Leadless Pacemakers in Patients with Congenital Heart Disease

Transcatheter leadless pacemakers have benefits in congenital heart disease because they eliminate the risks of lead malfunction, venous occlusions, and pocket complications. This newest pacemaker's utility in this population has been limited by the large sheath and delivery system, need for atrioventricular synchronous pacing, lack of explantation options, and possible lack of adequate access to the subpulmonary ventricle. With careful planning, leadless pacing can be successfully performed in these patients. Consideration of nonfemoral access, alternative implant sites to avoid myocardial scar or prosthetic material, anticoagulation for patients with persistent intracardiac shunts or systemic ventricular implantation, and operator experience are critical.

Transvenous Lead Extraction in Patients with Cardiac Implantable Device: The Impact of Systemic and Local Infection on Clinical Outcomes-An ESC-EHRA ELECTRa (European Lead Extraction Controlled) Registry Substudy

Background: Infections of cardiac implantable devices (CIEDI) have poor outcomes despite improvement in lead extraction (TLE) procedures. Methods: To explore the influence of CIEDI on the outcomes of TLE and the differences between patients with systemic (Sy) vs. local (Lo) CIEDI, we performed a sub-analysis of the EORP ELECTRa (European Lead Extraction ConTRolled) Registry. Results: Among 3555 patients enrolled by 73 centers in 19 Countries, the indication for TLE was CIEDI in 1850: 1170 with Lo-CIEDI and 680 with Sy-CIEDI. Patients with CIEDI had a worse in-hospital prognosis in terms of major complications (3.57% vs. 1.71%; p = 0.0007) and mortality (2.27% vs. 0.49%; p < 0.0001). Sy-CIEDI was an independent predictor of in-hospital death (H.R. 2.14; 95%CI 1.06−4.33. p = 0.0345). Patients with Sy-CIEDI more frequently had an initial CIED implant and a higher prevalence of comorbidities, while subjects with Lo-CIEDI had a higher prevalence of previous CIED procedures. Time from signs of CIEDI and TLE was longer for Lo-CIEDI despite a shorter pre-TLE antibiotic treatment. Conclusions: Patients with CIEDI have a worse in-hospital prognosis after TLE, especially for patients with Sy-CIEDI. These results raise the suspicion that in a relevant group of patients CIEDI can be systemic from the beginning without progression from Lo-CIEDI. Future research is needed to characterize this subgroup of patients.

Pacemaker lead rupture in a patient with subacute endocarditis: a case report

Background

Cardiac implantable electronic device (CIED)-related infections are associated with severe morbidity and mortality. Few cases have previously documented both lead endocarditis and lead rupture simultaneously.

Case summary

We describe the case of a 73-year-old man with a dual-chamber pacemaker presenting with subacute endocarditis and recurrent cholangitis. A few months prior, the patient was diagnosed with localized colon cancer and Streptococcus sanguinis lead endocarditis based on nuclear imaging. He was given prolonged antibiotic therapy and lead explantation was to be performed after sigmoidectomy. During the following weeks, his condition worsened and he was readmitted for biliary sepsis. A chest X-ray revealed, incidentally, a complete ventricular lead rupture. Pacemaker electrogram showed ventricular undersensing, loss of ventricular capture, and high impedance. As his health declined, removal of the pacemaker was deemed unreasonable and the patient died of biliary sepsis in the next few weeks.

Discussion

We describe the case of an asymptomatic intracardiac lead fracture in the setting of colon cancer and a medically managed Streptococcus lead infection. As this complication occurred during lead infection, bacterial damage may have weakened the lead over time. As illustrated by the patient’s outcomes, long-term antibiotic therapy should only be used in cases unsuitable for device removal. Complete hardware removal remains the first-line therapy in patients with CIED-related infections.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSION

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

Multicentre early experience with totally subcutaneous cardioverter-defibrillators in Poland

INTRODUCTION

Implantable cardioverter-defibrillators (ICD) have a strong position in the prevention of sudden death. Nowadays, the most commonly used high-energy cardiac devices are transvenous ICDs. A new technology of totally subcutaneous ICDs (S-ICD) was invented and recently introduced into clinical practice in order to reduce lead-related complications of conventional ICDs. The aim of this paper is to present early experience with this new technology implemented in a few centres in Poland.

MATERIAL AND METHODS

Medical records of patients who had S-ICD-related interventions in Poland were retrospectively analysed.

RESULTS

During the first year of S-ICD introduction into the Polish health system 18 patients underwent surgery connected with S-ICDs. Majority of them (17 patients) were implanted de novo. In one patient surgical revision of a device implanted abroad was performed. Most of patients (78%) had S-ICDs implanted for secondary prevention. Inability of transvenous system implantation due to venous access obstruction or high risk of infection related with transvenous leads accounted for 83% of indications for S-ICD. Only in three patients were S-ICDs implanted due to young age and active mode of life. The implantations of S-ICDs were performed without important early or late complications. During follow-up one patient had episodes of ventricular arrhythmia successfully terminated with high-energy shocks. One patient died due to progression of heart failure.

CONCLUSIONS

S-ICD implantation procedure has been successfully and safely introduced in Polish clinical routine. Nevertheless, despite clear indications in recent ESC guidelines, this therapy is not directly reimbursed in Poland and needs individual application for refund.

Neointimal fibrotic lead encapsulation - Clinical challenges and demands for implantable cardiac electronic devices

Every tenth patient with a cardiac pacemaker or implantable cardioverter-defibrillator implanted is expected to have at least one lead problem in his lifetime. However, transvenous leads are often difficult to remove due to thrombotic obstruction or extensive neointimal fibrotic ingrowth. Despite its clinical significance, knowledge on lead-induced vascular fibrosis and neointimal lead encapsulation is sparse. Although leadless pacemakers are already available, their clinical operating range is limited. Therefore, lead/tissue interactions must be further improved in order to improve lead removals in particular. The published data on the coherences and issues related to lead associated vascular fibrosis and neointimal lead encapsulation are reviewed and discussed in this paper.

Lead-related infective endocarditis: factors influencing the formation of large vegetations

Aims

The presence of intracardiac lead vegetations (ILV) is one of the important criteria for diagnosis of lead-related infective endocarditis (LRIE). The objective of the present study was to evaluate risk factors of ILV and their impact on vegetation size.

Methods and results

Clinical data of 500 patients with LRIE undergoing transvenous lead extraction in 2006-15 were retrospectively analysed. The study population consisted of 352 patients with the presence of vegetations (giant, >3 cm; large, 2.0-2.9 cm; moderate-sized, 1.0-1.9 cm; and small, <1 cm) and 148 patients without ILV. We identified risk factors for vegetation occurrence and ILV size. Intracardiac lead vegetations were found more frequently in younger patients (P < 0.05), slightly more often in women (P = 0.084), and less commonly in patients with atrial fibrillation (P < 0.05). Intracardiac lead vegetation occurred significantly more frequently in patients with intracardiac lead abrasion (OR 2.373; 95% CI [1.497-3.765]; P < 0.001) and much less frequently in the concomitant presence of pocket infection (PI) (OR 0.127; 95% CI [0.074-0.218]; P < 0.00). Large vegetations were significantly more common in patients with renal failure (RF) (P < 0.001), heart failure (P < 0.001), implantable cardioverter defibrillator (P < 0.05), and loops of the leads (P < 0.001).

Conclusion

Intracardiac lead abrasion is one of the most common factors influencing the occurrence of ILV. Metabolic disorders in patients with RF, heart failure, defibrillation leads, and loops of the leads were found to contribute to the formation of large vegetations. In LRIE patients, ILVs were less frequently detected in the presence of concomitant PI, indicating a different mechanism of LRIE development in patients with and without vegetations.

Leads dislodged into the pulmonary vascular bed in patients with cardiac implantable electronic devices

INTRODUCTION

Spontaneous lead dislodgement into the pulmonary circulation is a rare complication of permanent pacing with unproven harmfulness and an indication of controversial class for transvenous lead extraction (TLE).

AIM

To assess TLE safety in patients with leads dislodged into the pulmonary artery.

MATERIAL AND METHODS

A retrospective analysis of a 9-year-old database of transvenous lead extraction procedures comprising 1767 TLEs was carried out, including a group of 19 (1.1%) patients with leads dislodged into the pulmonary artery (LDPA).

RESULTS

Under univariate analysis the factors that increased the likelihood of the presence of an electrode in the pulmonary artery were mean lead dwelling time (increase of risk by 9% per year), total number of leads in the heart before TLE (increase of risk by 66% for one lead) and the number of abandoned leads (increase of risk by 119%). The presence of LDPA was associated with frequent occurrence of intracardiac lead abrasion (increase by 316%) and isolated lead-related infective endocarditis (LRIE) (increase by 500%). There were no statistically significant differences in clinical (p = 0.3), procedural (p = 0.94) or radiological (p = 0.31) success rates in compared (LDPA and non-LDPA) groups. Long-term mortality after TLE was comparable in both groups.

CONCLUSIONS

As the effectiveness and safety of TLE in patients with LDPA are comparable to those in standard TLE procedures, in our opinion, such patients should be considered TLE candidates.

What would surgeons like from materials scientists?

Surgery involves the repair, resection, replacement, or improvement of body parts and functions and in numerous ways, surgery should be considered human engineering. There are many areas in which surgical materials could be improved, but surgeons are generally unaware of materials available for use, while materials scientists do not know what surgeons require. This article will review some of the areas where surgeons and materials scientists have interacted in the past and will discuss some of the most pressing problems which remain to be solved. These include better implant materials for hernia repair, breast reconstruction, the treatment of diabetes, vascular stenting and reconstruction, and electrical pacing devices. The combination of tissue engineering and nanomaterials has great potential for application to nearly every aspect of surgery. Tissue engineering will allow cells or artificial organs to be grown for specific uses while nanotechnology will help to ensure maximal biocompatibility. Biosensors will be combined with improved electrodes and pacing devices to control impaired neurological functions.