Incidence of cardiac implantable electronic device infections and migrations in Japan: Results from a 129 institute survey

Regional Disparities in Transvenous Lead Extraction for Cardiac Implantable Electronic Device Infection in Japan - A Descriptive Study Using the National Database Open Data

BACKGROUND

Because the penetration of transvenous lead extraction (TLE) for cardiac implantable electronic device (CIED) infection has not been investigated in Japan, we conducted a population-based, retrospective, descriptive study to evaluate regional disparities in the use of TLE for CIED infection and the potential undertreatment of CIED infection using a nationwide insurance claims database.

METHODS AND RESULTS

Patients who underwent CIED implantation or generator exchange and TLE between April 2018 and March 2020 were identified. Moreover, the penetration ratio of TLE for CIED infection in each prefecture was estimated. CIED implantation and TLE were most prevalent in the age categories of 80-89 years (40.3%) and 80-89 years (36.9%), respectively. There was no correlation between the number of CIED implantations and that of TLE (rho=-0.087, 95% confidence interval -0.374 to 0.211, P=0.56). The median penetration ratio was 0.00 (interquartile range 0.00-1.29). Of the 47 prefectures, 6, comprising Okinawa, Miyagi, Okayama, Fukuoka, Tokyo, and Osaka, showed a penetration ratio ≥2.00.

CONCLUSIONS

Our study data indicated great regional disparities in the penetration of TLE and potential undertreatment of CIED infection in Japan. Additional measures are needed to address these issues.

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.

Preclinical evaluation of a third-generation absorbable antibacterial envelope

BACKGROUND

The TYRX (Medtronic) absorbable antibacterial envelope has been shown to stabilize implantable cardiac devices and reduce infection. A third-generation envelope was developed to reduce surface roughness with a redesigned multifilament mesh and enhanced form factor but identical polymer coating and antibiotic concentrations as the currently available second-generation envelope.

OBJECTIVE

The purpose of this study was to compare drug elution, bacterial challenge efficacy, stabilization, and absorption of second- vs third-generation envelopes.

METHODS

Antibiotic elution was assessed in vitro and in vivo. For efficacy against gram-positive/gram-negative bacteria, 40 rabbits underwent device insertions with or without third-generation envelopes. For stabilization (migration, rotation), 5 sheep were implanted with 6 devices each in second- or third-generation envelopes. Prespecified acceptance criteria were <83-mm migration and <90° rotation. Absorption was assessed via gross pathology.

RESULTS

Elution curves were equivalent (similarity factors ≥50 per Food and Drug Administration guidance). Third-generation envelopes eluted antibiotics above minimal inhibitory concentration (MIC) in vivo at 2 hours postimplant through 7 days, consistent with second-generation envelopes. Bacterial challenge showed reductions (P <.05) in infection with second- and third-generation envelopes. Device migration was 5.5 ± 3.5 mm (third-generation) vs 9. 9 ±7.9 mm (second-generation) (P <.05). Device rotation was 18.9° ± 11.4° (third-generation) vs 17.6° ± 15.1° (second-generation) and did not differ (P = .79). Gross pathology confirmed the absence of luminal mesh remainders and no differences in peridevice fibrosis at 9 or 12 weeks.

CONCLUSION

The third-generation TYRX absorbable antibacterial envelope demonstrated equivalent preclinical performance to the second-generation envelope. Antibiotic elution curves were similar, elution was above MIC for 7 days, infections were reduced compared to no envelope, and acceptance criteria for migration, rotation, and absorption were met.

Safe and effective transvenous lead extraction for elderly patients utilizing non-laser and laser tools: a single-center experience in Japan

Transvenous lead extraction (TLE) for cardiac implantable electric device (CIED) infection is becoming increasingly common, but is believed to be particularly risky in elderly patients. This study aimed to clarify the safety and effectiveness of TLE in the elderly, evaluating the use of both non-laser and laser extraction tools. We retrospectively analyzed the characteristics, device type, indications, procedures, and clinical results in younger (YG; age: 15-79 years; n = 48) and elderly groups (EG; age: ≥ 80 years; n = 27) of patients who underwent percutaneous TLE between April 2014 and December 2019 at our hospital. The average age was 68 and 88 years in the YG and EG, respectively. Indications for TLE were infection in 33 (68.8%) patients and other in 15 (30.6%) patients in the YG, and infection in all 27 (100%) EG patients. Bloodstream infection was detected in 9 and 4 patients in the YG and EG, respectively, with methicillin-resistant Staphylococcus epidermidis being the most common causative pathogen. All TLE procedures were performed under general anesthesia in an operating room with cardiovascular surgeon backup. An excimer laser sheath (76 leads), a laser followed by a mechanical sheath (45 leads), Evolution RL^® (17 leads), a mechanical sheath (9 leads), and manual traction (one lead) were employed to extract a total of 148 leads (98 and 50 in the YG and EG, respectively). A mechanical sheath or Evolution RL^® was more frequently used in the YG. The respective average implantation durations in the YG and EG were 5.3 and 5.0 years, respectively, which were comparable (p = 0.46). Procedural success rates were identical between the YG and EG (99% vs. 100%, respectively). There was only one procedure-related complication in the entire cohort (cardiac tamponade in a YG patient). Taken together, the success rates of TLE were high in the EG, with no complications, with extraction being the indication for infection in all EG patients. Percutaneous TLE was safe and effective in elderly patients using both non-laser and laser techniques.

Infection and migration incidence of cardiac implantable electrical devices in Japan: Web-based survey results

Web-based survey was conducted for experiences of cardiac implantable electrical device (CIED) infection and migration in Japan. A total of 155 cardiologists' answer was collected in January, 2018. CIED includes pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy ICD (CRT-D) and total of 10,499 CIEDs' experiences of within previous twelve months were reported. CIED includes pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy ICD (CRT-D.). The infection rate of PM, ICD, CRT-P, and CRT-D was 0.79%, 0.81%, 0.45%, and 2.0%, respectively, and the device migration rate was 0.68%, 0.64%, 0.45%, and 0.93%, respectively. The overall infection rate was 0.85% and migration rate was 0.68%.

Cardiac implantable electronic device infection in the cardiac referral center in Thailand: incidence, microbiology, risk factors, and outcomes

BACKGROUND

Despite the long experience of cardiac implantable electronic device (CIED) implantation in Thailand, epidemiology of CIED infection in Thailand has never been studied.

METHODS

A retrospective cohort study was conducted at the cardiac referral center in Thailand to investigate incidence of CIED infection and causative organisms between October 2002 and December 2017. A matched case-control study was performed to determine the factors associated with CIED infection.

RESULTS

Incidence of CIED infection was 0.9% with a stable trend during the studied period. There were 54 episodes of CIED infection. The median (interquartile range) age of the patients was 67.5 (53.0-75.0) years. A total of 29 (53.7%), 18 (33.3%), and 7 (13.0%) were permanent pacemaker, automatic implantable cardioverter-defibrillator, and cardio-resynchronization therapy-related infection, respectively. Gram-positive cocci were the most common organism (24 episodes, 44.4%). Gram-negative bacilli were isolated in six episodes (11.1%). About 9.3% were polymicrobial and 35.2% were culture negative. Multivariate analysis showed that previous CIED infection and generator revision procedure were associated with CIED infection (odds ratio [OR] 48.56, 95% confidence interval [CI] 3.72-633.62; P = 0.003 and OR 19.99, 95% CI 1.28-333.24; P = 0.033 respectively). Forty (74.1%) cases were cured. Leaving device in situ was the only factor significantly associated with poor outcome (OR 11.40, 95% CI 1.52-85.73; P = 0.018).

CONCLUSIONS

In Thailand, while CIED implantation is rising, incidence of CIED infection is stable. Microbiology of CIED infection in Thailand is similar to western countries, albeit a higher proportion of negative culture. Previous CIED infection and generator revision procedure are associated with CIED infection.

Hypoglossal nerve stimulator generator migration: INSPIRE device reimplantation with parallels to cardiac implantable electronic devices

Implantation rates of hypoglossal nerve stimulators, such as INSPIRE, are increasing. The device is still in its early stages of complication reporting, which to date includes implant related infection requiring device removal, and stimulation lead cuff dislodgement requiring replacement. Here we present a 48-year-old female who experienced generator migration and stimulator lead tension requiring an additional operation in order to resecure the generator device. This proved unsuccessful and a second surgery was performed with complete relocation of the device generator to inhibit device migration. This is the first documented case of INSPIRE migration to date, though the implant generator has comparable likeness to cardiovascular implantable electronic devices (CIEDs) where migration risk factors are better studied. Given our patient's case, we identify obesity and abundant breast tissue as potential risk factors for device migration. We believe such factors can be identified prior to initial device implantation to avoid migration and the need for surgical revision. Superior positioning of the generator proved successful, and can be a solution in those with similar body habitus as TYRX pouching and additional security sutures were ineffective. Also, for revisions requiring tunneling of the stimulation lead as in this case we recommend the use of zero degree endoscope for ease of adhesion lysis.

Successful intermuscular implantation of subcutaneous implantable cardioverter defibrillator in a Japanese patient with pectus excavatum

The entirely subcutaneous implantable cardioverter-defibrillator (ICD) system was developed to provide a life-saving defibrillation therapy that does not affect the heart and vasculature. The subcutaneous ICD is preferred over the transvenous ICD for patients with a history of recurrent infection presenting major life-threatening rhythms. In this case report, we describe the first successful intermuscular implantation of a completely subcutaneous ICD in a Japanese patient with pectus excavatum. There were no associated complications with the device implantation or lead positioning. Further, the defibrillation threshold testing did not pose any problem with the abnormal anatomy of the patient.