Effectiveness of Implantable Cardioverter Defibrillators and Cardiac Resynchronization Therapy in Heart Failure

Transvenous lead extraction after heart transplantation: How to avoid abandoned lead fragments

BACKGROUND

Many patients awaiting heart transplantation (HTX) have a cardiac implantable electronic device (CIED). Lead removal is often still a part of the HTX procedure. Abandoned lead fragments carry a risk for infections and prohibit magnetic resonance imaging (MRI) imaging. This study evaluated the concept of an elective lead management algorithm after HTX.

METHODS AND RESULTS

Between 2009 and 2018, 102 consecutive patients with previously implanted CIED underwent HTX. Lead removal by manual traction during HTX was performed in 74 patients until December 2014. Afterward, treatment strategy was changed and 28 patients received elective lead extraction procedures in a hybrid operating room (OR) using specialized extraction tools. Total of 74 patients with 157 leads underwent lead extraction by manual traction during HTX. The mean lead age was 32.3 ± 38.7 months. Postoperative X-ray revealed abandoned intravascular lead fragments in 31(41.9%) patients, resulting in a complete lead extraction rate of only 58.1%. The high rate of unsuccessful lead extractions led to the change in the extraction strategy in 2015. Since then, HTX was performed in 28 CIED patients. In those patients, 64 leads with a mean lead age of 53.8 ± 42.8 months were treated in an elective lead extraction procedure. No major or minor complications occurred during lead extraction. All leads could be removed completely, resulting in a procedural success rate of 100%.

CONCLUSION

Our results demonstrate that chronically implanted leads should be removed in an elective procedure, using appropriate extraction tools. This enables complete lead extraction, which reduces the infection risk in this patient population with the necessity for permanent immunosuppressive therapy and allows further MRI surveillance.

End of life decisions in heart failure: to turn off the intracardiac device or not?

PURPOSE OF REVIEW

Heart failure is a significant public health concern around the world. Implantable cardioverter defibrillators with or without cardiac resynchronization therapy (CRT-D) have proven survival benefit. As patients progress to end-stage disease, management shifts to palliative care, and cardiologists are often confronted with how to best manage these devices.

RECENT FINDINGS

Studies suggest that up to one-third of patients with an implantable cardioverter defibrillator receive painful shocks in the last 24 h of life. Disabling pacing or resynchronization devices may further weaken the heart function and expedite death, particularly if the patient has no underlying ventricular rhythm. Is it ethical or legal to discontinue functions of the implantable device? The discussion and the decision to be made are whether to continue both pacing and tachyarrhythmia therapies, disable tachyarrhythmia therapies while maintaining pacing, or discontinue both.

SUMMARY

The decision to disable all or parts of the device function is ultimately up to the patient. To avoid painful shocks near the end of life, it is recommended that tachyarrhythmia therapies be turned off when the patient is being treated palliatively. After informed discussion, withdrawing the resynchronization or pacing device option is also acceptable if requested by the patient regardless of the potential outcomes.

Diabetes Mellitus and Outcomes of Cardiac Resynchronization With Implantable Cardioverter-Defibrillator Therapy in Older Patients With Heart Failure

Background—

Large-scale data on outcomes with cardiac resynchronization therapy with defibrillator in patients with diabetes mellitus are limited. We compared outcomes after cardiac resynchronization therapy with defibrillator implantation among patients with heart failure who have diabetes mellitus versus those without diabetes mellitus.

Methods and Results—

Survival curves and covariate adjusted hazard ratio (HR) or odds ratio were used to assess the risks for death, readmission, and device-related complications by diabetes mellitus status among 18 428 patients at least 65 years old receiving cardiac resynchronization therapy with defibrillator from the National Cardiovascular Data Registry, implantable cardioverter-defibrillator registry between 2006 and 2009, with up to 3 years of follow-up. Accounting for differences between groups, compared with those without diabetes mellitus (n=11 345), patients with diabetes mellitus (n=7083) had a higher risk of death both at 1 year (HR, 1.16 [95% confidence interval (CI), 1.05–1.29]; P =0.0037) and 3 years (HR, 1.21 [1.14–1.29]; P <0.001) after device implantation and higher risks of all-cause readmission (sub-HR, 1.16 [1.11–1.21] at 1 year; P <0.0001; sub-HR, 1.15 [1.11–1.19] at 3 years; P <0.0001) and heart failure–related readmission (sub-HR, 1.18 [1.09–1.28] at 1 year; P <0.0001; and sub-HR, 1.22 [1.15–1.30] at 3 years; P <0.0001). Device-related complications within 90 days did not differ between those with and without diabetes mellitus (odds ratio: 0.90 [0.77–1.06]; P =0.37). Interactions of age, sex, ischemic cardiomyopathy, renal failure, or QRS duration were not significant.

Conclusions—

In older patients with heart failure receiving cardiac resynchronization therapy with defibrillator, diabetes mellitus was independently associated with greater risks of death and rehospitalization, but similar risks of procedural complications.

Enrollment and monitoring of women in post-approval studies for medical devices mandated by the Food and Drug Administration

BACKGROUND

Disease presentation, prevalence, and treatment effects vary by sex, thus it is important to ensure adequate participation of both sexes in medical device post-approval studies (PAS).

METHODS

The goals of this study were to determine the participation rate of women in PAS mandated by the Food and Drug Administration (FDA) and if participation varied by clinical area. The study also evaluated the frequency in which enrollment by sex is reported by applicant reports and FDA reviews, as well as the frequency in which final study reports analyze whether outcomes differ by sex.

RESULTS

Of 89 studies with enrollment completed, data on sex of participants were available in 93% of submitted reports, while data on enrollment by sex was evaluated and noted in 43% of FDA review memos. Study participation varied by clinical area, with female participation ranging from 32% in cardiovascular PAS to 90% in PAS for reconstructive devices. Of 53 completed studies, data on enrollment by sex was provided in 49 of the final reports. Of these 14% included a multivariate analysis that included sex as a covariate and 4% included a subgroup analysis for female participants.

CONCLUSIONS

Data on sex was not routinely assessed in FDA reviews. Based on these findings, FDA implemented new procedures to ensure participation by sex is evaluated in PAS reviews. FDA will continue working with applicants to develop PAS that enroll and retain proportions of women consistent with the sex-specific prevalence for the disease or condition the device is used to treat.