Resurrecting the Idea of Mandatory Post-Mortem Cardiac Device Retrieval

A 59-year-old man with an ischemic cardiomyopathy and an implantable defibrillator is found dead at home. His girlfriend, who found him, has difficulty finding someone to sign the death certificate, so she finally calls his electrophysiologist three weeks later. The nurse of the electrophysiologist took the call. After hearing that the patient died unexpectedly at home, the electrophysiologist reviews the patient’s medical records and requests that a representative from the company that manufactured his defibrillator go to the funeral home. Fortunately, the device had been removed from the patient before cremation and was still available at the mortuary. Upon interrogation of the device, it was revealed that the patient suffered a ventricular fibrillation arrest. The defibrillator detected the event and delivered a shock, but there was a shock impedence of zero and an alert that there was failure of the high-voltage circuit. No further therapies were delivered. The device was sent back to the manufacturer for analysis and inspection. The investigation revealed an arc and residue on the can consistent with a short circuit between the device and lead within the pocket, most likely from erosion through the lead insulation. Had the girlfriend of the patient not contacted the electrophysiologist, none of this information would have been known.

Most professionals who care for patients with a transvenous defibrillator are well aware that the lead is the weakest link in the system, that a few leads have recently been recalled, and that the failure rate of leads is likely underreported. However, it is not common knowledge of how devices are handled after a patient dies, and how important it is that the device be retrieved and sent back to the manufacturer. In 2007, Kirkpatrick et al published a paper on this topic. The study surveyed 71 embalmers and funeral home directors in the Chicago area as well as 150 device patients regarding routine postmortem device interrogation and explantation.¹ The results demonstrated that implantable pacemakers and defibrillators are rarely interrogated or returned to the manufacturer after a patient dies. Only four respondents recalled an interrogation of an implantable device. The most common methods of disposal were placement in medical waste (44%) and donation for human reimplantation in developing nations (18%). Many embalmers mentioned that the most common reason for removal was preparation for cremation, because devices explode in extreme heat. Funeral directors and embalmers also indicated that routine postmortem interrogation and retrieval of devices would be feasible, assuming that proper consent could be obtained from the family. Eighty-seven percent of device patients had no understanding of how their device would be handled after death. However, a majority (82%) indicated a willingness to have their device interrogated after death, and most (79%) were willing to have it returned to manufacturers.

Since that survey, high-profile lead recalls have occurred involving small-caliber defibrillator leads, and no progress has been made toward promotion of routine postmortem device analysis. Given the ongoing and incomplete understanding of how to manage patients who already have these leads, it is critical that as much information be collected as possible. Postmortem device interrogation and retrieval would yield invaluable information related to the frequency and mechanisms of device and lead failures. Based on published survey data, systematic postmortem device retrieval appears to be feasible and would be accepted by morticians and patients with proper consent. Device advance directives could assist in overcoming current ethical and legal barriers to routine cardiac rhythm management device interrogation and retrieval. Further efforts, including government legislation, support from industry, and promotion by professional organizations are needed to implement universal postmortem device evaluation.

Reference

1. Kirkpatrick JN, Ghani SN, Burke MC, Knight BP. Postmortem interrogation and retrieval of implantable pacemakers and defibrillators: a survey of morticians and patients. J Cardiovasc Electrophysiol. 2007;18:478-482.