Multicenter experience with extraction of the Riata/Riata ST ICD lead

Poorer outcomes associated with more invasive lead management strategies for Abbott Riata® leads: a large, multicenter experience

BACKGROUND

Over 100,000 Abbott Riata® were implanted in the United States before they were recalled in 2010. There are still a significant number of Abbott Riata® leads in use, and it is unclear how these leads should be managed at the time of generator change or lead malfunction. Although data comparing both Sprint Fidelis® and Abbott Riata® leads in this setting is available, there are no multicenter comparative studies of outcomes for various lead management strategies, including lead extraction (LE), lead abandonment/revision (LA), and generator change (GC) only at the time of device at elective replacement interval (ERI) for Abbott Riata® leads.

METHODS

A retrospective, multicenter study was undertaken to compare short-term outcomes (major complications-MC, death, extended or re-hospitalizations within 60 days-RH, lead malfunction-LM) and total outcomes (short-term outcomes & lead malfunction during follow-up) of patients with Riata® leads undergoing LE, LA, or GC.

RESULTS

152 patients (65 ± 13 years, 68% male) were followed for a mean 33 ± 30 months following intervention. Out of 166 procedures, 13 patients underwent LE, 16 patients underwent LA, and 137 patients underwent GC. There was 1 major complication in each group, yielding an event rate of 7.7% for LE, 6.3% for LA, and 0.7% for GC cohorts. There were significantly more short-term and total adverse outcomes in the group of patients getting LE and LA versus GC only (38.5% & 31.3% vs 7.3%, P < 0.001). Total Riata® lead dwell time follow-up was 17,067 months. A total of 3 Riata® lead malfunctions were noted during long-term follow-up. Inappropriate shocks were similar between LE 7.7% (1/13), LA 6.3% (1/16). and GC 11.0% (4/136); P = 0.57.

CONCLUSIONS

There were more short-term and total adverse outcomes in more invasive management strategies (LE and LA) versus GC alone. The failure rate of Riata® leads was substantially lower compared to previous reports. Therefore, we recommend only performing battery exchange when a device with an active Riata® lead is at ERI, unless there is malfunction of the Riata® lead noted on testing. There were significantly more short-term adverse outcomes in the lead extraction (5/13) and lead abandonment/revision (5/16) groups than the generator only (8/137) group (P < 0.001). GIB - Gastrointestinal bleed, CHF - congestive heart failure, NSTEMI - non-ST elevation MI.

Comparative outcomes of Riata and Fidelis lead management strategies: Results from the NCDR-ICD Registry

BACKGROUND

The Medtronic Sprint Fidelis® and Abbott Riata®/Riata ST® leads are at risk of failure and are subject to FDA recall. Comparative risks of various lead management strategies during elective generator change in a multi-center population are unknown. We aim to describe patients with functional, recalled ICD leads undergoing elective generator replacement and report outcomes according to lead management strategies.

METHODS

Using data from the NCDR ICD Registry, patients with a functioning Riata® or Fidelis® lead undergoing generator replacement are described according to lead management: reuse, abandon/replace, and extract/replace. Adjusted rates of death and pre-discharge complications are reported.

RESULTS

There were 13,144 generator replacement procedures involving a functioning, non-infected Riata® or Fidelis® lead (extraction n = 414, abandonment n = 427). Extraction patients were younger (mean 58 vs. 67 years) with fewer comorbidities than the reuse group. Maximum lead dwell time was similar between groups with average 94, 90, and 99 months in the extraction, abandonment, and reuse groups, respectively. In-hospital complications or mortality were more common in the extraction group (10.14%, 4.35%) compared with abandonment (1.64%, 0.47%) and reuse (0.22%, 0.07%). Compared with reuse, the adjusted odds of death or pre-discharge complication were significantly higher in the extraction group (OR 7.77 95% CI 2.42-24.95, p < .001) but not the abandonment group (OR 1.70 95% CI 0.52-5.61, p = .38).

CONCLUSIONS

In this real-world population, extraction of functional recalled ICD leads was associated with significant risk of in-hospital mortality and complications. Additional work is needed to clarify whether longer term outcomes balance these peri-procedural risks.

Outcomes of transvenous lead extraction using the TightRail™ mechanical rotating dilator sheath and excimer laser sheath

BACKGROUND

Transvenous lead extraction (TLE) is an important part of comprehensive lead management. The selection of tools available has expanded in recent years but data on their efficacy is limited.

OBJECTIVE

To evaluate outcomes using the TightRail™ mechanical rotating mechanical dilator sheath in comparison to excimer laser sheaths and describe factors predictive of successful extraction.

METHODS

Patients undergoing TLE at a single tertiary center (2013-2019) were included in a prospective registry. Leads targeted for extraction with either an SLS II/Glidelight™ or TightRail™ sheath were included. Outcomes were analyzed on a per-lead basis. Generalized estimating equation (GEE) models were used to assess differences in lead extraction success by extraction tool used while adjusting for nonindependence of multiple leads extracted from the same patient. Covariates included patient comorbidities, lead characteristics, and sheath size.

RESULTS

A total of 575 leads extracted from 372 patients were included. Overall success rate was 97%. TightRail™ was the first tool used in 180 (31.3%) leads with success rate of 61.7%; laser sheaths were the first tool in 395 leads (68.7%) with success rate of 67.8%. Predictors of successful extraction included lead age, lead type, and sheath sizing. Extraction success did not differ based on whether a laser or TightRail™ sheath was used (adjusted odds ratio = 0.94; 95% confidence interval = 0.59-1.50).

CONCLUSION

The TightRail™ sheath is an effective tool for TLE. Lead age, lead type, and sheath sizing were predictive of successful extraction but sheath type was not. These findings are hypothesis generating and warrant further investigation in a prospective, randomized study.

Study Design of the Nationwide Japanese Lead Extraction (J-LEX) Registry: Protocol for a Prospective, Multicenter, Open Registry

BACKGROUND

Transvenous lead extractions (TLEs) in Japan have grown to become the standard therapy since the approval of the laser extraction system in 2008. However, little is known about the current indications, methods, success rate, and acute complications in the real-world setting.

METHODS

The Japanese Lead EXtraction (J-LEX) registry is a nationwide, multicenter, observational registry, performed by the Japanese Heart Rhythm Society (JHRS) in collaboration with the National Cerebral and Cardiovascular Center. This study is a nationwide registry ordered by the JHRS and its data are collected prospectively using the Research Electronic Data Capture (REDCap) system. The acute success rate at discharge and complications associated with TLEs will be collected in all cases. Based on the provided information, the annual incidence and predictive factors for the outcomes will be investigated by the Event Assessment Committee (EAC). This registry started in July 2018 and the number of participating medical institutions will be more than 50 hospitals and the target number of procedures will be 500-1000 per year. We will also compare the results with other registries in foreign countries.

RESULT

The results of this study are currently under investigation.

CONCLUSION

The J-LEX registry will provide real-world data regarding the results and complications of TLEs for the various types of indications, methods, and performing hospitals in Japan.

Algorithm for the analysis of pre-extraction computed tomographic images to evaluate implanted lead-lead interactions and lead-vascular attachments

BACKGROUND

The number of lead extractions is growing because of the greater population and increasing age of individuals with a cardiac implantable electronic device. Lead extraction procedures can be complex undertakings with risk of significant mortality, and vascular tears in the superior vena cava are of greatest concern.

OBJECTIVE

The purpose of this study was to study whether a novel algorithm that analyzes pre-extraction computed tomographic (CT) images can determine the likelihood and location of lead-lead interactions and lead-vessel attachment within patients' venous vasculatures. This information can be used to identify potential case challenges in the planning stages.

METHODS

We developed an algorithm to estimate the presence and position of lead-lead interactions and lead-vessel adherences by tracking distance between the leads and distance between the lead and superior vena cava in a sample of 12 patients referred to the United Heart and Vascular Clinic for lead extractions due to infection (n = 5), lead failure (n = 5), and tricuspid regurgitation (n = 2).

RESULTS

Preliminary results indicate that the developed algorithm successfully identified lead-lead and lead-vascular attachments compared to review of CT images by medical experts.

CONCLUSION

With future validation and clinical implementation, this algorithm could aid physician preparedness by minimizing intraprocedural emergencies and may improve patient outcomes.

Trends of Cardiovascular Implantable Electronic Device Infection in 3 Decades: A Population-Based Study

OBJECTIVES

This study assessed trends in the incidence of cardiovascular implantable electronic device (CIED) infection in the last 3 decades using a population-based records linkage study.

BACKGROUND

Infection remains an important issue associated with increased implantation rate and dwell time of CIEDs.

METHODS

We identified a cohort of all adults with CIEDs who resided in Olmsted County, Minnesota, from 1988 to 2015, using the medical linkage system of the Rochester Epidemiology Project. Standardized criteria were used to identify all CIED infection cases. The cumulative rate of CIED infection was estimated using the Kaplan-Meier method, and the trends of CIED infection incidence were calculated with person-years of follow-up after device implantation.

RESULTS

The cumulative probabilities of overall CIED infection were 6.2% (95% confidence interval [CI]: 4.0% to 8.4%) at 15 years and 11.7% (95% CI: 6.8% to 17.3%) at 25 years of follow-up. The incidence of CIED infection every 7 years from 1988 to 2015 was 1.3, 5.7, 4.1, and 4.7 per 1,000-person years, respectively. The 15-year cumulative probabilities of CIED infection after the initial, second, and third procedures were 2.6% (95% CI: 1.4% to 3.8%), 2.7% (95% CI: 1.2% to 4.2%), and 24.1% (95% CI: 3.8% to 44.4%), respectively. Generator changes (hazard ratio [HR]: 3.91; 95% CI: 1.47 to 10.37; p = 0.006) and upgrades (HR: 3.08; 95% CI: 1.24 to 7.62; p = 0.02) were significantly associated with infection.

CONCLUSIONS

The incidence of CIED infection had a trend of increasing in the past 2 decades. Contemporary implantable cardioverter-defibrillator and cardiac resynchronization therapies and repeated manipulation of device pockets introduced a greater risk of CIED infection.

Failure-free survival of the Riata implantable cardioverter-defibrillator lead after a very long-term follow-up

Aims

Riata^® implantable cardioverter-defibrillator (ICD) leads from St. Jude Medical are prone to malfunction. This study aimed to describe the rate of this lead's malfunction in a very long-term follow-up.

Methods

This single-centre observational study included 50 patients who received a Riata 7Fr dual-coil lead between 2003 and 2008. Follow-up was conducted both in person and remotely, and analysed at 8-month intervals. We evaluated the rates of cable externalization (CE), electrical failure (EF), and the interaction of these two complications. Structural lead failure was defined as radiographic CE. Oversensing of non-cardiac signal or sudden changes in impedance, sensing, or pacing thresholds constituted EF.

Results

During a mean follow-up of 10.2 ± 2.9 years, 16 patients (32%) died. We observed lead malfunction in 13 patients (26%): three (23%) due to CE, six (46%) to EF and four (31%) to both complications. Of the malfunctioning leads, 77% failed after seven years of follow-up. The incidence rate (IR) of overall malfunction per 100 patients per year was 0.9 during the first seven years post-implantation, increased to 7.0 after the 7th year and more than doubled (to 16.7) after 10 years. Beyond seven years post-implantation, IR per 100 patient-years increased in both EF and CE (from 0.6 to 5.6 vs. 0.3 to 4.2, respectively). Presence of CE was associated with a 4-fold increase in the proportion of EF.

Conclusion

The incidence of Riata ICD lead malfunction, both for EF and CE, increased dramatically after seven years and then more than doubled after 10 years post-implantation.

Transvenous Extraction and Removal of Pacing Leads Placed after Cardiac Transplantation

There is an increasing prevalence of cardiac implantable electronic devices (CIEDs) due to expanding adoption and availability of these evidence-based therapies. With the increased prevalence of these life-saving devices, there has also been an increased demand for lead removal and lead extraction. Understanding the specific subgroups of patients at high risk for complications during and after lead extraction has become imperative to properly manage endovascular CIED leads. There have been multiple published studies describing clinical variables that predict adverse outcomes in CIED system extractions; however, the risk of complications in leads placed after cardiac transplantation has not specifically been addressed to date. We present four cases of transvenous extraction and removal of pacing leads placed after cardiac transplantation. There were no major complications related to extraction in these four cases; however, three of the four patients died within one year after the procedure. While the etiology of death in these cases seemed to be unrelated to the extraction procedure, the indications for extraction (infection in the setting of immunosuppression and calcineurin-associated ESRD and poor sensing/capture possibly secondary to chronic rejection and/or frequent right heart biopsies) likely contributed at least indirectly to the subsequent death.

Is ventricular sensing always right, when it is left?

BACKGROUND

Ventricular sensing in transvenous cardiac implantable electronic devices (CIEDs) occurs conventionally from the right ventricular (RV) channel, though it evolved from epicardial sensing both in pacemakers and implantable cardioverter-defibrillators (ICDs).

HYPOTHESIS

The objective of this study was to observe the reliability of left ventricular (LV) sensing by transvenous leads placed in coronary veins.

METHODS

LV leads were used for sensing and arrhythmia detection in clinical situations where placement of an RV lead across the tricuspid valve was either not preferred or not feasible, or RV signal was unsuitable for arrhythmia detection, or in the event of sensing failure of an RV lead under advisory in cardiac resynchronization therapy defibrillator (CRTD) recipients.

RESULTS

Thirty-seven patients had an IS-1 LV lead connected to the RV port of CIEDs (17 pacemakers, 5 cardiac resynchronization therapy pacemaker [CRTP], 2 ICDs, and 13 CRTDs). Along a median 41 (25-67) months follow-up, lead performance remained stable; there were neither undersensing nor oversensing of non-cardiac signals. VT/VF were correctly detected and terminated by ATP and shocks (one and three patients, respectively); no inappropriate arrhythmia detection. Device reprogramming occurred in four CRTD recipients because of transient counting the QRS (short intervals) when paced in LV-only, and in two with T-wave oversensing.

CONCLUSIONS

Ventricular sensing by an LV lead is feasible in transvenous devices. Sensing programmability is an unmet need: to fix RV lead sensing issues in cardiac resynchronization therapy (CRT) recipients at no risk of infection (no pocket opening); to avoid interaction with the tricuspid valve; to avoid lead redundancy in the vasculature. Moreover, it will be mandatory owing to the loss of lead interchangeability due to the adoption of DF-4 and quadripolar leads.

Giant right atrial thrombus associated with ICD lead externalized conductors: a case report

Introduction

Narrow calibre ICD leads are prone to present insulation defects and conductor externalization. Close follow-up of these leads is recommended but as long as their electrical function is maintained, no prophyllactic replacement or extraction is advised. Although the risk of thrombus formation involving externalized conductors has been described, this risk seems considered as negligible compared with the risk of a prophylactic lead extraction. However, when an intracavitar thrombus is identified, the safest therapeutic approach remains undetermined.

Case presentation

In the present clinical vignette, we describe the case of a giant thrombus developed along the externalized portion of an electrically functional ICD lead. In this case, the thrombus was successfully treated with a systemic oral anticoagulation.

Discussion

This case report supports the concept of a prolonged anticoagulation for both the diagnosis and the long-term treatment of thrombus developed along externalized ICD leads, in particular when the patient prefers to avoid or postpone the risk of a trans-venous lead extraction.

Key Lessons from the ELECTRa Registry in the Modern Era of Transvenous Lead Extraction

The implantation rate of cardiac electronic devices has grown over the past decades. The number of treated patients has increased in parallel with the complexity of the patient population treated, being older, frailer, having more complex devices (in particular, cardiac resynchronisation therapy) and presenting with a greater comorbidity burden. As a consequence, there is a rising number of related implanted system complications, including malfunction and infection. Thus, the demand for transvenous lead extraction (TLE) has also substantially increased. To identify the indication to TLE by various operators and centres, techniques used to perform TLE, and the safety and efficacy of the current clinical practice of TLE, a large prospective registry has been started in Europe - the European Lead Extraction Controlled (ELECTRa) Registry. The key findings of the ELECTRa Registry are discussed in the present review and placed in the context of previous knowledge. The ELECTRa Registry confirms that the TLE procedure is a safe and effective treatment, with an acceptable risk-benefit ratio that is comparable with other well-known cardiological invasive procedures. Of course, TLE is accompanied by potential life-threatening complications; the vast majority of these can be managed by an experienced multidisciplinary team. Multiple factors predict complications, including patient/lead profile, centre experience and procedure volumes, which may suggest caution when accepting a patient for TLE.

Long-Range Real Migration of Implantable Cardioverter Defibrillator Lead

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

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

Implantable Cardioverter Defibrillator Outcomes in Pediatric and Congenital Heart Disease: Time to System Revision

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are intended to prevent sudden cardiac death yet also impose a risk of morbidity. This study describes the outcomes of ICDs in a pediatric and congenital heart disease (CHD) population from a single center.

METHODS

Retrospective cohort study of all patients with an ICD followed at the University of Michigan Congenital Heart Center from 2005-2013. The primary outcome was ICD system revision for any reason excluding routine generator change for battery depletion.

RESULTS

There were 191 ICD systems in 131 patients, including 57 with CHD, 24 with hypertrophic cardiomyopathy, and 45 with structurally normal hearts. Median age was 16 years at initial implant. Total follow-up was 850 patient-years; median 4.9 years/patient. There were 43 (33%) patients who required 60 ICD revisions; 70 revisions/1,000 patient-years of follow-up. Revisions included 25 lead extractions with replacement, 21 lead additions, five lead repositions, and four full system revisions. Kaplan-Meier (K-M) median time to appropriate shock was similar to the median time to system revision. K-M time to system revision was significantly affected by recalled lead performance.

CONCLUSIONS

The need for ICD system revision is high in this pediatric and CHD population and occurs at a rate similar to the rate of receiving appropriate therapy. These results highlight the need for judicious implant criteria and improved device longevity.

Long-Term Performance of the Riata/ST Implantable Cardioverter-Defibrillator Lead

Riata and Riata ST implantable cardioverter-defibrillator leads are prone to structural and electrical failure (EF). Our objective was to evaluate Riata/ST lead performance over a long-term follow-up. Of 184 patients having undergone Riata/ST and Riata ST Optim lead implantation from September 2003 to June 2008, 154 patients were evaluated for EF and radiographic conductor externalization (CE). Survival analysis for EF was performed for Riata/ST leads, both for failure-free lead survival and cumulative hazard. Subanalysis on 7Fr leads was performed to evaluate EF and CE rates both for different Riata ST lead management (monitoring vs proactive) and between Riata ST and Riata ST Optim leads. During a mean follow-up of 7 years, Riata/ST lead EF rate was 13% overall. Similar failure-free survival rate was noted for 7Fr as for 8Fr leads (log-rank, p = 0.63). Of all failed leads, 64% failed only after 5 years of follow-up. Compared with the absolute failure rate of 1.84% per device year, cumulative hazard analysis for leads surviving past 5 years revealed an estimated failure rate of 7% per year. No clinical or procedural predictors for EF were found. The subanalysis on 7Fr leads showed an excellent outcome both for a proactive lead management approach as for Optim leads. In conclusion, long-term survival of the Riata/ST lead is impaired with an accelerating EF risk over time. An initial exponential trend was followed by a linear lead failure pattern for leads surviving past 5 years, corresponding to an estimated 7% annual EF rate. These findings may have repercussions on the lead management strategy in patients currently surviving with a Riata/ST lead to prevent significant clinical events like inappropriate shocks or failed device interventions.

A Questionable Indication For ICD Extraction After Successful VT Ablation

Sustained ventricular tachyarrhythmias represent a kind of complication shared by a number of clinical presentations of heart disease, sometimes leading to sudden cardiac death. Many efforts have been made in the fight against such a complication, mainly being represented by the implantable cardioverter defibrillator (ICD). In recent years, catheter ablation has grown as a means to effectively treat patients with sustained ventricular arrhythmias, in the contest of different cardiac substrates. Since carrying an ICD is associated with a potential risk deriving from its possible infective or malfunctioning complications, and given the current effectiveness of lead extraction procedures, it has been thought not to be unreasonable to ask ourselves about how to deal with ICD patients who have been successfully treated by means of ablation of their ventricular arrhythmias. To date, no control data have been published on transvenous lead extraction in the setting of VT ablation. In this paper we will review the current evidence about ICD therapy, catheter ablation of ventricular arrhythmias and lead extraction, trying to outline some considerations about how to face this new clinical issue.

Managing patients with advisory defibrillator leads: what can we learn from published data?

Defibrillator lead advisories stir a lot of emotions, both with patients and physicians, and this may influence lead management. We reviewed the literature for a more evidence-based approach to this issue.

From the complications of two of the current advisory leads, the Medtronic Sprint Fidelis and St. Jude Riata leads, and the consequences of possible interventions, we can conclude that a restrained approach to premature replacement is appropriate. It may be opportune to replace the leads during a scheduled generator replacement in case of a higher electrical failure rate, in order to prevent future premature interventions.

We found no support to extract non-functional advisory leads. In contrast, extraction is often more demanding than anticipated, and the risk substantially exceeds that of simply abandoning the leads.

Cost of a recall of a single-center experience managing the Riata defibrillator lead

Riata and Riata ST defibrillator leads (St. Jude Medical, Sylmar, California) were recalled in 2011 due to increased risk of insulation failure leading to externalized cables. Fluoroscopic screening can identify insulation failure, although the relation between mechanical failure and electrical failure is unclear. At the time of the recall, the University of Virginia developed a screening program, including fluoroscopic evaluation, education sessions, device interrogation, and remote monitoring for patients with this defibrillator lead. The aim of this study was to review the outcomes of the screening program, including costs, which were absorbed by our institution. Costs were calculated using Medicare reimbursement estimates. Forty-eight patients participated in the screening program. At initial screening, 31% were found to have evidence of insulation failure but electrical function was normal in all leads. The cost of this program was $35,358.72. The cost per diagnosis of mechanical lead failure was $2,357.25. During 2 years of follow-up, 1 patient experienced Riata lead electrical failure without fluoroscopic evidence of insulation failure. Patients were more likely to have a lead revision if there was evidence of insulation failure. Lead revisions occurred at the time of generator change in 88% of patients with insulation failure but in only 14% of patients with a fluoroscopically normal lead (p = 0.04). The cost of recall-related defibrillator lead revisions was $81,704.55. In conclusion, our Riata screening program added expense without clear benefit to patients. In fact, patients may have been put at more risk by undergoing defibrillator lead revisions based solely on the results of the fluoroscopic screening.

Insight into the mechanism of failure of the Riata lead under advisory

BACKGROUND

Cable externalization and insulation abrasion are known to occur with the St Jude Medical Riata leads under advisory. The distribution of these abnormalities and how they relate to clinical presentation have not been well described.

OBJECTIVE

In this study, we sought to determine the relationship between structural lead failure and clinical presentation by using the analysis of returned Riata products in Canada.

METHODS

The analyses of returned Riata products in Canada were obtained from St Jude Medical, Sylmar, CA. These data were correlated with the clinical presentation of patients just before lead removal from service.

RESULTS

As of May 1, 2013, there were 263 returned Riata leads in Canada. Of these, 43 (16.8%) were found to have insulation abrasion that was due to either lead-can or lead-other device interaction (70%) or inside-out abrasion (27.9%). The predilection of lead-to-can abrasion was seen in the Riata 7-F leads (84.2% vs 58.4%; P = .07), while inside-out abrasion was more common in the Riata 8-F leads (37.5% vs 15.8%; P = .12). Electrical abnormalities were frequent (20 of 31 [65.4%]) and most often due to electrical noise (45.2%), although inappropriate shocks were present (25.8%). Death occurred in 1 of 43 (2.3%) of those patients with an insulation defect in the lead-can abrasion group.

CONCLUSION

Lead-can abrasion is the most common form of insulation defect in the Riata group of leads under advisory. Management of this group of leads under advisory should not neglect the issue of lead-can abrasion, in addition to detection of cable externalization.