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Introduction Despite advanced in diagnosis and medical therapies heart failure remains an incurable long term condition; with an increasing prevalence it has arguably the greatest impact on quality of life.The disease trajectory is often unpredictable with patients spending varying times in different phases of disease and episodes of clinical deterioration and death occurring at any time.It is appreciated that prognostication in heart failure is difficult with comorbidities playing a part. Difficulties in recognising end of life results in loss of opportunity to access palliative care and to address advanced care planning including discussions around future care and wishes. Recognising the need for a simple tool that holistically assesses the heart failure patient with regards to end of life was the motivation for the development of the “Knowsley Trigger Tool”. Methods Heart failure nurses and other healthcare professionals often have a “gut” instinct about a patients prognosis and a tool was designed to rationalise this and provide evidence of the consideration of end of life.A tool, using recognised end of life guidelines, was designed to consider prognostic indicators for end of life in heart failure, to give consideration to co-morbidities and patient wishes;with an aid to timely communication with other health professionals involved in the patients care. To evaluate, the tool was compared to the recognised “MAGGIC” prognostic indicator tool.Alongside usual care, including consideration of disease progression and end of life, over a 3 week period prognostic indicators were considered on all patients and both trigger tool and MAGGIC completed. Results/conclusions and implications for practice Total of 75 patients were reviewed with 32 triggering for consideration of end of life care when holistic assessment completed with trigger tool.When compared to MAGGIC score for the same patients there was a strong relationship between the two when considering predicted risk of death.Heart failure nurses found the tool easy to use with positive feedback regarding the consideration of comorbidities.Nurses found that the tool promoted good communication between nurses and other healthcare professionals.Further follow up studies are required with regards to the patients who were included to validate the tool further. The tool has been embraced by the cardiac network and palliative leads; it is anticipated that it will form part of their guidelines for prognostic indicators in end of life in heart failure.Tool already features in community heart failure care pathway, prompting discussions and consideration of prognosis and end of life at initial review and at set periods during patient journey. Events to promote its use in primary care are in hand and it is hoped that the tool can be embraced by other health professionals to promote early recognition of end of life in heart failure and to allow for timely intervention and support.

Introduction Cardiac rhythm device implantation rates continue to grow, yet procedure complications are inadequately reported. Accurate reporting is necessary to generate quality standards as a benchmark for consultant revalidation. We present complication rates within the first year following de novo pacemaker (PPM), defibrillator (ICD) and cardiac resynchronisation (CRT) implant procedures. Mortality censoring is introduced as a novel method for analysing such data. Methods Between April 2008–March 2011, consecutive virgin PPM, ICD and CRT device implants were prospectively followed for 1 year post implant for pre-defined complications. Results 2614 new devices were implanted. Mean patient follow-ups were 0.94, 0.98 and 0.95 years for PPM, ICD and CRT devices respectively. Mortality at 1 year after PPM, ICD or CRT implant was 9.43%, 4.40% and 10.38%. Conclusion Complication rates for new PPM, ICD and CRT implants are 5.23%, 4.69% and 7.64% at 1-year. Censoring data for mortality aids data interpretation.

Introduction The annual implantation rate for bradyarrhythmia pacing devices continues to increase, due to the aging population fulfilling the indication criteria defined in national guidelines. Morbidity and mortality benefits conferred by pacemaker implantation, are well documented and evidence based. However, the complications arising from such invasive procedures are less well documented. The reported rates of complications are out of date and compounded by variation in complication definitions and the time scale of evaluation. Further confusion arises as a result of the denominator utilised to report complication rates for example, per procedure volume, or per number of leads deployed. The predominant focus on complication data has been peri-procedure and is thus insufficient to accurately represent patient morbidity. This study presents novel complication data reporting for de novo bradyarrhythmia pacing systems implanted at a high volume centre, with all complications and any form of re-operation tracked to 1-year post implant. Methodology A prospective review was performed following consecutive virgin pacemaker implants, between April 2008 and March 2011, at a tertiary cardiothoracic centre in the UK. All procedures were consultant led. Health records for each patient were reviewed independently by two clinicians, analysing the documentation pertaining to the primary procedure and all subsequent health care episodes within 1 year. Complications within this period were defined as follows; (1) radiographic evidence of a pneumothorax confirmed by a consultant radiologist, (2) pericardial effusion demonstrated on transthoracic echocardiogram indicated on clinical grounds and (3) any return to theatre within one calendar year post implant. Results Between April 2008 and March 2011, 1224 new bradyarrhythmia devices were implanted. Within 1 year of the index implant, 53 patients (4.3%) had one or more complications or re-operations. Cumulatively, 58 complications and re-operations were encountered (4.7%), with 5 patients sustaining two events. 6 pneumothoraces (0.5%) were identified, 1 haematoma mandating surgical evacuation (0.1%) and 1 pericardial effusion (0.1%). Regarding re-operation within the first year, 6 device extractions (0.5%) were performed, 30 procedures for either lead displacement or to refine pacing parameters (2.5%), 9 upgrades to cardiac resynchronisation therapy or implantable cardioverter defibrillator (0.7%) and 2 pocket revisions (0.2%). Conclusions For primary bradyarrhythmia pacemaker implantation at a high volume tertiary cardiothoracic centre, we report an overall 4.7% complication rate to 1 year post implant.

The image (figure 1) shows the dangers of lead overcoiling. In the first post-implant image, a biventricular defibrillator is present with a St. Jude Quicksite left ventricular (LV) lead (SJM, Saint Paul, Minnesota, USA) positioned in a middle cardiac vein. On day 1 post-implant, loss of LV capture was noted. Repeat x-ray shows that the LV lead recoiled to the innominate vein (solid black …