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Patel K, Toomu S, Lee E, Darden D, Jacobs K, Pollema T, Ho G, Birgersdotter-Green U. Computed tomography predictors of increased transvenous lead extraction difficulty. Pacing Clin Electrophysiol 2024. [PMID: 38967391 DOI: 10.1111/pace.15034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 05/19/2024] [Accepted: 06/18/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject. OBJECTIVE To identify CT characteristics associated with increased TLE difficulty. METHODS All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac-gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead-removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty. RESULTS A total of 343 patients were analyzed. The mean age of the study population was 63.8 ± 15.4 years; 71% were male. The mean lead dwell-in duration was 8.6 ± 5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead-removal fluoroscopy time (p = 0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p < 0.001, 95% CI: 2.54-10.46) and (odds ratio:3.72, p < 0.001, 95% CI: 1.89-7.35), respectively. CONCLUSION In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead-associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath.
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Affiliation(s)
- Kavisha Patel
- Department of Cardiology, University of California San Diego, La Jolla, California, USA
| | - Sandeep Toomu
- Department of Cardiology, University of California San Diego, La Jolla, California, USA
| | - Euyhyun Lee
- Department of Cardiology, University of California San Diego, La Jolla, California, USA
| | - Douglas Darden
- Department of Cardiology, Kansas City Heart Rhythm Institute, Kansas City, Kansas, USA
| | - Kathleen Jacobs
- Department of Cardiology, University of California San Diego, La Jolla, California, USA
| | - Travis Pollema
- Department of Cardiology, University of California San Diego, La Jolla, California, USA
| | - Gordon Ho
- Department of Cardiology, University of California San Diego, La Jolla, California, USA
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Virmani R, Philippon F, Mittal S, Finn A, Kudlik D, Kirchhof N, Lexcen D, Kassotis J. Effects of envelopes on cardiac implantable electronic device pocket healing: A head-to-head preclinical evaluation. Heart Rhythm 2024:S1547-5271(24)00226-1. [PMID: 38555971 DOI: 10.1016/j.hrthm.2024.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/06/2024] [Accepted: 02/23/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The healing response to cardiac implantable electronic device (CIED) implantation results in inflammation that can lead to fibrous pocket formation, which may disrupt pocket healing or complicate future interventions. OBJECTIVE The purpose of this study was to assess CIED pocket healing with use of the second-generation TYRX absorbable antibacterial envelope (T2), the next-generation (NG) TYRX absorbable antibacterial envelope under development, and the CanGaroo® extracellular matrix envelope (ECM) compared to no envelope. METHODS A total of 110 CIEDs were implanted in an ovine model, either with (T2, NG, or ECM) or without envelopes. Histopathologic and morphometric analyses were completed at several timepoints after implant (3 days, 7 days, 4 weeks, 12 weeks, 24 weeks). An independent pathologist completed a blinded histopathology assessment of the pockets. RESULTS TYRX (T2/NG) pockets showed similar inflammatory and healing profiles to controls with more rapid provisional matrix formation compared to controls and ECM. ECM pockets exhibited increased acute (3 and 7 days) and chronic (24 weeks) inflammation. T2/NG had almost complete (T2) or complete (NG) absorption by week 12. ECM remained present at week 24 and was associated with significantly thicker capsules (ECM 0.80 ± 0.14 mm; NG 0.37 ± 0.10 mm; control 0.56 ± 0.17 mm). CONCLUSION Compared to ECM, pockets with TYRX showed less inflammation, more rapid provisional matrix formation, faster absorption, and thinner capsules. TYRX pockets had low inflammation comparable to controls with accelerated provisional matrix deposition and tissue adhesion. The healing response to CIEDs used with TYRX fosters the formation of a well-healed pocket, which may bring patient benefit beyond its proven infection reduction.
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Affiliation(s)
| | - Francois Philippon
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec, Canada
| | | | - Aloke Finn
- CV Path Institute, Gaithersburg, Maryland
| | | | | | | | - John Kassotis
- Peconic Bay Medical Center-Northwell Health, Riverhead, New York
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3
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Celikyurt U, Acar B, Torun A, Karakullukcu M, Cakir O, Baris O, Vural A, Agacdiken A. Radiographic predictors of failure of simple manual traction of transvenous implantable cardioverter-defibrillator leads: a single-center experience. J Interv Card Electrophysiol 2023; 66:1341-1347. [PMID: 35751717 DOI: 10.1007/s10840-022-01289-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/21/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extraction of the implantable cardioverter-defibrillator (ICD) leads could be a difficult procedure due to fibrous tissue around the lead and anatomical variations. In this report, we present our experience in the radiographic predictors of failure of simple manual traction (SMT) in patients with dual-coil ICD requiring lead extraction (LE). METHODS Between January 2017 and February 2021, 103 leads were removed in 65 consecutive patients; 65 (63.1%) were dual-coil ICD leads, 22 (21.4%) were atrial, and 16 (15.5%) were coronary sinus leads. Patient-based and procedural data were collected and analyzed retrospectively. Clinical and procedural characteristics were compared and radiographic predictors of failure of SMT of ICD leads were assessed. Projected anteroposterior (AP) lead tortuosity was measured and lead slack score was estimated on chest X-ray (CXR). RESULTS Simple manual traction failed in 27 (42%) of the ICD leads. Ottawa slack score (odds ratio [OR] 2.368, 95% CI [1.261-4.447]; P = 0.007), AP lead tortuosity > 1.10 (OR 7.477, 95% CI [1.718-35.542]; P = 0.007), and number of previous interventions (OR 6.016, 95% CI [1.184-30.557]; P < 0.030) were found to be independently related to the failure of SMT. Receiver-operator characteristic curve analysis yielded an AP lead tortuosity cutoff value of > 1.10 for predicting the failure of SMT. The area under the curve was 0.744; the 95% confidence interval (CI) was 0.617 to 0.871 (P = 0.001), with a sensitivity of 63% and a specificity of 73%. CONCLUSION Simple manual traction success in our study varied based on radiographic lead-related parameters. Before planning the procedure, increased AP lead tortuosity in vasculature and higher lead slack score can be easily determined on CXR and may be associated with more fibrous adherences, the complexity of the LE, and failure of SMT.
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Affiliation(s)
- Umut Celikyurt
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Department of Cardiology, Kocaeli University Medical Faculty, Umuttepe Yerleskesi, İzmit, 41380, Kocaeli, Turkey.
| | - Burak Acar
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Department of Cardiology, Kocaeli University Medical Faculty, Umuttepe Yerleskesi, İzmit, 41380, Kocaeli, Turkey
| | - Akin Torun
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Department of Cardiology, Kocaeli University Medical Faculty, Umuttepe Yerleskesi, İzmit, 41380, Kocaeli, Turkey
| | - Muzeyyen Karakullukcu
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Department of Cardiology, Kocaeli University Medical Faculty, Umuttepe Yerleskesi, İzmit, 41380, Kocaeli, Turkey
| | - Ozgur Cakir
- Department of Radiology, Kocaeli University Medical Faculty, İzmit, Kocaeli, Turkey
| | - Ozgur Baris
- Department of Cardiovascular Surgery, Kocaeli University Medical Faculty, İzmit, Kocaeli, Turkey
| | - Ahmet Vural
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Department of Cardiology, Kocaeli University Medical Faculty, Umuttepe Yerleskesi, İzmit, 41380, Kocaeli, Turkey
| | - Aysen Agacdiken
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Department of Cardiology, Kocaeli University Medical Faculty, Umuttepe Yerleskesi, İzmit, 41380, Kocaeli, Turkey
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Pocket histology at cardiac implantable electronic device replacement: What's new? Heart Rhythm 2023; 20:198-206. [PMID: 36309157 DOI: 10.1016/j.hrthm.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Repeated procedures involving the cardiac implantable electronic device (CIED) pocket increase the infection risk, and the extent of pocket adhesions may prolong the procedure time. Few data on pocket histology at the time of CIED replacement are available. OBJECTIVE The purpose of this study was to describe CIED pocket histology in a cohort of patients undergoing CIED replacement or upgrade. METHODS All consecutive patients undergoing CIED replacement or upgrade at our center between November 2019 and May 2020 were enrolled. Subclinical pocket infection was ruled out by physical inspection and laboratory parameters before the procedure. Pocket tissue specimens from the anterior and posterior pockets were obtained intraoperatively. A systematic histological analysis of capsular thickness, fibrous connective tissue, neovascularization, inflammation, and calcifications was performed. RESULTS Thirty patients (6 women, 20%) were enrolled. The mean capsular thickness was 0.8 ± 0.3 mm in the anterior wall and 1.1 ± 0.4 mm in the posterior wall. Subcapsular fibrosis was mild and multifocal in the anterior wall and moderate and focal in the posterior wall. Neovascularization was focal in most cases, and vessel remodeling mainly involved the tunica media. Chronic inflammation was usually mild and nongranulomatous, and in a quarter of cases, subacute exudative fibrous inflammation was detected in the posterior pocket wall. CONCLUSION The CIED pocket is a histopathologically dynamic environment, given the coexistence of both a subacute foreign body response and fibrous tissue growth, implying continuous remodeling due to an injury-repair mechanism. Strategies to interact with foreign body response might minimize inflammatory pocket activity, especially device encapsulation by tight fibrous tissue, and possibly complications related to repeated CIED procedures.
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Love CJ, Hanna I, Thomas G, Greenspon AJ, Christie M, Goodman J, Christopherson M, Balaji V, Skulsky S, Sanders M, Bauer C, Schindeldecker W, Kirchhof N, Sohail MR. Preclinical evaluation of a third-generation absorbable antibacterial envelope. Heart Rhythm 2023; 20:737-743. [PMID: 36693614 DOI: 10.1016/j.hrthm.2023.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/03/2023] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Charles J Love
- Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland.
| | - Ibrahim Hanna
- Cardiac Electrophysiology, Brookwood Baptist Health, Birmingham, Alabama
| | - George Thomas
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Arnold J Greenspon
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | | | | | | | | | | | | | | | - M Rizwan Sohail
- Department of Medicine, Baylor College of Medicine, Houston, Texas
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6
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de Guzman RC, Meer AS, Mathews AA, Israel AR, Moses MT, Sams CM, Deegan DB. Reduced fibrous capsule elastic fibers from biologic ECM-enveloped CIEDs in minipigs, supported with a novel compression mechanics model. Biomed Mater Eng 2022:BME221488. [PMID: 36617774 DOI: 10.3233/bme-221488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Fibrous capsules (Fb) in response to cardiovascular implantable electronic devices (CIEDs), including a pacemaker (P) system, can produce patient discomfort and difficulties in revision surgery due partially to their increased compressive strength, previously linked to elevated tissue fibers. OBJECTIVE A preliminary study to quantify structural proteins, determine if biologic extracellular matrix-enveloped CIEDs (PECM) caused differential Fb properties, and to implement a realistic mechanical model. METHODS Retrieved Fb (-P and -PECM) from minipigs were subjected to biomechanical (shear oscillation and uniaxial compression) and histological (collagen I and elastin) analyses. RESULTS Fb-PECM showed significant decreases compared to Fb-P in: low strain-loss modulus (390 vs. 541 Pa) across angular frequencies, high strain-compressive elastic modulus (1043 vs. 2042 kPa), and elastic fiber content (1.92 vs. 3.15 μg/mg tissue). Decreases in elastin were particularly noted closer to the implant's surface (Fb-PECM = 71% vs. Fb-P = 143% relative to dermal elastin at mid-tangential sections) and verified with a solid mechanics hyperelasticity with direction-dependent fiber viscoelasticity compression simulation (r2 ≥ 98.9%). CONCLUSIONS The biologic envelope composed of decellularized porcine small intestine submucosa ECM for CIEDs promoted fibrous tissues with less elastic fibers. Novel compression modeling analyses directly correlated this singular reduction to more desirable subcutaneous tissue mechanics.
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Affiliation(s)
- Roche C de Guzman
- Bioengineering Program, Department of Engineering, Hofstra University, Hempstead, NY, USA
| | - Allison S Meer
- Bioengineering Program, Department of Engineering, Hofstra University, Hempstead, NY, USA.,Department of Biology, Hofstra University, Hempstead, NY, USA
| | - Aidan A Mathews
- Bioengineering Program, Department of Engineering, Hofstra University, Hempstead, NY, USA.,Department of Biology, Hofstra University, Hempstead, NY, USA
| | - Atara R Israel
- Bioengineering Program, Department of Engineering, Hofstra University, Hempstead, NY, USA
| | - Michael T Moses
- Bioengineering Program, Department of Engineering, Hofstra University, Hempstead, NY, USA
| | - Clarence M Sams
- Bioengineering Program, Department of Engineering, Hofstra University, Hempstead, NY, USA
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7
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Woodard DA, Kim G, Nilsson KR. Risk Profiles and Outcomes of Patients Receiving Cardiovascular Implantable Electronic Devices With and Without Antibacterial Envelopes. Cureus 2022; 14:e24739. [PMID: 35686253 PMCID: PMC9170375 DOI: 10.7759/cureus.24739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/05/2022] Open
Abstract
Background The increasing use of cardiac implantable electronic devices (CIEDs) in a growing patient population has led to an even greater increase in CIED infection rates. Antibacterial CIED envelopes are often used as part of an infection risk-reduction strategy. However, best practices for when to use an envelope and which envelope to choose remain to be elucidated. Methods In this retrospective study, the records of 455 patients undergoing CIED implantation by a single surgeon were reviewed to identify trends in envelope use and outcomes after implantation through 12 months of follow-up. Of these patients, 165 were managed with a biologic antibacterial CIED envelope (CanGaroo®, Aziyo Biologics, Inc., Silver Spring, MD), 219 with a non-biologic envelope (Tyrx®, Medtronic Inc., Monmouth Junction, NJ), and 71 with no envelope. Results Most patients had two or more infection risk factors (77.9% with any envelope vs. 52.1% with no envelope; P < 0.001). Factors significantly associated with the use of an envelope included the history of heart failure, systemic anticoagulant use, the use of high-power or more complex devices, and reoperations. The overall rate of adverse events was 9.2% (n = 42). Rates of infection and hematoma were 1.8% and 2.6%, respectively. A decision tree is proposed that may aid clinical decision-making when considering CIED envelope usage. Conclusions There were no significant differences between groups in overall or individual adverse event rates. These data provide insight into real-world clinical decisions regarding the use of CIED envelopes and support the use of antibiotic-eluting CIED envelopes to limit infection risk in high-risk patients.
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8
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Callahan TD. Looking for Lead Adhesions While Planning for Transvenous Lead Extraction. J Cardiovasc Electrophysiol 2022; 33:1041-1044. [PMID: 35245950 DOI: 10.1111/jce.15436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/26/2022]
Abstract
The first implantable pacemaker was placed in the 1958, ushering in a new frontier of cardiovascular medicine. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Thomas D Callahan
- Director, Inpatient Electrophysiology Service, Associate Program Director, Cardiovascular Medicine Fellowship.,Cleveland Clinic, Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
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Beaser AD, Aziz Z, Besser SA, Jones CI, Jameria Z, Kannan A, Upadhyay GA, Broman MT, Ozcan C, Tung R, Nayak HM. Characterization of Lead Adherence Using Intravascular Ultrasound to Assess Difficulty of Transvenous Lead Extraction. Circ Arrhythm Electrophysiol 2020; 13:e007726. [DOI: 10.1161/circep.119.007726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Clinical factors associated with development of intravascular lead adherence (ILA) are unreliable predictors. Because vascular injury in the superior vena cava-right atrium during transvenous lead extraction is more likely to occur in segments with higher degrees of ILA, reliable and accurate assessment of ILA is warranted. We hypothesized that intravascular ultrasound (IVUS) could accurately visualize and quantify ILA and degree of ILA correlates with transvenous lead extraction difficulty.
Methods:
Serial imaging of leads occurred before transvenous lead extraction using IVUS. ILA areas were classified as high or low grade. Degree of extraction difficulty was assessed using 2 metrics and correlated with ILA grade. Lead extraction difficulty was calculated for each patient and compared with IVUS findings.
Results:
One hundred fifty-eight vascular segments in 60 patients were analyzed: 141 (89%) low grade versus 17 (11%) high grade. Median extraction time (low=0 versus high grade=97 seconds,
P
<0.001) and median laser pulsations delivered (low=0 versus high grade=5852,
P
<0.001) were significantly higher in high-grade segments. Most patients with low lead extraction difficulty score had low ILA grades. Eighty-six percentage of patients with high lead extraction difficulty score had low IVUS grade, and the degree of transvenous lead extraction difficulty was similar to patients with low IVUS grades and lead extraction difficulty scores.
Conclusions:
IVUS is a feasible imaging modality that may be useful in characterizing ILA in the superior vena cava-right atrium region. An ILA grading system using imaging correlates with extraction difficulty. Most patients with clinical factors associated with higher extraction difficulty may exhibit lower ILA and extraction difficulty based on IVUS imaging.
Graphic Abstract:
A
graphic abstract
is available for this article.
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Affiliation(s)
- Andrew D. Beaser
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Zaid Aziz
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Stephanie A. Besser
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Christopher I. Jones
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Zenith Jameria
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Arun Kannan
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Gaurav A. Upadhyay
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Michael T. Broman
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Cevher Ozcan
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Roderick Tung
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
| | - Hemal M. Nayak
- Department of Medicine, Section of Cardiology, University of Chicago Pritzker School of Medicine, IL
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Robotti F, Sterner I, Bottan S, Monné Rodríguez JM, Pellegrini G, Schmidt T, Falk V, Poulikakos D, Ferrari A, Starck C. Microengineered biosynthesized cellulose as anti-fibrotic in vivo protection for cardiac implantable electronic devices. Biomaterials 2019; 229:119583. [PMID: 31707297 DOI: 10.1016/j.biomaterials.2019.119583] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/21/2019] [Accepted: 10/26/2019] [Indexed: 01/13/2023]
Abstract
Upon cardiac implantable electronic device (CIED) exchange, upgrade, or revision surgery patients are exposed to a considerable risk of adverse events. The presence of firm fibrotic tissue endangers these procedures. Leads can be damaged in the attempt of freeing them from fibrotic tissue. Hematoma can form as result of capsulectomy, pocket debridement and leads dissection. Due to the increasing number of CIED exchange, upgrade and revision surgeries, the incidence of related complications is expected to rise in the near future.The aim of the study was to evaluate the feasibility, safety, and performance of a rationally micro-engineered non-resorbable biosynthesized cellulose (BC) membrane as conformal wrapping protection around CIED implants. Protective membranes were generated by means of a recently established method to transfer on-demand microscale geometries onto the surface of BC. A chronic minipig animal model was selected to investigate the performance of the BC anti-fibrotic protection, directly measured as reduction of fibrotic tissue formation. Sixteen (n = 16) animals received each one BC coated pacemaker (PMC) and one native pacemaker (BI) at equivalent anatomical sites. BC protective layers were juxtaposed around pacemakers through a fast and well-repeatable procedure. Explants were performed at 3 and 12 months after implantation. Endpoint analysis showed that the BC protective layers were 100% integer, with no sign of chemical or mechanical degradation and appeared as a thin layer of white-tan material, adherent to the surrounding thin fibrous capsule, from which it could be peeled off by gently pulling with forceps. The protective effect of micro-engineered BC yielded an average thickness reduction of 66% of the fibrotic tissue thickness generated around PMC, as compared to that measured around the naked counterpart (i.e. the BI). When protected by in BC, both the generator and the proximal parts of the leads were completely free from fibrotic tissue. The insertion of an anti-adhesive, non-resorbable and well-tolerated BC interface between the implant and the surrounding tissue in the surgical pocket significantly reduced the formation of fibrotic tissue, ensuring an easy access to the device pocket, and thus creating the conditions for simplified CIED revision surgeries.
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Affiliation(s)
- Francesco Robotti
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Sonneggstrasse 3, CH-8092 Zurich, Switzerland; Wyss Zurich Translational Center, Zurich, Switzerland
| | - Ita Sterner
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Simone Bottan
- Wyss Zurich Translational Center, Zurich, Switzerland
| | - Josep M Monné Rodríguez
- Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland.
| | - Giovanni Pellegrini
- Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Tanja Schmidt
- Charité- Universitätsmedizin Berlin, Forschungseinrichtungen für experimentelle Medizin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; Division of Cardiovascular Surgery, Charité, Berlin, Germany; German Center of Cardiovascular Research (DZHK), partner site, Berlin, Germany; Department of Health Science and Technology, ETH Zurich, Switzerland
| | - Dimos Poulikakos
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Sonneggstrasse 3, CH-8092 Zurich, Switzerland
| | - Aldo Ferrari
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Sonneggstrasse 3, CH-8092 Zurich, Switzerland; EMPA, Swiss Federal Laboratories for Material Science and Technology, Überlandstrasse 129, Dübendorf 8600, Switzerland.
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; German Center of Cardiovascular Research (DZHK), partner site, Berlin, Germany.
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11
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Robotti F, Bottan S, Fraschetti F, Mallone A, Pellegrini G, Lindenblatt N, Starck C, Falk V, Poulikakos D, Ferrari A. A micron-scale surface topography design reducing cell adhesion to implanted materials. Sci Rep 2018; 8:10887. [PMID: 30022037 PMCID: PMC6052105 DOI: 10.1038/s41598-018-29167-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 06/27/2018] [Indexed: 12/21/2022] Open
Abstract
The micron-scale surface topography of implanted materials represents a complementary pathway, independent of the material biochemical properties, regulating the process of biological recognition by cells which mediate the inflammatory response to foreign bodies. Here we explore a rational design of surface modifications in micron range to optimize a topography comprised of a symmetrical array of hexagonal pits interfering with focal adhesion establishment and maturation. When implemented on silicones and hydrogels in vitro, the anti-adhesive topography significantly reduces the adhesion of macrophages and fibroblasts and their activation toward effectors of fibrosis. In addition, long-term interaction of the cells with anti-adhesive topographies markedly hampers cell proliferation, correlating the physical inhibition of adhesion and complete spreading with the natural progress of the cell cycle. This solution for reduction in cell adhesion can be directly integrated on the outer surface of silicone implants, as well as an additive protective conformal microstructured biocellulose layer for materials that cannot be directly microstructured. Moreover, the original geometry imposed during manufacturing of the microstructured biocellulose membranes are fully retained upon in vivo exposure, suggesting a long lasting performance of these topographical features after implantation.
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Affiliation(s)
- Francesco Robotti
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Sonneggstrasse 3, CH-8092, Zurich, Switzerland
| | - Simone Bottan
- Wyss Zurich, ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Federica Fraschetti
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Sonneggstrasse 3, CH-8092, Zurich, Switzerland
| | - Anna Mallone
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Giovanni Pellegrini
- Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Dimos Poulikakos
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Sonneggstrasse 3, CH-8092, Zurich, Switzerland
| | - Aldo Ferrari
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Sonneggstrasse 3, CH-8092, Zurich, Switzerland.
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Sharma S, Ekeruo IA, Nand NP, Sundara Raman A, Zhang X, Reddy SK, Hariharan R. Safety and Efficacy of Transvenous Lead Extraction Utilizing the Evolution Mechanical Lead Extraction System. JACC Clin Electrophysiol 2018; 4:212-220. [DOI: 10.1016/j.jacep.2017.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/30/2017] [Accepted: 12/07/2017] [Indexed: 11/17/2022]
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13
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Keiler J, Schulze M, Sombetzki M, Heller T, Tischer T, Grabow N, Wree A, Bänsch D. Neointimal fibrotic lead encapsulation - Clinical challenges and demands for implantable cardiac electronic devices. J Cardiol 2017; 70:7-17. [PMID: 28583688 DOI: 10.1016/j.jjcc.2017.01.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 01/16/2017] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Jonas Keiler
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany.
| | - Marko Schulze
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
| | - Martina Sombetzki
- Department for Tropical Medicine and Infectious Diseases, Rostock University Medical Center, Rostock, Germany
| | - Thomas Heller
- Institute of Diagnostic and Interventional Radiology, Rostock University Medical Center, Rostock, Germany
| | - Tina Tischer
- Heart Center Rostock, Department of Internal Medicine, Divisions of Cardiology, Rostock University Medical Center, Rostock, Germany
| | - Niels Grabow
- Institute for Biomedical Engineering, Rostock University Medical Center, Rostock, Germany
| | - Andreas Wree
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
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2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm 2017; 14:e503-e551. [PMID: 28919379 DOI: 10.1016/j.hrthm.2017.09.001] [Citation(s) in RCA: 710] [Impact Index Per Article: 101.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 02/06/2023]
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15
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Hansky B, Kaymer W, zu Vilsendorf DM, Strunk-Müller C, Stellbrink C. [Practical aspects of pacemaker and ICD-lead extractions]. Herzschrittmacherther Elektrophysiol 2013; 24:158-64. [PMID: 23959041 DOI: 10.1007/s00399-013-0282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 07/22/2013] [Indexed: 11/30/2022]
Abstract
Special tools for lead removal enables transvenous lead extractions without cardiac exposure. The risk of fatal complications during extraction of long-term implanted leads requires detailed knowledge and trained physicians. In addition to patients’ age and gender, individual extraction risk factors are access and time since implantation, lead position, kind and number of leads. Locking stylets to anchor the lead within the lumen are necessary in all extraction procedures while the use of external sheaths is optional. Higher risk of cardiac or central vein perforation during lead mobilisation with external laser sheaths has to be respected, and these tools should be used with strong indication only. In cases of high risk, lead explantation with an open heart procedure should be considered as an alternative.
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Affiliation(s)
- Bert Hansky
- Klinik für Kardiologie und internistische Intensivmedizin, Klinikum Bielefeld, Bielefeld, Germany.
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