HLC 2157 No.

of Pages 5

Heart, Lung and Circulation (2016) xx, 1–5 ORIGINAL ARTICLE

1443-9506/04/$36.00
http://dx.doi.org/10.1016/j.hlc.2016.06.1206

Pacemaker Use in New Zealand – Data

From the New Zealand Implanted Cardiac
Device Registry (ANZACS-QI 15)
P.D. Larsen, PhD a*, A.J. Kerr, MBChB, FRACP b,
M. Hood, MBChB, FRACP c, S.A. Harding, MBChB, FRACP d,
D. Hooks, MBChB, PhD, FRACP d, D. Heaven, MBChB, FRACP b,
N.A. Lever, MBChB, FRACP c, S. Sinclair, BApplSci c,
D. Boddington, MBChB, FCP, FRACP e, E.W. Tang, MBChB, FRACP f,
J. Swampillai, MBBS, MD, FRACP g, M.K. Stiles, MBChB, PhD, FRACP g,
On behalf of the ANZACS-QI investigators
a
Department of Surgery and Anaesthesia, University of Otago, Wellington, NZ
b
Cardiology Department, Middlemore Hospital, Auckland, NZ
c
Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, NZ
d
Cardiology Department, Wellington Hospital, Wellington, NZ
e
Cardiology Department, Tauranga Hospital, Tauranga, NZ
f
Cardiology Department, Palmerston North Hospital, Palmerston North, NZ
g
Cardiology Department, Waikato Hospital, Hamilton, NZ

Received 7 March 2016; received in revised form 30 May 2016; accepted 1 June 2016; online published-ahead-of-print xxx

Background The New Zealand Cardiac Implanted Device Registry (Device) has recently been developed under the
auspices of the New Zealand Branch of the Cardiac Society of Australia and New Zealand. This study
describes the initial Device registry cohort of patients receiving a new pacemaker, their indications for
pacing and their perioperative complications.

Methods The Device Registry was used to audit patients receiving a first pacemaker between 1st January 2014 and 1st
June 2015.
Results We examined 1611 patients undergoing first pacemaker implantation. Patients were predominantly male
(59%), and had a median age of 70 years. The most common symptom for pacemaker implantation was
syncope (39%), followed by dizziness (30%) and dyspnoea (12%). The most common aetiology for a pace-
maker was a conduction tissue disorder (35%), followed by sinus node dysfunction (22%). Atrioventricular
(AV) block was the most common ECG abnormality, present in 44%. Dual chamber pacemakers were most
common (62%), followed by single chamber ventricular pacemakers (34%), and cardiac resynchronisation
therapy – pacemakers (CRT-P) (2%). Complications within 24 hours of the implant procedure were reported
in 64 patients (3.9%), none of which were fatal. The most common complication was the need for reoperation
to manipulate a lead, occurring in 23 patients (1.4%).

*Corresponding author at: University of Otago, Wellington PO Box 7343 Wellington New Zealand Tel.: +64 4 9185103; fax: +64 4 3895318,
Email: peter.larsen@otago.ac.nz
© 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V.
All rights reserved.

Please cite this article in press as: Larsen PD, et al. Pacemaker Use in New Zealand – Data From the New Zealand Implanted
Cardiac Device Registry (ANZACS-QI 15). Heart, Lung and Circulation (2016), http://dx.doi.org/10.1016/j.hlc.2016.06.1206
 HLC 2157 No. of Pages 5

2 P.D. Larsen et al.

Conclusion This is the first description of data entered into the Device registry. Patients receiving a pacemaker were
younger than in European registries, and there was a low use of CRT-P devices compared to international
rates. Complications rates were low and compare favourably to available international data.
Keywords Cardiac pacemakers  Pacemaker leads  Registry

response are also recorded. Perioperative complications

Introduction
The use of pacemakers in New Zealand has increased
steadily over the last 15 years, from 914 new implants in
2001[1] to 1641 new implants in 2013[2]. While the total
number of implanted devices, and some details regarding
device type have been regularly surveyed [1–4], there are
limited data on the patient population receiving these
devices.
The New Zealand Cardiac Implanted Device Registry
(Device) has recently been developed on the All New Zea-
land Acute Coronary Syndrome – Quality Improvement
(ANZACS-QI) platform, under the auspices of the New Zea-
land Branch of the Cardiac Society of Australia and New
Zealand. This registry aims to collect consistent information
on all cardiac device implantations in New Zealand to aid
quality improvement initiatives and to allow examination of
equity of access to therapy.
This present study describes the initial cohort of patients
receiving a new pacemaker, their indications for pacing and
their perioperative complications.
Methods
We used the New Zealand Cardiac Implanted Device Regis-
try to audit patients undergoing their first implantation of a
pacemaker device between 1st January 2014 and 1st June 2015.
Participating hospitals were North Shore, Auckland City,
Middlemore, Waikato, Tauranga, Palmerston North, Wel-
lington and Dunedin. The Device Registry is built on the
ANZACS-QI platform that uses a web-based data collection
platform to collect information on patients receiving
implanted devices. All data items in the registry are manda-
tory. Participation in the registry is voluntary, and a number
of hospitals contributing data to the registry joined during
the study period. As such, this dataset does not represent
every device implanted during this period at these hospitals.
Each participating centre receives a monthly report detailing
the number of patients registered in the Device registry and
dataset completion rates.
Data are entered by medical and cardiac physiology staff at
the time of procedure, and included basic demographic
details. The primary patient symptom, aetiology and most
significant documented ECG finding are also recorded. The
device type is recorded. For cardiac resynchronisation ther-
apy – pacemaker (CRT-P) patients, the QRS duration, pres-
ence and type of bundle branch block, left ventricular ejection
fraction (LVEF) and New York Heart Association (NYHA)
class are also collected. History of atrial fibrillation (AF) or
atrial flutter is noted. Pacing mode and intention to use rate
defined as within 24 hours of the procedure are also collected.
Ethics: ANZACS-QI is a sub-study within the PREDICT
study which was approved by the Northern Region Ethics
Committee Y in 2003 (AKY/03/12/314) with subsequent
annual approval by the National Multi Region Ethics Com-
mittee since 2007 (MEC07/19/EXP).
Results
The Device registry included 1611 patients who received new
pacemaker systems during the study period. Patient demo-
graphics and indications for pacing are given in Table 1. The
patients were predominantly male (59%), 81% were Euro-
pean, and 8% Maori. The median age was 70 years, with 25%
of pacemaker recipients over 84 years of age.
Symptoms
The most common symptom leading to pacemaker implan-
tation was syncope (39%), followed by dizziness (30%) and
dyspnoea (12%). Tachycardia (5%), fatigue (2%) and other
symptoms (3%) were also reported. In 10% of patients a new
pacemaker was implanted prophylactically.
Aetiology
The most common reason for implanting a pacemaker was
some form of conduction tissue disorder (35%), followed by
sinus node dysfunction (22%). Atrial fibrillation (AF) man-
agement was the reason for pacemaker implantation in 11%.
Cardiac surgery (4%), coronary artery disease (3%) and heart
failure (1.5%) were less frequent indications. In 20% of cases
the aetiology was listed as unknown.
Electrocardiographic (ECG)
Indications for Pacing
Atrioventricular block (AVB) was the most common ECG
abnormality, present in 44%, most commonly third degree
AVB (29%). Sick sinus syndrome was present in 19%, AF with
bradycardia was the present in 17% and 1% had AF and were
preparing to go for AV node ablation. In 9% of patients, no
ECG abnormality had been observed.
In the 38% of patients with a history of AF, 55% had
paroxysmal AF, 10% had persistent AF, and 35% were in
permanent AF. There were 3% of patients with a history of
atrial flutter.

Please cite this article in press as: Larsen PD, et al. Pacemaker Use in New Zealand – Data From the New Zealand Implanted
Cardiac Device Registry (ANZACS-QI 15). Heart, Lung and Circulation (2016), http://dx.doi.org/10.1016/j.hlc.2016.06.1206
 HLC 2157 No. of Pages 5

Pacemaker Use in New Zealand – Data From the New Zealand Implanted Cardiac Device Registry (ANZACS-QI 15) 3

Table 1 Demographic Data and Pacing Indications Device Type

n=1611 Dual chamber pacemakers were most common (62%), fol-
Age, years (median, interquartile range) 70 (65-84) lowed by single chamber ventricular pacemakers (34%).
Male Gender 951 (59%) CRT-P (2%) and single chamber atrial pacemakers (1.6%)
were less commonly implanted.
Ethnicity
In the group of 32 patients receiving CRT-P devices,
European 1301 (81%)
29 (90%) had a left bundle branch block pattern on their
Maori 133 (8%)
ECG with 24 (75%) having QRS duration of 150ms or longer.
Pacific Island 67 (4%)
In 18 (56%) left ventricular ejection fraction (LVEF) was less
Indian 29 (2%)
than 30%, and 26 (81%) LVEF was less than 35%. In this group
Other 81 (5%)
19 (60%) were classified as New York Heart Association
Primary Symptoms
(NYHA) class II, 12 (38%) NYHA class III, and one (2%)
Syncope 623 (39%)
NYHA class IV. Of the six patients with a LVEF greater than
Dizzy spells 488 (30%)
35%, four had symptomatic bradycardia due to AV block,
Dyspnoea 185 (12%)
one had AF with bradycardia and one had sick sinus
Tachycardia 75 (5%)
syndrome.
None 153 (10%)
Fatigue 34 (2%)
Other 47 (3%)
Primary Aetiology
Lead Access
Conductive tissue disorder 560 (35%) Venous access was most commonly via the cephalic vein
Sinus node dysfunction 354 (22%) (60%), followed by the axillary vein (23%) and the subclavian
Atrial fibrillation 182 (11%) vein (12%). There were six epicardial systems (0.4%), and in
Cardiac surgery 63 (4%) 52 cases (3%) more than one access route was used, either
Coronary artery disease 47 (3%) cephalic and axillary veins (1%), cephalic and subclavian
Heart failure 27 (2%) veins (2%), or cephalic vein and an epicardial lead (in one
Other cause 58 (4%) case).
Unknown 320 (20%)
Most Significant ECG Finding
Normal [1_TD$IF]sinus rhythm 144 (9%) Programming
First degree AVB 63 (4%)
Second degree AVB type 1 36 (2%) The most common programming modes in the overall cohort
Second degree AVB type 2 139 (9%) were DDD (53%) and VVI (36%). The programming mode by
Complete AVB 472 (29%) device type is shown in Table 2, and this shows that the 97%
AF and AV node ablation 14 (1%) of dual chamber devices were programmed to preserve AV
Intraventricular conduction defect 77 (5%) synchrony. There was an intention to use rate response in
Sick sinus syndrome 307 (19%) 71% of patients at the time of implantation.
AF and bradycardia 274 (17%)
Other 77 (5%)
Peri-Procedural Complications
AVB = atrioventricular block, AV = atrioventricular, AF = Atrial
Fibrillation.
Complications within 24 hours of the implant procedure
were reported in 64 patients (3.9%), none of which were

Table 2 Programming mode by device type

AAI VVI DDD DDI AAI/DDD

Single Chamber Atrial 100% - - - -

Single Chamber Ventricular - 99% - - -
Dual Chamber - 0.6% 83% 2% 14%
CRT-P - - 68% 25% -

AAI = single chamber pacing in the atria, VVI = single chamber pacing in the ventricle, DDD = dual chamber AV sequential pacing with two leads, DDI = dual
chamber pacing, inhibited by atrial sensing, AAI/DDD single chamber atrial pacing with automatic mode switching to dual chamber pacing, CRT-P = cardiac
resynchronisation therapy – pacemaker.

Please cite this article in press as: Larsen PD, et al. Pacemaker Use in New Zealand – Data From the New Zealand Implanted
Cardiac Device Registry (ANZACS-QI 15). Heart, Lung and Circulation (2016), http://dx.doi.org/10.1016/j.hlc.2016.06.1206
 HLC 2157 No. of Pages 5
4 P.D. Larsen et al.
fatal. The most common complication was the need for reop-
eration to manipulate a lead, occurring in 23 patients (1.4%).
In 57% of these cases the atrial lead required reoperation, and
the ventricular lead in 43%. Twenty of the 23 (87%) lead
reoperations occurred in patients with dual chamber devices,
one in a patient with CRT-P and two in single chamber
devices. Haematoma requiring some form of intervention
was reported in 12 cases (0.7%), and in four cases (0.2%)
there was some other form of access site complication. A
pneumothorax was reported in five cases (0.3%), and hae-
modynamic instability in three cases (0.2%). There was one
coronary sinus dissection and one myocardial perforation,
and nine other complications.
Discussion
This is the first report from the New Zealand Implanted
Cardiac Device registry, and describes patient characteristics,
indications for pacing and perioperative complications for
1611 new pacemaker implantations over an 18-month period.
This is the first multicentre description of patients receiving
pacemakers in New Zealand. The median age of pacemaker
patients was 70, and 59% were male. The most common
symptom indications for pacing were syncope and dizziness
and the most common ECG indications for pacing were AV
block and sick sinus syndrome. The underlying aetiologies
were conduction tissue disorder and sinus node dysfunction.
Perioperative complications occurred in 3.9%, most com-
monly the need for reoperation to manipulate a lead.
During the first 18 months of use of the Device registry, data
for 1611 new pacemakers were entered into the registry. Eight
of the 10 implanting centres in New Zealand contributed
patients to the registry, and based on 2013[2] survey data,
the registry is likely to represent 60 to 65% of all new pace-
makers implanted in New Zealand during this time period.
Patients were slightly younger than in European registries,
with a median age of 70 years, compared to 76 years in
Sweden[5], 77 years in Spain[6] and 80 years in Italy[7]. While
an implantation rate cannot be accurately determined from
our dataset, previous surveys describe a substantially lower
rate of implantation of new pacemakers in New Zealand
(367/million) than in Australia (652/million) in 2013[2]. In
2011 the average European implant rate was 604/million[8].
The low average age of pacemaker recipients and the low
implant rate together may indicate reduced access to pace-
maker therapy in the elderly in New Zealand compared to
other health systems.
The most common ECG finding was AVB, with complete
heart block observed in 29% of cases, followed by sick sinus
syndrome. This is consistent with observations from interna-
tional registries[5–7]. The most common symptom presenta-
tions were syncope and dizziness, in keeping with
international pacemaker registries[5–7].
The proportion of CRT-P devices was relatively low com-
pared to international registries. In 2013 8.5% of new pace-
makers in the UK were CRT-P [9], 4.5% in the Netherlands [9],
Please cite this article in press as: Larsen PD, et al. Pacemaker Use in New Zealand – Data From the New Zealand Implanted
Cardiac Device Registry (ANZACS-QI 15). Heart, Lung and Circulation (2016), http://dx.doi.org/10.1016/j.hlc.2016.06.1206
4.3% in Norway [9] 4% in Australia [2] and 1.8% in an Italian
registry 1.8% [7]. Most of the cohort of patients receiving a
CRT-P device in our study had significantly impaired left
ventricular function, with an LVEF of less than 30% in
56%, and less than 35% in 81%. This could suggest that some
of these patients may fulfil criteria for a primary prevention
ICD[10]. However, the registry does not collect data on contra-
indications, so further investigation into the choice of CRT-P
over CRT-D in this patient group would be required to exam-
ine the appropriateness of device selection in this group.
The overall complication rate observed in this study was
3.9%. Comparison with international series is difficult, due to
the absence of standard definitions of complications, and
variance in the timeframe over which complications are
examined. Complication rates of 12.4% at two months[11],
7.7% at three months[12] and 5.3% at one year [5] have been
reported in recent series. The most common complication in
our series was lead dislodgement requiring reoperation,
occurring in 1.4%. This is a slightly lower rate than 2.2%–
3.7% reported in other series[5,11,12]. While the majority of
lead dislodgements in these other series occurred early, there
were also dislodgements beyond the first 24 hours in each.
This data is not captured in our dataset. There is intent to
collect complications at one month within our registry, and
this will be important to establish a more complete picture of
early complications associated with pacemaker implantation.
The rates of pneumothorax and myocardial perforation were
slightly lower in our series compared to recent publications
[5,11–13]. New Zealand has a relatively small group of highly
experienced cardiologists undertaking device implantation,
and it is possible that this contributes to the low complication
rate, as experience has been associated with a lower rate of
complications[14].
Future directions: The Device registry is supported by the
New Zealand National Cardiac Clinical Network and Heart
Rhythm NZ for use to capture all pacemaker and ICD
implants in NZ public hospitals. In centres using the registry
comprehensively, the hospital level summary Device reports
generated from the ANZACS-QI platform are being used by
clinicians for local audit and quality improvement purposes.
It is intended that within a year all centres will comprehen-
sively capture and report implantation using this registry.
Limitations
This study is a descriptive report of data collected by the New
Zealand Implanted Cardiac Devices registry. This registry is
voluntary, and there is no routine audit to determine overall
levels of accuracy of data entered; therefore, data needs to be
interpreted with some caution. In addition, the proportion of
patients entered into the registry by participating hospitals is
not monitored. This currently limits our ability to examine
implant rates and to examine equity of access to pacemaker
therapy across the country. The Device registry allows cap-
ture of post-discharge complications, but currently many of
the records are incomplete and this data has therefore not
 HLC 2157 No. of Pages 5
Pacemaker Use in New Zealand – Data From the New Zealand Implanted Cardiac Device Registry (ANZACS-QI 15)
been reported. The Device registry also collects data on ICD
implants but because two high volume implanting centres
are not currently utilising the Device registry we have not
reported on those procedures.
Conclusions
This is the first description of data entered into the New
Zealand Implanted Cardiac Device registry, and describes
1611 new pacemaker implants. Complications rates compare
favourably with available international data. Patients receiv-
ing a pacemaker were younger than in European registries,
and this combined with previous data describing a low
overall implant rate in New Zealand[2] may warrant review
of patient access to pacemakers. There was a low use of CRT-
P devices, and reasons for this require further evaluation.
Conflict of Interest
The authors have no conflicts of interest with respect to this
work.
Acknowledgments
ANZACS-QI [3_TD$IF]program implementation, coordination and
analysis: The ANZACS-QI software was developed and sup-
ported by Enigma Solutions. Programme implementation is
coordinated by the National Institute for [3_TD$IF]Health Innovation
(NIHI) at the University of Auckland. The ANZACS-QI
program is funded by the NZ Ministry of Health. The
DEVICE registry software development was funded by
Counties-Manukau District Health Board and national
licensing is supported by a grant from the NZ branch of
the Cardiac Society of Australia and New Zealand.
ANZACS-QI research is supported by grants from the NZ
Health Research Council and National Heart Foundation.
ANZACS-QI Governance group: Andrew Aitken, Gerry
Devlin, Karen Evison, Andrew Kerr (chair), Peter Larsen,
Kim Marshall, Chris Nunn, Mark Simmonds, Michael Wil-
liams, David Smyth, Ralph Stewart, Harvey White.
ANZACS-QI Project management: Kristin Sutherland,
Sarah Masson, Charmaine Flynn (Northern coordinator),
Maxine Rhodes (Southern coordinator).
Data management and analysis: Mildred Lee, Michelle
Jenkins, John Faatui
We acknowledge all the NZ cardiac physiologists, cardi-
ologists, physicians, nursing staff and radiographers who
have supported and contributed to ANZACS-QI.
Please cite this article in press as: Larsen PD, et al. Pacemaker Use in New Zealand – Data From the New Zealand Implanted
Cardiac Device Registry (ANZACS-QI 15). Heart, Lung and Circulation (2016), http://dx.doi.org/10.1016/j.hlc.2016.06.1206
5
References
[1] Mond HG, Whitlock RM. The Australian and New Zealand cardiac
pacing and implantable cardioverter-defibrillator survey: calendar year
2001. Heart, Lung and Circulation 2004;13(2):145–9.
[2] Mond HG, Crozier I. The Australian and New Zealand cardiac pace-
maker and implantable cardioverter-defibrillator survey: calendar year
2013. Heart, Lung and Circulation 2015;24(3):291–7.
[3] Mond HG, Whitlock RM. The Australian and New Zealand cardiac
pacing and implantable cardioverter-defibrillator survey: calendar year
2005. Heart, Lung and Circulation 2008;17(2):85–9.
[4] Mond HG, Whitlock RM. The Australian and New Zealand cardiac
pacing and implantable cardioverter-defibrillator survey: calendar year
2009. Heart, Lung and Circulation 2011;20(2):99–104.
[5] Gadler F, Valzania C, Linde C. Current use of implantable electrical
devices in Sweden: data from the Swedish pacemaker and implantable
cardioverter-defibrillator registry. Europace: European pacing, arrhyth-
mias, and cardiac electrophysiology: journal of the working groups on
cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of
the European Society of Cardiology 2015;17(1):69–77.
[6] Cano Perez O, Pombo Jimenez M, Coma Samartin R. Spanish Pacemaker
Registry. Twelfth official report of the Spanish Society of Cardiology
Working Group on Cardiac Pacing (2014). Revista espanola de cardio-
logia 2015;68(12):1138–53.
[7] Proclemer A, Zecchin M, D’Onofrio A, Botto GL, Rebellato L, Ghidina M,
et al. [The pacemaker and implantable cardioverter-defibrillator registry
of the Italian Association Arrhythmology Cardiac Pacing and cardiac
pacing - annual report 2013]. G Ital Cardiol (Rome) 2014;15(11):638–50.
[8] Arribas F, Auricchio A, Wolpert C, Merkely B, Merino JL, Boriani G, et al.
The EHRA White Book. Europace: European pacing, arrhythmias, and
cardiac electrophysiology: journal of the working groups on cardiac
pacing, arrhythmias, and cardiac cellular electrophysiology of the
European Society of Cardiology 2012;14(Suppl 3):iii1–iii55.
[9] Raatikainen MJ, Arnar DO, Zeppenfeld K, Merino JL, Levya F, Hindriks
G, et al. Statistics on the use of cardiac electronic devices and electrophys-
iological procedures in the European Society of Cardiology countries:
2014 report from the European Heart Rhythm Association. Europace:
European pacing, arrhythmias, and cardiac electrophysiology: journal of
the working groups on cardiac pacing, arrhythmias, and cardiac cellular
electrophysiology of the European Society of Cardiology 2015;17(Suppl 1):
i1–i75.
[10] Authors/Task Force M, Priori SG, Blomstrom-Lundqvist C, Mazzanti A,
Blom N, Borggrefe M, et al. ESC Guidelines for the management of
patients with ventricular arrhythmias and the prevention of sudden
cardiac death: The Task Force for the Management of Patients with
Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
of the European Society of Cardiology (ESC) Endorsed by: Association
for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J
2015;2015.
[11] Udo EO, Zuithoff NP, van Hemel NM, de Cock CC, Hendriks T, Doe-
vendans PA, et al. Incidence and predictors of short- and long-term
complications in pacemaker therapy: the FOLLOWPACE study. Heart
Rhythm: the official journal of the Heart Rhythm Society 2012;9(5):728–35.
[12] Pakarinen S, Oikarinen L, Toivonen L. Short-term implantation-related
complications of cardiac rhythm management device therapy: a retro-
spective single-centre 1-year survey. Europace: European pacing,
arrhythmias, and cardiac electrophysiology: journal of the working
groups on cardiac pacing, arrhythmias, and cardiac cellular electrophys-
iology of the European Society of Cardiology 2010;12(1):103–8.
[13] Migliore F, Zorzi A, Bertaglia E, Leoni L, Siciliano M, De Lazzari M, et al.
Incidence, management, and prevention of right ventricular perforation
by pacemaker and implantable cardioverter defibrillator leads. Pacing
Clin Electrophysiol 2014;37(12):1602–9.
[14] Freeman JV, Wang Y, Curtis JP, Heidenreich PA, Hlatky MA. Physician
procedure volume and complications of cardioverter-defibrillator
implantation. Circulation 2012;125(1):57–64.