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Deactivation of cardiovascular implantable electronic devices in patients nearing end of life

Reality or only recommendation?

Deaktivierung kardiovaskulärer implantierbarer elektronischer Systeme bei Patienten am Lebensende

Realität oder nur Empfehlung?

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Abstract

Background

Current guidelines recommend considering deactivation of cardiac implantable electronic devices (CIEDs) in patients nearing death. We evaluated the implementation of this recommendation in unselected deceased individuals with CIEDs.

Methods

Over a 7-month period in 2016, all deceased persons taken to the Rostock crematorium were prospectively screened for CIEDs and these were interrogated in situ. Pacing rate, pacing mode, and lead output were documented as well as patient data including location and time of death. In implantable cardioverter-defibrillators (ICDs), tachycardia therapy adjustment and occurrence of shocks 24 h prior to death were also recorded.

Results

We examined 2297 subjects, of whom 154 (6.7%) had CIEDs. Of these subjects, 125 (100%) pacemakers (PMs) and 27 (96.4%) ICDs were eligible for analysis. Death in persons with ICDs occurred most frequently in hospital (55.6%), while this was less frequently the case for individuals with PMs (43.2%). Furthermore, 33.3% of subjects with ICDs and 18.5% with PMs died in palliative care units (PCU). Shock therapies were switched off in three (60%) individuals with ICDs who died in the PCU, whereas antibradycardia therapy was not withdrawn in any PM patient in the PCU. Therapy withdrawal occurred in two patients with PMs (1.3%) who died in hospital. Patients with PMs had high ventricular pacing rates at the last interrogation (69 ± 36.0%) and often suffered atrioventricular block (39.2%). Six (25%) of the 24 active ICDs presented shocks near the time of death.

Conclusion

Many CIED patients died in hospital; nonetheless, in practice, CIED deactivation near death is rarely performed and might be less feasible in subjects with PMs. However, there is still a need to consider deactivation, especially in individuals with ICDs, as one fourth of them received at least one shock within 24 h prior to death.

Zusammenfassung

Hintergrund

Aktuellen Leitlinien zufolge wird empfohlen, die Deaktivierung kardialer implantierbarer elektronischer Systeme (CIED) bei Patienten in Erwägung zu ziehen, bei denen das Lebensende kurz bevorsteht. Die Autoren untersuchten die Umsetzung dieser Empfehlung bei unselektierten Verstorbenen mit CIED.

Methoden

Im Jahr 2016 wurde 7 Monate lang bei allen Verstorbenen, die ins Krematorium Rostock überführt wurden, prospektiv geprüft, ob sie ein CIED implantiert bekommen hatten, und dieses in situ untersucht. Schrittmacherfrequenz, Stimulationsmodus und Elektrodenfunktion wurden ebenso dokumentiert wie die Patientendaten einschließlich Ort und Zeitpunkt des Todes. Bei implantierbaren Kardioverter-Defibrillatoren (ICD) wurde auch die Anpassung der Tachykardietherapie und das Auftreten von Schocks 24 h vor dem Tod vermerkt.

Ergebnisse

Es wurden 2297 Verstorbene untersucht, von denen 154 (6.7 %) ein CIED trugen. Dabei waren 125 (100 %) Schrittmacher (PM) und 27 (96.4 %) ICD zur Auswertung geeignet. Der Tod bei Personen mit ICD ereignete sich in den meisten Fällen im Krankenhaus (55.6 %), für Personen mit PM war dies seltener der Fall (43.2 %). Darüber hinaus verstarben 33.3 % der Personen mit ICD und 18.5 % derer mit PM auf Palliativstationen (PCU). Die Schocktherapie war bei 3 Personen mit ICD (60 %), die auf einer PCU starben, abgestellt, während die Antibradykardietherapie bei keinem PM-Patienten auf der PCU abgestellt war. Eine Beendigung der Therapie erfolgte bei 2 Patienten mit PM (1.3 %), die im Krankenhaus starben. Patienten mit PM wiesen hohe Ventrikelstimulationsfrequenzen bei der letzten Untersuchung auf (69 ± 36.0 %) und zeigten häufig einen Atrioventrikularblock (39.2 %). Bei 6 (25 %) der 24 aktiven ICD waren Schocks in zeitlicher Nähe zum Todeszeitpunkt nachweisbar.

Schlussfolgerung

Viele CIED-Patienten sterben im Krankenhaus, trotzdem zeigt die Praxis, dass die Deaktivierung des CIED nur selten erfolgt, sie ist möglicherweise weniger praktikabel bei Personen mit PM. Allerdings besteht noch Bedarf in der Hinsicht, dass die Deaktivierung überhaupt in Erwägung gezogen wird, insbesondere bei Personen mit ICD, da ein Viertel von ihnen mindestens einmal einen Schock innerhalb der letzten 24 h vor dem Tod erhielt.

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Authors and Affiliations

  1. Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany

    T. Tischer MD, A. Bebersdorf, C. Albrecht, A. Öner MD, H. Ince MD & E. Caglayan MD

  2. Institute of Legal Medicine, Rostock University Medical Center, Rostock, Germany

    J. Manhart MD & A. Büttner MD

  3. Department of Cardiology, Vivantes Klinikum im Friedrichshain und Am Urban, Berlin, Germany

    E. Safak MD & J. Ortak MD

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  1. T. Tischer MD
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Correspondence to T. Tischer MD.

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Conflict of interest

T. Tischer, A. Bebersdorf, C. Albrecht, J. Manhart, A. Büttner, A. Öner, E. Safak, H. Ince, J. Ortak, and E. Caglayan declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Tischer, T., Bebersdorf, A., Albrecht, C. et al. Deactivation of cardiovascular implantable electronic devices in patients nearing end of life. Herz 45 (Suppl 1), 123–129 (2020). https://doi.org/10.1007/s00059-019-4836-1

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