British Heart Rhythm Society Newsletter

Winter 2015

Welcome to the latest BHRS newsletter. This edition will give you an update on what Council has been up to in the last few months plus information on matters that may affect you and your practice. I hope you find it informative and interesting.

There are contributions from a number of members and I have specifically asked Trudie Lobban to give an update on work the Arrhythmia Alliance is undertaking. I think this is important to know about so that BHRS can engage constructively in these projects.

STANDARDS DOCUMENT

We have now released an update to the Standards document for implantable cardiac devices, which was agreed by Council in December. The major difference is that guidance for follow up of such devices, aimed primarily at physiologists, has been created by Sue Jones and Stuart Allen as a separate document following requests for this from a number of members. The only significant difference to the main document is the inclusion of upgrades into the number of devices required for CRT. Click here to access the document.

MRI AND CARDIAC DEVICES

We have developed a guidance document on MRI procedures in patients with cardiac devices. This has been a long time in coming, however, importantly it has been undertaken in conjunction with the Royal College of Radiologists. Whilst the document is still in draft form, I am hoping that it will be agreed by the RCR in the New Year. It's important that we have this document endorsed by the RCR as it tends to be general radiologists who have difficulties in undertaking scans in such patients and getting the RCR on board is crucial. We are also working with the MHRA to clarify some aspects of the recent document they released on MRI scanning – view the MHRA document here. We felt some of the wording needed modifying as in places it is somewhat dogmatic about scans in patients with cardiac devices and we felt there needed to be some clinical leeway.

PERI OPERATIVE CARDIAC DEVICE DEACTIVATION

Both Steve Furniss and I have received a number of requests for advice on the management of cardiac devices, particularly ICDs, around the time of surgery. Although we appreciate there is a good MHRA document available, it was felt that more specific advice was needed to supplement this document. We hope to complete this in the next few months.

ATRIO-OESOPHAGEAL FISTULA FOLLOWING AF ABLATION

I was contacted by the South London Coroner following an inquest into the death of a patient with this complication to produce a report on ways in which the incidence of this complication could be reduced and identified more readily.

Atrio-oesophageal fistula is a well-known complication of AF ablation that has been reported with not just traditional RF catheter ablation, but surgical and even cryoablation. Mercifully it is very rare (probably around 1-2 in 1,000 cases), as it is almost always fatal. The complication is often diagnosed late as it typically presents weeks after the original procedure, often to other specialities (A&E, infectious diseases, neurology) and often to other hospitals. It is possible that some cases are never diagnosed, with fatality ascribed to stroke, MI, or overwhelming infection and not even linked to the ablation procedure. For a patient to have any chance of survival, immediate diagnosis and treatment are vital.

I stated that I would draw this to members’ attention in our Newsletter to remind operators about the risk of this complication, particularly when ablating on the posterior wall and roof of the left atrium. We are also working with the AF Association and Arrhythmia Alliance to redesign patient information leaflets to make patients more aware of this complication and what warning signs to look for. The leaflet will also contain recommendations on management as these patients tend to present to their local hospital rather than the centre that performed the procedure. Reducing any delay in diagnosis is an important factor in improving morbidity and mortality associated with this complication.

Meanwhile, we urge all electrophysiologists undertaking AF ablation to think: "do my colleagues inside/outside my department, and in my referring hospitals, know about this complication? Do they know how to diagnose it (urgent CT with water-soluble contrast swallow or MRI are probably best)? Is there a referral pathway for the only procedure associated with survival (emergency thoracic/oesophageal surgery)?” This is the only way that the dismal survival for this rare complication can be improved.

ONLINE SURVEY OF ICD DEACTIVATION

We have received a request from Loreena Hill and Donna Fitzsimons at the Institute of Nursing and Health Research in Belfast to take part in a survey on attitudes and decision making in ICD deactivation. If you have time to complete a short survey on this, please click here. Your help in this matter would be much appreciated.

COMMISSIONING THROUGH EVALUATION FOR LEFT ATRIAL APPENDAGE OCCLUSION

After many delays, this has now gone live with 10 centres that were successful in applying to undertake this procedure having been notified by NHS England. NHSE are clear that CtE is a specific project aimed at evaluating the technology in selected centres and is not a pilot phase or initial run out of an approved / funded service. The selection process was not as transparent as it could have been however centres were selected primarily on the basis of the application they submitted, with input from the Strategic Clinical Networks. LAAO will be potentially offered to patients with atrial fibrillation at high risk of thromboembolic stroke (CHA2DS2-VASc score of 2 or more) with a contraindication to oral anticoagulation (intolerance, previous significant bleed, high bleeding risk) or evidence of a thromboembolic event in spite of adequate oral anticoagulant therapy. Patients can be referred by cardiologists, stroke physicians or other specialists in secondary care to a multidisciplinary team in the selected specialist cardiac centre.

The dataset for procedures to be undertaken in this financial year, which will have to be completed in all patients in order to obtain funding, was uploaded to the NICOR web site on 6 th January and is extensive. The web-enabled version should be available towards the end of February. The process has been very difficult to work through but it is now up and running and it is important that we remain engaged with it. I am aware that centres not selected to undertake LAAO under CtE may still be considering undertaking procedures. Can I please urge all centres to complete the dataset for these patients as this is essential if we want to have this procedures more widely adopted.

ESC AFFILIATION

I have been approached by Iain Simpson, President of the British Cardiovascular Society, with regards to the matter of affiliation to the European Society of Cardiology. The BCS is a member of the ESC; however, the ESC has recently changed its Statutes to potentially diminish the influence of national societies on ESC policy and increase the voting power of ESC Associations, Councils and Working Groups. Prior to the changes in the Statutes, BCS had similar voting power to the other main national societies of the ESC such as Germany, France etc. With the new Statutes in place, the number of votes within the ESC is directly related to the number of members of the national society. Countries such as Germany and France will have a greater number of votes due to the number of members of their national societies, which in part is because in many countries, allied professionals are members of the national society. If BCS were able to include members of its affiliated groups in its overall membership numbers, this would increase the number of votes the BCS had in Europe, which is reflected in its perceived influence in the ESC.

What does it mean to BHRS members? You would first need to agree to this as an individual. This would be done either as an “opt in” or an “opt out” via an email shot. If you agreed, you would become an associate member of both the BCS and the ESC. Information that is held on our database, specifically contact details, would be made available to both organisations. You may receive newsletters and occasional mail shots from both organisations. There is no cost involved to you as an individual.

Click here to view the letter I received from Iain Simpson. Please feedback your thoughts on this to BHRS at [email protected] or, if you prefer, to me directly at [email protected]. I need to respond to Iain by early February so I would like to have some feedback to gauge your views.

Dr Nick Linker

President

Vanishingly Rare Cardiac Drugs

At a recent BHRS Council meeting the question of increasing difficulty in obtaining supplies of intravenous isoprenaline was raised. The discussion rapidly widened to include other drugs such as quinidine, mexiletine, nadolol and midodrine. It was agreed that these drugs were very useful and often needed to be obtained very quickly in the setting of serious arrhythmic emergencies.

It also became apparent that individual Trusts had managed to source these drugs and that there would be merit in sharing this information centrally via the BHRS website for the benefit of all. I would be happy to collate any such useful information and then work with Steve Murray to get this uploaded onto the BHRS website.

Dr Alistair Slade Secretary

Update on National Databases

The national device report for 2013/14 was published in December by BHRS and NICOR. The national ablation report is also complete and is waiting a statutory review by HQIP (the agency that commissions the audit on behalf of the NHS), but we hope it will also be released soon. These and past audits can be viewed/downloaded at www.bhrs.com/audit

The new national datasets for EP/ablation and device procedures were announced in the autumn of 2013 and became operational on 1st April 2014. After a period of grace, inputs to the old dataset were no longer accepted from 1st July 2014. We are delighted to see that most centres and third party IT suppliers have embraced the changes, which have radically modernised (and, we hope, future-proofed) the audit and will provide relevant feedback to Trusts, commissioners, professionals, and patients. Our next steps are to move towards on-line reporting. This means the NICOR and BHRS websites will publish activity and eventually complications by centre and operator, probably on a quarterly basis. This is being increasingly required in all cardiac specialities and as a professional body we are keen to steer the process (or someone else will)!

It is therefore especially important to make sure that your submitted data are correct. Disappointingly, in the 2013/4 reports, one or two large centres and possibly some smaller ones, seemed to have submitted data that is not only incomplete, but missing a proportion of procedures completely. Furthermore one major IT provider has moved extremely slowly in implementing the changes and at the time of writing some of the centres using their software are still unable to make submissions to the new dataset.

We would remind centres and IT providers that submission to the national cardiac audits is not a voluntary activity. In addition to the obvious benefits to all (e.g. benchmarking your centre against the rest of the country, providing evidence in support of revalidation etc., defending your hospital/practice against malicious allegations or litigation), it is a statutory part of the service contracted to providers and completeness and quality of submissions will be examined by Commissioners.

Dr Francis Murgatroyd Chair, BHRS Registry & Audit Committee

Guidelines for the Diagnosis, Prevention and Management of Cardiac Implantable Electronic Device Infection

We are faced with an increasingly elderly device population with increasing co-morbidity. This together with rising use of more complex devices, especially CRT pacemakers and defibrillators is leading to a rise in the incidence of infection in such patients. The expense and time in managing such infection is considerable and therefore it is opportune that guidelines have recently been published taking us through various aspects of the management of potential and actual device infection. This document was written by a Working Party consisting of members of the British Society for Antimicrobial Chemotherapy (BSAC), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE).

The document reviews many aspects of device infection and in particular attempts to standardise advice about antibiotic prophylaxis prior to device implantation. Whilst much of the evidence falls short of multi-centre randomised controlled trial it is a valuable document that should help shape our ongoing practice.

The document is available on the BHRS website and can be viewed here, it is also currently available from the Journal of Antimicrobial Therapy website published online 29th October.

Proposed Changes to Specialized Commissioning Threatens EP/Device Activity

Just before Christmas, NHS England issued a consultation document regarding proposals for the 2015-16 tariff for specialized commissioning (which affects all CRT/ICD devices and ablations). Aside from the expected reductions in tariffs for procedures, it is proposed that any growth in activity will only be paid at 50% of the tariff. The definition of "growth" is not clear, but seems to be based on the 2014-15 plan (which was based on 2013-14 activity!). The proposals can be seen on the Monitor website https://www.gov.uk/government/consultations/national-tariff- payment-system-201516-a-consultation-notice. An open letter from hundreds of senior clinicians and managers was reported by the Daily Telegraph just before Christmas. Despite the short notice (deadline for feedback was midnight on 25th December), a majority of Trusts appealed and publication of the final tariff has been delayed. Whatever the ultimate outcome, it seems clear that NHS England's hopes to severely curb any increase in activity for EP and other specialized activity.

BHRS is working with the Arrhythmia Alliance to develop a strategy to respond to this via the media and MPs.

BHRS in Negotiations with BUPA over Proposed Changes to Fee Structure

Physician members will be aware that BUPA undertook a consultation exercise with cardiologists last summer, regarding proposed changes to the complexity (and thus fee) structure for procedures. A number of EP and device procedures were to be reassigned to lower complexity (i.e. lower remuneration). This comes against a background that the fees paid have not increased for around 20 years (equivalent to a >30% depreciation)!

BHRS has engaged with BUPA as a professional body and provided reasoned arguments for new proposals, supported by clinical evidence (e.g. procedure durations from the national audits). We have put forward a new set of procedure codes that reflect modern practice (e.g. typical atrial flutter less complex than SVTs, but AF ablation more complex). In general, we have been pleased with the response. Our proposals for EP/ablation have largely been accepted by BUPA, but there is still significant negotiation required with regards to device procedures. Any agreement will need to go to CCSD (the national body that sets procedure codes), but we hope in due course to have a structure of codes and complexities that will be fair and unambiguous. We will inform members of progress.

Update on IQIPS

Improving Quality In Physiological Services (IQIPS) is a professionally-led accreditation programme with the aim of improving service quality, care and safety for patients undergoing physiological tests, examinations and treatment. It is sponsored by Professor Sue Hill, the Chief Scientific Officer at NHS England and hosted by the RCP. The United Kingdom Accreditation Service (UKAS) is the appointed independent provider of accreditation to the IQIPS standards.

Currently there are 19 services at 36 sites registered and BHRS would like to emphasise the benefit of registering your service for IQIPS. Accreditation has been recognised as providing valuable evidence during the Care Quality Commission’s inspection of hospitals. It is also helping to establish and maintain confidence in the quality and safety of healthcare for NHS Trusts, independent and third sector organisations, commissioners and crucially families who use those services

The 2015 BHRS standards for Devices will be incorporated into the IQIPS programme providing an opportunity for centres which offer device follow up to accredit their service with IQIPS.

Stuart Allen

EP Wire Survey on Left Atrial Appendage Closure

Please find below the first 2015 EP Wire Survey from the EHRA Scientific Initiatives Committee on “Left atrial appendage closure: indications, techniques and outcomes.” The purpose of this EP Wire is to investigate how catheter based methods for LAAO are being used in Europe.

You’re invited to read and answer the questionnaire; it will only take you a few minutes of your time.

Take the survey

Support the Arrhythmia Alliance Group in 2015

Arrhythmia Alliance President, Professor A. John Camm, has said that across the UK “screening for AF is a sorry story which we must solve."

In July 2014, the UK National Screening Committee issued guidance on AF screening, finding that systematic population screening is not recommended as it is not clear that those identified as at risk through screening would benefit from early diagnosis. AF Association and its sister charity Arrhythmia Alliance, strongly refute this claim and is focussing on gathering data to challenge the UK NSC’s decision; during 2015 both charities will support pilot schemes at several locations across the UK to help secure an early review. Data alone will not achieve change, however. The A-A Group is calling on its supporters to sign an ePetition calling for an early review of the UK NSC policy on screening for AF among those aged 65 and above. 2015 will be the year that AF is placed firmly on the healthcare agenda. Click here to sign the petition.

Membership of the A-A Group charities, Syncope Trust And Reflex anoxic Seizures (STARS), Arrhythmia Alliance and AF Association continues to grow strongly, with many individuals contacting the charities during Heart Rhythm Week 2014 as Arrhythmia Alliance renewed its vow and commitment to support the improvement of arrhythmia services at our annual event in Parliament, celebrating its tenth anniversary. Healthcare professionals are invited to join A-A and qualify for exclusive discounts to Heart Rhythm Congress, which will also celebrate its tenth year facilitating clinician education and supporting patients through diagnosis and treatment in 2015.

Arrhythmia Alliance – Australia joins UK based charities under the A-A umbrella in attracting a loyal and dedicated following on its social media pages, with strategies in place to support further growth over the coming months. A charity ‘Thunderclap’ launched at the start of Heart Rhythm Week 2014 was successful in reaching one million people, with a simple ask to ‘Join us on 2 June to save 100k lives from SCA, improve the lives of 2m people with arrhythmias and donate £3’ – a bold ask in 140 characters or less. The second annual AF Aware Week was endorsed by yet more groups working in heart rhythm care, with events taking place to support Detection, Protection and Correction in AF at hospitals across Australia and the USA. With early diagnosis, procedures to help restore the heart to permanent sinus rhythm are proven to be more effective. Please contact the A-A Group for patient information resources to share in your clinic. The number of registrants for the BHRS exam illustrates a growth in interest when compared to this time last year; Arrhythmia Alliance continues to oversee and provide full BHRS admin and ensure healthcare professionals are well supported as they work to earn advanced professional accreditation. Arrhythmia Alliance looks forward to working more closely with Dr Kim Rajappan in his role as HRC Programme Director and will continue to enjoy an excellent relationship with Dr Nick Linker as the new BHRS President. Our work will continue to ensure thorough dissemination and implementation of NICE clinical guidance CG180 on the management of AF, to improve outcomes and restore hope to those one million people across the England living with AF. AF Association will continue to lobby in government to help achieve this, with the All Party Parliamentary Group on AF of paramount importance in facilitating discussion. Heart Rhythm Week will run from 1-7 June 2015. Please email [email protected] to receive event updates, or if you would like to take part in AF Aware Week 2015 from 23- 29 November. Regional cardiac update meetings are taking place throughout 2015; visit http://bit.ly/cardiacupdatemeetings to confirm your place. To support AF screening in your place of work, please contact AF Association to request a free toolkit. Trudie Lobban

Founder & Trustee, Arrhythmia Alliance

Crossword kindly provided by Jonathan Sibley.

View crossword answers