• Interventional Techniques & Devices Clinical Trials

Device therapy in Trinidad and Tobago is complicated by regional limitations and inadequate resources. However, sudden cardiac arrest (SCA) events are generally associated with poor survival rates, even in the setting of cutting-edge early defibrillation programs, because most SCA events are not witnessed and treatment is not initiated within the crucial 8-minute response window. Lana Boodhoo, MD, Eastbourne General Hospital, Eastbourne, UK, discussed the challenges and approaches to improve the success rate of device therapy in this population.

Cost, infrastructure, equipment, and personnel limitations pose barriers to implantable cardioverter defibrillator (ICD) treatment in Trinidad and Tobago. There is no state funding for these devices, which are quite costly, averaging $15,000 to $25,000 in this region. There are three centers in the region that possess implantation capabilities, only one of which is a public institution, and there are no coronary care units within the public sector. Availability of these devices is also a problem, as they generally require preordering, which lengthens the time to implantation, and equipment for lead extraction is scarce. Skilled personnel with specialized knowledge of devices are also in short supply.

Recent initiatives to raise awareness and expand availability within Trinidad and Tobago include industry-sponsored ICD training courses for physicians and technical staff, the development of ICD support groups for physicians and patients, and a sudden cardiac death audit and education program (launch pending). These initiatives have contributed to a rapid increase in ICD implantation procedures between 2008 and 2009, most of which were provided within the public sector through organization such as Heartbeat International.

The average age of the patients at the time of ICD implantation (n=20) was 55 years (65% was male), the mean left ventricular ejection fraction was 35%, and 50% of patients had NYHA class III. At 1 year, device therapy was successful in 10% of patients. The mortality rate at 1 year was 10%. These preliminary outcome data are consistent with those seen in ICD recipients in other populations.

Though device therapy has expanded in Trinidad and Tobago, there remains a treatment gap in this region, and eligible patients are still being overlooked. This discrepancy may be due to cost, poor SCA survival outcomes, a lack of awareness, cultural perceptions (ie, cardiac death being seen as merciful), and the absence of a national cardiology framework. The implementation of specific eligibility guidelines and a national cardiac services plan, while fostering ICD awareness and investment that is related to ICD infrastructure, personnel, and equipment, will allow for successful ICD implantation in Trinidad and Tobago on a broader scale in the future.

• © 2010 MD Conference Express