Considerations for cardiac device lead extraction

Stepwise transvenous lead extraction due to pacemaker pocket infection following lactational mastitis complicated with breast abscess

BACKGROUND

Lactational mastitis is a common painful and debilitating inflammation of breast tissue, generally treated conservatively or with pus puncture in case of breast abscess. However, treating mastitis in patients with implantable surgical material located in the affected breast region can be extremely challenging. We present an unusual case of lactational mastitis complicated by pacemaker pocket infection in a breastfeeding mother.

CASE PRESENTATION

A 35-year-old pacemaker-dependent female developed lactational mastitis seven weeks postpartum. Initially, the condition was treated conservatively with analgesics and antibiotics. After abscess formation, pus was aspirated using fine-needle aspiration technique. Four weeks after mastitis resolution, pacemaker pocket infection developed. According to current cardiovascular implantable electronic device infection treatment guidelines a complete surgical extraction of the entire electronic system, followed by targeted antibiotic treatment and reimplantation of a new device after infection resolution, was recommended. However, after thorough discussion with the young woman and her family and after detailed review of surgery-related risks, she declined a potentially high-risk surgical procedure. Thus, only the pulse generator was explanted; pacing leads positioned in the sub-pectoral pocket; new pacemaker implanted on the contralateral side and broad-spectrum antibiotic therapy continued for six weeks. After breastfeeding cessation, and with chronic fistula development at the primary pacemaker implantation site, the possibility of delayed surgical intervention including complete extraction of retained pacemaker leads was again thoroughly discussed with her. After thoughtful consideration the woman consented to the proposed treatment strategy. A surgical procedure including transvenous lead extraction through the primary implantation venous entry site, using hand-powered bidirectional rotational sheaths, was successfully performed, removing all retained leads through the left subclavian venous entry site, and leaving the fully functional and clinically uninfected pacemaker on the contralateral site intact.

CONCLUSION

Although patients' decisions for delayed extraction in a case of cardiovascular implantable electronic device infection should be discouraged by attending physicians and members of interdisciplinary teams, our case shows that a stepwise treatment strategy may be successful as a bailout clinical scenario in patients with specific requests, demands and / or clinical needs.

Antidromic snare technique for re-implantation of a coronary sinus lead into the same cardiac vein after transvenous lead extraction: a case report

Background

After coronary sinus (CS) lead extraction in patients with cardiac resynchronization therapy (CRT), occlusion of the branch vessel from which CS lead was extracted is a major obstacle to re-implantation, particularly if that vessel is the only optimal vessel for resynchronization.

Case summary

A 75-year-old female who underwent CRT implantation 11 years prior presented with worsening dyspnoea, right ventricle-only pacing rhythm, and increased CS lead pacing threshold. Because she was a CRT responder, we decided to replace the malfunctioning CS lead. After successful extraction, the vessel from which CS lead was extracted was not visualized, and guidewire re-insertion attempts failed. No other branch vessels suitable for re-implantation were observed. Fortunately, distal portion of the target vessel was viewed by a retrograde flow of contrast. A guidewire was advanced retrograde into the target vein via a connecting vessel, and the distal end of the guidewire was snared around CS ostium and then pulled out of the sheath. A new CS lead was inserted through the distal end of the guidewire and successfully implanted antegrade into the same target vein using a veno-venous loop of the guidewire ('anti-dromic snare technique'). The patient was discharged 2 days after the procedure without complications.

Discussion

Antegrade re-implantation of CS lead may not be possible after extracting CS leads with long dwell times, possibly due to extraction-induced vessel occlusion. If the occluded vessel is the only proper vessel for CS lead re-implantation, the anti-dromic snare technique could be a safe and effective bail-out strategy.

Ghost in the right atrium: A case report on successful identification of residual fibrous tissue

The term "ghost" refers to residual fibrous tissue that remains within the cardiovascular system following the removal of implanted device leads. In this case, a 75-year-old male underwent a transvenous lead extraction procedure prompted by an infection. After the procedure, transesophageal echocardiography (TEE) revealed a stable "ghost" in the right atrium. Figures and videos dynamically depicted the ghost's morphology, clearly showing that one end of this spectral entity was firmly attached to the atrial wall, while the other end displayed unrestrained mobility within the bloodstream. After undergoing a thorough evaluation that confirmed the benign nature of the "ghost", there was evidently no need for medical intervention. In summary, the article portrayed a rare yet intriguing "ghost" observed during the perioperative period. Furthermore, this study emphasizes the crucial significance of accurately distinguishing between these "ghosts" and genuinely pathological structures. Such differentiation holds immense importance in preventing unnecessary medical interventions.

Transvenous lead extraction in children with bidirectional rotational dissection sheaths

Objectives

Due to the limited longevity of endovascular leads, children require thoughtful lifetime lead management strategies including conservation of access vessel patency. Consequently, there is an increasing interest in transvenous lead extraction (TLE) in children, however, data on TLE and the use of powered mechanical dissection sheaths is limited.

Methods

We performed a retrospective cohort study analyzing all children <18 years that underwent TLE in our institution from 2015 to 2022. Procedural complexity, results and complications were defined as recommended by recent consensus statements.

Results

Twenty-eight children [median age 12.8 (interquartile range 11.3-14.6) years] were included. Forty-one leads were extracted [median dwell time 85 (interquartile range 52-102) months]. Extractions of 31 leads (76%) in 22 patients (79%) were complex, requiring advanced extraction tools including powered bidirectional rotational dissection sheaths in 14 children. There were no major complications. Complete procedural success was achieved in 18 (64%) and clinical success in 27 patients (96%), respectively. Procedural success and complexity varied between lead types. The Medtronic SelectSecure™ lead was associated with increased odds of extraction by simple traction (p = 0.006) and complete procedural success (p < 0.001) while the Boston Scientific Fineline™ II lead family had increased odds of partial procedural failure (p = 0.017).

Conclusions

TLE with the use of mechanical powered rotational dissection sheaths is feasible and safe in pediatric patients. In light of rare complications and excellent overall clinical success, TLE should be considered an important cornerstone in lifetime lead management in children. Particular lead types might be more challenging and less successful to extract.

Leadless Pacing: Therapy, Challenges and Novelties

Leadless pacing is a rapidly growing field. Initially designed to provide right ventricular pacing for those who were contraindicated for conventional devices, the technology is growing to explore the potential benefit of avoiding long-term transvenous leads in any patient who requires pacing. In this review, we first examine the safety and performance of leadless pacing devices. We then review the evidence for their use in special populations, such as patients with high risk of device infection, patients on haemodialysis, and patients with vasovagal syncope who represent a younger population who may wish to avoid transvenous pacing. We also summarise the evidence for leadless cardiac resynchronisation therapy and conduction system pacing and discuss the challenges of managing issues, such as system revisions, end of battery life and extractions. Finally, we discuss future directions in the field, such as completely leadless cardiac resynchronisation therapy-defibrillator devices and whether leadless pacing has the potential to become a first-line therapy in the near future.

Mortality after transvenous lead extraction: A risk prediction model for sustainable care delivery

BACKGROUND AND AIMS

Transvenous lead extraction (TLE) has become a pivotal part of a comprehensive lead management strategy, dealing with a continuously increasing demand. Nonetheless, the literature about the long-term impact of TLE on survivals is still lacking. Given these knowledge gaps, the aim of our study was to analyse very long-term mortality in patients undergoing TLE in public health perspective.

METHODS

This prospective, single-centre, observational study enrolled consecutive patients with cardiac implantable electronic device (CIED) who underwent TLE, from January 2005 to January 2021. The main goal was to establish the independent predictors of very long-term mortality after TLE. We also aimed at assessing procedural and hospitalization-related costs.

RESULTS

We enrolled 435 patients (mean age 70 ± 12 years, with mean lead dwelling time 6.8 ± 16.7 years), with prevalent infective indication to TLE (92%). Initial success of TLE was achieved in 98% of population. After a median follow-up of 4.5 years (range: 1 month-15.5 years), 150 of the 435 enrolled patients (34%) died. At multivariate analysis, death was predicted by: age (≥77 years, OR: 2.55, CI: 1.8-3.6, p < 0.001), chronic kidney disease (CKD) defined as severe reduction of estimated glomerular filtration rate (eGFR <30 mL/min/1.73 m² , OR: 1.75, CI: 1.24-2.4, p = 0.001) and systolic dysfunction assessed before TLE defined as left ventricular ejection fraction (LVEF) <40%, OR: 1.78, CI 1.26-2.5, p = 0.001. Mean extraction cost was €5011 per patient without reimplantation and €6336 per patient with reimplantation respectively.

CONCLUSIONS

Our study identified three predictors of long-term mortality in a high-risk cohort of patients with a cardiac device infection, undergoing successful TLE. The future development of a mortality risk score before might impact on public health strategy.

Transvenous lead extractions in a single high-volume center over 24 years: High success rate and low complication rate

Background

Transvenous lead extraction (TLE) procedures can be complicated and are associated with a small but significant risk of cardiovascular complications. However, methods and tools vary among centers.

Objective

The purpose of this study was to the present the methods and results of pacemaker and implantable cardioverter-defibrillator TLE procedures in our center over a 24-year period.

Methods

From April 1997 through 2020, we attempted to extract 2964 leads in 1780 procedures and 1642 patients. We mainly utilized single sheath technique using snaring or mechanical rotational sheaths and steel sheaths when necessary. Difficult procedures were performed by an experienced cardiologist, and close supervision was emphasized. Most of the extractions were performed using local anesthesia with sedation.

Results

Median age of patients was 65.0 [interquartile range 20.00] years, and median dwelling time of leads was 5.0 [7.0] years. Clinical success was achieved in 1739 procedures (97.7%) and complete technical success in 2841 leads (95.8%). Clinical success (leaving <4 cm of the lead in the body and achieving the clinical goal for the patient) was achieved for 79 leads (2.7%). TLE failed in 44 leads (1.1%) and 41 procedures (2.3%) among 36 patients (2.2%). There were 23 cases (1.3%) of major complications, with only 1 death directly related to the procedure (<0.1%). In addition, 2 patients with sepsis died within the first 24 hours after the procedure. No caval tears occurred.

Conclusion

Single sheath lead extractions utilizing snaring or mechanical rotational sheaths were effective and safe in our high-volume center as performed by experienced operators.

Transvenous lead extraction in conduction system pacing

Conduction System Pacing (CSP) delivered by His Bundle Pacing (HBP) or Left Bundle Pacing (LBP) are exciting novel interventions in the field of Cardiac Resynchronization Therapy (CRT). As the evidence base for CSP grows, the volume of implants worldwide is projected to rise significantly in the coming years. As such, physicians will be confronted with increasingly prevalent and vital issues arising in long-term follow up, including the management of infected, malfunctioning, or redundant CSP leads. Transvenous lead extraction (TLE) is the first-line option for removal of pacing leads when indicated in these circumstances. The evidence base for TLE in the context of CSP is still in its infancy. In this article, we first provide a brief overview of TLE. We then examine the data on the long-term performance of HBP leads. Next, we describe the features of the Medtronic Select Secure 3,830 lead, and how experience of TLE of this lead in the paediatric population has informed our practice. Finally, we review the current evidence for TLE in HBP and LBP, and discuss how future studies can address gaps in our current knowledge.

An Unusual Cause of Cerebral Embolism

We report an exceptionally rare complication of cardiac pacing: a case of spontaneous fracture of a modern bipolar pacing lead that led to migration across a patent foramen ovale into the left atrium and embolic stroke. (Level of Difficulty: Advanced.)

Comparison between TightRail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction

BACKGROUND

There are limited data on the comparative analyses of TightRail rotating dilator sheath (Philips) and laser sheath for lead extraction.

OBJECTIVE

To evaluate the effectiveness and safety of the TightRail sheath as a primary or secondary tool for transvenous lead extraction (TLE).

METHODS

Retrospective cohort analysis of 202 consecutive patients who underwent TLE using either TightRail sheath and/or GlideLight laser sheath (Philips) in our hospital. The study population was divided into three groups: Group A underwent TLE with laser sheath only (N = 157), Group B with TightRail sheath only (N = 22), and Group C with both sheaths (N = 23).

RESULTS

During this period, 375 leads in 202 patients were extracted, including 297 leads extracted by laser sheath alone, 45 leads by TightRail sheath alone, and 33 by both TightRail sheath and laser sheaths. The most common indications included device infection (44.6%) and lead-related complications (44.1%). The median age of leads was 8.9 years. TightRail sheath (Group B) achieved similar efficacy as a primary extraction tool compared with laser sheath (Group A), with complete procedure success rate of 93.3% (vs. 96.6%, P = .263) and clinical success rate of 100.0% (vs. 98.1%, P = .513). Among 32 leads in which Tightrail was used after laser had failed (Group C), the complete procedure success rate was 75.8%. No significant difference in procedural adverse events was observed.

CONCLUSION

Our single-center experience confirms that the TightRail system is an effective first-line and second-line method for TLE. Further investigation is required to guide the selection of mechanical and laser sheaths in lead extraction cases.

Comparing the safety of subcutaneous versus transvenous ICDs: a meta-analysis

PURPOSE

The use of transvenous implantable cardioverter defibrillators (TV-ICDs) is associated with multiple risks related to the presence of the defibrillator leads within the venous system and right side of the heart, including endocarditis, venous occlusion, tricuspid regurgitation, and potential lead failure. The emergence of subcutaneous ICDs (S-ICDs) may potentially overcome the aforementioned disadvantages. However, evidence validating the safety of S-ICDs relative to TV-ICDs is limited. The present study aimed to synthesize and analyze available data from published studies to comprehensively compare transvenous and subcutaneous ICDs.

METHODS

Different databases were searched for full-text publications with a direct comparison of TV- and S-ICDs. Fixed effect models were applied to pooled data, and no study-to-study heterogeneity was detected.

RESULTS

Data from 7 studies totaling 1666 patients were pooled together. Compared to S-ICDs, the risk of suffering device-related complications was higher in patients with TV-ICDs (OR = 1.71; 95% CI: 1.23-2.38). The number of patients with an S-ICD who suffered inappropriate shocks (IS) was not significantly different than patients with a TV-ICD (OR = 0.92; 95% CI: 0.65-1.30). Subgroup analysis indicated that the TV-ICD group had a higher risk of IS due to supraventricular oversensing (OR = 3.29; 95% CI: 1.92-5.63) while T-wave oversensing tending to cause IS in the S-ICD group (OR = 0.09; 95% CI: 0.03-0.23). The risk of device-related infection in the S-ICD group was not any lower than that in the TV-ICD group (OR = 1.57; 95% CI: 0.67-3.68). The survival rate without any complications during a 1-year follow-up period was similar between the 2 groups (HR = 1.23; 95% CI: 0.81-1.86), although it was assumed that the trend leaned toward more complications in patients with a TV-ICD.

CONCLUSION

The present study verified the safety of S-ICDs based on pooled data. Although there were no differences between TV- and S-ICDs in the short term, fewer adverse events were found in patients with S-ICDs during long-term follow-up.

Negative-pressure wound therapy (NPWT) for the treatment of pacemaker pocket infection in patients unable or unwilling to undergo CIED extraction

PURPOSE

The occurrence of cardiac pacemaker pocket infection has markedly increased and has become a new problem facing cardiovascular internists. The aim of our study was to investigate the effectiveness and safety of treating cardiac pacemaker pocket infection using negative-pressure wound therapy (NPWT) in patients who are unwilling or unable to have their cardiac implantable electronic devices (CIEDs) removed.

METHODS

From March 2013 to April 2019, NPWT was applied to 26 patients with cardiac pacemaker pocket infection who were unwilling or unable to have their CIEDs removed. In the first stage, a negative-pressure drainage system was placed in the pacemaker pocket after debridement. Then, NPWT was used to seal the wound, and the negative pressure (300-400 mmHg) was sustained for 5-7 days. In the second stage, the pacemaker was relocated to the subpectoral layer, and the wound was closed.

RESULTS

In all but three of our 26 patients, the wound healed completely without complications and without evidence of residual infection. The average follow-up period was 26.92 ± 9.46 months. Only 3 diabetic patients whose tissue bacterial cultures revealed that methicillin-resistant Staphylococcus epidermidis developed uncontrolled infections. Eventually, the entire original pacemaker systems were removed, and new pacemakers were implanted in the contralateral chest wall.

CONCLUSIONS

When warranted by strictly selected indications, the method of NPWT without CIED extraction can be considered as a new and effective treatment for patients with pacemaker pocket infection who are unwilling or unable to have the device removed.

Extraction of infected cardiac implantable electronic devices and the need for subsequent re-implantation

BACKGROUND

Little is known about rates of re-implantation and outcomes of patients not implanted with a device after transvenous lead extraction (TLE) in cardiac device related infections (CDRI).

METHODS

All patients with CDRI were included in a prospective registry. After TLE, the indication for re-implantation was evaluated according to the patients' history and most recent cardiac examinations. All patients were followed for complications and mortality. In addition, in patients discharged without device the frequency of device implantations was analyzed.

RESULTS

Among 302 patients, only 123 (40.7%) met the indication for implantation of the same cardiac implantable electronic device (CIED), 68 (22.5%) received a different device and 111 (36.8%) patients were discharged without CIED. Reimplanted patients were younger (70 ± 11 vs. 73 ± 13 years; p = 0.004), more often male (83 vs. 69%, p = 0.006), had less systemic infection (38 vs. 60%; p < 0.001) and a higher prevalence of complete heart block (28 vs. 7%, p < 0.001). Reasons against re-implantation were: loss of indication (45%), never met indication (27%), patients' preference (17%), persistent infection (8%) and advanced age (3%). During 26 ± 18 months of follow-up, mortality in both groups was similar after adjusting for cofactors (HR 0.79; 95% CI 0.49-1.29; p = 0.352).

CONCLUSION

More than one third of patients undergoing TLE for CDRI in our study are not implanted with a new device. Careful evaluation of the initial CIED indication allows for detection of over treated patients and may avoid unnecessary device-related complications.

Lead Removal Without Extraction Tools: A Single-Center Experience

Introduction

Indications for cardiac devices have been increasing as well as the need for lead extractions as a result of infections, failed leads and device recalls. Powered laser sheaths, with a global trend towards the in-creasingly technological tools, meant to improve the procedure’s outcome but have economic implications.

Objective

The aim of this study is to demonstrate the experience of a Bra-zilian center that uses simple manual traction in most lead removals per-formed annually, questioning the real need for expensive and technically challenging new devices.

Methods

This retrospective observational study included 35 patients who had a transvenous lead extraction in the period of a year between January 1998 and October 2014 at Hospital de Messejana Dr. Carlos Alberto Studart Gomes, in Fortaleza, CE, Brazil. Data were collected through a records review. They were evaluated based on age, type of device, dwelling time, indication for removal, technique used and immediate outcomes.

Results

The median dwelling time of the devices was 46.22 months. Infec-tion, lead fracture and device malfunction were the most common indica-tions. Simple traction was the method of choice, used in 88.9% of the pro-cedures. Manual traction presented high success rates, resulting in com-plete removal without complications in 90% of the cases.

Conclusion

This article suggests that lead extraction by simple manual traction can still be performed effectively in countries with economic diffi-culties as a first attempt, leaving auxiliary tools for a second attempt in case of failure or contraindications to the simple manual traction technique.

Endovascular Occlusion Balloon for Treatment of Superior Vena Cava Tears During Transvenous Lead Extraction

Background:

Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon.

Methods:

We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration–maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality.

Results:

From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used ( P =0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04–0.40; P <0.001).

Conclusions:

From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.

The role of transvenous lead extraction in the management of redundant or malfunctioning pacemaker and defibrillator leads post ELECTRa

Cardiac implantable electronic devices implantation rates have increased over the past decade due to broader indications and an ageing population. Similarly, device and lead complications have also risen. The management of pacemaker/defibrillator leads that are no longer required (redundant) or malfunctioning, can be contentious. There is a need to balance the risk of transvenous lead extraction (TLE) against those of lead abandonment. The recently published European Lead Extraction ConTRolled Registry (ELECTRa) study provides contemporary outcomes for TLE across Europe with important implications for the management of redundant and/or malfunctioning leads. This review article discusses the potential complications for each interventional approach when managing redundant or malfunctioning pacemaker leads.

Facilitated music listening: Music therapy in an invasive cardiac procedure

This article presents and discusses a clinical music therapy protocol for use during an invasive cardiac procedure and the theoretical rationale behind it. The protocol was developed for a specific invasive cardiac procedure performed transvenously with local anaesthesia: cardiac implantable electronic device lead extraction. The music listening intervention presented in the protocol aims to optimise stress and pain management for patients through patient involvement, communication, individualised music listening and relaxation techniques. The Music Therapist remains present throughout the peri-operative phase (in the operating theatre during the operation). The music is chosen from a limited set of prepared playlists through a process involving assessment and patient preference. Biological, psychological and social components are integrated into the protocol, which is also informed by the theory of music therapy as procedural support, the neuromatrix theory of pain and receptive music therapy techniques. The protocol was developed to be standardised for implementation into the existing medical procedure, yet flexible enough to meet individual patient needs. It is the cornerstone of the research protocol of an ongoing randomised controlled trial at the Department of Cardiology at Oslo University Hospital Ulleval. Results of the randomised controlled trial, focussing on quantitative efficacy outcomes, are expected in 2020.

Cardiac Implantable Electronic Device-Related Infection Due to Granulicatella adiacens

Cardiac implantable electronic device–related infection is clinically challenging. Curative treatment commonly includes system removal. A case caused by Granulicatella adiacens occurred in a 32-year-old woman. Clinical course, literature review, and biofilm investigations enabled successful antibiotic management without system removal.

Safety of Transvenous Lead Removal in Patients ≥70 Years of Age in the United States from 2005 to 2012

Cardiac devices are increasingly an element of treatment for the elderly, leading to more frequent transvenous lead removal (TLR) procedures in this population. Data on TLR in very elderly patients, especially nonagenarians, is scarce. We used Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify a total of 36,099 patients ≥70 years who underwent TLR from 2005 to 2012, with outcomes including in-hospital mortality and complications. The in-hospital mortality rate was significantly higher in nonagenarians without device infection (0.9% in age 70 to 79 vs 0.7% in age 80 to 89 vs 2.6% in age ≥90, p = 0.012), but overall complication rates were not different in age groups regardless of infection status and co-morbidity index (all p >0.05). Among patients with device infection, octogenarians, and nonagenarians were not associated with increased risk of in-hospital mortality relative to septuagenarians after controlling for all other confounders. However, in patients without device infection, logistic regression showed significantly higher mortality in patients age ≥90 years (odd ratio 4.22, 95% confidence interval 1.66 to 10.75, p = 0.003), but not in patients age 80 to 89 years (odd ratio 1.05, 95% confidence interval 0.48 to 2.30, p = 0.907), compared with patients age 70 to 79 years. In conclusion, in nonagenarians with infection, mortality is driven more by the patient's other conditions than by age. For patients without infection, however, nonagenarians experienced higher mortality than younger patients.

Are Endovascular Interventions for Central Vein Obstructions due to Cardiac Implanted Electronic Devices Effective?

Objective: One of the late-onset complications of cardiac implanted electronic devices (CIEDs) is central venous obstruction (CVO). The aim of this study was to investigate the feasibility, efficacy, and safety of endovascular treatment of CIED-related CVOs.

Methods:Eighteen patients who underwent endovascular management of their device-related CVO were reviewed. Patients were classified into three groups: Group I patients were asymptomatic and needed lead replacement; Group II patients presented with symptomatic CVO without lead dysfunction, and Group III patients were referred with both symptomatic CVO and lead dysfunction. A treatment strategy involved recanalization and balloon angioplasty for Group I and angioplasty/stents for Groups II and III. Technical success, clinical success, complications, and long-term follow-up were assessed.

Results: Thirteen patients were in Group I, four in Group II, and one in Group III. Technical and clinical success was achieved in 17 patients (94%). No major complications were reported. Restenosis was observed in two patients at 40 and 42 weeks of follow-up, and these patients were successfully treated with angioplasty.

Conclusion: Endovascular management of CVO due to CIED is a safe and efficient technique. Plain balloon angioplasty is sufficient for lead replacement purposes, while stenting is needed for symptomatic CVO to achieve good long-term patency.

Transvenous Lead Extractions: Current Approaches and Future Trends

The use of cardiac implantable electronic devices (CIEDs) has continued to rise along with indications for their removal. When confronted with challenging clinical scenarios such as device infection, malfunction or vessel occlusion, patients often require the prompt removal of CIED hardware, including associated leads. Recent advancements in percutaneous methods have enabled physicians to face a myriad of complex lead extractions with efficiency and safety. Looking ahead, emerging technologies hold great promise in making extractions safer and more accessible for patients worldwide. This review will provide the most up-to-date indications and procedural approaches for lead extractions and insight on the future trends in this novel field.

Comparative study about the tensile strength and yielding mechanism of pacing lead among major manufacturers

BACKGROUND

With extraction of cardiovascular implantable electronic devices (CIED) increasingly necessitated, various studies have contemplated to investigate clinical predictors for its success and complications. Intrinsic parameters of CIED leads have been studied less extensively and are the foci of this study.

METHODS

Three major pacemaker manufacturers accepted invitation. Leads then underwent tensile test in vitro with their composite tensile strength (TS) compared. Mechanism of yielding, under tensile stress, was also observed among them.

RESULTS

All pacing leads, participated in this study, surpassed requirement of European Standard EN 45502-2-1. Boston Scientific's FINELINE II STEROX 4456/52 cm (Boston Scientific Corp., St. Paul, MN, USA) and Medtronic's CAPSURE SENSE 4074/52 cm (Medtronic, Minneapolis, MN, USA) showed similar composite TS and both were stronger compared with St. Jude Medical's ISOFLEX OPTIM 1948/52 cm (P <0.001; St. Jude Medical, Sylmar, CA, USA). Despite a difference in the exact site, the Medtronic 4074 and St. Jude Medical 1948 yielded similarly in that their distal tip electrode remained connected with a flimsy inner coil to proximal portion of the lead after their composite TS was exceeded. Boston Scientific 4456's insulation tubing and coil wire broke almost simultaneously and separated completely from the tip electrode when it yielded.

CONCLUSIONS

FINELINE II STEROX 4456/52 cm and CAPSURE SENSE 4074/52 cm showed stronger composite tensile strength than ISOFLEX OPTIM 1948/52 cm. FINELINE II STEROX 4456 was found more prone to complete severance. Limitations and precautions to translate these differences directly into real-life scenario are discussed.

Simultaneous lead traction from above and below: A novel technique to reduce the risk of superior vena cava injury during transvenous lead extraction

BACKGROUND

Superior vena cava (SVC) injury is a rare but dreaded complication during percutaneous transvenous lead extraction (TLE) that carries high morbidity and mortality. Despite technological advances and improved efficacy, complication rates remain unchanged.

OBJECTIVE

We sought to develop and test a novel technique that could reduce the risk of SVC injury during TLE.

METHODS

Fifteen patients referred for TLE of an implantable cardioverter-defibrillator lead were included. Patients underwent fluoroscopic and intracardiac echocardiographic (ICE) imaging of the lead-SVC interface with traction from above, below, and simultaneously. Clinical characteristics, fluoroscopic and ICE findings, and procedural outcomes were collected and analyzed.

RESULTS

Fourteen of 15 patients were men (93%) with a mean age of 58 years. The mean lead dwell time was 8.09 ± 3.97 years (range 1.08-16.25 years), and 12 of 15 leads (80%) were dual-coil. Acceptable ICE imaging was not possible in 3 of 15 patients (20%). Simultaneous traction showed greater leftward fluoroscopic shift compared with traction from above (24.96 ± 8.82 mm vs 13.68 ± 6.86 mm; P < .01), created greater separation between the lead and the SVC wall upon ICE imaging (2.0 ± 0.52 mm vs 1.24 ± 0.38 mm; P < .01), and maintained a more parallel relationship of the lead with the SVC wall (24.41° ± 4.14° vs 27.91° ± 4.92°; P < .05).

CONCLUSION

In patients presenting for TLE, simultaneous traction results in increased separation and a more parallel alignment of the lead and SVC wall, allowing the sheath to be better oriented in the desired cleavage plane. This improved sheath alignment is particularly critical when powered sheaths are to be used.

Impact of Abandoned Leads on Cardiovascular Implantable Electronic Device Infections: A Propensity Matched Analysis of MEDIC (Multicenter Electrophysiologic Device Infection Cohort)

OBJECTIVES

This study sought to evaluate the impact of abandoned cardiovascular implantable electronic device (CIED) leads on the presentation and management of device-related infections.

BACKGROUND

Device infection is a serious consequence of CIEDs and necessitates removal of all hardware for attempted cure. The merits of extracting or retaining presumed sterile but nonfunctioning leads is a subject of ongoing debate.

METHODS

The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled patients with CIED infections at 10 institutions in the United States and abroad between January 1, 2009, and December 31, 2012. Within a propensity-matched cohort, relevant clinical information was compared between patients who had 1 or more abandoned leads at the time of infection and those who had none.

RESULTS

Matching produced a cohort of 264 patients, including 176 with no abandoned leads and 88 with abandoned leads. The groups were balanced with respect to Charlson comorbidity index, oldest lead age, device type, sex, and race. At the time of admission, those with abandoned leads were less likely to demonstrate systemic signs of infection, including leukocytosis (p = 0.023) and positive blood cultures (p = 0.005). Conversely, patients with abandoned leads were more likely to demonstrate local signs of infections, including skin erosion (p = 0.031) and positive pocket cultures (p = 0.015). In addition, patients with abandoned leads were more likely to require laser extraction (p = 0.010).

CONCLUSIONS

The results of a large prospective registry of CIED infections demonstrated that patients with abandoned leads may present with different signs, symptoms, and microbiological findings and require laser extraction more than those without abandoned leads.

Effect of Applied Potential on Fatigue Life of Electropolished Nitinol Wires

Nitinol is used as a metallic biomaterial in medical devices due to its shape memory and pseudoelastic properties. The clinical performance of nitinol depends on factors which include the surface finish, the local environment, and the mechanical loads to which the device is subjected. Preclinical evaluations of device durability are performed with fatigue tests while electrochemical characterization methods such as ASTM F2129 are employed to evaluate corrosion susceptibility by determining the rest potential and breakdown potential. However, it is well established that the rest potential of a metal surface can vary with the local environment. Very little is known regarding the influence of voltage on fatigue life of nitinol. In this study, we developed a fatigue testing method in which an electrochemical system was integrated with a rotary bend wire fatigue tester. Samples were fatigued at various strain levels at electropotentials anodic and cathodic to the rest potential to determine if it could influence fatigue life. Wires at potentials negative to the rest potential had a significantly higher number of cycles to fracture than wires held at potentials above the breakdown potential. For wires for which no potential was applied, they had fatigue life similar to wires at negative potentials.

Coronary Venous Lead Extraction

The increasing number of cardiac resynchronization therapy devices implanted, coupled with the increasing incidence of cardiac implantable electronic device infection, has led to a greater need for extraction of coronary venous pacing leads. The objectives of this study were to review the indications, techniques and published results of coronary venous lead extraction. In this study, we searched PubMed using the search terms "lead extraction," "coronary sinus," "coronary venous," "pacing," and "cardiac resynchronization therapy" for relevant papers. The reference lists of relevant articles were also searched, and personal experience was drawn upon. Published success rates and complications were found to be similar to those reported for non-coronary venous leads in experienced centers. However, reimplantation success differs and can be limited by vessel occlusion postextraction. The available active fixation coronary sinus lead (Attain Starfix™; Medtronic, MN, USA) is a particularly complex lead to extract, whereas limited data on the newer active fixation leads (Attain Stability™, Medtronic, MN, USA) suggest that they are less challenging to remove. The study concluded that coronary venous lead extraction presents unique challenges, especially reimplantation, that require special consideration and planning to overcome.