Large, single-center, single-operator experience with transvenous lead extraction: Outcomes and changing indications

Joint British Society consensus recommendations for magnetic resonance imaging for patients with cardiac implantable electronic devices

Magnetic Resonance Imaging (MRI) is increasingly a fundamental component of the diagnostic pathway across a range of conditions. Historically, the presence of a cardiac implantable electronic device (CIED) has been a contraindication for MRI, however, development of MR Conditional devices that can be scanned under strict protocols has facilitated the provision of MRI for patients. Additionally, there is growing safety data to support MR scanning in patients with CIEDs that do not have MR safety labelling or with MR Conditional CIEDs where certain conditions are not met, where the clinical justification is robust. This means that almost all patients with cardiac devices should now have the same access to MRI scanning in the National Health Service as the general population. Provision of MRI to patients with CIED, however, remains limited in the UK, with only half of units accepting scan requests even for patients with MR Conditional CIEDs. Service delivery requires specialist equipment and robust protocols to ensure patient safety and facilitate workflows, meanwhile demanding collaboration between healthcare professionals across many disciplines. This document provides consensus recommendations from across the relevant stakeholder professional bodies and patient groups to encourage provision of safe MRI for patients with CIEDs.

Comparison of non-laser and laser transvenous lead extraction: a systematic review and meta-analysis

AIMS

Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature. We sought to compare non-laser and laser TLE in a meta-analysis.

METHODS AND RESULTS

We searched Medline, Embase, Scopus, ClinicalTrials.gov, and CENTRAL databases for TLE studies published between 1991 and 2021. From the included 68 studies, safety and efficacy data were carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR), and pooled rates were synthesized from eligible studies to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed. Non-laser in comparison with laser had lower procedural mortality (pooled rate 0% vs. 0.1%, P < 0.01), major complications (pooled rate 0.7% vs. 1.7%, P < 0.01), and superior vena cava (SVC) injury (pooled rate 0% vs. 0.5%, P < 0.001), with higher complete success (pooled rate 96.5% vs. 93.8%, P < 0.01). Non-laser comparatively to laser was more likely to achieve clinical [OR 2.16 (1.77-2.63), P < 0.01] and complete [OR 1.87 (1.69-2.08), P < 0.01] success, with a lower procedural mortality risk [OR 1.6 (1.02-2.5), P < 0.05]. In the subgroup analysis, rotational tool compared with laser achieved greater complete success (pooled rate 97.4% vs. 95%, P < 0.01) with lower SVC injury (pooled rate 0% vs. 0.7%, P < 0.01).

CONCLUSION

Non-laser TLE is associated with a better safety and efficacy profile when compared with laser methods. There is a greater risk of SVC injury associated with laser sheath extraction.

Radiographic predictors of failure of simple manual traction of transvenous implantable cardioverter-defibrillator leads: a single-center experience

BACKGROUND

Extraction of the implantable cardioverter-defibrillator (ICD) leads could be a difficult procedure due to fibrous tissue around the lead and anatomical variations. In this report, we present our experience in the radiographic predictors of failure of simple manual traction (SMT) in patients with dual-coil ICD requiring lead extraction (LE).

METHODS

Between January 2017 and February 2021, 103 leads were removed in 65 consecutive patients; 65 (63.1%) were dual-coil ICD leads, 22 (21.4%) were atrial, and 16 (15.5%) were coronary sinus leads. Patient-based and procedural data were collected and analyzed retrospectively. Clinical and procedural characteristics were compared and radiographic predictors of failure of SMT of ICD leads were assessed. Projected anteroposterior (AP) lead tortuosity was measured and lead slack score was estimated on chest X-ray (CXR).

RESULTS

Simple manual traction failed in 27 (42%) of the ICD leads. Ottawa slack score (odds ratio [OR] 2.368, 95% CI [1.261-4.447]; P = 0.007), AP lead tortuosity > 1.10 (OR 7.477, 95% CI [1.718-35.542]; P = 0.007), and number of previous interventions (OR 6.016, 95% CI [1.184-30.557]; P < 0.030) were found to be independently related to the failure of SMT. Receiver-operator characteristic curve analysis yielded an AP lead tortuosity cutoff value of > 1.10 for predicting the failure of SMT. The area under the curve was 0.744; the 95% confidence interval (CI) was 0.617 to 0.871 (P = 0.001), with a sensitivity of 63% and a specificity of 73%.

CONCLUSION

Simple manual traction success in our study varied based on radiographic lead-related parameters. Before planning the procedure, increased AP lead tortuosity in vasculature and higher lead slack score can be easily determined on CXR and may be associated with more fibrous adherences, the complexity of the LE, and failure of SMT.

Long-Term Outcomes of Transvenous Lead Extraction: A Comparison in Patients with or without Infection from the Italian Region with the Oldest Population

BACKGROUND

The gold standard for the treatment of cardiac implantable electronic devices (CIEDs)-related infection and lead malfunction is transvenous lead extraction (TLE). To date, the risk of mortality directly related to TLE procedures is relatively low, but data on post-procedural and long-term mortality are limited, even more in the aging population.

METHODS

Consecutive patients with CIEDs who underwent TLE were retrospectively studied. The primary outcome was the endpoint of death, considering independent predictors of long-term clinical outcomes in the TLE aging population comparing patients with and without infection.

RESULTS

One hundred nineteen patients (male 77%; median age 76 years) were included in the analysis. Eighty-two patients (69%) documented infection, and thirty-seven (31%) were extracted for a different reason. Infected patients were older (80 vs. 68 years, p-value > 0.001) with more implanted catheters (p-value < 0.001). At the last follow-up (FU) available (median FU 4.1 years), mortality reached 37% of the patient population, showing a statistically significant difference between infected versus non-infected groups. At univariable analysis, age at TLE, atrial fibrillation, and anemia remained significant correlates of mortality; at multivariable analysis, only patients with anemia and atrial fibrillation have a 2.3-fold (HR 2.34; CI 1.16-4.75) and a 2.5-fold (HR 2.46; CI 1.33-4.54) increased rate of death, respectively.

CONCLUSION

Our long-term data showed that aging patients who underwent TLE for CIED-related infection exhibit a high mortality risk during a long-term follow-up, potentially leading to a rapid and effective procedural approach in this patient population.

Success and Complication Rates of Transvenous Lead Extraction in a Developing High-Volume Extraction Center: The Zurich Experience

Introduction: Transvenous lead extractions are increasingly performed for malfunction or infection of cardiac implantable electronic devices, but they harvest a potential for complications and suboptimal success. Apart from multicenter registries and reports from highly experienced single centers, the outcome in individual newly developing high-volume centers starting a lead extraction program is less well established. We aimed to evaluate the clinical and radiological success and complication rate at our center, having started a lead extraction program less than a decade ago. Methods: We retrospectively analyzed patients who underwent transvenous lead extraction at the University Hospital Zurich from 2013 to 2021 regarding success as well as complications and compared our results to previously reported outcome rates. Results: A total of 346 patients underwent 350 transvenous lead extractions from January 2013 to December 2021. Combined radiological success was achieved in 97.7% and clinical success in 96.0% of interventions. Procedure-related major complications occurred in 13 patients (3.7%). Death within 30 days after transvenous lead extractions occurred in 13 patients (3.7%), with a procedure-related mortality of 1.4% (five patients). Summary: Transvenous lead extractions in newly developing high-volume centers can be performed with high clinical and radiological success rates, but procedure-related major complications may affect a relevant number of patients. Compared to large single or multicenter registries of experienced centers, the success rate may be lower and the complication rate higher in centers newly starting with lead extraction, which may have important implications for patient selection, procedural planning, proctoring, and safety measures.

Lead Extraction at a Pediatric/Congenital Heart Disease Center: The Importance of Patient Age at Implant

OBJECTIVES

This study sought to evaluate the safety and efficacy of transvenous lead extraction (TLE) at a single pediatric/congenital heart disease (CHD) center.

BACKGROUND

Data on TLE in pediatric and CHD patients are limited.

METHODS

Retrospective cohort study evaluating TLE from 2008 to 2019.

RESULTS

A total of 113 patients underwent TLE with 162 leads removed (including 38 high-voltage leads). Median age at lead implantation was 13 years (range 0.6-61.8 years), with a median age at extraction of 21.6 years (6.4-64.3 years). Median lead age was 7.2 years (1.0-35.3 years). Successful extraction occurred in 110 (97%) patients, 159 (98%) leads. Complex extraction was needed for 120 leads; 52 (44%) using laser alone, 27 (23%) mechanical sheath alone, and 21 (18%) using both. Femoral extraction was used for 19 (16%) leads. Risk factors for complex extraction were ≥2 leads extracted (odds ratio: 3.36; 95% confidence interval [CI]: 1.2-9.36; P = 0.021), lead within the right ventricle (odds ratio: 2.8; 95% CI: 1.2-6.5; P = 0.017), and a combination of younger patient age at implant and older lead age at extraction, with patients ≤12 years of age at implant and leads ≥7 years of age having an odds ratio: of 10.1 (95% CI: 2.21-45.9; P = 0.003). Major complications occurred in 5 (4.4%) of patients, with no mortality, but a high incidence of tricuspid valve injury.

CONCLUSIONS

TLE can be performed successfully and safely in a pediatric and CHD center. Patient age at lead implantation, not age at extraction, is an important predictor of needing a complex extraction, with younger patients at implant and older leads at extraction having the highest risk.

Significantly less inappropriate shocks in ischemic patients compared to non-ischemic patients: The S-ICD experience of a high volume single-center

BACKGROUND

The subcutaneous cardioverter-defibrillator (S-ICD) continues to be preferentially used in relatively young patients, with less advanced heart disease.

OBJECTIVE

We, therefore, studied the short and long-term efficacy and safety of the S-ICD in subgroups of patients, which are underreported at present.

METHODS

A total of 218 patients between November 2010 and February 2019 undergoing S-ICD with a follow up of at least 6 months implantation were included in a prospective registry. Mean follow up was 38 months.

RESULTS

The most common indication for S-ICD implantation was ischemic cardiomyopathy (n = 106, 49%). Complication rate needing invasive intervention was 9% (n = 21). Appropriate shock rate in patients with an S-ICD was 3.5%/year. A total of 30 inappropriate shocks (IAS) occurred in 19 patients (8.7%; 2.7%/year). The proportion of appropriate and inappropriate shock rates in patients with different cardiomyopathies shows remarkable variances. There were significant more IAS (3.6%/year vs. 1.7%/year, p = .048) in patients with non-ischemic cardiomyopathy versus patients with ischemic cardiomyopathy. Multivariate analysis identified, besides type of cardiomyopathy, atrial fibrillation (AF) as predictor for IAS.

CONCLUSION

In this real-world prospective registry we analyzed S-ICD performance in the more traditional ICD patient. Patients with ischemic cardiomyopathy had significantly less inappropriate therapy compared to patients with non-ischemic cardiomyopathy and appear to be appropriate patients for this type of device.

Safety and efficacy of transvenous mechanical lead extraction in patients with abandoned leads

AIMS

Optimal management of redundant or malfunctioning leads is controversial. We aimed to assess safety and efficacy of mechanical transvenous lead extraction (TLE) in patients with abandoned leads.

METHODS AND RESULTS

Consecutive TLE procedures performed in our centre from January 2009 to December 2017 were considered. We evaluated the safety and efficacy of mechanical TLE in patients with abandoned (Group 1) compared to non-abandoned (Group 2) leads. We analysed 1210 consecutive patients that required transvenous removal of 2343 leads. Group 1 accounted for 250 patients (21%) with a total of 617 abandoned leads (26%). Group 2 comprised 960 patients (79%) with 1726 leads (74%). The total number of leads (3.0 vs. 2.0), dwelling time of the oldest lead (108.00 months vs. 60.00 months) and infectious indications for TLE were higher in Group 1. Clinical success was achieved in 1168 patients (96.5%) with a lower rate in Group 1 (90.4% vs. 98.1%; P < 0.001). Major complications occurred in only 9 patients (0.7%), without significant differences among the two groups. The presence of one or more abandoned leads [odds ratio (OR) 3.47; 95% confidence interval (CI) 1.07-11.19; P = 0.037] and dwelling time of the oldest lead (OR 1.01 for a month; 95% CI 1.01-1.02; P < 0.001) were associated with a higher risk of clinical failure.

CONCLUSION

Transvenous mechanical lead extraction is a safe procedure also in high-risk settings, as patients with abandoned leads. Success rate resulted a bit lower, especially in the presence of abandoned leads with long implantation time.

Comparison between TightRail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction

BACKGROUND

There are limited data on the comparative analyses of TightRail rotating dilator sheath (Philips) and laser sheath for lead extraction.

OBJECTIVE

To evaluate the effectiveness and safety of the TightRail sheath as a primary or secondary tool for transvenous lead extraction (TLE).

METHODS

Retrospective cohort analysis of 202 consecutive patients who underwent TLE using either TightRail sheath and/or GlideLight laser sheath (Philips) in our hospital. The study population was divided into three groups: Group A underwent TLE with laser sheath only (N = 157), Group B with TightRail sheath only (N = 22), and Group C with both sheaths (N = 23).

RESULTS

During this period, 375 leads in 202 patients were extracted, including 297 leads extracted by laser sheath alone, 45 leads by TightRail sheath alone, and 33 by both TightRail sheath and laser sheaths. The most common indications included device infection (44.6%) and lead-related complications (44.1%). The median age of leads was 8.9 years. TightRail sheath (Group B) achieved similar efficacy as a primary extraction tool compared with laser sheath (Group A), with complete procedure success rate of 93.3% (vs. 96.6%, P = .263) and clinical success rate of 100.0% (vs. 98.1%, P = .513). Among 32 leads in which Tightrail was used after laser had failed (Group C), the complete procedure success rate was 75.8%. No significant difference in procedural adverse events was observed.

CONCLUSION

Our single-center experience confirms that the TightRail system is an effective first-line and second-line method for TLE. Further investigation is required to guide the selection of mechanical and laser sheaths in lead extraction cases.

Percutaneous management of superior vena cava syndrome in patients with cardiovascular implantable electronic devices

BACKGROUND

There is no consensus regarding the optimal management of cardiovascular implantable electronic device (CIED)-related superior vena cava (SVC) syndrome.

OBJECTIVE

We report our experience with transvenous lead extractions (TLEs) in the setting of symptomatic CIED-related SVC syndrome.

METHODS

We reviewed all TLEs performed at a high-volume center over a 14-year period and identified patients in which TLE was performed for symptomatic SVC syndrome. Patient characteristics, extraction details, percutaneous management of SVC occlusions, and clinical follow up data were analyzed.

RESULTS

Over a 14-year period, more than 1600 TLEs were performed. Of these, 16 patients underwent TLE for symptomatic SVC syndrome. The mean age was 53.1 ± 12.8 years, and 9 (56.3%) were men. Thirty-seven leads, with a mean dwell time of 5.8 years (range 2-12 years), were extracted. After extraction, 6 patients (37.5%) received an SVC stent. Balloon angioplasty was performed before stenting in 5 cases (31.3%). There was 1 major complication (6.3%) due to an SVC tear that was managed surgically with a favorable outcome. Eleven patients underwent reimplantation of a CIED. Over a median follow-up of 5.5 years (interquartile range 2.0-8.5 years), 12 patients (75%) remained free of symptoms.

CONCLUSION

Combining TLE with the percutaneous treatment of symptomatic SVC syndrome is a safe and viable treatment strategy.

Comparative Analysis of Procedural Outcomes and Complications Between De Novo and Upgraded Cardiac Resynchronization Therapy

OBJECTIVES

This study compared rates of procedural success and complications between de novo cardiac resynchronization therapy (CRT) implantation versus upgrade, including characterization of technical challenges.

BACKGROUND

CRT upgrade is common, but data are limited on the incidence of procedural success and complications as compared to de novo implantation.

METHODS

All patients who underwent a transvenous CRT procedure at a single institution between 2013 and 2018 were reviewed for procedure outcome, 90-day complications, reasons for unsuccessful left ventricular lead delivery, and the presence of venous occlusive disease (VOD) that required a modified implantation technique.

RESULTS

Among 1,496 patients, 947 (63%) underwent de novo implantation and 549 (37%) underwent device upgrade. Patients who received a device upgrade were older (70 ± 12 years vs. 68 ± 13 years; p < 0.01), with a male predominance (75% vs. 66%; p < 0.01) and greater prevalence of comorbidities. There was no difference in the rate of procedural success between de novo and upgrade CRT procedures (97% vs. 96%; p = 0.28) or 90-day complications (5.1% vs. 4.6%; p = 0.70). VOD was present in 23% of patients who received a device upgrade and was more common among patients with a dual-chamber versus a single-chamber device (26% vs. 9%; p < 0.001). Patients with and without VOD had a similar composite outcome of procedural failure or complication (8.0% vs. 7.8%; p = 1.0).

CONCLUSIONS

Rates of procedural success and complications were no different between de novo CRT implantations and upgrades. VOD frequently increased procedural complexity in upgrades, but alternative management strategies resulted in similar outcomes. Routine venography before CRT upgrade may aid in procedural planning and execution of these strategies.

Comparison of transvenous vs subcutaneous defibrillator therapy in patients with cardiac arrhythmia syndromes and genetic cardiomyopathies

BACKGROUND

Inherited arrhythmia syndromes and genetic cardiomyopathies attribute in a significant proportion to sudden cardiac death. Implantable cardioverter defibrillators (ICDs) are the cornerstone in the prevention of sudden death in high-risk patients. However, ICD therapy is also associated with high rates of inappropriate shocks and/or device-related complications especially in young patients.

OBJECTIVE

To determine the outcome of high-risk patients with inherited arrhythmia syndromes and genetic cardiomyopathies comparing two defibrillator technologies.

METHOD

Between 2010 and 2018, 183 consecutive patients from two large German tertiary care centers were enrolled in the study. The majority of patients (83%) had either cardiac channelopathies or idiopathic ventricular fibrillation without cardiac structural abnormalities, while the remaining 17% had a genetic cardiomyopathy (HCM/ARVC). Eighty-six patients (47%) received a transvenous ICD (TV-ICD), while a subcutaneous ICD (S-ICD) was implanted in another 97 patients (53%).

RESULTS

During a mean follow-up of 4.3 years, 30 patients had an appropriate ICD therapy (annual rate 3.8%). Fifteen patients experienced an inappropriate shock (annual rate 1.9%). Lead failure occurred in 17 (9%) patients and was less frequent in the S-ICD group (OR 0.48, 95%CI 0.38-0.62). Adverse defibrillator events, defined as a composite of inappropriate shocks and lead failure requiring surgical revision were significantly lower in the S-ICD group as compared to the TV-ICD group (OR 0.55, 95%CI 0.41-0.72). There was a non-significant trend towards lower appropriate shocks in the S-ICD group, that in combination with all-cause shocks yielded in a significantly higher freedom of any shock in the S-ICD group (RR 39%, p = 0.003). No deaths occurred during follow-up.

CONCLUSION

The present data favor the use of the subcutaneous ICD for patients with inherited arrhythmia syndromes and genetic cardiomyopathies who do not need anti-bradycardia pacing.

Histological properties of oscillating intracardiac masses associated with cardiac implantable electric devices

Background

There have been a few cases of echogenic cardiac implantable electric device (CIED) lead‐associated oscillating intracardiac masses (ICMs) in leads imaged by echocardiography. The histological properties of ICMs could help clarify the etiological diagnosis. Although there is extensive literature on mass size, the histological properties of such masses have not been characterized. The aim of this research was to clarify the histological features of oscillating ICMs in CIED patients.

Methods

Preoperative echocardiography was performed in all candidates for CIED removal. In the patients with ICMs, specimens were obtained by 3 methods: direct tissue collection during open‐heart surgery; tissue collection together with the CIED lead during transvenous extraction; and tissue collection by catheter vacuum during transvenous CIED removal. A standard histopathological examination of ICM tissue was performed.

Results

A total of 106 patients underwent lead removal in our institute (April 2009‐March 2018); 14 patients had an ICM (13.2%), and 7 specimens were obtained in patients with CIED lead‐related ICM. Following histological examination, 2 types of ICM were identified: one mainly composed of thickened endocardium (EN type; 3 patients), and the other mainly an aggregate of inflammatory cells as a neutrophil cell (NC type; 4 patients).

Conclusions

Two histological types of intracardiac masses, including a thickened endocardium type and a neutrophil cell type, were identified. These classifications might help make an accurate histological diagnosis of lead‐associated intracardiac masses.

Outcomes of cardiac implantable electronic device transvenous lead extractions performed in centers without onsite cardiac surgery

BACKGROUND

While major complications associated with CIED lead extractions are uncommon, they carry a significant risk of morbidity and mortality in the absence of surgical intervention. However, there is limited data on the differences in outcomes of these procedures between centers with and without on-site CS support. The present study examined outcomes of transvenous cardiac implantable electronic device (CIED) lead extractions according to admitting hospitals' cardiac surgery (CS) facilities.

METHODS

We analyzed the National Inpatient Sample for CIED lead extraction procedures, stratified by hospitals' CS facilities into two groups; on-site and off-site CS. Logistic regression analyses were performed to estimate the adjusted odds (aOR) of procedure-related complications in off-site CS centers.

RESULTS

In 221,606 procedures over an 11-year-period, CIED lead extractions were increasingly undertaken in on-site as opposed to off-site CS centers (Onsite CS 2004 vs. 2014: 78.2% vs. 90.4%, p < 0.001) during the study period. In comparison to on-site CS group, patients admitted to off-site CS group were older, less comorbid, and experienced lower adjusted odds of major adverse cardiovascular events (0.72 [0.67, 0.77]), mortality (0.60 [0.52, 0.69]), procedure-related bleeding (0.48 [0.44, 0.54]) and complications (thoracic: 0.81 [0.75, 0.88]; cardiac: 0.45 [0.38, 0.54]) (p < 0.001 for all).

CONCLUSIONS

Our national analysis demonstrates that transvenous CIED lead extractions are being increasingly undertaken in centers with on-site CS surgery, in compliance with international guideline recommendations. Patients managed with lead extractions in on-site CS centers are more comorbid and critically ill compared to those admitted to off-site CS centers, and remain at a higher risk of procedure-related complications.

Transvenous lead extraction procedures in women based on ESC-EHRA EORP European Lead Extraction ConTRolled ELECTRa registry: is female sex a predictor of complications?

AIMS

Female sex is considered an independent risk factor of transvenous leads extraction (TLE) procedure. The aim of the study was to evaluate the effectiveness of TLE in women compared with men.

METHODS AND RESULTS

A post hoc analysis of risk factors and effectiveness of TLE in women and men included in the ESC-EHRA EORP ELECTRa registry was conducted. The rate of major complications was 1.96% in women vs. 0.71% in men; P = 0.0025. The number of leads was higher in men (mean 1.89 vs. 1.71; P < 0.0001) with higher number of abandoned leads in women (46.04% vs. 34.82%; P < 0.0001). Risk factors of TLE differed between the sexes, of which the major were: signs and symptoms of venous occlusion [odds ratio (OR) 3.730, confidence interval (CI) 1.401-9.934; P = 0.0084], cumulative leads dwell time (OR 1.044, CI 1.024-1.065; P < 0.001), number of generator replacements (OR 1.029, CI 1.005-1.054; P = 0.0184) in females and the number of leads (OR 6.053, CI 2.422-15.129; P = 0.0001), use of powered sheaths (OR 2.742, CI 1.404-5.355; P = 0.0031), and white blood cell count (OR 1.138, CI 1.069-1.212; P < 0.001) in males. Individual radiological and clinical success of TLE was 96.29% and 98.14% in women compared with 98.03% and 99.21% in men (P = 0.0046 and 0.0098).

CONCLUSION

The efficacy of TLE was lower in females than males, with a higher rate of periprocedural major complications. The reasons for this difference are probably related to disparities in risk factors in women, including more pronounced leads adherence to the walls of the veins and myocardium. Lead management may be key to the effectiveness of TLE in females.

Making MRI available for patients with cardiac implantable electronic devices: growing need and barriers to change

Abstract

More than half of us will need a magnetic resonance imaging (MRI) scan in our lifetimes. MRI is an unmatched diagnostic test for an expanding range of indications including neurological and musculoskeletal disorders, cancer diagnosis, and treatment planning. Unfortunately, patients with cardiac pacemakers or defibrillators have historically been prevented from having MRI because of safety concerns. This results in delayed diagnoses, more invasive investigations, and increased cost. Major developments have addressed this—newer devices are designed to be safe in MRI machines under specific conditions, and older legacy devices can be scanned provided strict protocols are followed. This service however remains difficult to deliver sustainably worldwide: MRI provision remains grossly inadequate because patients are less likely to be referred, and face difficulties accessing services even when referred. Barriers still exist but are no longer technical. These include logistical hurdles (poor cardiology and radiology interaction at physician and technician levels), financial incentives (re-imbursement is either absent or fails to acknowledge the complexity), and education (physicians self-censor MRI requests). This article therefore highlights the recent changes in the clinical, logistical, and regulatory landscape. The aim of the article is to enable and encourage healthcare providers and local champions to build MRI services urgently for cardiac device patients, so that they may benefit from the same access to MRI as everyone else.

Key Points

• There is now considerable evidence that MRI can be provided safely to patients with cardiac implantable electronic devices (CIEDs). However, the volume of MRI scans delivered to patients with CIEDs is fifty times lower than that of the estimated need, and patients are approximately fifty times less likely to be referred.

• Because scans for this patient group are frequently for cancer diagnosis and treatment planning, MRI services need to develop rapidly, but the barriers are no longer technical.

• New services face logistical, educational, and financial hurdles which can be addressed effectively to establish a sustainable service at scale.

Is it safe to remove an infected cardiac implantable electronic device at the time of heart transplantation? Report of two cases

Cardiac implantable electronic device (CIED) infections are treated with antibiotics and device explantation. Lack of CIED removal is associated with infection recurrence. However, CIED removal can be associated with major complications including death. We reported two patients with advanced heart disease who developed CIED infection due Staphylococcus epidermidis while awaiting for orthotopic heart transplantation (OHT). Both patients were managed with a different approach. They were treated with antibiotic therapy and had their CIED removal postponed until OHT. Both patients were kept on suppressive antibiotic treatment until undergoing simultaneous OHT and removal of infected CIED. None of the patients had infection recurrence. Large studies are needed to assess whether the approach of delaying CIED removal until OHT is safe among carefully selected patients with CIED infection.

Complete Pocket Resection with Regional Flap Closure for Treatment of Cardiac Implantable Device Infections

Background:

Cardiac implantable electronic device infections are associated with substantial morbidity and mortality. There are varied recommendations in the literature about treatment of the wound after extraction of all hardware, but only conservative, time-consuming approaches such as open packing and negative-pressure therapy along with a long interval before reimplanting any hardware have generally been recommended for the treatment.^1–4

Methods:

A retrospective review was performed of 42 patients treated at Jersey Shore University Medical Center for implantable cardioverter defibrillator and permanent pacemaker infections between July 2010 and April 2018 with an aggressive, multidisciplinary approach utilizing an invasive cardiologist and a plastic surgeon. Clinical and demographic data were collected, and a descriptive analysis was conducted.

Results:

A total of 42 patients, with a median age of 76 years, were selected for our treatment of pacemaker pocket infection. Patients underwent removal of all hardware followed by debridement and flap closure of the wound soon after extraction. Reimplantation was performed when indicated typically within a week after initial extraction and typically on the contralateral side. There were no reports of reinfection and no mortality in all 42 patients treated.

Conclusion:

We found that the aggressive removal of all hardware and excisional debridement of the entire capsule followed by flap coverage and closure of the wound allowed for a shortened interval to reimplantation with no ipsilateral or contralateral infections during the follow-up period.

Cardiac and Vascular Injuries Sustained During Transvenous Lead Extraction

The rise in indications for cardiac implantable electronic devices has necessitated the development of tools for removal of the electrodes that connect the heart to these externally located pacemakers and defibrillators. After implant of a cardiac electrode, variable but progressive fibrous adhesion occurs. Removal of these adhesions can cause devastating complications with high risk of mortality if not treated surgically in a highly expeditious and appropriate manner. This article describes the incidence, risk factors, and diagnosis of these injuries followed by discussion of recent evidence for use of superior vena cava balloon occlusion, and conventional surgical repair of these injuries.

Total laser cycles-a measure of transvenous lead extraction difficulty

BACKGROUND

Several variables have been identified as predictors for difficult or complicated transvenous lead extraction (TLE), including age and number of implanted leads, as well as patient's age; however, a standard measure of TLE difficulty has not been described.

OBJECTIVE

Total laser cycles (TLCs) delivered during laser-assisted TLE is an objective variable that could reflect the difficulty of TLE. This study investigated whether TLC is correlated with known predictors of difficult TLE.

METHODS

In a retrospective study of TLE procedures using the laser sheath, we analyzed TLC delivered and compared it to established predictors of procedural failure and complications.

RESULTS

Of 166 patients undergoing TLE, the laser sheath (SLS II or Glidelight, Spectranetics Inc.,) was used as the primary extraction sheath in 130 patients, and 100 patients had complete TLC data available. The mean age of the oldest lead (AOL) was 7.1 ± 3.2 years with a median of 6.91 (interquartile range [IQR] 0.48-16.69) years, and 1.6 ± 0.7 leads (range, 1-4) were extracted per procedure. Two thirds of procedures involved ICD leads. Clinical success was 99%, with one patient (1%) experiencing a major complication. Median TLC delivered was 1165 (IQR, 567-2062; range, 49-9522). TLC was positively correlated with AOL (r = 0.227, p = 0.023), and the combined age of leads was extracted (r = 0.307, p = 0.002). TLC was also positively correlated with number of leads extracted per procedure (ρ = 0.227, p = 0.024). There was a non-significant negative trend towards correlation between TLC and patient's age (r = -0.112, p = 0.268).

CONCLUSION

TLC showed significant correlation with known predictors of difficulty during TLE using the laser sheath. TLC is an objective method to report the difficulty of TLE and could usefully be reported in future series of laser lead extractions.

Outcomes of repeated transvenous lead extraction

INTRODUCTION

The outcomes of repeated cardiovascular implantable electronic device (CIED) lead extraction have not been well studied. We sought to determine the indications, outcomes, and safety of repeated lead extraction procedures.

METHODS

This retrospective study was conducted using data from two medical centers, including 38 patients who had undergone two or more lead extraction procedures compared to 439 patients who had a single procedure. The electronic medical records and procedural databases were reviewed to determine the indications, procedural characteristics, and outcomes. The outcomes of the first procedure were compared to the outcomes of subsequent procedures.

RESULTS

The 5-year cumulative probability of a repeated extraction procedure was 11% (95% confidence interval, 7%-15%). In 439 patients who underwent single lead extractions, 72% had device and lead related infections as the procedure indication compared to 39% for 38 patients who underwent repeated extraction (P < 0.001). The mean duration from device reimplant to repeated extraction procedures was 63 ± 48 months. Ninety-eight percent of the leads were removed completely in repeated procedures, similar to the 95% success rate of the first procedure (P = 0.51). There was no significant difference in major complication rate in the first or repeated extractions (2.6% vs 5.2%, P = 0.79).

CONCLUSIONS

Repeated transvenous lead extraction is not uncommon. It had a high success rate comparable to that of the initial procedure and was not associated with an increased incidence of adverse events.

Primary Cardiac B-Non-Hodgkin Lymphoma Disguised as a Pacemaker Endocarditis

Background  Pacemaker infections rates are high compared with the incidence of primary malignant cardiac tumors. However, they can look alike in diagnostics and patient presentation. Case Description  We hereby report a rare case of a suspected pacemaker endocarditis which in fact turned out to be a primary cardiac B cell lymphoma. The lymphoma was removed surgically. Conclusion  Sometimes we encounter the unexpected. Suboptimal preoperative diagnostics certainly lead to the faulty conclusion of an endocarditis. Nonetheless, even such an enhanced primary cardiac tumor can be resected with good clinical outcome and long-term survival.

Percutaneous Lead Extraction in Infection of Cardiac Implantable Electronic Devices: a Systematic Review

INTRODUCTION

In the last two decades, the increased number of implants of cardiac implantable electronic devices has been accompanied by an increase in complications, especially infection. Current recommendations for the appropriate treatment of cardiac implantable electronic devices-related infections consist of prolonged antibiotic therapy associated with complete device extraction. The purpose of this study was to analyze the importance of percutaneous extraction in the treatment of these devices infections.

METHODS

A systematic review search was performed in the PubMed, BVS, Cochrane CENTRAL, CAPES, SciELO and ScienceDirect databases. A total of 1,717 studies were identified and subsequently selected according to the eligibility criteria defined by relevance tests by two authors working independently.

RESULTS

Sixteen studies, describing a total of 3,354 patients, were selected. Percutaneous extraction was performed in 3,081 patients. The average success rate for the complete percutaneous removal of infected devices was 92.4%. Regarding the procedure, the incidence of major complications was 2.9%, and the incidence of minor complications was 8.4%. The average in-hospital mortality of the patients was 5.4%, and the mortality related to the procedure ranged from 0.4 to 3.6%. The mean mortality was 20% after 6 months and 14% after a one-year follow-up.

CONCLUSION

Percutaneous extraction is the main technique for the removal of infected cardiac implantable electronic devices, and it presents low rates of complications and mortality related to the procedure.

Success and complication rates of lead extraction with the first- vs. the second-generation Evolution mechanical sheath

Aims

The Evolution sheath (Cook Medical, USA) is a power sheath frequently used for chronic lead extraction. In 2013, a novel type (bidirectional) of Evolution sheath (the RL type) was introduced. We evaluated differences in success and complication rates of the two types.

Methods and results

From 2009 to 2015, all lead extractions requiring the use of an Evolution sheath were prospectively examined. According to the current guidelines, complete procedural success was defined as the removal of all targeted lead materials. Clinical success was the retention of a small portion of the lead, and failure was the inability to achieve either complete procedural or clinical success or the development of any permanently disabling complication. The Evolution sheath was used to extract 149 leads in 103 patients. The first 56 leads were extracted with the original unidirectional sheath, and 93 leads were extracted with the novel bidirectional R/L type. The median age of the lead at the time of extraction was 6.8 vs. 9.1 years (P = 0.007). Complete procedural success was higher for the Evolution R/L (80.0 vs. 98%, P = 0.0004). Clinical success rate was 98 vs. 99%. There were no major complications and 6 (12.0%) vs. 2 (3.8%) minor complications (P = 0.153). We did not observe changes in success rates or complications over time, meaning that the difference cannot be explained by learning curve.

Conclusion

Use of the novel Evolution R/L sheath vs. the original Evolution sheath was associated with significant higher complete success rates, without major complications and with a trend towards the reduction of minor complications.

Venous System Interventions for Device Implantation

Subclavian obstruction is common after lead implantation and the need to add or replace a lead is increasing. Subclavian venoplasty (SV) is a safe and effective option for venous occlusion. Peripheral venography overestimates the severity of the obstruction. A wire can usually be advanced into the central circulation for SV. Compared with dilators, SV improves the quality of venous access, providing unrestricted catheter manipulation for His bundle pacing and left ventricular lead implantation. SV preserves venous access and reduces lead burden. SV can easily be added to the implanting physicians lead management options.

Overcoming the current issues surrounding device leads: reducing the complications during extraction

INTRODUCTION

The implantation rate of cardiac implantable electronic devices has consistently increased in the last 20 years, as have the related complication rates. The most relevant issue is the removal of pacing and implantable cardioverter defibrillator (ICD) leads, which a few months after implantation tend to develop intravascular fibrosis, often making extraction a challenging and risky procedure. Areas covered: The transvenous lead extraction (TLE) scenario is constantly evolving. TLE is a key procedure in lead management strategies. Many efforts have been made to develop new TLE approaches and techniques allowing a safe and effective procedure for patients. The increasing rate of cardiac implantable electronic device (CIED) implantations and of CIED related complications highlight the importance of TLE. Lead related- and patient-related factors may change the future of extractions. We review the current status of TLE, focusing on the strategies available to perform the optimal procedure in the right patient and reducing procedure related complications. Expert commentary: Understanding the importance of an accurate TLE risk stratification is mandatory to optimize the procedural risk-to-benefits ratio. The use of adequate tools, techniques and approaches, and appropriate training are cornerstones for the achievement of safer procedures.

Brain magnetic resonance imaging examination in a patient with non-magnetic resonance conditional pacemaker

Clinical dilemmas arise when patients with a non-magnetic resonance (MR) conditional pacemaker are required to undergo magnetic resonance imaging (MRI). We encountered a pacemaker patient with debilitating non-motor symptoms of Parkinson׳s disease, who required an MRI prior to deep brain stimulation (DBS) surgery. MRI was performed safely without adverse events despite the presence of a conventional pacemaker.

ICD lead extraction: Not a benign procedure. External chest compression: Not a benign manoeuvre

This is the case of a 45-year-old man who was electively admitted to our hospital for revision and extraction of his faulty implantable cardioverter–defibrillator lead and box. The procedure was complicated by cardiac tamponade requiring pericardiocentisis (unsuccessful) and cardiopulmonary resuscitation. The patient was then rushed to theatre for emergency sternotomy and institution of cardiopulmonary bypass. A tear in the superior vena cava was identified and repaired. Unfortunately, the patient suffered of a liver laceration, due to chest compression, which required emergency laparotomy. The aim of this report is to highlight the combination and management of two rare life-threatening complications that occurred in a single case.

Strategies for Transvenous Lead Extraction Procedures

Transvenous lead extraction (TLE) has undergone an explosive evolution since its inception as a rudimentary skill with limited technology and therapeutic options. Early techniques involved simple manual traction that frequently proved ineffective for chronically implanted leads, and carried a significant risk of myocardial avulsion, tamponade, and death. The morbidity and mortality associated with these early extraction techniques limited their application to use only in life-threatening situations, such as infection and sepsis. The past four decades, however, have witnessed significant advances in lead extraction technology, resulting in more efficacious techniques and tools, providing the skilled extractor with a well-equipped armamentarium. With the development of the discipline, we have witnessed a growth in the community of TLE experts coincident with a marked decline in the incidence of procedure-related morbidity and mortality, with recent registries at high-volume centers reporting high success rates with exceedingly low complication rates. Future developments in lead extraction are likely to focus on new tools that will allow for us to provide comprehensive device management, develop alternative systems for extraction training, and focus on the design of new leads conceived to facilitate future extraction.

Frequency and clinical impact of retained implantable cardioverter defibrillator lead materials in heart transplant recipients

End-stage heart failure patients with implantable cardioverter-defibrillator (ICD) with/without cardiac resynchronization therapy (CRT-D) often require heart transplantation (HTPL) as a last-resort treatment. We aimed to assess the frequency and clinical impact of retained ICD lead materials in HTPL patients. In this retrospective single center study, we examined the clinical records and chest radiographs of patients with ICD and CRT-D who underwent HTPL between January 1992 and July 2014. Of 40 patients with ICD and CRT-D at HTPL, 19 (47.5%) patients had retained ICD lead materials within the central venous system. Retained ICD lead materials following HTPL were more frequently noted in patients with longer implantation durations until HTPL. None of the patients underwent extraction procedures after HTPL. All patients were asymptomatic and did not exhibit significant complications or death related to the retained ICD lead materials. Seven (7/40, 17.5%) patients without any retained ICD lead materials underwent magnetic resonance imaging (MRI) during the follow-up period (median, 29.5 months); none of the patients with retained lead materials were given MRI. Considering the common use of MRI in HTPL patients, further studies on the prophylactic extraction of retained ICD lead materials and safety of MRI in these patients are needed.

Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillator

BACKGROUND

The presence of a cardiovascular implantable electronic device has long been a contraindication for the performance of magnetic resonance imaging (MRI). We established a prospective registry to determine the risks associated with MRI at a magnetic field strength of 1.5 tesla for patients who had a pacemaker or implantable cardioverter-defibrillator (ICD) that was "non-MRI-conditional" (i.e., not approved by the Food and Drug Administration for MRI scanning).

METHODS

Patients in the registry were referred for clinically indicated nonthoracic MRI at a field strength of 1.5 tesla. Devices were interrogated before and after MRI with the use of a standardized protocol and were appropriately reprogrammed before the scanning. The primary end points were death, generator or lead failure, induced arrhythmia, loss of capture, or electrical reset during the scanning. The secondary end points were changes in device settings.

RESULTS

MRI was performed in 1000 cases in which patients had a pacemaker and in 500 cases in which patients had an ICD. No deaths, lead failures, losses of capture, or ventricular arrhythmias occurred during MRI. One ICD generator could not be interrogated after MRI and required immediate replacement; the device had not been appropriately programmed per protocol before the MRI. We observed six cases of self-terminating atrial fibrillation or flutter and six cases of partial electrical reset. Changes in lead impedance, pacing threshold, battery voltage, and P-wave and R-wave amplitude exceeded prespecified thresholds in a small number of cases. Repeat MRI was not associated with an increase in adverse events.

CONCLUSIONS

In this study, device or lead failure did not occur in any patient with a non-MRI-conditional pacemaker or ICD who underwent clinically indicated nonthoracic MRI at 1.5 tesla, was appropriately screened, and had the device reprogrammed in accordance with the prespecified protocol. (Funded by St. Jude Medical and others; MagnaSafe ClinicalTrials.gov number, NCT00907361 .).

Hybrid Minimally Invasive Approach for Transvenous Lead Extraction: A Feasible Technique in High-Risk Patients

INTRODUCTION

Despite the overall safety, transvenous lead extraction (TLE) remains a challenging procedure with inherent risks, where surgery can still be required in elective cases. In this study, we report our experience with a minimally invasive "hybrid" approach, defined as a procedure performed by an electrophysiologist with the support of a cardiac surgeon in the same operative session.

METHODS AND RESULTS

We reported 12 cases of planned hybrid lead extraction; minithoracotomy and thoracoscopy were performed on 10 (83%) and 2 (17%) patients, respectively. A total of 25 leads out of 27 (median lead age 19 years) were successfully extracted with laser, mechanical or combined transvenous sheath. In 3 patients, the direct monitoring of vascular and myocardial integrity allowed for prompt treatment of potential vascular injury during the lead extraction maneuvers. Mean in-hospital stay was 4 ± 2 days. There were no major intraoperative complications and no deaths occurred after 30 days' follow-up.

CONCLUSION

The hybrid approach, with minithoracotomy or thoracoscopy, is feasible and it might increase the safety in the most challenging TLE procedures: the minimally invasive surgical intervention allows for continuous monitoring of the critical cardiac structures and prompt treatment of potential complications.

Use of Preprocedural MDCT for Cardiac Implantable Electric Device Lead Extraction: Frequency of Findings That Change Management

OBJECTIVE

Five percent of cardiac implantable electric devices (CIEDs) are removed each year. Percutaneous extraction is preferred but can be complicated if the leads adhere to the vasculature or perforate. The goal of this study is to assess the frequency of findings on dedicated MDCT that alter preprocedural planning for percutaneous CIED extraction.

MATERIALS AND METHODS

One hundred patients with CIEDs who underwent MDCT before percutaneous lead extraction were analyzed. Major findings that could preclude percutaneous removal, including lead course and termination, were distinguished from moderately significant findings that could alter but not preclude percutaneous removal, including endofibrosis of leads to the vasculature, lead termination abnormalities, central vein stenosis, or thrombus. Incidental findings were characterized separately. Findings were correlated with preprocedural decisions, the extraction procedure performed, and procedural outcomes.

RESULTS

Twenty-six women and 74 men with 125 right ventricular leads, 84 right atrial leads, and 26 coronary venous leads were evaluated. Major findings were present in 7% of patients, including six patients with lead perforation and one with a lead coursing outside a tricuspid annuloplasty ring. Moderately significant findings of endothelial fibrosis were found in 78% of patients. The central veins were narrowed or occluded in 42% of patients, and thrombus was present in 2% of patients. Thirty-six percent of patients had incidental findings, and 4% of patients had unexpected findings requiring immediate inpatient attention.

CONCLUSION

MDCT performed before CIED lead extraction is able to identify major and moderately significant findings that can alter either percutaneous extraction or preprocedural planning. The use of dedicated preprocedural MDCT can help to stratify patient risk, guide decision making by the proceduralist, and identify non-catheter-related findings that affect patient management.

Long-Range Real Migration of Implantable Cardioverter Defibrillator Lead

The need for pacemaker and implantable cardioverter defibrillator (ICD) lead revisions and extractions is steadily increasing. Despite the lack of representative studies, the risk of lead extraction is frequently considered to be lower than leaving nonfunctional leads in situ.

We report the case of a patient who was referred to our institution for exchange of a malfunctioning ICD lead. The diagnostic work-up revealed a long-segment transmural migration of the ICD lead at the site of the subclavian and innominate vein. Due to the unpredictable risk of vein perforation, we abandoned the extraction procedure.

Cardiac Implantable Electronic Device Infections: Added Complexity and Suboptimal Outcomes With Previously Abandoned Leads

OBJECTIVES

This study sought to assess the impact of previously abandoned leads on the clinical management of cardiac device infections, notably transvenous lead extraction and subsequent clinical course.

BACKGROUND

The population of patients with cardiac implantable electronic devices continues to grow with a disproportionate increase in device infections, which are invariably life threatening. A potentially complicating issue is the widely practiced strategy of device lead abandonment at the time of system revision, change, or upgrade, which is affecting an increasing number of patients.

METHODS

The study assessed the impact of previously abandoned leads in a prospectively maintained registry of consecutive patients undergoing percutaneous extraction of infected cardiac devices at the Cleveland Clinic between August 1996 and September 2012. The primary clinical endpoint was complete procedural and clinical success defined as the successful removal of the device and all lead material from the vascular space, in the absence of a major complication.

RESULTS

Of 1,386 patients with infected cardiac devices, 323 (23.3%) had previously abandoned leads. Failure to achieve the primary endpoint occurred more frequently in patients with abandoned leads (13.0% vs. 3.7%; p < 0.0001). This was primarily due to retention of lead material (11.5% vs. 2.9%; p < 0.0001), which was associated with poor clinical outcomes including higher rates of 1-month mortality (7.4% vs. 3.5% in those without lead remnants). Lead extraction procedures in patients with previously abandoned leads were longer (p < 0.0001), with longer fluoroscopy times (p < 0.0001), and more likely to require specialized extraction tools (94.4% vs. 81.8%; p < 0.0001) or adjunctive rescue femoral workstations (14.9% vs. 2.9%; p < 0.0001). Procedural complications occurred more frequently in patients with previously abandoned leads (11.5% vs. 5.6%; p = 0.0003), which was true for both major (3.7% vs. 1.4%; p = 0.009) and minor complications (7.7% vs. 4.4%; p = 0.02).

CONCLUSIONS

Previously abandoned leads complicate the management of cardiac device infections, leading to worse clinical outcomes.