1. Patient work up – the arrhythmia nurse perspective Hilary Bugden RN, MSc Papworth Hospital Cambridge

2. Proof of concept 2000 Commenced my role in 2003 Patients enrolled in the feasibility study Initially attracted to the simple, not-in-heart approach Concerns regarding comfort and reliability The early days

3. Patient acceptance Comfort Effective Safe removal Evolving design Today

4. Transvenous issues Infection Lead failure/damage Extraction risks Inappropriate therapy (AF)

5. 45yr old male with Brugada syndrome ICD implanted 2006 for primary prevention No therapies delivered in 9 years Now presents with Riata lead externalisation SVC occlusion Lead extraction with complications Case study

6. Offers protection without those risks Initially considered only for young people Now recognised as appropriate for other age groups Not only for primary prevention Either may be suitable S-ICD

7. If either is suitable, they should both be considered and discussed with the patient (if appropriate) Principles of the ICD Pros and cons of each Patient involvement

8. Lead into the heart Pacing capability ATP Smaller device Lower energy More widely used (tried and tested) Complications more widely known Transvenous vs S-ICD Lead not touching the heart No pacing capability No ATP Different position Unlikely to be awake for appropriate therapy Numbers increasing Still evolving

9. Provide information Be honest and open Allow discussion Use resources (booklets, internet, other ICD patients) Discuss the role of screening New technology

10. Why not S-ICD? ‘Might need pacing’ ‘Might benefit from ATP’ ‘My patient has HCM’ Brugada ARVC ICD or S-ICD?

11. 47yr old, with HCM Brother had tranvenous ICD Implanted in 2010, first DFT successful Lung surgery EUR HCM

12. First implant 2009, 63yr old, family history of SCD, Brugada ECG, EUR 2014 30yr old with syncope with febrile illness, found to have Brugada ECG Brugada

13. 45yr old recurrent VF arrest on haemodialysis, implanted 2010. Appropriate therapy, recent EUR, good quality of life. 22yr old OOHCA probably due to myocarditis, implanted 2010.Fully recovered in 3 years. Patient progress

14. Valuable alternative when seeking a less invasive device Avoids the risks associated with leads in the heart Suitable for more than just the very young or very sick Appropriate as first line therapy option Conclusion

15. Thank you