The impact of the humanitarian EP

Inspired by the 2017 Heart Rhythm Society (HRS) Scientific Sessions opening plenary theme “Becoming a citizen of the world” and the key speaker, Hugh Evans (humanitarian, social entrepreneur and co-founder/chief executive officer at Global Citizen/Global Poverty Project), HRS highlighted the humanitarian work of electrophysiologists who generously give their time and expertise in various “less-privileged” regions across the world with the goal of reducing death and suffering from heart rhythm disorders. Cardiac Rhythm News features the leading work of HRS members: Sri Sundaram (South Denver Cardiology Associates, Littleton, USA) with the Jeremiah’s Hope project in Cambodia, Cynthia Tracy (George Washington University, Washington DC, USA) with the project of cardiac care in Honduras, and Behzad Pavri (Thomas Jefferson University Hospital, Philadelphia, USA) who is an advocate for re-use of cardiac implantable electronic devices in patients with limited access to them. Speaking on the importance of giving back to communities, past president of HRS John D Day (Intermountain Heart Institute near Salt Lake City, USA) told Cardiac Rhythm News: “Giving back through humanitarian outreach can be a great way to find professional and spiritual fulfilment. It is also a great reminder to be grateful for what we have in this life.”

Sri Sundaram – Jeremiah’s Hope in Cambodia

About the project
My group’s name is Jeremiah’s Hope and the purpose is to help the sick and poor in Cambodia.  Jeremiah’s Hope started approximately 20 years ago by Dr Mark Sheehan, my general cardiology partner, and Dr Dan Smith, a cardiothoracic surgeon. We are a registered non-profit and entirely voluntary organisation. One hundred per cent of all proceeds go directly to patient care in Cambodia.

Community benefits
The community in Cambodia has benefitted by having free healthcare for the sick and poor and education of Cambodian physicians. Through the years, Jeremiah’s Hope has grown having different US medical teams going to Cambodia every other month. For instance, there have been general surgery, ENT, neurosurgery, orthopaedics, cardiology and EP teams volunteering their time and equipment. We work with Cambodian physicians at Calmette Hospital in Phnom Penh and also have our own hospital—Jeremiah’s Hope Clinic. Our hospital has 15 inpatient beds, two operating rooms, five exam rooms, five full-time employed physicians and 20 staff. We see about 1,000 patients per month. The EP and cardiology teams normally go to Cambodia every February. The whole team includes about 40 members including general cardiologists, cardio thoracic surgeons, EPs, cardiac anaesthesiologists, critical care physicians and echo technologists. The EP team usually includes EPs and Pacing & EP representatives to support cases. We perform about 20 ablations per week and implant about 10 devices. We also carry out follow-ups of patients from previous years. In addition, the EP team organises The Cambodian-American Cardiology Conference. We provide American CME credits, have speakers from throughout the world and charge no admission for Cambodians. Approximately 400 Cambodian healthcare workers attend annually.

Sundaram’s personal benefits

I have enjoyed following patients through the years and I find gratifying to see how our care makes a difference in their lives. Without the aid of Jeremiah’s Hope, many patients in Cambodia would not have any other options. I also enjoy interacting with the many different international physicians who participate in the project.

Major challenges
Despite the high level of care and no cost to the patients, we initially did not have many EP patient referrals. So we realised that it was because many Cambodian physicians have never heard of the specialty of electrophysiology and do not know what we can treat. Therefore, one of our main objectives focuses on education for Cambodian physicians about cardiac electrical disorders.

How to get involved
We are happy to accept the help of healthcare workers from throughout the world. Anyone interested can contact me at [email protected] or contact Lee Shields at [email protected]. For more information visit http://cmmcjh.com.

Cynthia Tracy – Cardiac care in Honduras

About the project
We began our annual brigades in Honduras in 2010. At that time, I was inspired by a good friend of mine—Dr Richard Fry formerly of Cincinnati, USA. Rich and his group travelled to Honduras annually to provide primary care and I decided to go with him. It made more sense for my group to do what we know best, which is to provide cardiac care and to implant devices. We started very modestly, but every year the number of patients has grown. We work closely with the public health system in Honduras and with the local doctors. Our brigade is under the auspices of the George Washington Heart and Vascular Institute. We work out of Centro Medico Comayagua Colonial in Comayagua, Honduras. We provide cardiac care for indigent patients in Honduras. Specifically, we look for patients who require pacemakers and defibrillators. The public health system in this country does not receive enough donated devices to cater for all patients in need. We try to shorten the gap by providing our services for device implantation during the two weeks that we are there. We also perform follow-up device interrogations for the patients we implanted in prior years and for any other patient who has a device that needs interrogations. We also provide general cardiology evaluations and bring a hand-held echo machine.

Community benefits
We have implanted approximately 236 devices so far since 2010. Each year we see about 200 cardiology patients and perform about 100 echocardiograms. Most of these patients did not have any other access to a pacemaker or defibrillator and many would have died without a device.

Tracy’s personal benefits
The annual brigade to Honduras is the highlight of my year! This is a unique opportunity to provide immediate care to patients in tremendous need. The spirit of the team is incredible. Every fellow, resident or technology nurse who has come on these missions with us has found it to be a life-changing event. It is inspiring to work in a team with a sole mission of caring for the underserved and vulnerable and to be able to provide something that can really change lives.

Major challenges
There is always the element of unpredictability! Will we receive the donation we need? Will we have funding to travel? Will the equipment get there on time and intact? Will we get hung up at the border? What will the next case be?—some of the stories are heartbreaking. Can we actually do this much work in such a short time? What is going to break down and when? You can never predict what could happen next.

How to get involved
This year we have a fellow from Columbia University joining us. We got in touch at HRS 2017. Every year we are looking for a fellow, a resident, possibly an anesthesiologist, a technician and an industry device representative. If you want to get involved, I can be reached at the George Washington University School of Medicine & Health Sciences ([email protected]).

Saving lives with re-used cardiac implantable electronic devices

Behzad Pavri (Thomas Jefferson University Hospital, Philadelphia, USA) is an advocate for re-use of cardiac implantable electronic devices (CIEDs) as life-saving medical technology for patients in low-income countries, which in most cases have limited access to them. For the past 25 years, Pavri and a small group of cardiologists and electrophysiologists have been collecting used devices and re-implanted for free in indigent patients. In this commentary, he discusses the rationale for this practice and the evidence suggesting its safety.

The past several decades have seen the advent of novel technologies designed to improve quality of life, prevent human suffering, and save lives. In terms of life-prolonging technology, few inventions can parallel the cardiac pacemaker and implantable cardioverter defibrillator (ICD), collectively referred to cardiac implantable electronic devices (CIEDs). CIEDs are battery-powered, and these batteries typically last from eight to 14 years. Many CIED recipients die from other causes well before their device battery is exhausted.

It is the sad truth that healthcare access is highly inequitable around the world, and patients in low-income countries have very limited access to such life-saving medical technology. Although disparities exist in many areas of healthcare, none are as glaringly evident as in the rates of CIED utilisation around the world. CIED implantation rates vary by orders of magnitude from <10 per million population to >430 per million between developed and developing nations.¹

The rates of CIED utilisation are increasing rapidly in developed countries,² and this disparity of utilisation rates is only likely to diverge further. These discrepancies are primarily related to the cost of such life-saving therapy, with available money being allocated to endeavours that deliver greater benefits (preventing and treating diarrhoea in children, providing clean drinking water, combating infectious diseases, etc) in countries with limited resources. It is estimated that >1 million patients die annually from bradycardia due to the lack of a pacemaker;³ some estimates put the number as high as three million.⁴ By comparison, it is estimated that an average of 29,916 (range 4,310 to 63,329) persons die annually from influenza.⁵Another comparison would be mortality from HIV/AIDS: according to the World Health Organization, an estimated 1.6 million people died of HIV/AIDS in 2012.⁶ Death from bradycardia, it must be remembered, is eminently preventable. There is now a substantial body of data from France, Sweden, Germany, Italy, Netherlands, Norway, Canada, United States, Nicaragua, Nigeria and India, and dating from 1976 to the current era ^7‒17 and all of which confirm that explanted CIEDs can be safely resterilised, as evidenced by very low (<2%) rates of complications after re-implantation. Many concerned physicians have, over the past three decades, proven that reuse of pacemakers and ICDs (taken from hospitalised patients at the time of device infection or upgrades or from funeral homes) is a safe and effective option for poorer patients who would otherwise have no other means of obtaining such devices. I have myself had the privilege of participating in a similar effort with a few other like-minded physicians for the past 25 years, and the results of our efforts have been published.¹⁸

Individual doctors can only provide a small number of such devices. A potential large resource could be after patient demise, as long as the pacemaker or ICD has more than five years of remaining battery life. After death, implanted CIEDs are routinely removed by morticians before cremation to prevent explosions; however, for burial, the majority of these devices are buried with the patient. This represents a travesty, with thousands of reusable devices being wasted while patients who cannot afford them die from lack of such devices. Studies also show that >90% of patients and their families are supportive of the idea of their device being removed after demise and being made available for reuse in poorer nations; the concept of a “Device Will” has been explored. 

Ultimately, the guiding consideration should be that access to a reused CIED is better than no access at all when faced with substantial mortality and morbidity from preventable causes such as heart block and ventricular fibrillation. Such considerations have led to calls for reappraisals of labelling CIEDs.¹⁹

Based on available data, mortality of “doing nothing” far exceeds any possible mortality associated with device reuse. This is borne out by the “appropriate use rate” of reused ICDs (>54% over 2.3 yrs), which far exceeds that in US populations. Individuals or groups of physicians will continue their independent efforts to send CIEDs overseas an important, but ultimately a very small effort. Systematic CIED reuse will require collaboration with patients, funeral homes/morticians, physicians, non-profit charitable organisations, and the FDA. Hopefully, robust data from prospective trials will become available, and free re-used devices from the “taint of the secondhand” while saving lives.²⁰

References:

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2. Greenspon AJ, Patel JD, Lau E, et al. Trends in permanent pacemaker implantation in the United States From 1993 to 2009: Increasing complexity of patients and procedures.J Am Coll Cardiol 2012;60(16):1540‒1545
3. Mond HG, Mick W, Maniscalco BS. Heartbeat International: Making “Poor” Hearts Beat Better. HeartRhythm 2009;6:1538‒1540
4. https://www.heartbeatsaveslives.org/pdf/2009%20HBI%20Annual%20Report.pdf (last accessed on 8 July 2014)
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6. http://aids.gov/federal-resources/around-the-world/global-aids-overview/ (last accessed on 8 July 2014)
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8. Havia T, Schuller H. The re-use of previously implanted pacemakers. Scand J Thorac Cardiovasc Surg 1978;(suppl)22:33‒4
9. Amikam S, Feldman S, Boal B, Riss E, Neufeld H. Long-term follow-up of patients with re-used implanted pacemakers. In: Steinbach K, Glogan D, Laszkovics A, Scheibelhofer W, Weber H, eds. Cardiac Pacing. Proceedings of the Vllth World Symposium on Cardiac Pacing. Germany: Steinkopff-Verlag-Darmstadt, 1983:491‒3
10. Rosengarten MD, Portnoy D, Chiu RCJ, Peterson AK. Reuse of permanent cardiac pacemakers. Can Med Assoc J 1985;133:279‒283
11. Linde CL, Bocray A, Jonsson H, et al. Re-used pacemakers — as safe as new? A retrospective case-control study. European Heart Journal 1998;19:154–157
12. Namboodiri KKN, Sharma YP, Bali HK and Grover A. Re-use of Explanted DDD Pacemakers as VDD- Clinical Utility and Cost Effectiveness. Indian Pacing Electrophysiol 2004;4(1):3
13. Baman TS, Romero A, Kirkpatrick JN, et al. Safety and efficacy of pacemaker reuse in underdeveloped nations: A case series. J Am Coll Cardiol 2009;54:1557‒1558
14. Hasan R, Ghanbari H, Feldman D, et al. Safety, efficacy and performance of implanted recycled cardiac rhythm management (CRM) devices in underprivileged patients. Pacing Clin Electrophysiol 2011;34:653–658
15. Kantharia BK, Patel SS, Kulkarni G, et al. Reuse of explanted permanent pacemakers donated by funeral homes.Am J Cardiol 2012;109:238–240
16. Pavri BB, Lokhandwala Y, Kulkarni GV, et al. Initial experience with re-use of explanted, resterilized implantable cardioverter-defibrillators.Ann Intern Med 2012;157:542‒548
17. Nava S, Morales JL, Márquez MF, et al.Reuse of pacemakers: Comparison of short and long-term performance. Circ 2013;127:1177‒1183
18. Pavri BB, Lokhandwala Y, Kulkarni GV, et al. Initial experience with re-use of explanted, resterilized implantable cardioverter-defibrillators.Ann Intern Med 2012;157:542‒548
19. Pantos I, Efstathopoulos EP, Katritsis DG. Reuse of devices in cardiology: Time for a reappraisal. Hellenic J Cardiol 2013;54:376‒381
    20. Farmer P. Bukhman G. Reuse of medical devices and global health equity. Ann Intern Med 2012;157:591‒592

Behzad Pavri is CCEP Fellowship director at Thomas Jefferson University Hospital, Philadelphia, USA. For more information on this initiative please contact him at [email protected]