Risks of spontaneous injury and extraction of an active fixation pacemaker lead: report of the Accufix Multicenter Clinical Study and Worldwide Registry

Indications for Lead Extraction

Cardiac implantable electronic devices (CIEDs) are being implanted at increasing rates. Patients with CIEDs require more lead management in contemporary clinical practice, given the increased survival of heart failure patients. There are multiple indications for extraction with the strongest class I indications being in patients with CIED infections. Extraction with complete hardware removal is underutilized and often delayed when it is utilized in patients with CIED infections, resulting in higher mortality. Patient and provider preferences are critical to decision-making when considering extraction. Lead extraction referral and management care pathways are needed in order to optimize care for our patients with CIEDs.

Lead Extraction History, Training, Volume, and Location

Transvenous lead extraction (TLE) has evolved significantly since the introduction of cardiac pacing systems in the 1950s. The need for TLE has grown due to the increasing complexity of cardiac devices and patients, alongside rising infection rates and regulatory recalls. Despite its challenges, improved institutional support and advanced training programs have made TLE more accessible. Modern TLE indications are well-defined, evolving through scientific statements to include comprehensive lead management best practices and safety protocols. However, underutilization persists, particularly in infection management, highlighting the need for continued education and adherence to guidelines.

When pacing or defibrillator leads become redundant: Extract or abandon?

The 2017 Heart Rhythm Society expert consensus paper on lead management and extraction did not express a preference for either extracting or abandoning pacing or defibrillator leads that are dysfunctional or superfluous after an upgrade (hereafter referred to as redundant leads). However, no randomized or even nonrandomized trials show a better patient outcome with extraction. Many experienced centers currently advise patients to have redundant leads removed to prevent more complicated procedures after years of abandonment. According to the literature, however, not all abandoned leads need to be extracted as >90% will have an uneventful follow-up. As immediate extraction of redundant leads has a small but significant risk, this will generate more adverse events at the population level than when extraction is limited to the patients with future lead complications, even considering a higher extraction risk at that time. Lead extraction is also limited to specialized centers and often necessitates expensive tools, in contrast to abandoning leads, which can be safely performed by any experienced device specialist without additional cost.

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Cardiac pacemaker-related endocarditis complicated with pulmonary embolism: Case report

Cardiac device-related endocarditis as a device-therapy complication is a growing problem due to higher life expectancy and the increasing number of abandoned leads and subclinical symptoms. We reported a case of a 47-year-old woman with an implanted pacemaker who was admitted to the clinic for cardiology due to the right-sided device-related infective endocarditis of the pacemaker leads with vegetations, predominantly in the right atrium and right ventricle and complicated by pulmonary embolism. Several years after pacemaker implantation, she was diagnosed with systemic lupus erythematosus and started immunosuppressive therapy. The patient was treated with prolonged intravenous antibiotic therapy. The atrial and ventricular lead was extirpated, and the posterior leaflet of the tricuspid valve was shaved.

Subcutaneous and Transvenous ICDs: an Update on Contemporary Questions and Controversies

PURPOSE OF REVIEW

While the subcutaneous (S-) implantable cardioverter-defibrillator (ICDs) is an alternative to the transvenous (TV-) ICD in many patients, optimal use remains unclear. In this review, we summarize recent clinically relevant data on sensing algorithms, inappropriate shocks, defibrillation testing, and battery and electrode failures.

RECENT FINDINGS

Changes in sensing algorithms and S-ICD programming have significantly decreased inappropriate shock rates. Avoiding fat below the S-ICD coil and can is key for reducing the defibrillation threshold. While S-ICD battery and electrode failures have resulted in recalls, system components remain commercially available since failure rates are low and no other similar devices are available. The S-ICD is a good alternative to the TV-ICD for many patients, and particularly in light of recently developed device algorithms and improvements in implant technique. Future research will need to better understand: the impact of S-ICD electrode and battery failures and the potential for integrating leadless pacing into a modular S-ICD platform.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Magnetic resonance conditionality of abandoned leads from active implantable medical devices at 1.5 T

PURPOSE

During MR scans, abandoned leads from active implantable medical devices (AIMDs) can experience excessive heating at the lead tip, depending on the type of termination applied to the proximal contacts (proximal end treatment). The influence of different proximal end treatments (ie, [1] freely exposed in the tissue, [2] terminated with metal in contact with the tissue, or [3] capped with plastic, and thereby fully insulated, on the RF-induced lead-tip heating) are studied. A technique to ensure that MR Conditional AIMD leads remain MR Conditional even when abandoned is recommended.

METHODS

Abandoned leads from three MR Conditional AIMDs ([1] a sacral neuromodulation system, [2] a cardiac rhythm management pacemaker system, and [3] a deep brain stimulator system) were investigated in this study. The computational lead models (ie, the transfer functions) for different proximal end treatments were measured and used to assess the in vivo lead-tip heating for four virtual human models (FATS, Duke, Ella, and Billie) and compared with the lead-tip heating of the complete MR Conditional AIMD system.

RESULT

The average and maximum lead-tip heating for abandoned leads proximally capped with metal is always lower than that from the complete AIMD system. Abandoned leads proximally insulated could lead to an average in vivo temperature rise up to 3.5 times higher than that from the complete AIMD system.

CONCLUSION

For the three investigated AIMDs under 1.5T MR scanning, our results indicate that RF-induced lead-tip heating of abandoned leads strongly depends on the proximal lead termination. A metallic cap applied to the proximal termination of the tested leads could significantly reduce the RF-induced lead-tip heating.

Cardiac perforation due to a fracture of a recalled Accufix bipolar active fixation pacing lead 29 years after implantation: A case report

The Accufix bipolar active fixation atrial pacing lead (Model 330-801; Telectronics) can have mechanical complications due to a fracture of its J retention wire. An 80-year-old man had the Accufix atrial pacing lead implanted 29 years prior, and surgical removal was required because a part of the lead was perforating the apex of the right ventricle. Regular follow-up examinations are recommended to eliminate the possibility of protrusion and detachment of the J retention wire, even if the clinical course after implantation is stable for a prolonged period.

Unexpected high failure rate of a specific MicroPort/LivaNova/Sorin pacing lead

BACKGROUND

Pacing leads are the Achilles heel of pacemakers. Most manufacturers report a 3-year survival rate of >99% of their leads. We observed several failures of the Beflex/Vega leads (MicroPort, Shanghai, China; formerly Sorin/LivaNova).

OBJECTIVE

The purpose of this study was to investigate failure rates of Beflex/Vega leads.

METHODS

We analyzed the performance of Beflex/Vega leads implanted at our tertiary referral center. All-cause lead failures (any issues requiring reinterventions such as lead dislocations, cardiac perforations, and electrical abnormalities) were identified during follow-up. The Beflex/Vega lead was compared with a reference lead (CapSureFix Novus 5076, Medtronic, Minneapolis, MN) implanted within the same period and by the same operators.

RESULTS

A total of 585 leads were analyzed (382 Beflex/Vega and 203 CapSureFix Novus 5076 leads). Cumulative failure rate estimates were 5.2%, 6.3%, and 12.4% after 1, 2, and 3 years for the Beflex/Vega lead. This was worse compared to the reference lead (1.5%, 1.5%, 3.7% after 1, 2, and 3 years; P = .001). Early failure manifestations up to 3 months occurred at a similar rate (Beflex/Vega vs CapSureFix Novus 5076 lead: 1.3% vs 0.5% for dislocations; 1.3% vs 1.0% for perforations). During follow-up, electrical abnormalities such as noise oversensing (P = .013) and increased pacing thresholds (P = .003) became more frequent in the Beflex/Vega group. Electrical abnormalities were the most common failure manifestation 3 years after implantation in this group (9.4% vs 2.2% for the CapSureFix Novus 5076).

CONCLUSION

The failure rate of the Beflex/Vega lead of >10% after 3 years was higher than that of a competitor lead. This gives rise to concern since >135,000 such leads are active worldwide.

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.

Anesthesia Considerations for Lead Extraction

The role of the anesthesiologist in lead extraction procedures is multifaceted and highlights the collaborative, multidisciplinary teamwork needed to ensure patient safety and procedural success in these complex cases. Thorough preoperative evaluation and identification of high-risk characteristics enable the anesthesiologist to tailor a comprehensive intraoperative and postoperative care plan for each case. Institutional practices may vary but anesthetic management typically includes general anesthesia with an endotracheal tube, invasive measurement of arterial blood pressure, vascular access for rapid volume expansion, echocardiographic monitoring, preparation for blood transfusion, and initiation of cardiopulmonary bypass in the event of an emergency.

Overcoming the current issues surrounding device leads: reducing the complications during extraction

INTRODUCTION

The implantation rate of cardiac implantable electronic devices has consistently increased in the last 20 years, as have the related complication rates. The most relevant issue is the removal of pacing and implantable cardioverter defibrillator (ICD) leads, which a few months after implantation tend to develop intravascular fibrosis, often making extraction a challenging and risky procedure. Areas covered: The transvenous lead extraction (TLE) scenario is constantly evolving. TLE is a key procedure in lead management strategies. Many efforts have been made to develop new TLE approaches and techniques allowing a safe and effective procedure for patients. The increasing rate of cardiac implantable electronic device (CIED) implantations and of CIED related complications highlight the importance of TLE. Lead related- and patient-related factors may change the future of extractions. We review the current status of TLE, focusing on the strategies available to perform the optimal procedure in the right patient and reducing procedure related complications. Expert commentary: Understanding the importance of an accurate TLE risk stratification is mandatory to optimize the procedural risk-to-benefits ratio. The use of adequate tools, techniques and approaches, and appropriate training are cornerstones for the achievement of safer procedures.

Characterization of a previously unrecognized clinical phenomenon: Delayed shock after cardiac implantable electronic device extraction

BACKGROUND

Transvenous lead extraction remains a challenging procedure with inherent risk and associated complications.

OBJECTIVE

We sought to characterize and evaluate predictors of delayed shock after transvenous lead extraction with no intraprocedural complications.

METHODS

We retrospectively analyzed data of 217 consecutive patients who underwent extraction between 2010 and 2015. The primary end point was sudden onset of shock more than 4 hours after the completion of the procedure. Shock was defined as at least 30 minutes of persistent hypotension, necessitating vasopressors. Patients with mechanical or hemorrhagic shock were excluded.

RESULTS

Seventeen patients (9%) developed delayed shock during the first 24 hours. Reasons for shock were sepsis (47%) or no apparent cause (53%). In multivariate analysis, patients with delayed shock had significantly lower glomerular filtration rate (median estimated glomerular filtration rate 53 mL/min vs 73 mL/min; P = .001), had more signs of systemic infection before extraction (fever, bacteremia, and leukocytosis; P < .05), and had more lead/tip remnants (29% vs 3%; P < .001). Patients presenting with delayed shock had significantly higher mortality rates at 1-year follow-up (10 [59%] vs 40 [23%], respectively; P < .01). Multivariate analysis adjusted for 1-year mortality risk was 114% higher (hazard ratio 2.14; 95% confidence interval 1.02-4.47; P < .05) in patients presenting with delayed shock.

CONCLUSION

We describe a previously unrecognized clinical phenomenon of delayed shock developing after extraction. Patients with predictors of this condition at baseline should be identified and followed up closely. Even with prompt treatment, long-term mortality rates remain high.

Lead Extraction Considerations for the Referring Cardiologist

The population of patients with cardiac implantable electronic devices (CIEDs) continues to grow due to increasing indications in an aging population and breakthroughs in both the medical and the surgical care of patients with heart disease. As a result, there has been a growing need for device and lead extractions due to the growing population of patients with CIEDs and the subsequent need for system upgrades or revisions because of complications, infections, and lead advisory alerts.

Cardiac Implantable Electronic Device Infections: Added Complexity and Suboptimal Outcomes With Previously Abandoned Leads

OBJECTIVES

This study sought to assess the impact of previously abandoned leads on the clinical management of cardiac device infections, notably transvenous lead extraction and subsequent clinical course.

BACKGROUND

The population of patients with cardiac implantable electronic devices continues to grow with a disproportionate increase in device infections, which are invariably life threatening. A potentially complicating issue is the widely practiced strategy of device lead abandonment at the time of system revision, change, or upgrade, which is affecting an increasing number of patients.

METHODS

The study assessed the impact of previously abandoned leads in a prospectively maintained registry of consecutive patients undergoing percutaneous extraction of infected cardiac devices at the Cleveland Clinic between August 1996 and September 2012. The primary clinical endpoint was complete procedural and clinical success defined as the successful removal of the device and all lead material from the vascular space, in the absence of a major complication.

RESULTS

Of 1,386 patients with infected cardiac devices, 323 (23.3%) had previously abandoned leads. Failure to achieve the primary endpoint occurred more frequently in patients with abandoned leads (13.0% vs. 3.7%; p < 0.0001). This was primarily due to retention of lead material (11.5% vs. 2.9%; p < 0.0001), which was associated with poor clinical outcomes including higher rates of 1-month mortality (7.4% vs. 3.5% in those without lead remnants). Lead extraction procedures in patients with previously abandoned leads were longer (p < 0.0001), with longer fluoroscopy times (p < 0.0001), and more likely to require specialized extraction tools (94.4% vs. 81.8%; p < 0.0001) or adjunctive rescue femoral workstations (14.9% vs. 2.9%; p < 0.0001). Procedural complications occurred more frequently in patients with previously abandoned leads (11.5% vs. 5.6%; p = 0.0003), which was true for both major (3.7% vs. 1.4%; p = 0.009) and minor complications (7.7% vs. 4.4%; p = 0.02).

CONCLUSIONS

Previously abandoned leads complicate the management of cardiac device infections, leading to worse clinical outcomes.

Unusual cause of hypoxemia after automatic implantable cardioverter-defibrillatorleads extraction

The indication of pacemaker/AICD removal are numerous. Serious complication can occur during their removal, severe tricuspid regurgitation is one of the complication. The occurrence of PFO is not uncommon among adult population. Shunting across PFO in most circumstance is negligible, but in some necessitates closure due to hypoxemia. We report a case of 62 year old man, while undergoing AICD removal, had an emergency sternotomy for cardiac tamponade. Postoperatively, he experienced profound hypoxemia refractory to oxygen therapy. Transthoracic Echocardiogram was performed to rule out intracardiac shunts at an early stage, but it was difficult to obtain an good imaging windows poststernotomy. A small pulmonary emboli was noted on CTPA, but was not sufficient to account for the level of hypoxemia and did not resolve with anticoagulation. Transesophageal echocardiogram showed flail septal tricuspid valve with severe TR and bidirectional shunt through large PFO. Patient was posted for surgery, tricuspid valve was replaced and PFO surgically closed. Subsequently, patient recovered well ad was discharged to home. Cause of hypoxemia might be due to respiratory or cardiac dysfunction. But for hypoxemia refractory to oxygen therapy, transoesophageal echocardiogram should be always considered and performed early as an diagnostic tool in post cardiac surgical patients.

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

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

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

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

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

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

Variability in clinical features of early versus late cardiovascular implantable electronic device pocket infections

BACKGROUND

Cardiovascular implantable electronic device (CIED) pocket infections are often related to recent CIED placement or manipulation, but these infections are not well characterized. The clinical presentation of CIED pocket infection, based on temporal onset related to last CIED procedure, deserves further study.

METHODS

The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with CIED infection. Subjects were stratified into those whose infection occurred <12 months (early) or ≥ 12 months (late) since their last CIED-related procedure.

RESULTS

There were 132 subjects in the early group and 106 in the late group. There were more females (P = 0.009) and anticoagulation use (P = 0.039) in the early group. Subjects with early infections were more likely to have had a generator change or lead addition as their last procedure (P = 0.03) and had more prior CIED procedures (P = 0.023). Early infections were more likely to present with pocket erythema (P < 0.001), swelling (P < 0.001), and pain (P = 0.007). Late infections were more likely to have pocket erosion (P = 0.005) and valvular vegetations (P = 0.009). In bacteremic subjects, early infections were more likely healthcare-associated (P < 0.001). In-hospital and 6-month mortality were equivalent.

CONCLUSION

A total of 45% of patients with CIED pocket infection presented >12 months following their last CIED-related procedure. Patients with early infection were more likely to be female, on anticoagulation, and present with localized inflammation, whereas those with late infection were more likely to have CIED erosion or valvular endocarditis.

From lead management to implanted patient management: systematic review and meta-analysis of the last 15 years of experience in lead extraction

Percutaneous lead extraction is considered a safe and effective procedure, although published results derive primarily from cohort studies. The authors performed a systematic review and meta-analysis of the last 15 years' experience in this field, to give an objective evaluation of the efficacy and safety of this procedure. Moreover, the subsequent metaregression analysis enabled the identification of the main factors influencing these results: patient age, presence of leads in situ for more than 1 year, presence of device infection and use of laser sheath. These findings are significant in order to improve our extraction approach, data reporting and future research.

Late atrial appendage perforation from a pacemaker lead pacemaker complication

Lead perforation is a rare complication of device implantation, varying between 0.3% and 1%, although the prevalence may be higher. Late lead perforations (>1 month after implantation) are believed to be very rare. We describe the successful treatment of a 65-year-old man with late cardiac perforation due to the pacemaker active fixation lead after an uneventful implantation.

Increasing lead burden correlates with externalized cables during systematic fluoroscopic screening of Riata leads

PURPOSE

Riata and Riata ST defibrillator leads (St. Jude Medical, Sylmar, CA, USA) have been recalled due to increased risk of insulation failure leading to externalized cables. As this mechanical failure does not necessarily correlate with electrical failure, it can be difficult to diagnose. Fluoroscopic screening can identify insulation failure. Studies have suggested that insulation failure is predominantly seen in 8-Fr, single-coil models. Our patients have exclusively dual-coil leads and a high proportion of 7-Fr leads.

METHODS

Fluoroscopic screening was performed in 48 patients with recalled Riata leads. Twenty-three patients had 8-Fr Riata leads and 25 patients had 7-Fr Riata ST leads. Images were recorded in at least three projections and studies were reviewed by seven attending electrophysiologists.

RESULTS

Externalized cables were seen in ten patients (21 %), and another five patients (10 %) had abnormal cable spacing. All device interrogations showed normal parameters. Patients with abnormal leads had more leads in situ (2.5 ± 0.7 vs. 1.6 ± 0.8 leads; P = 0.002) and a higher rate of nonischemic cardiomyopathy (80 vs. 24 %; P = 0.03). There were no differences between the groups with regards to patient age, body mass index, lead age, lead parameters, or vascular access site. There was no difference with regard to lead size (P = 0.76).

CONCLUSIONS

The Riata family of leads has a high incidence of mechanical failure, as demonstrated on fluoroscopic screening. In this study, the 7-Fr models were just as likely to mechanically fail as the 8-Fr models. Increasing lead burden and a diagnosis of nonischemic cardiomyopathy correlated with insulation failure.

Cell and gene therapy for arrhythmias: Repair of cardiac conduction damage

Action potentials generated in the sinoatrial node (SAN) dominate the rhythm and rate of a healthy human heart. Subsequently, these action potentials propagate to the whole heart via its conduction system. Abnormalities of impulse generation and/or propagation in a heart can cause arrhythmias. For example, SAN dysfunction or conduction block of the atrioventricular node can lead to serious bradycardia which is currently treated with an implanted electronic pacemaker. On the other hand, conduction damage may cause reentrant tachyarrhythmias which are primarily treated pharmacologically or by medical device-based therapies, including defibrillation and tissue ablation. However, drug therapies sometimes may not be effective or are associated with serious side effects. Device-based therapies for cardiac arrhythmias, even with well developed technology, still face inadequacies, limitations, hardware complications, and other challenges. Therefore, scientists are actively seeking other alternatives for antiarrhythmic therapy. In particular, cells and genes used for repairing cardiac conduction damage/defect have been investigated in various studies both in vitro and in vivo. Despite the complexities of the excitation and conduction systems of the heart, cell and gene-based strategies provide novel alternatives for treatment or cure of cardiac arrhythmias. This review summarizes some highlights of recent research progress in this field.

How Should Implantable Cardioverter-Defibrillator Lead Failures be Managed and What is the Role of Lead Extraction?

Despite remarkable advances in design, implantable cardioverter-defibrillator (ICD) leads remain the component most susceptible to failure, which often leads to substantial adverse clinical outcomes. This article focuses on management strategies when ICD lead systems fail. Two cases involving management decisions for ICD lead failures are presented and discussed. One involves a common mode of presentation, inappropriate shocks. The second involves an alert in a patient with a complex system and multiple comorbidities. Although a systematic approach is outlined, management decisions must be balanced by a risk-and-benefit assessment of the individual patient.

Critical appraisal of cardiac implantable electronic devices: complications and management

Population aging and broader indications for the implant of cardiac implantable electronic devices (CIEDs) are the main reasons for the continuous increase in the use of pacemakers (PMs), implantable cardioverter-defibrillators (ICDs) and devices for cardiac resynchronization therapy (CRT-P, CRT-D). The growing burden of comorbidities in CIED patients, the greater complexity of the devices, and the increased duration of procedures have led to an augmented risk of infections, which is out of proportion to the increase in implantation rate. CIED infections are an ominous condition, which often implies the necessity of hospitalization and carries an augmented risk of in-hospital death. Their clinical presentation may be either at pocket or at endocardial level, but they can also manifest themselves with lone bacteremia. The management of these infections requires the complete removal of the device and subsequent, specific, antibiotic therapy. CIED failures are monitored by competent public authorities, that require physicians to alert them to any failures, and that suggest the opportune strategies for their management. Although the replacement of all potentially affected devices is often suggested, common practice indicates the replacement of only a minority of devices, as close follow-up of the patients involved may be a safer strategy. Implantation of a PM or an ICD may cause problems in the patients’ psychosocial adaptation and quality of life, and may contribute to the development of affective disorders. Clinicians are usually unaware of the psychosocial impact of implanted PMs and ICDs. The main difference between PM and ICD patients is the latter’s dramatic experience of receiving a shock. Technological improvements and new clinical evidences may help reduce the total burden of shocks. A specific supporting team, providing psychosocial help, may contribute to improving patient quality of life.

The effect of device advisories on implantable cardioverter-defibrillator therapy

Implantable cardioverter-defibrillators have been shown to improve survival by terminating life-threatening ventricular tachyarrhythmias. As the devices have become more complex, there has been an increase in the incidence of device and lead malfunction. The device manufacturers issue advisories and recalls to alert physicians of the potential for malfunction. When patients are faced with a recalled device or lead, the initial question is whether or not to replace it. A rational approach to evaluating these patients and the associated advisory can help gauge the competing risks of elective device removal or extraction versus keeping the device in place. It is important to keep in mind that the risks of replacing devices or extracting leads are not insignificant and may outweigh the risks of death from malfunction. Despite the increasing number of advisories and attention to device and lead failure, the overall reliability and efficacy of these devices for appropriate patients remains high. In general, patients should be counseled prior to implant of the potential for device and lead malfunction, and careful consideration must be employed when decisions are made to replace generators or extract leads.

Late perforation by cardiac implantable electronic device leads: clinical presentation, diagnostic clues, and management

Late intracardiac lead perforation is defined as migration and perforation of an implanted lead after 1 month of cardiac electronic device implantation. It is an under-recognized complication with significant morbidity and mortality, particularly if not recognized early. Two patients with late perforation caused by passive-fixation leads are reported and the clinical features of their presentation and management are reviewed. We conducted a thorough review of the available English language literature pertaining to this complication to draw relevant conclusions regarding presentation, diagnosis, and management. Early recognition of this complication is important as the indications for and numbers of patients who receive cardiac implantable electronic devices continue to expand.

Focus on management of pacemaker and ICD advisories, recalls, and alerts

Because the number of implantable cardiac devices has dramatically increased, device alerts and advisories have become a part of routine clinical practice. When a physician is faced with the management of a patient with an implanted device that has been the subject of a recall or advisory, the major concern facing the clinician is how to manage the patient and whether the device needs to be replaced. A rational approach to evaluating patients with a device or lead that is the subject of a US Food and Drug Administration advisory requires evaluating the competing risks of elective device or lead replacement versus keeping the recalled device or lead in place. It is important to keep in mind that the risks of replacing devices are not insignificant and may outweigh the risks of death from device malfunction. Ultimately, this decision should be based on the estimated device (lead) malfunction rate, device (lead) dependency, and an individual center's procedural risk for complications from generator (lead) removal, and should also factor in patient preferences.