Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA)

Multicentric Experience With the Use of Short 13Fr Mechanical Rotating Dilator Sheath for Transvenous Lead Extraction

BACKGROUND

The need for transvenous lead extraction (TLE) is increasing worldwide. Since the course of the subclavian vein until the junction with the superior vena cava is a frequent place of lead adherences, we aim to assess the safety and efficacy of a short 13Fr bidirectional rotational mechanical sheath as first choice.

METHODS AND RESULTS

In this multicentric study, 202 carriers of a cardiac implantable electronic device (CIED) undergoing TLE using a short 13 Fr bidirectional rotational mechanical sheath were prospectively enrolled. All procedures were performed using a stepwise approach. The indication for TLE were infection (62%), malfunction (32%), and upgrade (6%). Overall, 471 leads were extracted: 65% pacing leads, 20% defibrillator leads, 9% coronary sinus leads, and 6% abandoned leads. Clinical success and complete lead extraction have been achieved in 97% and 95% of cases, respectively. The short sheath was always effective in gaining venous access at the start of the procedure and was sufficient for complete TLE in 67% of cases. Lead dwell time, defibrillator lead, number of leads per patient, and lead malfunction were predicting factors of long bidirectional rotational mechanical sheath use. There were no cases of intraprocedural death, and major complications were reported in 2% of patients. Overall survival was 97% at 1-year follow-up.

CONCLUSION

This multicentric experience using a short 13Fr bidirectional rotational mechanical sheath reported high safety and efficacy, demonstrating the utility of routine use of short extraction sheaths of higher caliper as the first choice.

Removal of Spontaneously Fractured Leads with Their Proximal Ends in the Heart and Vasculature-Description of Different Approaches and Tools

Background: Removal of spontaneously fractured leads with their proximal ends migrated into the vascular space has not been analysed in detail thus far. The study aimed to compare the effectiveness of different approaches and auxiliary tools for removing fractured leads with migrated proximal ends. Methods: Retrospective analysis of 72 cases from a database containing 3847 TLEs (transvenous lead extraction). Results: Most of the leads were passive, especially unipolar. Procedure complexity in such cases was high but with satisfying effectiveness (procedural success rate 93.06%) and independent of the position of the proximal end. The rate of major complications was 2.78%, which may be attributed to long implant duration (152.2 months). Extraction of such leads did not influence long-term survival. The femoral approach was most often used (62.50%). In 79.16% of leads, mechanical dissection was required. In 66.7%, proximal ends were strongly attached to the wall, and a loop had to be applied. In 15.28% of procedures, the lead was wrapped around a pig-tail catheter ("spaghetti twisting technique"). Conclusions: (1) Spontaneous lead fracture with the proximal ends migrated into the vascular space is a rare finding (1.87% of the TLE). (2) Removal of such leads requires the use of different approaches as well as dedicated and non-dedicated tools. (3) Despite a high level of procedure complexity, its effectiveness is high, with an acceptable rate of major complications.

Elective Sternotomy With Fluoroscopic Guidance for the Removal of a Residual Implantable Cardioverter Defibrillator Lead: A Case Report and Literature Review

Infectious myocarditis (IM) and infective endocarditis (IE), sometimes associated with infection of the surrounding mediastinal tissue or embolic complications caused by residual implantable cardioverter defibrillator (ICD) lead material embedded in the ventricle, present a significant challenge for cardiac surgeons due to the difficulty of precisely locating the old intracardiac pacing lead remnants because of the heart's continuous movement. We present the case of successful two-stage elective sternotomy extraction of two residual defibrillator leads, one trapped in the left innominate vein, easily removed after veinotomy without cardiopulmonary bypass (CPB), and the other embedded intramyocardially in the inferior wall of the right ventricle, successfully removed under CPB after fluoroscopic guidance. The patient was discharged four weeks post-operation without complications. In our case, transesophageal echocardiography (TEE) was not performed due to the patient's history of esophageal achalasia.

Lead Extraction in Children and Young Adults: When is the Best Time for Lead/System Replacement?

The best strategy for lead management in children is a matter of debate, and our experiences are limited. This is a retrospective single-center study comparing difficulties and outcomes of transvenous lead extraction (TLE) implanted ich childhood and at age < 19 years (childhood-implanted-childhood-extracted, CICE) and at age < 19 (childhood-implanted-adulthood-extracted, CIAE). CICE patients-71 children (mean age 15.1 years) as compared to CIAE patients (114 adults (mean age 28.61 years) were more likely to have VVI than DDD pacemakers. Differences in implant duration (7.96 vs 14.08 years) appeared to be most important, but procedure complexity and outcomes also differed between the groups. Young adults with cardiac implantable electronic device implanted in childhood had more risk factors for major complications and underwent more complex procedures compared to children. Implant duration was significantly longer in CIAE patients than in children, being the most important factor that had an impact on patient safety and procedure complexity. CIAE patients were more likely to have prolonged operative duration and more complex procedures due to technical problems, and they were 2-3 times more likely to require second-line or advanced tools compared to children, but the rates of clinical and procedural success were comparable in both groups. The difference between the incidence of major complications between CICE and CIAE patients is very clear (MC 2.9 vs 7.0%, hemopericardium 1.4 vs 5.3% etc.), although statistically insignificant. Delay of lead extraction to adulthood seems to be a riskier option than planned TLE in children before growing up.

Leadless pacemaker implantation after delayed atrial lead perforation and battery depletion: a case report

BACKGROUND

Delayed lead perforation is a rare complication of cardiac implantable electronic device (CIED). Clinical presentations range from completely asymptomatic to pericardial tamponade. Surgical lead extraction is recommended and transvenous lead extraction (TLE) with surgical backup is an alternative method.

CASE PRESENTATION

A male with paroxysmal atrial fibrillation and sick sinus syndrome implanted a dual-chamber pacemaker with two passive fixation lead. He was on oral anticoagulants and played golf for almost 1 h every day after implantation. However, he complained of thoracic stabbing in the sternal manubrium with abnormal findings on pacemaker interrogation. Imaging confirmed the perforated atrial electrode with lead tip protrusion from the pericardium adjacent to the inferior wall of the main right pulmonary artery, but without pericardial effusion. Lead removal by TLE with surgical support was suggested, but he refused. Given the stable conditions, conservative treatment was chosen in the absence of complications during a follow-up period of 14 years. Then ventricular lead failure and battery depletion appeared and a leadless pacemaker was implanted.

CONCLUSIONS

Chest pain in CIED with abnormal electrical parameters, especially ongoing treatment with anticoagulants and regular physical activity, should always raise suspicion of lead perforation. A conservative strategy may be appropriate and feasible for those in the absence of perforation-related complications. For patients with noninfectious abandoned leads and battery depletion after CIED, leadless pacemaker may be an alternative approach according to patient and provider preferences.

How to Approach Patients with Cardiac Implantable Electronic Devices and Bacteremia

The approach to a patient with a cardiac implantable electronic device (CIED) and bacteremia requires a high index of suspicion. The microorganism and duration of bacteremia affect the pretest probability of CIED infection. When transesophageal echocardiography findings are equivocal, fluorodeoxyglucose-PET/computed tomography can increase the sensitivity and specificity for CIED infection. Confirmed CIED infection warrants complete system extraction. In patients with persistent gram-positive bacteremia despite antimicrobial therapy and unclear involvement of the CIED, the device is sometimes empirically extracted. Long-term effects of extraction (such as risk of suboptimal/failed cardiac resynchronization therapy reimplant) should be factored into decisions regarding empiric CIED extraction.

Lead Extraction History, Training, Volume, and Location

Transvenous lead extraction (TLE) has evolved significantly since the introduction of cardiac pacing systems in the 1950s. The need for TLE has grown due to the increasing complexity of cardiac devices and patients, alongside rising infection rates and regulatory recalls. Despite its challenges, improved institutional support and advanced training programs have made TLE more accessible. Modern TLE indications are well-defined, evolving through scientific statements to include comprehensive lead management best practices and safety protocols. However, underutilization persists, particularly in infection management, highlighting the need for continued education and adherence to guidelines.

What Important Information Does Transesophageal Echocardiography Provide When Performed before Transvenous Lead Extraction?

Background: Transesophageal echocardiography (TEE) is mandatory before transvenous lead extraction (TLE), but its usefulness remains underestimated. This study aims to describe the broad range of TEE findings in TLE candidates, as well as their influence on procedure complexity, major complications (MCs) and long-term survival. Methods: Preoperative TEE was performed in 1191 patients undergoing TLE. Results: Lead thickening (OR = 1.536; p = 0.007), lead adhesion to heart structures (OR = 2.531; p < 0.001) and abnormally long lead loops (OR = 1.632; p = 0.006) increased the complexity of TLE. Vegetation-like masses on the lead (OR = 4.080; p = 0.44), lead thickening (OR = 2.389; p = 0.049) and lead adhesion to heart structures (OR = 6.341; p < 0.001) increased the rate of MCs. The presence of vegetations (HR = 7.254; p < 0.001) was the strongest predictor of death during a 1-year follow-up period. Conclusions: TEE before TLE provides a lot of important information for the operator. Apart from the visualization of possible vegetations, it can also detect various forms of lead-related scar tissue. Build-up of scar tissue and the presence of long lead loops are associated with increased complexity of the procedure and risk of MCs. Preoperative TEE performed outside the operating room may have an impact on the clinical decision-making process, such as transferring potentially more difficult patients to a more experienced center or having the procedure performed by the most experienced operator. Moreover, the presence of masses or vegetations on the leads significantly increases 1-year and all-cause mortality.

Computed tomography predictors of increased transvenous lead extraction difficulty

BACKGROUND

The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject.

OBJECTIVE

To identify CT characteristics associated with increased TLE difficulty.

METHODS

All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac-gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead-removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty.

RESULTS

A total of 343 patients were analyzed. The mean age of the study population was 63.8 ± 15.4 years; 71% were male. The mean lead dwell-in duration was 8.6 ± 5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead-removal fluoroscopy time (p = 0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p < 0.001, 95% CI: 2.54-10.46) and (odds ratio:3.72, p < 0.001, 95% CI: 1.89-7.35), respectively.

CONCLUSION

In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead-associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath.

Effective and safe mechanical transvenous lead extraction in a low-volume center

Background

Transvenous lead extraction (TLE) of cardiac implantable electronic devices was once deemed highly risky by high-volume centers. However, advancements in technology have significantly reduced the risk, making TLE a safer procedure in electrophysiology.

Objective

The purpose of this study was to examine the efficacy and safety of mechanical TLEs in a low-volume center with a single operator.

Methods

This study retrospectively accessed electronic medical records from the Tulane University School of Medicine system in New Orleans, Louisiana, and included patients who received mechanical TLE from 2016 to 2023. We analyzed the indications for TLE, patient characteristics, lead characteristics, success rate, and complications.

Results

We included 149 consecutive mechanical TLEs with an average implant duration of 105 months. A total of 53.7% (80) of TLEs were indicated for infectious reasons, and 37.6% (56) were high-voltage leads. Clinical success and complete procedural success rates were both 94.6% with no procedure-related mortality or major complications. The periprocedural mortality rate was 1.25% (1). Minor complications included a left chest pocket hematoma, a left groin hematoma, and urinary retention.

Conclusion

The efficacy and safety of mechanical TLEs performed in a low-volume center are comparable with those in high-volume centers.

Safety of magnetic resonance imaging in patients with cardiac implantable electronic devices and abandoned or epicardial leads: a systematic review and meta-analysis

AIMS

Persistent reluctance to perform magnetic resonance imaging (MRI) in patients with abandoned and/or epicardial leads of cardiac implantable electronic devices is related to in vitro studies reporting tip heating. While there is a plethora of data on the safety of MRI in conditional and non-conditional implantable devices, there is a clear lack of safety data in patients with abandoned and/or epicardial leads.

METHODS AND RESULTS

Relevant literature was identified in Medline and CINAHL using the key terms 'magnetic resonance imaging' AND 'abandoned leads' OR 'epicardial leads'. Secondary literature and cross-references were supplemented. For reporting guidance, the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 was used. International Prospective Register of Systematic Reviews (PROSPERO) registration number 465530. Twenty-one publications with a total of 656 patients with 854 abandoned and/or epicardial leads and 929 MRI scans of different anatomical regions were included. No scan-related major adverse cardiac event was documented, although the possibility of under-reporting of critical events in the literature should be considered. Furthermore, no severe device dysfunction or severe arrhythmia was reported. Mainly transient lead parameter changes were observed in 2.8% in the subgroup of patients with functional epicardial leads. As a possible correlate of myocardial affection, subjective sensations occurred mainly in the subgroup with abandoned epicardial leads (4.0%), but no change in myocardial biomarkers was observed.

CONCLUSION

Existing publications did not report any relevant adverse events for MRI in patients with abandoned and/or epicardial leads if performed according to strict safety guidelines. However, a more rigorous risk-benefit calculation should be made for patients with epicardial leads.

Case Series and Review of Literature for Superior Vena Cava Injury During Laser Lead Extraction

Transvenous laser lead extraction poses a risk of major complications (0.19%-1.8%), notably injury to the superior vena cava (SVC) in 0.19% to 0.96% of cases. Various factors contribute to SVC injury, which can be categorized as patient-related (such as female gender, low body mass index, diabetes, renal problems, anemia, and reduced ejection fraction), device-related (including the number, dwell time, and type of leads), or procedural-related (such as reason for extraction, venous obstructions, and bilateral lead placements).

Open Chest Approach Lead Extraction in a Patient with a Large Vegetation: The Importance of Multidisciplinary Approach, Advanced Imaging, and Procedural Planning

We present a complex case of cardiac implantable electronic device infection and extraction in the setting of bacteremia, large lead vegetation, and patent foramen ovale. Following a comprehensive preprocedural workup including transesophageal echocardiogram and computed tomography lead extraction protocol, in addition to the involvement of multiple subspecialties, an open chest approach to extraction was deemed a safer option for eradication of the patient's infection. Despite percutaneous techniques having evolved as the preferred extraction method during the last few decades, this case demonstrates the importance of a thorough evaluation at an experienced center to determine the need for open chest extraction.

Successful left ventricular lead placement by way of an azygos vein for a patient performing cardiac resynchronization therapy implantation with an occluded left subclavian vein: A case report

Central venous obstruction following pacemaker implantation is not uncommon and can prove challenging in the case of a system upgrade to a cardiac resynchronization therapy pacemaker (CRT-P). We describe the case of a patient who underwent a successful upgrading procedure of a pacemaker to a CRT-P in the presence of an occluded left subclavian vein and superior vena cava, using collateral veins that drained into right atrium.

Inflammatory biomarkers as predictors of systemic vs isolated pocket infection in patients undergoing transvenous lead extraction

Background

Cardiovascular implantable electronic device (CIED) infections are a common indication for device extraction. Early diagnosis and complete system removal are crucial to reduce morbidity and mortality. The lack of clear infectious symptoms makes the diagnosis of pocket infections challenging and may delay referral for extraction.

Objective

We aimed to determine if inflammatory biomarkers can help diagnose CIED isolated pocket infection.

Methods

We performed a retrospective analysis of all patients undergoing transvenous lead extraction for CIED infection at the University of California San Diego from 2012 to 2022 (N = 156). Patients were classified as systemic infection (n = 88) or isolated pocket infection (n = 68). Prospectively collected preoperative procalcitonin (PCT), C-reactive protein, and white blood cell count were compared between groups.

Results

Pairwise comparisons revealed that the systemic infection group had a higher PCT than the control group (P < .001) and the pocket infection group (P = .009). However, there was no significant difference in PCT value between control subjects and isolated pocket infection subjects. Higher white blood cell count was only associated with systemic infection when compared with our control group (P = .018).

Conclusion

In patients diagnosed with CIED infections requiring extraction, inflammatory biomarkers were not elevated in isolated pocket infection. Inflammatory markers are not predictive of the diagnosis of pocket infections, which ultimately requires a high level of clinical suspicion.

Leads with the Cut Proximal Ends Migrated into the Heart and Vasculature: A Rare Phenomenon among 3847 Lead Extraction Procedures

Background: The study aimed to describe the phenomenon of leads migrated (MPLE) into the cardiovascular system (CVS). Methods: Retrospective analysis of 3847 transvenous lead extractions (TLE). Results: Over a 17-year period, 72 (1.87%) MPLEs (median dwell time 137.5 months) were extracted, which included mainly ventricular leads (56.94%). Overall, 68.06% of MPLEs had their cut proximal ends in the venous system. Most of them were pacing (95.83%) and passive fixation (98.61%) leads. Independent risk factors for MPLE included abandoned leads (OR = 8.473; p < 0.001) and leads located on both sides of the chest (2.981; p = 0.045). The higher NYHA class lowered the probability of MPLE (OR = 0.380; p < 0.001). Procedure complexity was higher in the MPLE group (procedure duration, unexpected procedure difficulties, use of additional (advanced) tools and alternative venous approach). There were no more major complications in the MPLE group, but the rate of procedural success was lower due to more frequent retention of non-removable lead fragments. Extraction of MPLEs did not influence long-term survival. Conclusions: 1. Extraction of leads with MPLE is rare among other TLE procedures (1.9%), 2. risk factors include abandoned leads and presence of leads on both sides of the chest but a higher NYHA class lowers the probability of MPLE, 3. complexity of MPLE extraction is higher regarding procedure duration, unexpected procedure difficulties, use of advanced tools and techniques but rates of major complications are comparable, and 4. extraction of MPLEs did not influence long-term survival.

Lead Break during Extraction: Predisposing Factors and Impact on Procedure Complexity and Outcome: Analysis of 3825 Procedures

Background: Currently, there are no reports describing lead break (LB) during transvenous lead extraction (TLE). Methods: This study conducted a retrospective analysis of 3825 consecutive TLEs using mechanical sheaths. Results: Fracture of the lead, defined as LB, with a long lead fragment (LF) occurred in 2.48%, LB with a short LF in 1.20%, LB with the tip of the lead in 1.78%, and LB with loss of a free-floating LF in 0.57% of cases. In total, extractions with LB occurred in 6.04% of the cases studied. In cases in which the lead remnant comprises more than the tip only, there was a 50.31% chance of removing the lead fragment in its entirety and an 18.41% chance of significantly reducing its length (to less than 4 cm). Risk factors for LB are similar to those for major complications and increased procedure complexity, including long lead dwell time [OR = 1.018], a higher LV ejection fraction, multiple previous CIED-related procedures, and the extraction of passive fixation leads. The LECOM and LED scores also exhibit a high predictive value. All forms of LB were associated with increased procedure complexity and major complications (9.96 vs. 1.53%). There was no incidence of procedure-related death among such patients, and LB did not affect the survival statistics after TLE. Conclusions: LB during TLE occurs in 6.04% of procedures, and this predictable difficulty increases procedure complexity and the risk of major complications. Thus, the possibility of LB should be taken into account when planning the lead extraction strategy and its associated training.

Analysis of 1051 ICD Leads Extractions in Search of Factors Affecting Procedure Difficulty and Complications: Number of Coils, Tip Fixation and Position-Does It Matter?

Background: Implantable cardioverter-defibrillator (ICD) leads are considered a risk factor for major complications (MC) during transvenous lead extraction (TLE). Methods: We analyzed 3878 TLE procedures (including 1051 ICD lead extractions). Results: In patients with ICD lead removal, implant duration was almost half as long (69.69 vs. 114.0 months; p < 0.001), procedure complexity (duration of dilatation of all extracted leads, use of more advanced tools or additional venous access) (15.13% vs. 20.78%; p < 0.001) and MC (0.67% vs. 2.62%; p < 0.001) were significantly lower as compared to patients with pacing lead extraction. The procedural success rate was higher in these patients (98.29% vs. 94.04%; p < 0.001). Extraction of two or more ICD leads or additional superior vena cava (SVC) coil significantly prolonged procedure time, increased procedure complexity and use of auxiliary or advanced tools but did not influence the rate of MC. The type of ICD lead fixation and tip position did not affect TLE complexity, complications and clinical success although passive fixation reduces the likelihood of procedural success (OR = 0.297; p = 0.011). Multivariable regression analysis showed that ICD lead implant duration ≥120 months (OR = 2.956; p < 0.001) and the number of coils in targeted ICD lead(s) (OR = 2.123; p = 0.003) but not passive-fixation ICD leads (1.361; p = 0.149) or single coil ICD leads (OR = 1.540; p = 0.177) were predictors of higher procedure complexity, but had no influence on MC or clinical and procedural success. ICD lead implant duration was of crucial importance, similar to the number of leads. Lead dwell time >10 years is associated with a high level of procedure difficulty and complexity but not with MC and procedure-related deaths. Conclusions: The main factors affecting the transvenous removal of ICD leads are implant duration and the number of targeted ICD leads. Dual coil and passive fixation ICD leads are a bit more difficult to extract whereas fixation mechanism and tip position play a much less dominant role.

Do Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death in End-Stage Renal Disease Patients on Dialysis?

Chronic kidney disease patients appear to be predisposed to heart rhythm disorders, including atrial fibrillation/atrial flutter, ventricular arrhythmias, and supraventricular tachycardias, which increase the risk of sudden cardiac death. The pathophysiological factors underlying arrhythmia and sudden cardiac death in patients with end-stage renal disease are unique and include timing and frequency of dialysis and dialysate composition, vulnerable myocardium, and acute proarrhythmic factors triggering asystole. The high incidence of sudden cardiac deaths suggests that this population could benefit from implantable cardioverter-defibrillator therapy. The introduction of implantable cardioverter-defibrillators significantly decreased the rate of all-cause mortality; however, the benefits of this therapy among patients with chronic kidney disease remain controversial since the studies provide conflicting results. Electrolyte imbalances in haemodialysis patients may result in ineffective shock therapy or the appearance of non-shockable underlying arrhythmic sudden cardiac death. Moreover, the implantation of such devices is associated with a risk of infections and central venous stenosis. Therefore, in the population of patients with heart failure and severe renal impairment, periprocedural risk and life expectancy must be considered when deciding on potential device implantation. Harmonised management of rhythm disorders and renal disease can potentially minimise risks and improve patients' outcomes and prognosis.

Multilevel Venous Obstruction in Patients with Cardiac Implantable Electronic Devices

Background and Objectives: The nature of multilevel lead-related venous stenosis/occlusion (MLVSO) and its influence on transvenous lead extraction (TLE) as well as long-term survival remains poorly understood. Materials and Methods: A total of 3002 venograms obtained before a TLE were analyzed to identify the risk factors for MLVSO, as well as the procedure effectiveness and long-term survival. Results: An older patient age at the first system implantation (OR = 1.015; p < 0.001), the number of leads in the heart (OR = 1.556; p < 0.001), the placement of the coronary sinus (CS) lead (OR = 1.270; p = 0.027), leads on both sides of the chest (OR = 7.203; p < 0.001), and a previous device upgrade or downgrade with lead abandonment (OR = 2.298; p < 0.001) were the strongest predictors of MLVSO. Conclusions: The presence of MLVSO predisposes patients with cardiac implantable electronic devices (CIED) to the development of infectious complications. Patients with multiple narrowed veins are likely to undergo longer and more complex procedures with complications, and the rates of clinical and procedural success are lower in this group. Long-term survival after a TLE is similar in patients with MLVSO and those without venous obstruction. MLVSO probably better depicts the severity of global venous obstruction than the degree of vein narrowing at only one point.

VDD Lead Extraction-Differences with Other Leads and Practical Tips in Management

Background: VDD (atrial sensing, ventricular sensing/pacing) leads are relatively rarely implanted; therefore, experience in their extraction is very limited. We aimed to investigate whether VDD lead removal may be a risk factor for the increased complexity of transvenous lead extraction (TLE) or major complications. Methods: We retrospectively analyzed 3808 TLE procedures (including 103 patients with VDD leads). Results: If TLE included VDD lead removal, procedure duration (lead dilation time) was prolonged, complicated extractions were slightly more common, and more advanced tools were required. This is partly due to longer implant duration (in patients with VDD systems-135.2 months; systems without VDD leads-109.3 months; p < 0.001), more frequent presence of abandoned leads (all systems containing VDD leads-22.33% and all systems without VDD leads-10.77%), and partly to the younger age of patients with VDD leads (51.74 vs. 57.72 years; p < 0.001, in the remaining patients) at the time of system implantation. VDD lead extraction does not increase the risk of major complications (1.94 vs. 2.34%; p = 0.905). Conclusions: The extraction of VDD leads may be considered a risk factor for increased procedure complexity, but not for major complications. However, this is not a direct result of VDD lead extraction but specific characteristics of the patients with VDD leads. Operator skill and team experience combined with special custom maneuvers can enable favorable results to be achieved despite the specific design of VDD leads, even with older VDD lead models.

LECOM (Lead Extraction COMplexity): A New Scoring System for Predicting a Difficult Procedure

(1) Background: Transvenous lead extraction (TLE) can become far more complex when unanticipated difficulties arise. The aim was to develop a simple scoring system that allows for the prediction of the difficulty and complexity of this significant procedure. (2) Methods: Based on analysis of 3741 TLE procedures with and without complicating factors (extended fluoroscopy time, need for second-line instruments, and advanced techniques and instruments), a five-point Complex Indicator of Difficulty of (TLE) Procedure (CID-TLEP) scale was developed. Two or more points on the CID-TLEP scale indicate a higher level of procedure complexity. (3) Results: Patient age below 51 years at first CIED implantation, number of abandoned leads, number of previous procedures, passive fixation and multiple leads to be extracted, and a ratio of dwell time of oldest lead to patient age during TLE of >0.13 are significant predictors of higher levels of lead extraction complexity. The ROC analysis demonstrates that a point total (being the sum of the odds ratios of the above variables) of >9.697 indicates a 21.83% higher probability of complex TLE (sensitivity 74.08%, specificity 74.46%). Finally, a logistic function was calculated, and we constructed a simple equation for lead extraction complexity that can predict the probability of a difficult procedure. The risk of complex extraction (as a percentage) is calculated as [1/(1 + 55.34 · 0.754X)] · 100 (p < 0.001). (4) Conclusion: The LECOM score can effectively predict the risk of a difficult transvenous lead extraction procedure, and predicting the probability of a more complex procedure may help clinicians in planning lead removal and improving patient management.

Long-term outcomes of abandoned leads of cardiac implantable electronic devices

BACKGROUND

Evidence of the long-term outcomes of abandoned leads (ALs) in patients with cardiac implantable electronic devices (CIEDs) is scarce.

OBJECTIVE

This study aimed to investigate the long-term outcomes of ALs.

METHODS

This retrospective cohort study reviewed a single-center CIED registry of 2962 procedures performed from 1984-2018 and identified 130 patients with AL (AL group). We matched 2 controls without AL (by age, sex, device type, and device revision/removal date) to each patient with AL (n = 260) and compared CIED-related infection, venous thrombosis/stenosis, and all-cause mortality between groups using a Cox proportional hazard model analysis.

RESULTS

For a mean follow-up period of 11.2 ± 8.2 years, 14 (3.6%), 7 (1.8%), and 143 (36.7%) patients had a CIED-related infection, venous thrombosis/stenosis, or experienced all-cause mortality, respectively. The AL group had more comorbidities than the control group. Lead malfunction was the most common cause of abandonment (64.6%). After adjustment for covariates, no significant intergroup differences were noted in the risks of infection, venous thrombosis/stenosis, or all-cause mortality (adjusted hazard ratio [aHR] 2.52; 95% confidence interval [CI] 0.77-8.25; aHR 1.18; 95% CI 0.25-5.64; aHR 1.26; 95% CI 0.89-1.80, respectively). Patients with multiple ALs had increased risks of infection and all-cause mortality vs controls (aHR 8.61; 95% CI 2.13-34.84; aHR 2.42; 95% CI 1.17-5.00, respectively).

CONCLUSION

Patients with a single AL showed similar risks of CIED-related infections, venous thrombosis/stenosis, and all-cause mortality as those without ALs, whereas those with multiple ALs showed increased risks of infection and all-cause mortality.

Misplacement of pacemaker leads: How to avoid and how to approach?

The use of cardiac implantable electronic devices has increased in recent years due to factors such as a growing population, increased life expectancy, and improved access to healthcare services. In parallel with this trend, complications related to pacemakers have also increased. One of the most important and preventable complications among these is lead misplacement. Misplacement of a permanent pacemaker lead in the LV can lead to a variety of complications, including damage to the heart muscle, arrhythmias, blood clotes and cerebrovascular events. It is recommended to use the fluoroscopic 40° LAO view during implantation. That view clearly defines the interatrial and interventricular septum. Right bundle branch block pattern on ECG is an important clue to suspected misplaced lead. In addition to the postero-anterior (PA) projection of x-ray, the latero-lateral (LL) projection provides a clearer view of lead malposition. In the LL view, the tip of an incorrectly positioned LV lead is characteristically directed toward the spine. If diagnosed soon after implantation, percutaneous lead extraction can reduce the risk of future thromboembolic events without the need for lifelong anticoagulation. It should be noted that in cases with a lead in the LV for a long time, lead removal is not the primary recommendation. Patient-based approach should be fundamental.

Associated factors and outcomes of crossover from a laser sheath to a bidirectional rotational mechanical sheath during transvenous lead extraction

Background

During transvenous lead extraction (TLE), a GlideLight laser sheath (Philips) cannot always be advanced over the lead, and crossover to the Evolution system (i.e., an Evolution RL sheath or Evolution Shortie RL sheath [Cook Medical]) is required. We aimed to determine the associated factors and outcomes of such device crossover.

Methods

This observational study included 112 patients who underwent TLE. The patients were divided into crossover and non-crossover groups. Outcomes and associated factors of crossover were evaluated.

Results

Overall, 57 (50.9%) patients required crossover to the Evolution system (crossover group), whereas 55 (49.1%) patients did not require crossover (non-crossover group). Clinical success rate was similar between the two groups (98.3% vs. 100%; p = 1.00). No major intraprocedural complications related to powered sheaths occurred. Multivariate logistic regression analysis results showed that dwell time of the oldest extracted lead (per year) (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02-1.36; p = .026), number of leads extracted per procedure (OR: 7.23, 95% CI: 1.74-29.99; p = .007), and use of a femoral approach (OR: 21.09, 95% CI: 2.33-190.67; p = .007) were associated factors of crossover. The cutoff for crossover was 7.7 years from the implant (sensitivity 90.5%, specificity 64.9%, area under the curve 0.80).

Conclusions

Both groups showed a high rate of clinical success. Switching to the Evolution system may facilitate a safe and effective TLE when a laser sheath does not advance despite laser activation.

Lead management in patients undergoing percutaneous tricuspid valve replacement or repair: a 'heart team' approach

Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads.

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Transvenous Lead Extraction: Outcomes From a Single Centre Providing a National Service for New Zealand

BACKGROUND

With increasing demand for cardiac implantable electronic devices there is a parallel increase in the need for transvenous lead extraction (TLE). Due to its small population, all TLE procedures in New Zealand are currently performed in a single centre, Auckland City Hospital. We analysed the clinical characteristics and outcomes of those undergoing TLE since this service was established.

METHODS

We performed a retrospective, single-centre cohort study of all TLE procedures between October 2015 and December 2021. Definitions from the European Lead Extraction Controlled study, Heart Rhythm Society, European Heart Rhythm Association consensus documents were used.

RESULTS

A total of 247 patients had 480 leads extracted, averaging 40 TLE procedures annually. Patients had a median lead dwell time of 6 (interquartile range [IQR] 3-11) years, 60 (13%) of leads had been in-situ >15 years, median age 61 (IQR 48-70) years, 73 (30%) female, 28 (11%) Māori, 23 (9%) Pasifika. Lead dysfunction (115 patients, 47%) and infection (90 patients, 37%) were the most common indications for TLE. Complete clinical and radiological success was achieved for 96% and 95%, respectively. Procedure-related complications occurred in 16 (7%) patients. Major intra-procedure complications occurred in 5 patients (2%), including 2 (1%) deaths. Death within one year of TLE occurred in 13 (26%) with systemic infection, 5 (3%) with local infection, and 5 (3%) with non-infection indications for TLE, p <0.01.

CONCLUSIONS

TLE is associated with high radiographic and clinical success, low complication, and low mortality rate. At our single centre providing a national service, TLE outcomes are comparable with those achieved internationally.

Single center experience with the novel rotating dilator sheath TightRailTM Sub-C in transvenous lead extraction

INTRODUCTION

Transvenous lead extraction has become a frequent procedure in the context of device lead management and various tools are available. The aim of this study was to investigate the efficacy and safety of the novel short rotating dilator sheath TightRailTM Sub-C (Sub-C) in transvenous lead extraction.

METHODS

For this retrospective single-center analysis, we included consecutive patients undergoing transvenous lead extraction using the Sub-C from January 2018 until February 2020 at the University Heart Center Zurich.

RESULTS

A total of 87 leads were extracted within 45 patients using the Sub-C extraction sheath. The mean dwell time of the leads was 112 ± 9.1 months. Complete procedural success was achieved in 95.6% (43/45) and clinical procedural success in 97.8% (44/45). Two major complications (4.4%, 2/45) occurred, but neither was directly related to the Sub-C.

CONCLUSION

This retrospective single-center analysis suggests that transvenous lead extraction with a routine use of the TightRailTM Sub-C extraction sheath is a safe strategy resulting in high success rates that may offer useful theoretical benefits. Future studies are needed to evaluate the incremental benefit of a routine use of short extraction sheaths including the Sub-C during TLE procedures.

Cardiologist-Directed Sedation Management in Patients Undergoing Transvenous Lead Extraction: A Single-Centre Retrospective Analysis

BACKGROUND

The demand for transvenous lead extraction (TLE) has increased. In line with this, the safety of such procedures has also increased. Traditionally, TLE is performed under resource-intensive general anaesthesia. This study aims to evaluate the safety and outcomes of Cardiologist-lead deep sedation for TLE.

METHODS

We retrospectively analysed 328 TLE procedures performed under deep sedation from 2016 to 2019. TLE procedures were performed by experienced electrophysiologists. Sedation was administered by a specifically trained cardiologist (bolus midazolam/fentanyl and propofol infusion). Procedural sedation data including blood pressure, medication administration and sedation time were collected. Complications related to sedation and the operative component of the procedure were analysed retrospectively.

RESULTS

The sedation-associated complication rate during TLE was 22.0%. The most common complication (75% of complications) was hypotension requiring noradrenaline, followed by bradycardia requiring atropine (13% of complications). Additionally, the unplanned presence of an anaesthesiologist was needed in one case (0.3%). Deep sedation was achieved with midazolam (mean dose 42.9 ± 26.5 µg/kg), fentanyl (mean dose 0.4 ± 0.6 µg/kg) and propofol (mean dose 3.5 ± 1.2 mg/kg/h). There was no difference in medication dosage between those with a sedation-associated complication and those without. Sedation-associated complications appeared significantly more in patients with reduced LVEF (p = 0.01), renal impairment (p = 0.01) and a higher American Society of Anaesthesiologists (ASA) class (p = 0.01).

CONCLUSION

Deep sedation for TLE can be safely performed by a specifically trained cardiologist, with a transition to general anaesthesia required in only 0.3% of cases. We continue to recommend the on-call availability of an anaesthesiologist and cardiac surgeon in case of major complications.

Utility of a multipurpose catheter for transvenous extraction of old broken leads: A novel technique for fragile leads

BACKGROUND

Transvenous lead extraction has been possible since the 1980s. However, complications during lead extraction, such as the distal end fragment of the lead remaining in the myocardium or venous system and injury to the veins or heart, have been reported.

OBJECTIVE

The purpose of this study was to examine our method for complete removal of a separated lead, as extraction of long-term implanted devices is difficult using standard methods and may require additional procedures. The removal of leads with inner conductor coil and lead tip separated from outer insulation, conductor coil, and proximal ring electrode using a multipurpose catheter is reported.

METHODS

In total, 345 consecutive patients who underwent transvenous lead extraction (TLE) from April 2014 to March 2021 were retrospectively analyzed. Lead characteristics, device type, and indications for extraction were further analyzed in 20 patients who developed separation of the proximal ring electrode and outer conductor coil from the inner conductor and distal tip at the time of extraction.

RESULTS

Extractions were performed using an excimer laser sheath laser and a Byrd polypropylene telescoping sheath (n = 15); laser, Byrd polypropylene telescoping sheath, and Evolution RL (n = 2); laser and Evolution RL (n = 3); Byrd polypropylene telescoping sheath and Evolution RL (n = 1); Byrd polypropylene telescoping sheath only (n = 4); and Evolution RL only (n = 2). Twenty-seven leads implanted for more than 10 years had lead separation. A multipurpose catheter was used to protect the fragile leads from further damage. All leads were completely extracted.

CONCLUSION

All distal tip-to-proximal ring electrode separated leads were successfully removed using laser and other sheaths with the assistance of a multipurpose catheter, without any part of the leads remaining in the heart.

Complicated Pocket Infection in Patients Undergoing Lead Extraction: Characteristics and Outcomes

Cardiac implantable electronic device (CIED) infection can present with pocket or systemic manifestations, both necessitating complete device removal and pathogen-directed antimicrobial therapy. Here, we aim to characterize those presenting with both pocket and systemic infection. A retrospective analysis of CIED extraction procedures included 300 patients divided into isolated pocket (n = 104, 34.7%), complicated pocket (n = 54, 18%), and systemic infection (n = 142, 47.3%) groups. The systemic and complicated pocket groups frequently presented with leukocytosis and fever > 37.8, as opposed to the isolated pocket group. Staphylococcus aureus was the most common pathogen in the systemic and complicated pocket groups (43.7% and 31.5%, respectively), while Coagulase-negative staphylococci (CONS) predominated (31.7%) in the isolated pocket group (10.6%, p < 0.001). No differences were observed in procedural success or complications rates. Kaplan-Meier survival analysis found that at three years of follow-up, the rate of all-cause mortality was significantly higher among patients with systemic infection compared to both pocket groups (p < 0.001), with the curves diverging at thirty days. In this study, we characterize a new entity of complicated pocket infection. Despite the systemic pattern of infection, their prognosis is similar to isolated pocket infection. We suggest that this special category be presented separately in future publications of CIED infections.

Use of Taurolidine in a Patient With a Cardiac Implantable Electronic Device Protrusion

We report the successful salvage of cardiac implantable electronic device pulse generator protrusion sealed by the surrounding skin in a frail patient presenting 5 months after the last surgical revision. (Level of Difficulty: Advanced.).

Superior vena cava tear during transvenous lead extraction: Medical management in hemodynamically stable patients

INTRODUCTION

Superior vena cava (SVC) tear is the most lethal complication during transvenous lead extraction (TLE) with a mortality rate as high as 50%. Treatment involves aggressive attempts to maintain cardiac output and immediate sternotomy to localize and repair the vascular tear. Occlusion balloons have been developed to provisionally occlude the lacerated SVC and to provide hemodynamic stability allowing time for surgery. In case of mediastinal hematoma without hemodynamic instability, the strategy remains unclear.

METHODS AND RESULTS

We describe two cases of SVC tear during TLE. The first case was a 60-year-old man who presented with a right ventricular single-chamber defibrillator lead fracture and innominate vein stenosis. The RV lead was removed using a laser sheath causing a mediastinal hematoma with no active bleeding during surgical exploration few hours later. The second case was a 28-year-old man that presented with a right atrial (RA) lead fracture and RV lead insulation failure in a dual-chamber defibrillator (ICD).

CONCLUSION

Both the RA and RV leads were removed with mechanical sheaths, and a mediastinal hematoma was medically managed.

Long-term outcomes following transvenous lead extraction: Data from a tertiary referral center

BACKGROUND

Transvenous lead extraction (TLE) has shown a safe and efficacy profile in the intraoperative and short-term setting; however, data on long-term outcomes are limited.

OBJECTIVE

The purpose of this study was to assess long-term outcomes and prognostic factors in patients who underwent TLE.

METHODS

Consecutive patients with cardiac implantable electronic device (CIED) who underwent TLE between 2014 and 2016 were retrospectively studied. The primary outcome was the composite endpoint of death and repeated TLE stratified by infective/non-infective indication. Individual components of the primary outcome were also evaluated.

RESULTS

One hundred ninety-one patients were included in the analysis, 50% extracted for CIED-related infection. Complete procedural success was achieved in 189 patients (99%) with no major acute complications. After a median of 6.5 years, infection indication was associated with significantly lower event-free survival (67% vs. 83% non-infection group, adjusted hazard ratio [aHR] 1.97, 95% confidence interval [CI] 1.02-3.81, p = 0.04). All-cause mortality rate was higher in the TLE infection group (30% vs. 10%, p < 0.01). The rate of repeated TLE did not differ between groups (4% vs. 7%, p = 0.62). Among patients who had TLE for infection, the presence of vegetation (aHR 2.56; 95%CI 1.17-5.63, p = 0.02) and positive blood cultures (aHR 2.64; 95%CI 1.04-6.70, p = 0.04) were independently associated with the primary outcome.

CONCLUSION

Patients who underwent TLE for CIED-related infection exhibit a high mortality risk during long-term follow-up. Vegetation and positive blood cultures in patients with CIED-related infection are associated with a worse prognosis regardless of successful and uncomplicated TLE.

Incomplete Lead Removal During the Extraction Procedure: Predisposing Factors and Impact on Long-Term Survival in Infectious and Non-Infectious Cases: Analysis of 3741 Procedures

BACKGROUND

The long-term significance of lead remnants (LR) following transvenous lead extraction (TLE) remains disputable, especially in infectious patients.

METHODS

Retrospective analysis of 3741 TLEs focused on the relationship between LR and procedure complexity, complications and long-term survival.

RESULTS

The study group consisted of 156 individuals with LR (4.17%), and the control group consisted of 3585 patients with completely removed lead(s). In a multivariable model, a younger patient age at CIED implantation, more CIED procedures and procedure complexity were independent risk factors for retention of non-removable LR. Although patients with LR showed better survival outcomes following TLE (log rank p = 0.041 for non-infectious group and p = 0.017 for infectious group), multivariable Cox regression analysis did not confirm the prognostic significance of LR either in non-infectious [HR = 0.777; p = 0.262], infectious [HR = 0.983; p = 0.934] or the entire group of patients [HR = 0.858; p = 0.321].

CONCLUSIONS

1. Non-removable LRs are encountered in 4.17% of patients. 2. CIED infection has no influence on retention of LRs, but younger patient age, multiple CIED-related procedures and higher levels of procedure complexity are independent risk factors for the presence of LR. 3. Better survival outcomes following TLE in patients with LRs are not the effects of their presence but younger patient and better health status.

Unexpected Procedure Difficulties Increasing the Complexity of Transvenous Lead Extraction: The Single Centre Experience with 3721 Procedures

BACKGROUND

Transvenous lead extraction (TLE) should be completed, even when facing difficulties which have yet to be described. The aim was to explore unexpected TLE obstacles (the circumstances of the occurrence and influence on TLE outcome).

METHODS

The retrospective analysis of a single centre database containing 3721 TLEs.

RESULTS

Unexpected procedure difficulties (UPDs) occurred in 18.43% of cases (singles in 12.20% of cases and multiples in 6.26% of cases). These included blockages in the lead venous approach in3.28% of cases, functional lead dislodgement in 0.91% of cases, and loss of broken lead fragment in 0.60% of cases. All of them, including implant vein-in 7.98% of cases, lead fracture during extraction-in 3.84% of cases, and lead-to-lead adherence-in 6.59% of cases, Byrd dilator collapse-in 3.41% of cases, including the use of an alternative prolonged the procedure but had no influence on long-term mortality. Most of the occurrences were associated with lead dwell time, younger patient age, lead burden, and poorer procedure effectiveness and complications (common cause). However, some of the problems seemed to be related to cardiac implantable electronic devices (CIED) implantation and the subsequent lead management strategy. A more complete list of all tips and tricks is still required.

CONCLUSIONS

(1) The complexity of the lead extraction procedure combines both prolonged procedure duration and the occurrence of lesser-known UPDs. (2) UPDs are present in nearly one fifth of the TLE procedures, and can occur simultaneously. (3) UPDs, which usually force the extractor to expand the range of techniques and tools, should become part of the training in transvenous lead extraction.

Early Lead Extraction for Infected Implanted Cardiac Electronic Devices: JACC Review Topic of the Week

Infection remains a serious complication associated with the cardiac implantable electronic devices (CIEDs), leading to substantial clinical and economic burden globally. This review assesses the burden of cardiac implantable electronic device infection (CIED-I), evidence for treatment recommendations, barriers to early diagnosis and appropriate therapy, and potential solutions. Multiple clinical practice guidelines recommended complete system and lead removal for CIED-I when appropriate. CIED extraction for infection has been consistently reported with high success, low complication, and very low mortality rates. Complete and early extraction was associated with significantly better clinical and economic outcome compared with no or late extraction. However, significant gaps in knowledge and poor recommendation compliance have been reported. Barriers to optimal management may include diagnostic delay, knowledge gaps, and limited access to expertise. A multipronged approach, including education of all stakeholders, a CIED-I alert system, and improving access to experts, could help bring paradigm shift in the treatment of this serious condition.

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.

Efficacy and safety of the extraction of cardiostimulation leads using a mechanical dissection tool. A single center experience

BACKGROUND

The percutaneous extraction of endovascular cardiostimulation and defibrillation leads is the most frequent technique nowadays. The tools used today must guarantee the success of the procedure, with the minimum of complications. Our objective was to analyze the safety and efficacy of lead extraction using the Evolution mechanical dissection tool (Cook Medical, USA).

METHODS

A retrospective study was carried out in a total of 826 consecutive patients from October 2009 to December 2018 who underwent the procedure with the Evolution mechanical dissection tool. Preoperative study included complete blood tests, echocardiogram, and chest X-ray. The procedures were performed in the operating room, under general anesthesia and echocardiographic control.

RESULTS

A total of 1227 leads were extracted with a mean chronicity of 10.3 ± 5.1 years. Clinical success (CS) rate was 99.7%. A total of 16 (1.9%) complications occurred, 2 (0.24%) were major complications and 14 (1.7%) were minor complications. There was no operative mortality. There was no statistically significant relationship between implant chamber and complete efficacy. The complete extraction was achieved in all left ventricular leads, in 762 of 774 (98.45%) of right ventricular lead removal, and in 330 of 334 (98.8%) of right atrial leads (p = .31).

CONCLUSION

In our experience, percutaneous extraction of intravenous leads via the use of the Evolution tool (Cook Medical, USA), is a very effective and safe technique that offers low morbidity and mortality.

A leadless pacemaker in the real-world setting: Patient profile and performance over time

Background

While prior Micra trials demonstrated a high implant success rate and favorable safety and efficacy results, changes in implant populations and safety over time is not well studied. The objective of this analysis was to report the performance of Micra in European and Middle Eastern patients and compare to the Micra Investigational Device Exemption (IDE) and Micra Post Approval Registry (PAR) studies.

Methods

The prospective, single-arm Micra Acute Performance European and Middle Eastern (MAP EMEA) registry was designed to further study the performance of Micra in patients from EMEA. The primary endpoint was to characterize acute (30-day) major complications. Electrical performance was analyzed. The major complication rate through 12 months was compared with the IDE and PAR studies.

Results

The MAP EMEA cohort (n = 928 patients) had an implant success rate of 99.9% and were followed for an average of 9.7 ± 6.5 months. Compared to prior studies, MAP EMEA patients were more likely to have undergone dialysis and have a condition which precluded the use of a transvenous pacemaker (p < .001). Within 30 days of implantation, the MAP EMEA cohort had a major complication rate of 2.59%. Mean pacing thresholds were low and stable through 12 months (0.61 ± 0.40 V at 0.24 ms at implant and 12 months). Through 12 months post-implantation, the major complication rate for MAP EMEA was not significantly different from IDE (p = .56) or PAR (p = .79).

Conclusion

Despite patient differences over time, the Micra leadless pacemaker was implanted with a high success rate and low complication rate, in-line with prior reports.

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.

A Rare Case of Persistent Bacteremia: Leadless Micra Pacemaker Endocarditis

Leadless pacing systems have revolutionized the field of electrophysiology given its low complication rates and almost non-existent rate of infections compared with traditional pacemakers. These devices boast resistance to infections given its unique features; however, as described in this report, device-related infection from these leadless devices is still possible. In patients with leadless pacing system that is persistently bacteremic in the future, evaluation of the device with transesophageal echocardiogram or intracardiac echocardiography should be performed, and if vegetation is noted on the device, device extraction should highly be considered, along with empiric intravenous antibiotics. Lastly, new leadless device should not be re-implanted within 2 weeks of the removal of the infected device to prevent seeding of the new device.

Case report: Left ventricular perforation caused by right ventricular pacemaker lead

Background

Perforation of the interventricular septum and left ventricular (LV) free wall by a right ventricular (RV) lead is an extremely rare and potentially life-threatening complication. In this case report, we discussed the diagnosis and management of a very unusual complication of pacemaker (PM) implantation, i.e., LV perforation brought on by an RV pacing lead.

Case summary

A 92-year-old man was admitted to Xiangyang No.1 People's Hospital due to a complete atrioventricular block. We performed a dual-chamber PM implantation; however, on the second postoperative day (POD), pacemaker failure occurred. Thoracic computed tomography (CT) scan showed that RV lead had pierced the interventricular septum and LV free wall. A transvenous lead extraction of the penetrating lead was performed uneventfully, and RV lead was refixed at the lower RV septum on the 5th POD.

Discussion

Identification of high-risk patients is mandatory to prevent this serious complication, and transvenous lead extraction with cardiac surgery backup may be an option.

Molecular Imaging of Valvular Diseases and Cardiac Device Infection

The use of positron emission tomography imaging with 18F-fluorodeoxyglucose in the diagnostic workup of patients with suspected prosthetic valve endocarditis and cardiac device infection (implantable electronic device and left ventricular assist device) is gaining momentum in clinical practice. However, in the absence of prospective randomized trials, guideline recommendations about 18F-fluorodeoxyglucose positron emission tomography in this setting are currently largely based on expert opinion. Measurement of aortic valve microcalcification occurring as a healing response to valvular inflammation using 18F-sodium fluoride positron emission tomography represents another promising clinical approach, which is associated with both the risk of native valve stenosis progression and bioprosthetic valve degeneration in research trials. In this review, we consider the role of molecular imaging in cardiac valvular diseases, including aortic stenosis and valvular endocarditis, as well as cardiac device infections.

The role of stents in hemodialysis vascular access

Vascular access is the Achilles' heel of dialysis therapy among patient with end stage kidney disease. The development of neointimal hyperplasia and subsequent stenosis is common in vascular access and is associated with significant morbidity. Percutaneous transluminal angioplasty using balloon inflation was the standard therapy of these lesions. However, the balloon-based approaches were associated with poor vascular access patency rate necessitating new inventions. It is within this context that different types of stents were developed in order to improve the overall dialysis vascular access functionality. In this article, we review the available literature regarding the use of stents in treating dialysis vascular access stenotic lesions. Further, we review the major clinical trials of stent use in different anatomic locations and in different clinical scenarios.