Transvenous extraction of pacemaker leads in infective endocarditis with vegetations ≥20 mm: our experience

Long- and short-term outcomes after transvenous lead extraction in a large single-centre patient cohort using the clinical frailty scale as a risk assessment tool

BACKGROUND AND AIMS

The rate of cardiac implantable electronic device (CIED) implantations and the need for transvenous lead extraction (TLE) are growing worldwide. This study examined a large Swedish cohort with the aim of identifying possible predictors of post-TLE mortality with special focus on systemic infection patients and frailty.

METHODS

This was a single centre study. Records of patients undergoing TLE between 2010 and 2018 were analysed. Statistical analyses were conducted to compare baseline characteristics of patients with different indications and identify risk factors of 30-day and 1-year mortality.

RESULTS

A total of 893 patients were identified. Local infection was the dominant indication and pacemaker was the most common CIED. The mean age was 65 ± 16 years, 73 % were male and median follow-up was 3.9 years. Heart failure was the most common comorbidity. Patients with systemic infection were significantly older, frailer and had significantly higher levels of comorbidities. 30-day mortality and 1-year mortality rates were 2.5 % and 9.9 %, respectively. Systemic infection and chronic kidney disease (CKD) were independently associated with 30-day and 1-year mortality. Clinical frailty scale (CFS) 5-7 correlated independently with 1-year mortality in the entire cohort and specifically in systemic infection patients. CKD, cardiac resynchronization therapy and CFS 5-7 were significant risk factors for long-term mortality (death >1 year after TLE) in multivariable analysis.

CONCLUSIONS

Systemic infection, kidney failure in addition to the novel parameter of frailty were associated with post-TLE all-cause mortality. These risk factors should be considered during pre-procedure risk stratification to improve post-TLE outcomes.

AngioVac system guided removal of vegetations from pacemaker lead-related infective endocarditis

The AngioVac aspiration system is a catheter-based technique that has been used for removal of unwanted intravascular material in growing numbers of institutions around the world since 2013. It provides an alternative and a less invasive approach for the treatment of venous thromboembolism and intrinsic or cardiac implantable electronic devices (CIED)-related infective endocarditis. This system uses venous cannulas and extracorporeal filtering mechanisms to effectively remove thrombi or vegetations resulting in less invasion and minimal blood loss. We present a case of a woman in her mid-50s who underwent successful AngioVac-guided removal of lead vegetations followed by percutaneous CIED removal.

Cardiac Implantable Electronic Devices Infection Assessment, Diagnosis and Management: A Review of the Literature

The use of increasingly complex cardiac implantable electronic devices (CIEDs) has increased exponentially in recent years. One of the most serious complications in terms of mortality, morbidity and financial burden is represented by infections involving these devices. They may affect only the generator pocket or be generalised with lead-related endocarditis. Modifiable and non-modifiable risk factors have been identified and they can be associated with patient or procedure characteristics or with the type of CIED. Pocket and systemic infections require a precise evaluation and a specialised treatment which in most cases involves the removal of all the components of the device and a personalised antimicrobial therapy. CIED retention is usually limited to cases where infection is unlikely or is limited to the skin incision site. Optimal re-implantation timing depends on the type of infection and on the results of microbiological tests. Preventive strategies, in the end, include antibiotic prophylaxis before CIED implantation, the possibility to use antibacterial envelopes and the prevention of hematomas. The aim of this review is to investigate the pathogenesis, stratification, diagnostic tools and management of CIED infections.

Lead-related infective endocarditis with vegetations: Prevalence and impact of pulmonary embolism in patients undergoing transvenous lead extraction

INTRODUCTION

The prevalence and impact of pulmonary embolism (PE) in patients with lead-related infective endocarditis undergoing transvenous lead extraction (TLE) are unknown.

METHODS

Twenty-five consecutive patients with vegetations ≥10 mm at transoesophageal echocardiography were prospectively studied. Contrast-enhanced chest computed tomography (CT) was performed before (pre-TLE) and after (post-TLE) the lead extraction procedure.

RESULTS

Pre-TLE CT identified 18 patients (72%) with subclinical PE. The size of vegetations in patients with PE did not differ significantly from those without (median 20.0 mm [interquartile range: 13.0-30.0] vs. 14.0 mm [6.0-18.0], p = 0.116). Complete TLE success was achieved in all patients with 3 (2-3) leads extracted per procedure. There were no postprocedure complications related to the presence of PE and no differences in terms of fluoroscopy time and need for advanced tools. In the group of positive pre-TLE CT, post-TLE scan confirmed the presence of silent PE in 14 patients (78%). There were no patients with new PE formation. Large vegetations (≥20 mm) tended to increase the risk of post-TLE subclinical PE (odds ratio 5.99 [95% confidence interval (CI): 0.93-38.6], p = 0.059). During a median 19.4 months follow-up, no re-infection of the implanted system was reported. Survival rates in patients with and without post-TLE PE were similar (hazard ratio: 1.11 [95% CI: 0.18-6.67], p = 0.909).

CONCLUSION

Subclinical PE detected by CT was common in patients undergoing TLE with lead-related infective endocarditis and vegetations but was not associated with the complexity of the procedure or adverse outcomes. TLE procedure seems safe and feasible even in patients with large vegetations.

The clinical role of transesophageal echocardiography during transvenous lead extraction

BACKGROUND

Transesophageal echocardiography (TEE) is commonly used during cardiothoracic procedures. TEE has also become standard during transvenous lead extraction (TLE) procedures, but its effect and role have not been optimally defined. The goal of this study is to identify how TEE was used during TLE at our institute and review its utility.

METHODS

We retrospectively reviewed high-risk patients undergoing TLE, for whom more complications during extraction procedures, from June 2012 to September 2020. The patients were divided into TEE group and non-TEE group according to real-time TEE monitoring. We compared the rate of procedural success, complications between two groups and concluded the clinical utility of TEE during TLE.

RESULTS

A total of 195 patients were included (105 in TEE group vs 90 in non-TEE group), the rate of procedure success (97.8% vs 96.5%, p = 0.41) and complications during extraction (8.6% vs 12.2%, p = 0.40, major complication 5.7% vs 12.2%, p = 0.11, minor complication 2.9% vs 0%, p = 0.30) were comparable. In TEE group, 12 patients (11.4%) received following benefits: altering surgical plans, guiding subsequent therapy strategies, and rapidly diagnosing complications, moreover no complications occurred from TEE.

CONCLUSIONS

This study demonstrates that real-time monitoring by TEE cannot change the rate of procedural success and complication during TLE; however, TEE provides valuable information to instruct clinical therapy and improves the safety of TLE.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

Transcatheter aspiration of large pacemaker and implantable cardioverter-defibrillator lead vegetations facilitating safe transvenous lead extraction

AIMS

Treatment of patients with systemic cardiac implantable electronic device (CIED) infection with large lead vegetations is challenging and associated with relevant morbidity and mortality. To avoid complications from open surgical extraction, a novel approach with percutaneous aspiration of large vegetations prior to transvenous lead extraction was instituted. The results of this treatment concept were retrospectively analysed in this multicentre study.

METHODS AND RESULTS

One hundred and one patients [mean age 68.2 ± 13.1 (30-92) years] were treated in four centres for endovascular CIED infection with large lead vegetations. Mean lead vegetation size was 30.7 ± 13.5 mm. Two hundred and forty-seven leads were targeted for extraction (170 pacemaker leads, 77 implantable cardioverter-defibrillator leads). Mean lead implant duration was 81.7 (1-254) months. The transcatheter aspiration system with a specialized long venous drainage cannula and a funnel-shaped tip was based on a veno-venous extracorporeal circuit with an in-line filter. The aspiration of vegetations showed complete procedural success in 94.0% (n = 95), partial success in 5.0% (n = 5). Three major complications (3.0%) were encountered. Complete procedural success (per lead) of the subsequently performed transvenous lead extraction procedure was 99.2% (n = 245). Thirty-day mortality was 3.0% (n = 3). Five patients (5.0%) died in the further course on Days 51, 54, 68, 134, and 182 post-procedure (septic complications: n = 4; heart failure: n = 1).

CONCLUSION

The percutaneous aspiration procedure is highly effective and is associated with a low complication profile. The aspiration of vegetations immediately prior and during the lead extraction procedure may avoid septic embolization into the pulmonary circulation. This may potentially lead to a long-term survival benefit.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially lifesaving treatments for a number of cardiac conditions but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased health care costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well-recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, antibacterial envelopes, prolonged antibiotics post-implantation, and others. When compared with previous guidelines or consensus statements, the present consensus document gives guidance on the use of novel device alternatives, novel oral anticoagulants, antibacterial envelopes, prolonged antibiotics post-implantation, as well as definitions on minimum quality requirements for centres and operators and volumes. The recognition that an international consensus document focused on management of CIED infections is lacking, the dissemination of results from new important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a Novel 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

Candida tropicalis defibrillator endocarditis: A case report and review of current literature

We provide a review of current literature and report on a case of electronic device infective endocarditis with C. tropicalis. A 64-year-old man presented for revision of his implantable cardioverter defibrillator. Echocardiography revealed extensive vegetations attached to the Eustachian valve and in the right ventricular apex. Microbiological findings presented C. tropicalis on the explanted material. The patient refused additional surgical intervention. We successfully treated the patient with liposomal Amphotericin B and Flucytosine for 8 weeks.

Deep sedation for transvenous lead extraction: a large single-centre experience

Aims

Transvenous lead extraction for cardiac implantable electronic devices (CIED) is of growing importance. Nevertheless, the optimal anaesthetic approach, general anaesthesia vs. deep sedation (DS), remains unresolved. We describe our tertiary centre experience of the feasibility and safety of DS.

Methods and results

Extraction procedures were performed in the electrophysiology (EP) laboratory by two experienced electrophysiologists. We used intravenous Fentanyl, Midazolam, and Propofol for DS. A stepwise approach with locking stylets, dilator sheaths, and mechanical sheaths via subclavian, femoral, or internal jugular venous access was utilized. Patient characteristics and procedural data were collected. Logistic regression models were used to identify parameters associated with sedation-related complications. Extraction of 476 leads (dwelling time/patient 88 ± 49 months, 30% ICD leads) was performed in 220 patients (64 ± 17 years, 80% male). Deep sedation was initiated with bolus administration of Fentanyl, Midazolam, and Propofol; mean doses 0.34 ± 0.12 μg/kg, 24.3 ± 6.8 μg/kg, and 0.26 ± 0.13 mg/kg, respectively. Deep sedation was maintained with continuous Propofol infusion (initial dose 3.7 ± 1.1 mg/kg/h; subsequently increased to 4.7 ± 1.2 mg/kg/h with 3.9 ± 2.6 adjustments) and boluses of Midazolam and Fentanyl as indicated. Sedation-related episodes of hypotension, requiring vasopressors, and hypoxia, requiring additional airway management, occurred in 25 (11.4%) and 5 (2.3%) patients, respectively. These were managed without adverse consequences. Five patients (2.3%) experienced major intraprocedural complications; there were no procedure-related deaths. All of our logistic regression models indicated intraprocedural support was associated with administration higher Fentanyl doses.

Conclusion

Transvenous lead extraction under DS in the EP laboratory is a safe procedure with high success rates when performed by experienced staff.

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.

Snare sheath versus evolution sheath in transvenous lead extraction

Lead extraction remains a challenging procedure with significant success. Owing to the increasing use of cardiac implantable electronic devices, there is a growing need for effective techniques management, to avoid the occurrence of device-related complications and lead dysfunction. We made a comparison of Evolution sheath and Needles Eye Snare sheath (abbreviated to Snare sheath) by analyzed the results using two kind of the methods in the Cardiology Center of Peking University People's Hospital. In the retrospective study we evaluated patients who underwent lead extraction from July 2013 to July 2014. Those who underwent lead removal without using evolution or snare were excluded. Primary endpoints included total exposure time, operation time, and complications. Data on clinical characteristics, indications, and outcomes were prospectively collected and analyzed. A total of 76 patients were included in the study (65.8% male; aged 68.1±14.34 years old). Snare and Evolution were used in 59 and 17 patients, respectively. A total of 134 leads were removed with 103 leads (76.87%) extracted using the Snare sheath. Lead age was 10.8±7.0 years. Complete extraction was observed in 67 patients of 124 leads. Evolution sheath was associated with significantly lower complication even after adjustment of the number of leads, type of leads, and lead age, compared to the Snare group (P<0.05). In the Snare sheath group, mortality rate was 1.69% and minor complication rate was 3.39%. When compared to the Snare sheath, lead extraction with the Evolution sheath has less X-ray exposure time and less operation time (P<0.05), while with a higher success rate (P<0.05). Besides, the Evolution group has fewer major and minor complications.

The characteristics and outcome of infective endocarditis involving implantable cardiac devices

Infection of implantable cardiac electronic devices in particular lead endocarditis (cardiac device infective endocarditis (CDIE)) is an emerging problem with significant morbidity, mortality and health care costs. The epidemiology is characterised with advanced age and health care association in cases presenting within 6 months of implantation. Risk factors include those of the patient, the procedure and the device. Staphylococcal species predominate as the causative organisms. Diagnosis is reliably made by blood cultures and transesophageal echocardiography. Complications include pulmonary and systemic emboli, persistent bacteremia and concomitant valvular involvement. Management includes complete device removal and prolonged antimicrobial therapy. With long-term follow-up to 1 year, the mortality of CDIE is as high as 23 %. It is associated with patient co-morbidities and concomitant valvular involvement and may be prevented by device removal during index admission.

Safety of transvenous lead extraction according to centre volume: a systematic review and meta-analysis

BACKGROUND

Transvenous lead extraction (TLE) is a complex invasive procedure and the experience of the operator and the team is a major determinant of procedural outcomes.

AIM

Because of very limited data available on minimum procedural volumes to enable training and ongoing competency for TLEs, we performed a meta-analysis aimed at assessing the outcomes of TLE in the centres with low, medium, and high volume of procedures.

METHODS

Of the 280 papers initially retrieved until February 2013, 66 observational studies met inclusion criteria and were included in at least one stratified meta-analysis: 17 were prospective studies; 47 had a retrospective design; and 2 were defined 'experience studies'. We included only articles published after the introduction of laser technique (year 1999). We divided the studies in low, medium, and high volume centres utilizing either the European Heart Rhythm Association (EHRA) or Lexicon classification criteria.

RESULTS

When meta-analyses were carried out separately for the studies with larger and smaller sample sizes, either using EHRA or Lexicon classification criteria, no clear differences emerged in the combined rate of major complications or intraoperative deaths. In contrast, both minor complications and mortality at 30 days decreased as centre volume increased.

CONCLUSIONS

In our meta-analysis of observational studies, patients who have been treated in higher volume centres have a lower probability of minor complications and death at 30 days regardless of the infection rate, length of lead duration, type of device, and type of extraction.

Right-sided infective endocarditis: recent epidemiologic changes

BACKGROUND

Infective endocarditis (IE) has been increasingly reported, however, little is available regarding recent development of right-sided IE.

METHODS

Right-sided IE was comprehensively analyzed based on recent 5⅓-year literature.

RESULTS

Portal of entry, implanted foreign material, and repaired congenital heart defects were the main predisposing risk factors. Vegetation size on the right-sided valves was much smaller than those beyond the valves. Multiple logistic regression analysis revealed that predisposing risk factors, and vegetation size and locations were independent predictive risks of patients' survival.

CONCLUSIONS

Changes of right-sided IE in the past 5⅓ years included younger patient age, and increased vegetation size, but still prominent Staphylococcus aureus infections. Complication spectrum has changed into more valve insufficiency, more embolic events, reduced abscess formation, and considerably decreased valve perforations. With effective antibiotic regimens, prognoses of the patients seemed to be better than before.

Complications of cardiac implants: handling device infections

Managing patients with cardiac implantable electrophysiological devices (CIED) infections can be challenging. The first step should be prevention, which involves patient selection, timing of implantation, and the procedure itself. After implantation, a high degree of suspicion should be applied in order to correctly diagnose patients with infected implanted devices. It is necessary to recognize that patients can present with a wide variety of signs and symptoms. Once diagnosed, the next step is determining if it is a local pocket infection or system infection. In almost every patient, in addition to antibiotics, complete removal of ALL hardware is required. Transvenous lead extraction is now safe and effective, but should only be performed at experienced centres with a practiced extraction team, all possible needed equipment, and cardiothoracic surgical backup. After extraction, the indication for CIED therapy should be re-evaluated to determine re-implantation is warranted. Timing of re-implantation depends on a variety of factors such as type of infection or valvular involvement and should be made in concordance with an infectious disease specialist. This review is aimed at introducing the steps needed to manage patients with infected cardiac devices.