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Aims/background The number of cardiac devices implanted increases year on year, as does the complexity of the patients being managed. A large proportion of this patient group have an indication for anticoagulation, and this raises challenges around the perioperative management of these agents. Method A quality improvement project was conducted to review current practice, understand local experience and improve patient care. Results Following the initial review, local guidelines were updated, the postoperative anticoagulation decision escalated to the responsible clinician and a clearer pathway for communicating the decision created. Conclusions The implemented changes have shown an overall improvement in junior doctor feedback and also clinical documentation in the electronic patient records.

Background/Aims Implantable cardiac defibrillators reduce the risk of sudden cardiac death in selected patients. The value of an implantable cardiac defibrillator declines as the patient's disease progresses. Guidelines suggest that the appropriateness of maintaining implantable cardiac defibrillator therapy be regularly reviewed as part of monitoring of the patient's disease trajectory. It is recommended that implantable cardiac defibrillators are deactivated as patients approach the end of life. Patients with a better understanding of their current state of health and the role that the implantable cardiac defibrillator plays within it are more likely to make informed decisions about the timing of deactivation. Methods: A quality improvement project was undertaken on appropriate deactivation of implantable cardiac defibrillators within a large tertiary cardiac centre. This was driven by audit data showing inadequate patient communication and documentation around deactivation. Drivers for change included the introduction of electronic data records, clinical review of comorbid patients approaching elective battery change and an ongoing forum for patient and carer education. Measured outcomes included the number of deactivations performed, evidence of patient discussion and consent, and timing of deactivation of the implantable cardiac defibrillator. Results There were increased numbers of timely device deactivations undertaken following the interventions with improved documented evidence of patient discussion and consent. The educational forum was received favourably. Conclusions Focused multidisciplinary interventions can impact favourably on appropriate implantable cardiac defibrillator deactivation and improve patient engagement.

With advancing technology and ever-expanding indications for implantable cardiac pacing and defibrillation devices, this article reviews modern day practice in this field. This article focuses on topics pertinent not only to cardiologists but also to general physicians, medical trainees and allied medical specialties.

A 67-year-old man was followed up by the thoracic surgeons with annual computed tomography (CT) scans for a chronic type B dissection of his thoracic aorta. He had medically treated hypertension and was a smoker. On the CT scan the descending aorta measured 6.4 cm and elective surgical intervention was planned. The patient was well and relatively asymptomatic with normal renal function. All peripheral pulses were present. He was listed for a coronary angiogram preoperatively. The procedure was undertaken via the right femoral artery. Access was gained easily but it was not possible to advance the guide wire beyond the arch. An arch aortogram was undertaken (Figure 1) which confirmed that the guide wire was in the false lumen. The coronary arteries were intubated via the right brachial approach (Figure 2). It appears that coronary and upper limb perfusion was from the true lumen and the rest from the false lumen.