveness

Abstract

Objective -This study was performed to observe the number of pacemakers that had never been reprogrammed after implantation, and the effect of optimised output programming on estimated longevity of pulse generators in patients with pacemaker Methods -Sixty patients with Teletronics Reflex pacemakers were evaluated in a pacemaker clinic, from the time of the beginning of its activities, in June 1998, until March 1999Electric pacing of the heart began around forty years ago and stands out as one of the major achievements in cardiac therapy in the 20th century, combining both physiologic knowledge and technologic advances in the treatment of potentially disabling and fatal bradyarrhythmias. Currently, about 400 thousands pacemakers are implanted every year world-wide 1 , and 50% of pacemaker recipients are still alive when the pulse generator lifespan is over, making them eligible for a new pulse generator. Therefore, the prolongation of the life of pulse generators has been considered desirable and cost-effective because it would postpone a second surgical intervention, eliminating the expense of new generators units 1,2 .Pacemaker longevity is defined as the interval between implantation and detection of the end of pulse generator life, which is determined by the energy consumption of the pulse generator and the deliverable capacity of its power source 3,4 . The deliverable capacity of the power source is fixed for a certain battery, but energy consumption depends on both fixed parameters and physiologic and programmable variables. Therefore, the determinants of the consuption are: programmable output parameters of the system (voltage and pulse width), the frequency and percentage of pacing, the lead impedance, and the static energy drain of the system. Although programming the pacing rate and AV interval can optimise the battery energy drain, the most important parameters that are available to optimise the longevity of a pacing system are stimulation voltage and pulse width 2 .Original settings programmed by the manufacturer are chosen to provide for a sufficient safety margin during the subacute period when stimulation thresholds typically rise. However, most leads used today enable stimulation with reduced output parameters of pacing, resulting in significant reduction in energy drain and, therefore, prolongation of pulse generator life. Thus, reprogramming a pacemaker after a subacute period, according to an obtained stimulation threshold, was a desirable practice recommended in most basic textbooks and by international guidelines 1,3-6 . However, the majority of pacemakers remain at the original programmed

Long‐Term RV Threshold Behavior by Automated Measurements: Safety is the Standpoint of Pacemaker Longevity!

“…This is of paramount importance, mainly when expensive devices such as cardiac resynchronization therapy‐defibrillators are concerned 8 . Reluctance to pacing output reprogramming below battery voltage is very common, being >80% of pacemakers unchanged with respect to shipment programming 21 mainly because of misleading perceptions or safety concerns. We, therefore, think that this experience may add confidence to the broad clinical arena of physicians practicing in the field of device therapy, enhancing the employment of AVC algorithms.…”

Optimizing Pacemaker Longevity with Pacing Mode and Settings Programming: Results from a Pacemaker Multicenter Registry

“…Therefore, any enhancement of pacemaker longevity appears relevant to reduce the risks for the patient and the burden of healthcare costs. [1][2][3] The pacemaker longevity is defined as the interval between implantation and detection of the end of the battery lifetime and depends on the energy consumption of the pulse generator and the battery capacity. 4,5 The main determinants which influence the energy consumption are pulse amplitude, pulse width, working mode and programmed rates, lead impedance, and static energy drain.…”

“…4,5 The main determinants which influence the energy consumption are pulse amplitude, pulse width, working mode and programmed rates, lead impedance, and static energy drain. 3 Although pulse amplitude and width are the most direct parameters influencing the energy consumption, adequate programming of the basic rate and the atrioventricular (AV) interval can optimize the use of the battery energy. 2 Dual chamber cardiac pacemaker is indicated for the treatment of bradycardia due to sinus C 2012, The Authors.…”

Response:

“…We completely agree that the battery longevity would be the same either by fixed or automated stimulation when the pacing threshold was below 1.5 V @ 0.4 ms and a small safety margin (0.25–0.5 V) was used, mimicking the same setting of automatic verification of capture (AVC) algorithms. Things would, however, be different for higher thresholds: clinical practice reports that safety margins greater than (threshold + 0.5 V) are used, and pacing output is rarely reprogrammed from shipment 1 …”

“…Tailoring the pacing output according to measured threshold is recommended to increase device longevity, 1,7–9 but may unnecessarily expose patients to exit block: AVC algorithms ensure patients' safety by automatic output adaptation and reversion into a safe setting in the event of a threshold increase, while maximizing device longevity. Thus, longevity comes to be a by‐product of patients’ safety.…”