Incidence and Predictors of Perioperative Complications With Transvenous Lead Extractions

Sex differences in long-term outcomes following transvenous lead extraction

INTRODUCTION

Transvenous lead extraction (TLE) is generally considered a safe procedure, albeit not without risks. While gender-based disparities have been noted in short-term outcomes following TLE, a notable gap exists in understanding the long-term consequences of this procedure. The objective of this analysis was to investigate sex differences in both acute and long-term outcomes among patients who underwent TLE at a tertiary referral center.

METHODS

In this retrospective cohort study, consecutive patients who underwent TLE between January 2014 and January 2016 were enrolled. The primary outcome comprised a composite of all-cause mortality and need for repeated TLE procedures. Secondary outcomes included fluoroscopy time, lead extraction techniques, success rates, and major and minor complications. Results were compared between female and male cohorts.

RESULTS

The study population comprised 191 patients (median age, 70 years), 29 (15.2%) being women and 162 men (84.8%). Study groups had similar baseline characteristics. Complete procedural success was achieved in 189 out of 191 patients (99.0%), with no significant difference observed between the two groups (p = .17). No major complications were reported in the total cohort. However, there was a significantly higher incidence of minor complications in women compared to men (17.2% vs. 2.5%, p < .01). Following a median follow-up of 6.5 years, the incidence of the primary composite outcome occurred similarly between the study groups (log-rank p = .68).

CONCLUSION

Women who underwent TLE exhibited a significantly higher incidence of minor acute intra- and peri-procedural complications than men. However, no differences in long-term outcomes between genders were observed.

Managing superior vena cava syndrome in patients with cardiac implantable electronic device leads: Strategies and considerations

BACKGROUND

Data on transvenous (TV) lead-associated superior vena cava (SVC) syndrome are limited. The management of this problem might require a multidisciplinary approach, often involving transvenous lead extraction (TLE) followed by angioplasty and stenting.

OBJECTIVE

The purpose of this study was to describe the management and outcome of TV lead-associated SVC syndrome.

METHODS

We retrospectively identified patients with a diagnosis of SVC syndrome and TV leads at Emory Healthcare between 2015 and 2023.

RESULTS

Fifteen patients with lead-related SVC syndrome were identified. The cohort average age was 50 years. Symptoms included swelling of the face, neck, and upper extremities (67%); shortness of breath (53%); and lightheadedness (40%). Patients had an average of 2 ± 0.7 leads crossing the SVC, with a lead dwell time of 9.8 ± 7.5 years. Thirteen patients were managed with TLE, followed by SVC stenting and angioplasty in 10 and angioplasty alone in 2; 1 patient had no intervention after TLE. One patient was managed with anticoagulation, and another had angioplasty and stenting with lead jailing. One patient experienced SVC perforation and cardiac tamponade during SVC stenting, which was managed successfully with a covered stent and pericardiocentesis. Among the 12 patients with TLE and angioplasty ± stenting, 7 underwent reimplantation of a transvenous lead. Two of those patients had symptoms recurrence, and none of the 5 patients without lead reimplantation had recurrence of symptoms.

CONCLUSION

Lead-related SVC syndrome management requires a multidisciplinary approach often including TLE followed by angioplasty and stenting. Avoiding TV lead reimplantation might help reduce symptoms recurrence.

Comparison of outcomes and required tools between transvenous extraction of pacemaker and implantable cardioverter defibrillator leads: Insight from single high-volume center experience

INTRODUCTION

Reports of comparison with procedural outcomes for implantable cardioverter defibrillator (ICD) and pacemaker (PM) transvenous lead extraction (TLE) are old and limited. We sought to compare the safety, efficacy, and procedural properties of ICD and PM TLE and assess the impact of lead age.

METHODS

The study cohort included all consecutive patients with ICD and PM TLE in the Cleveland Clinic Prospective TLE Registry between 2013 and 2022. Extraction success, complications, and failure employed the definitions described in the HRS 2017 TLE guidelines.

RESULTS

A total of 885 ICD leads, a median implant duration of 8 (5-11) years in 810 patients, and 1352 PM leads of 7 (3-13) years in 807 patients were included. Procedural success rates in ICD patients were superior to those of PM in >20 years leads but similar in ≤20 years leads. In the PM group, the complete success rate of TLE decreased significantly according to the increase of lead age, but not in the ICD group. ICD TLE required more extraction tools compared with PM TLE but cases with older leads required non-laser sheath extraction tools in both groups. The most common injury site in major complication cases differed between ICD and PM TLE, although major complication rates showed no difference in both groups (2.7% vs. 1.6%, p = .12).

CONCLUSION

The procedural success rate by TLE is greater for ICD patients than PM patients with leads >20 years old but requires more extraction tools. Common vascular complication sites and the impact of lead age on procedural outcomes and required tools differed between ICD and PM TLE.

Outcome and microbiological findings of patients with cardiac implantable electronic device infection

INTRODUCTION

Infections associated with cardiac implantable electronic devices (CIEDs) are a multifactorial disease that leads to increased morbidity and mortality.

OBJECTIVE

The aim was to analyze patient-, disease- and treatment-related characteristics including microbiological and bacterial spectrum according to survival status and to identify risk factors for 1- and 3-year mortality in patients with local and systemic CIED infection.

METHODS

In a retrospective cohort study, we analyzed data from patients with CIED-related local or systemic infection undergoing successful transvenous lead extraction (TLE). Survival status as well as incidence and cause of rehospitalization were recorded. Microbiology and antibiotics used as first-line therapy were compared according to mortality. Independent risk factors for 1- and 3-year mortality were determined.

RESULTS

Data from 243 Patients were analyzed. In-hospital mortality was 2.5%. Mortality rates at 30 days, 1- and 3 years were 4.1%, 18.1% and 30%, respectively. Seventy-four (30.5%) patients had systemic bacterial infection. Independent risk factors for 1-year mortality included age (OR 1.05 [1.01-1.10], p = 0.014), NT-proBNP at admission (OR 4.18 [1.81-9.65], p = 0.001), new onset or worsened tricuspid regurgitation after TLE (OR 6.04 [1.58-23.02], p = 0.009), and systemic infection (OR 2.76 [1.08-7.03], p = 0.034), whereas systemic infection was no longer an independent risk factor for 3-year mortality. Staphylococcus aureus was found in 18.1% of patients who survived and in 25% of those who died, p = 0.092. There was a high proportion of methicillin-resistant strains among coagulase-negative staphylococci (16.5%) compared to Staphylococcus aureus (1.2%).

CONCLUSIONS

Staphylococci are the most common causative germs of CIED-infection with coagulase-negative staphylococci showing higher resistance rates to antibiotics. The independent risk factors for increased long-term mortality could contribute to individual risk stratification and well-founded treatment decisions in clinical routine. Especially the role of tricuspid regurgitation as a complication after TLE should be investigated in future studies.

Case Series and Review of Literature for Superior Vena Cava Injury During Laser Lead Extraction

Transvenous laser lead extraction poses a risk of major complications (0.19%-1.8%), notably injury to the superior vena cava (SVC) in 0.19% to 0.96% of cases. Various factors contribute to SVC injury, which can be categorized as patient-related (such as female gender, low body mass index, diabetes, renal problems, anemia, and reduced ejection fraction), device-related (including the number, dwell time, and type of leads), or procedural-related (such as reason for extraction, venous obstructions, and bilateral lead placements).

Challenge Accepted: Lead Extraction in a Patient with Persistent Left Superior Vena Cava and Right Superior Vena Cava Occlusion

Persistent left superior vena cava (PLSVC) is an anatomic variant that is relatively uncommon in the general population. Lead extraction through PLSVC is extremely rare. Due to unusual anatomy, the procedure carries challenges that require special considerations and careful planning. The authors report a case of lead extraction through a PLSVC with occluded right superior vena cava and highlight the challenges and outcomes of the procedure.

Outcomes of tricuspid regurgitation after lead extraction

INTRODUCTION

Transvenous leads have been implicated in tricuspid valve (TV) dysfunction, but limited data are available regarding the effect of extracting leads across the TV on valve regurgitation. The aim of this study is to quantify tricuspid regurgitation (TR) before and after lead extraction and identify predictors of worsening TR.

METHODS

We studied 321 patients who had echocardiographic data before and after lead extraction. TR was graded on a scale (0 = none/trivial, 1 = mild, 2 = moderate, 3 = severe). A change of >1 grade following extraction was considered significant.

RESULTS

A total of 321 patients underwent extraction of a total of 338 leads across the TV (1.05 ± 0.31 leads across the TV per patient). There was no significant difference on average TR grade pre- and postextraction (1.18 ± 0.91 vs. 1.15 ± 0.87; p = 0.79). TR severity increased after extraction in 84 patients, but was classified as significantly worse (i.e., >1 grade change in severity) in only 8 patients (2.5%). Use of laser lead extraction was associated with a higher rate of worsening TR postextraction (44.0% vs. 31.6%, p = 0.04).

CONCLUSION

In our single-center analysis, extraction of leads across the TV did not significantly affect the extent of TR in most patients. Laser lead extraction was associated with a higher rate of worsening TR after extraction.

When and how to perform venoplasty for lead placement

Because of the increasing use of cardiac implantable electronic devices (CIEDs) with one or more intracardiac electrodes, the rate of lead failure is increasing. Moreover, upgrade of the CIED frequently is indicated for cardiac resynchronization therapy or other reasons. Both these situations require a new intervention, preferably using ipsilateral venous access. However, venous obstruction after CIED insertion occurs in 10%-20% of patients and poses a major obstacle for implantation of additional leads. Possible solutions include lead extraction, contralateral lead insertion, and venoplasty. Preprocedural venoplasty is associated with the lowest short- and long-term risks. Here we describe a step-by-step approach to this technique, which can be introduced and safely performed in most interventional catheterization laboratories.

Infective Endocarditis Involving Implanted Cardiac Electronic Devices: JACC Focus Seminar 1/4

Cardiac implantable electronic device-related infective endocarditis (CIED-IE) encompasses a range of clinical syndromes, including valvular, device lead, and bloodstream infections. However, accurately diagnosing CIED-IE remains challenging owing in part to diverse clinical presentations, lack of standardized definition, and variations in guideline recommendations. Furthermore, current diagnostic modalities, such as transesophageal echocardiography and [18F]-fluorodeoxyglucose positron emission tomography-computed tomography have limited sensitivity and specificity, further contributing to diagnostic uncertainty. This can potentially result in complications and unnecessary costs associated with inappropriate device extraction. Six hypothetical clinical cases that exemplify the diverse manifestations of CIED-IE are addressed herein. Through these cases, we highlight the importance of optimizing diagnostic accuracy and stewardship, understanding different pathogen-specific risks for bloodstream infections, guiding appropriate device extraction, and preventing CIED-IE, all while addressing key knowledge gaps. This review both informs clinicians and underscores crucial areas for future investigation, thereby shedding light on this complex and challenging syndrome.

Transvenous lead extraction safety and efficacy in infected and noninfected patients using mechanical-only tools: Prospective registry from a high-volume center

BACKGROUND

Transvenous lead extraction (TLE) is a well-established treatment option for patients with cardiac implantable electronic devices (CIED) complications.

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of TLE in CIED infection and non-CIED infection patients.

METHODS

Consecutive patients who underwent TLE between 2016 and 2022 entered the EXTRACT Registry. Models of prediction were constructed for periprocedural clinical and procedural success and the incidence of major complications, including death in 30 days.

RESULTS

The registry enrolled 504 patients (mean age 66.6 ± 12.8 years; 65.7% male). Complete procedural success was achieved in 474 patients (94.0%) and clinical success in 492 patients (97.6%). The total number of major and minor complications was 16 (3.2%) and 51 (10%), respectively. Three patients (0.6%) died during the procedure. New York Heart Association functional class IV and C-reactive protein levels defined before the procedure were independent predictors of any major complication, including death in 30 days in CIED infection patients. The time since the last preceding procedure and platelet count before the procedure were independent predictors of any major complication, including death in 30 days in non-CIED infection patients.

CONCLUSIONS

TLE is safe and successfully performed in most patients, with a low major complication rate. CIED infection patients demonstrate better periprocedural clinical success and complete procedural success. However, CIED infection predicts higher 30-day mortality compared with non-CIED infection patients. Predictors of any major complication, including death in 30 days, differ between CIED infection and non-CIED infection patients.

Impact of infective versus sterile transvenous lead removal on 30-day outcomes in cardiac implantable electronic devices

BACKGROUND

Transvenous lead removal (TLR) is associated with increased mortality and morbidity. This study sought to evaluate the impact of TLR on in-hospital mortality and outcomes in patients with and without CIED infection.

METHODS

From January 1, 2017, to December 31, 2020, we utilized the nationally representative, all-payer, Nationwide Readmissions Database to assess patients who underwent TLR. We categorized TLR as indicated for infection, if the patient had a diagnosis of bacteremia, sepsis, or endocarditis during the initial admission. Conversely, if none of these conditions were present, TLR was considered sterile. The impact of infective vs sterile indications of TLR on mortality and major adverse events was studied.

RESULTS

Out of the total 25,144 patients who underwent TLR, 14,030 (55.8%) received TLR based on sterile indications, while 11,114 (44.2%) received TLR due to device infection, with 40.5% having systemic infection and 59.5% having isolated pocket infection. TLR due to infective indications was associated with a significant in-hospital mortality (5.59% vs 1.13%; OR = 5.16; 95% CI 4.33-6.16; p < 0.001). Moreover, when compared with sterile indications, TLR performed due to device infection was associated with a considerable risk of thromboembolic events including pulmonary embolism and stroke (OR = 3.80; 95% CI 3.23-4.47, p < 0.001). However, there was no significant difference in the conversion to open heart surgery (1.72% vs. 1.47%, p < 0.111), and infection was not an independent predictor of cardiac (OR = 1.12; 95% CI 0.97-1.29) or vascular complications (OR = 1.12; 95% CI 0.73-1.72) between the two groups.

CONCLUSION

Higher in-hospital mortality and rates of thromboembolic events associated with TLR resulting from infective indications may warrant further pursuing this diagnosis in patients.

Which lesions are not amenable to tricuspid clipping?

PURPOSE OF REVIEW

Tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as a well tolerated and effective therapeutic option for many patients with symptomatic severe tricuspid regurgitation at prohibitive surgical risk. However, there remain several important limitations to clip-based technology in the context of other rapidly emerging percutaneous treatment options for tricuspid regurgitation.

RECENT FINDINGS

Tricuspid lesions pose unique challenges to treatment with the current toolbox of transcatheter clip-based technologies. This review will explore key issues related to patient factors, anatomical factors, and imaging factors that may render lesions to be unsuitable for treatment with T-TEER.

SUMMARY

Selection for T-TEER must include a detailed clinical evaluation in the context of a 'heart team' approach involving multiple subspecialists, with screening for patient/lesion characteristics that make T-TEER suboptimal with current clip-based technologies. Future directions for research include patient-specific 3D modeling techniques, leaflet grasping techniques, clip deployment strategies, and personalized device sizing to increase the spectrum of lesions that may be treated with T-TEER within the context of other emerging transcatheter treatment options.

LECOM (Lead Extraction COMplexity): A New Scoring System for Predicting a Difficult Procedure

(1) Background: Transvenous lead extraction (TLE) can become far more complex when unanticipated difficulties arise. The aim was to develop a simple scoring system that allows for the prediction of the difficulty and complexity of this significant procedure. (2) Methods: Based on analysis of 3741 TLE procedures with and without complicating factors (extended fluoroscopy time, need for second-line instruments, and advanced techniques and instruments), a five-point Complex Indicator of Difficulty of (TLE) Procedure (CID-TLEP) scale was developed. Two or more points on the CID-TLEP scale indicate a higher level of procedure complexity. (3) Results: Patient age below 51 years at first CIED implantation, number of abandoned leads, number of previous procedures, passive fixation and multiple leads to be extracted, and a ratio of dwell time of oldest lead to patient age during TLE of >0.13 are significant predictors of higher levels of lead extraction complexity. The ROC analysis demonstrates that a point total (being the sum of the odds ratios of the above variables) of >9.697 indicates a 21.83% higher probability of complex TLE (sensitivity 74.08%, specificity 74.46%). Finally, a logistic function was calculated, and we constructed a simple equation for lead extraction complexity that can predict the probability of a difficult procedure. The risk of complex extraction (as a percentage) is calculated as [1/(1 + 55.34 · 0.754X)] · 100 (p < 0.001). (4) Conclusion: The LECOM score can effectively predict the risk of a difficult transvenous lead extraction procedure, and predicting the probability of a more complex procedure may help clinicians in planning lead removal and improving patient management.

Extraction outcomes of implantable cardioverter-defibrillator leads vary by manufacturer and model family

AIMS

Transvenous lead extraction (TLE) of implantable cardioverter-defibrillator (ICD) leads is considered challenging. The structure of each ICD leads is variable between manufacturer and model families. The net impact of lead family on the safety and effectiveness of TLE is poorly characterized. We assessed the safety and efficacy of ICD TLE and the impact of manufacturer ICD model family on the outcomes.

METHODS AND RESULTS

The study cohort included all consecutive patients with ICD who underwent TLE between 2013 and 2022 and are enrolled in the Cleveland Clinic Prospective TLE Registry. A total of 885 ICD leads (median implant duration 8 years) in 810 patients were included. Complete ICD TLE success was achieved in 97.2% of the leads (n = 860) and in 98.0% of the patients (n = 794). Major complications occurred in 22 patients (2.7%). Complete procedural success rate varied by manufacturer and lead family; Medtronic 98.9%, Abbott 95.9%, Boston Scientific 95.0%, Biotronik 91.2%, P = 0.03, and Linox family leads had the lowest, 89.7% P = 0.02. Multivariable predictors of incomplete ICD lead removal included ICD lead age > 10 years and Linox family lead. Multivariable predictors of major complications included ICD lead age > 15 years and longer lead extraction time, and predictors of all-cause mortality within 30 days included lead extraction for infection, end-stage renal disease, and higher New York Heart Association functional class.

CONCLUSION

Complete and safe ICD lead removal rate by TLE is extremely high but varied by manufacturer and lead family. Linox family lead and >10 years lead age were independent predictors of incomplete lead removal.

Long-term follow-up of patients undergoing add-on pacing/sensing lead vs. ICD lead implantation for failed IS-1/DF-1 ICD leads: a single centre experience

BACKGROUND

Intracardiac defibrillator/cardioverter (ICD) is a cornerstone device for prevention of sudden cardiac death. Lead failure (LF) is one of the most important long-term complications. In this study, we sought to investigate mid-to-long term clinical, device and lead characteristics of patients who have undergone pacing sensing lead (PSL) implantation for an ICD LF and compare them to the patients who have undergone a new ICD lead implantation.

METHODS

In this retrospective, single centre, case-control study, we have screened all ICD patients presenting with LF. Patients with IS-1/DF-1 ICD leads with intact high-voltage conductor were included in the study group, while other patients were included in the control arm. Study group patients underwent PSL implantation, control group patients underwent ICD lead implantation.

RESULTS

Thirty patients were included in each arm of the study. The mean duration of follow-up after intervention was similar in both groups (47.6 months ± 20.4 vs. 46.1 months ± 25.7, p = .808). The total failure rate was not different between two groups (p = .640). Rate of high-voltage conductor disfunction was also similar between two arms: 1 (3.3%) in PSL arm and 0 in control arm (p = .303).

CONCLUSIONS

Addition of a PSL for IS-1/DF-1 ICD LF with normal high-voltage conductor measurements is a viable treatment option with similar long-term results to addition of a new ICD lead. This approach is potentially less costly, technically less demanding, and, in case of concomitant extraction procedure, associated with less acute complication risk.

Comparison of non-laser and laser transvenous lead extraction: a systematic review and meta-analysis

AIMS

Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature. We sought to compare non-laser and laser TLE in a meta-analysis.

METHODS AND RESULTS

We searched Medline, Embase, Scopus, ClinicalTrials.gov, and CENTRAL databases for TLE studies published between 1991 and 2021. From the included 68 studies, safety and efficacy data were carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR), and pooled rates were synthesized from eligible studies to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed. Non-laser in comparison with laser had lower procedural mortality (pooled rate 0% vs. 0.1%, P < 0.01), major complications (pooled rate 0.7% vs. 1.7%, P < 0.01), and superior vena cava (SVC) injury (pooled rate 0% vs. 0.5%, P < 0.001), with higher complete success (pooled rate 96.5% vs. 93.8%, P < 0.01). Non-laser comparatively to laser was more likely to achieve clinical [OR 2.16 (1.77-2.63), P < 0.01] and complete [OR 1.87 (1.69-2.08), P < 0.01] success, with a lower procedural mortality risk [OR 1.6 (1.02-2.5), P < 0.05]. In the subgroup analysis, rotational tool compared with laser achieved greater complete success (pooled rate 97.4% vs. 95%, P < 0.01) with lower SVC injury (pooled rate 0% vs. 0.7%, P < 0.01).

CONCLUSION

Non-laser TLE is associated with a better safety and efficacy profile when compared with laser methods. There is a greater risk of SVC injury associated with laser sheath extraction.

Transvenous versus subcutaneous implantable cardioverter defibrillators in young cardiac arrest survivors

Secondary prevention implantable cardioverter defibrillators (ICDs) are indicated in young patients presenting with aborted sudden cardiac death (SCD) because of ventricular arrhythmias. Transvenous-ICDs (TV-ICDs) are effective, established therapies supported by evidence. The significant morbidity associated with transvenous leads led to the development of the newer subcutaneous-ICD (S-ICD). This review discusses the clinical considerations when selecting an ICD for the young patient presenting with out-of-hospital cardiac arrest. The major benefits of TV-ICDs are their ability to pace (antitachycardia pacing [ATP], bradycardia support and cardiac resynchronisation therapy [CRT]) and the robust evidence base supporting their use. Other benefits include a longer battery life. Significant complications associated with transvenous leads include pneumothorax and tamponade during insertion and infection and lead failure in the long term. Comparatively, S-ICDs, by virtue of having no intravascular leads, prevent these complications. S-ICDs have been associated with a higher incidence of inappropriate shocks. Patients with an indication for bradycardia pacing, CRT or ATP (documented ventricular tachycardia) are seen as unsuitable for a S-ICD. If venous access is unsuitable or undesirable, S-ICDs should be considered given the patient is appropriately screened. There is a need for further randomised controlled trials to directly compare the two devices. TV-ICDs are an effective therapy for preventing SCD limited by significant lead-related complications. S-ICDs are an important development hindered largely by an inability to pace. Young patients stand to gain the most from a S-ICD as the cumulative risk of lead-related complications is high. A clinical framework to aid decision-making is presented.

Transvenous lead extraction: Efficacy and safety of the procedure in female patients

Background

Existing data on the impact of sex differences on transvenous lead extraction (TLE) outcomes in cardiac device patients are limited.

Objective

The purpose of this study was to evaluate the safety and efficacy of mechanical TLE in female patients.

Methods

A retrospective evaluation was performed on 3051 TLE patients (group 1: female; group 2: male) from a single tertiary referral center. All individuals received treatment using single sheath mechanical dilation and various venous approaches as required.

Results

Our analysis included 3051 patients (group 1: 750; group 2: 2301), with a total of 5515 leads handled with removal. Female patients were younger, had a higher left ventricular ejection fraction, and lower prevalences of coronary artery disease and diabetes mellitus. Infection was more common in male patients, whereas lead malfunction or abandonment were more frequent in female patients. Radiologic success was lower in female patients (95.8% vs 97.5%; P = .003), but there was no significant difference in clinical success between groups (97.2% vs 97.5%; P = .872). However, major complications (1.33% vs 0.60%; P <.001) and procedural mortality (0.4% vs 0.1%; P <.001) were higher in females compared to male patients. After multivariate analysis, female sex emerged as the only predictor of major complications, including deaths (odds ratio 3.96; 95% confidence interval 1.39-11.24).

Conclusion

TLE using unpowered simple mechanical sheaths in female patients is safe and effective, but is associated with lower radiologic success and higher complication rates and mortality than in males. This finding underscores the importance of recognizing sex differences in TLE outcomes.

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.

Radiographic predictors of failure of simple manual traction of transvenous implantable cardioverter-defibrillator leads: a single-center experience

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.

Sex differences in outcomes of transvenous lead extraction: insights from National Readmission Database

BACKGROUND

With the growing use of implantable cardiac devices, the need for transvenous lead extraction has increased, which translates to increased procedural volumes. Sex differences in lead extraction outcomes are not well studied.

OBJECTIVE

The present study aims at evaluating the impact of sex on outcomes of lead extraction.

METHODS

We identified 71,754 patients who presented between 2016 and 2019 and underwent transvenous lead extraction. Their clinical data were retrospectively accrued from the National Readmission Database (NRD) using the corresponding diagnosis codes. We compared clinical outcomes between male and female patients. Odds ratios (ORs) for the primary and secondary outcomes were calculated, and multivariable regression analysis was utilized to adjust for confounding variables.

RESULTS

Compared to male patients, female patients had higher in-hospital complications including pneumothorax (OR 1.26, 95% CI (1.07-1.4), P < 0.01), hemopericardium (OR 1.39, 95% CI (1.02-1.88), P = 0.036), injury to superior vena cava and innominate vein requiring repair (OR 1.88, 95% CI (1.14-3.1), P = 0.014; OR 3.4, 95% CI (1.8-6.5), P < 0.01), need for blood transfusion (OR 1.28, 95% CI (1.18-1.38), P < 0.01), and pericardiocentesis (OR 1.6, 95% CI (1.3-2), P < 0.01). Thirty-day readmission was also significantly higher in female patients (OR 1.09, 95% CI (1.02-1.17), P < 0.01). There was no significant difference regarding in-hospital mortality (OR 0.99, 95% CI (0.87-1.14), P = 0.95).

CONCLUSION

In female patients, lead extraction is associated with worse clinical outcomes and higher 30-day readmission rate.

Long-term survival following transvenous lead extraction: unpicking differences according to sex

AIMS

Female sex is a recognized risk factor for procedure-related major complications including in-hospital mortality following transvenous lead extraction (TLE). Long-term outcomes following TLE stratified by sex are unclear. The purpose of this study was to evaluate factors influencing long-term survival in patients undergoing TLE according to sex.

METHODS AND RESULTS

Clinical data from consecutive patients undergoing TLE in the reference centre between 2000 and 2019 were prospectively collected. The total cohort was divided into groups based on sex. We evaluated the association of demographic, clinical, device-related, and procedure-related factors on long-term mortality. A total of 1151 patients were included, with mean 66-month follow-up and mortality of 34.2% (n = 392). The majority of patients were male (n = 834, 72.4%) and 312 (37.4%) died. Males were more likely to die on follow-up [hazard ratio (HR) = 1.58 (1.23-2.02), P < 0.001]. Males had a higher mean age at explant (66.2 ± 13.9 vs. 61.3 ± 16.3 years, P < 0.001), greater mean co-morbidity burden (2.14 vs. 1.27, P < 0.001), and lower mean left ventricular ejection fraction (LVEF) (43.4 ± 14.0 vs. 50.8 ± 12.7, P = 0.001). For the female cohort, age > 75 years [HR = 3.45 (1.99-5.96), P < 0.001], estimated glomerular filtration rate < 60 [HR = 1.80 (1.03-3.11), P = 0.037], increasing co-morbidities (HR = 1.29 (1.06-1.56), P = 0.011), and LVEF per percentage increase [HR = 0.97 (0.95-0.99), P = 0.005] were all significant factors predicting mortality. The same factors influenced mortality in the male cohort; however, the HRs were lower.

CONCLUSION

Female patients undergoing TLE have more favourable long-term outcomes than males with lower long-term mortality. Similar factors influenced mortality in both groups.

Transvenous lead extraction of implantable cardioverter-defibrillators: A comprehensive outcome-and risk factor analysis

BACKGROUND

Device complications, such as infection or lead dysfunction necessitating transvenous lead extraction (TLE) are continuously rising amongst patients with transvenous implantable-cardioverter-defibrillator (ICD).

OBJECTIVES

Aim of this study was to characterize the procedural outcome and risk-factors of patients with indwelling 1- and 2-chamber ICD undergoing TLE.

METHODS

We conducted a subgroup analysis of all ICD patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for procedural failure and all-cause mortality were assessed.

RESULTS

We identified 842 patients with an ICD undergoing TLE with the mean age of 62.8 ± 13.8 years. A total number of 1610 leads were treated with lead dysfunction (48.5%) as leading indication for extraction, followed by device-related infection (45.4%). Lead-per-patient ratio was 1.91 ± 0.88 and 60.0% of patients had dual-coil defibrillator leads. Additional extraction tools, such as mechanical rotating dilator sheaths and snares were utilized in 6.5% of cases. Overall procedural complications occurred in 4.3% with 2.0% major complications and a procedure-related mortality of 0.8%. Clinical success rate was 97.9%. All-cause in-hospital mortality was 3.4%, with sepsis being the leading cause for mortality. Multivariate analysis revealed lead-age ≥10 years (OR:5.82, 95%CI:2.1-16.6; p = .001) as independent predictor for procedural failure. Systemic infection (OR:9.57, 95%CI:2.2-42.4; p < .001) and procedural complications (OR:8.0, 95%CI:2.8-23.3; p < .001) were identified as risk factors for all-cause mortality.

CONCLUSIONS

TLE is safe and efficacious in patients with 1- and 2-chamber ICD. Although lead dysfunction is the leading indication for extraction, systemic device-related infection is the main driver of all-cause mortality for ICD patients undergoing TLE.

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

BACKGROUND

Because the penetration of transvenous lead extraction (TLE) for cardiac implantable electronic device (CIED) infection has not been investigated in Japan, we conducted a population-based, retrospective, descriptive study to evaluate regional disparities in the use of TLE for CIED infection and the potential undertreatment of CIED infection using a nationwide insurance claims database.Methods and Results: Patients who underwent CIED implantation or generator exchange and TLE between April 2018 and March 2020 were identified. Moreover, the penetration ratio of TLE for CIED infection in each prefecture was estimated. CIED implantation and TLE were most prevalent in the age categories of 80-89 years (40.3%) and 80-89 years (36.9%), respectively. There was no correlation between the number of CIED implantations and that of TLE (rho=-0.087, 95% confidence interval -0.374 to 0.211, P=0.56). The median penetration ratio was 0.00 (interquartile range 0.00-1.29). Of the 47 prefectures, 6, comprising Okinawa, Miyagi, Okayama, Fukuoka, Tokyo, and Osaka, showed a penetration ratio ≥2.00.

CONCLUSIONS

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

Subcutaneous implantable cardioverter-defibrillator noise following left ventricular assist device implantation

Background

The incidence and impact of noise in a subcutaneous implantable cardioverter defibrillator (S-ICD) after left ventricular assist device (LVAD) implantation is not well established.

Methods

We performed a retrospective study of patients implanted with LVAD and with a pre-existing S-ICD between January 2005 and December 2020 at the three Mayo Clinic centers (Minnesota, Arizona, and Florida).

Results

Of the 908 LVAD patients, a pre-existing S-ICD was present in 9 patients (mean age 49.1 ± 13.7 years, 66.7% males), 100% with Boston Scientific third-generation EMBLEM MRI S-ICD, 11% with HeartMate II (HM II), 44% with HeartMate 3 (HM 3), and 44% with HeartWare (HW) LVAD. The incidence of noise from LVAD-related electromagnetic interference (EMI) was 33% and was only seen with HM 3 LVAD. Multiple measures attempted to resolve noise, including using alternative S-ICD sensing vector, adjusting S-ICD time zone, and increasing LVAD pump speed, were unsuccessful, necessitating S-ICD device therapies to be turned off permanently.

Conclusions

The incidence of LVAD-related S-ICD noise is high in patients with concomitant LVAD and S-ICD with significant impact on device function. As conservative management failed to resolve the EMI, the S-ICDs had to be programmed off to avoid inappropriate shocks. This study highlights the importance of awareness of LVAD-SICD device interference and the need to improve S-ICD detection algorithms to eliminate noise.

Cardiovascular implantable electronic device lead safety: Harnessing real-world remote monitoring data for medical device evaluation

BACKGROUND

Current methods to identify cardiovascular implantable electronic device lead failure include postapproval studies, which may be limited in scope, participant numbers, and attrition; studies relying on administrative codes, which lack specificity; and voluntary adverse event reporting, which cannot determine incidence or attribution to the lead.

OBJECTIVE

The purpose of this study was to determine whether adjudicated remote monitoring (RM) data can address these limitations and augment lead safety evaluation.

METHODS

Among 48,191 actively monitored patients with a cardiovascular implantable electronic device, we identified RM transmissions signifying incident lead abnormalities and, separately, identified all leads abandoned or extracted between April 1, 2019, and April 1, 2021. We queried electronic health record and Medicare fee-for-service claims data to determine whether patients had administrative codes for lead failure. We verified lead failure through manual electronic health record review.

RESULTS

Of the 48,191 patients, 1170 (2.4%) had incident lead abnormalities detected by RM. Of these, 409 patients had administrative codes for lead failure, and 233 of these 409 patients (57.0%) had structural lead failure verified through chart review. Of the 761 patients without administrative codes, 167 (21.9%) had structural lead failure verified through chart review. Thus, 400 patients with RM transmissions suggestive of lead abnormalities (34.2%) had structural lead failure. In addition, 200 patients without preceding abnormal RM transmissions had leads abandoned or extracted for structural failure, making the total lead failure cohort 600 patients (66.7% with RM abnormalities, 33.3% without). Patients with isolated right atrial or left ventricular lead failure were less likely to have lead replacement and administrative codes reflective of lead failure.

CONCLUSION

RM may strengthen real-world assessment of lead failure, particularly for leads where patients do not undergo replacement.

Success and Complication Rates of Transvenous Lead Extraction in a Developing High-Volume Extraction Center: The Zurich Experience

Introduction: Transvenous lead extractions are increasingly performed for malfunction or infection of cardiac implantable electronic devices, but they harvest a potential for complications and suboptimal success. Apart from multicenter registries and reports from highly experienced single centers, the outcome in individual newly developing high-volume centers starting a lead extraction program is less well established. We aimed to evaluate the clinical and radiological success and complication rate at our center, having started a lead extraction program less than a decade ago. Methods: We retrospectively analyzed patients who underwent transvenous lead extraction at the University Hospital Zurich from 2013 to 2021 regarding success as well as complications and compared our results to previously reported outcome rates. Results: A total of 346 patients underwent 350 transvenous lead extractions from January 2013 to December 2021. Combined radiological success was achieved in 97.7% and clinical success in 96.0% of interventions. Procedure-related major complications occurred in 13 patients (3.7%). Death within 30 days after transvenous lead extractions occurred in 13 patients (3.7%), with a procedure-related mortality of 1.4% (five patients). Summary: Transvenous lead extractions in newly developing high-volume centers can be performed with high clinical and radiological success rates, but procedure-related major complications may affect a relevant number of patients. Compared to large single or multicenter registries of experienced centers, the success rate may be lower and the complication rate higher in centers newly starting with lead extraction, which may have important implications for patient selection, procedural planning, proctoring, and safety measures.

Efficacy and safety of the extraction of cardiostimulation leads using a mechanical dissection tool. A single center experience

BACKGROUND

The percutaneous extraction of endovascular cardiostimulation and defibrillation leads is the most frequent technique nowadays. The tools used today must guarantee the success of the procedure, with the minimum of complications. Our objective was to analyze the safety and efficacy of lead extraction using the Evolution mechanical dissection tool (Cook Medical, USA).

METHODS

A retrospective study was carried out in a total of 826 consecutive patients from October 2009 to December 2018 who underwent the procedure with the Evolution mechanical dissection tool. Preoperative study included complete blood tests, echocardiogram, and chest X-ray. The procedures were performed in the operating room, under general anesthesia and echocardiographic control.

RESULTS

A total of 1227 leads were extracted with a mean chronicity of 10.3 ± 5.1 years. Clinical success (CS) rate was 99.7%. A total of 16 (1.9%) complications occurred, 2 (0.24%) were major complications and 14 (1.7%) were minor complications. There was no operative mortality. There was no statistically significant relationship between implant chamber and complete efficacy. The complete extraction was achieved in all left ventricular leads, in 762 of 774 (98.45%) of right ventricular lead removal, and in 330 of 334 (98.8%) of right atrial leads (p = .31).

CONCLUSION

In our experience, percutaneous extraction of intravenous leads via the use of the Evolution tool (Cook Medical, USA), is a very effective and safe technique that offers low morbidity and mortality.

Regional Antibiotic Delivery for Implanted Cardiovascular Electronic Device Infections

BACKGROUND

Present guidelines endorse complete removal of cardiovascular implantable electronic devices (pacemakers/defibrillators), including extraction of all intracardiac electrodes, not only for systemic infections, but also for localized pocket infections.

OBJECTIVES

The authors evaluated the efficacy of delivering continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket, obviating the need for device/lead extraction.

METHODS

The CITA group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, 9 patients declined lead extraction because of prohibitive operative risk, and 6 patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction, but opted for CITA treatment, were compared with 81 patients with pocket infection and similar characteristics who underwent device/lead extraction as primary therapy.

RESULTS

A total of 80 patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (n = 68 of 80) of patients, who remained free of infection (median follow-up 3 years [IQR: 1.0-6.8 years]). In the case-control study of CITA vs device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96.2% [n = 78 of 81] vs 84.6% [n = 55 of 65]; P = 0.027). However, rates of serious complications were also higher after extraction (n = 12 [14.8%] vs n = 1 [1.5%]; P = 0.005). All-cause 1-month and 1-year mortality were similar for CITA and device/lead extraction (0.0% vs 3.7%; P = 0.25 and 12.3% vs 13.6%; P = 1.00, respectively). Extraction was avoided in 90.8% (n = 59 of 65) of extraction-eligible patients treated with CITA.

CONCLUSIONS

CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction. (Salvage of Infected Cardiovascular Implantable Electronic Devices [CIED] by Localized High-Dose Antibiotics; NCT01770067).

Predictors for adverse events during cardiac lead extraction - Experience from a large single centre

BACKGROUND

As the use of cardiac implantable electronic devices (CIED) has increased in recent years, the need for transvenous lead extraction (TLE) has also steadily increased. However, the TLE procedure could lead to serious complications and even death. Clinical decision-making tools are necessary for predicting these adverse events, but the appropriate tools have not yet been developed.

OBJECTIVE

To explore the possible predictors and develop a clinical model to predict TLE related adverse events.

METHODS

All the patients who were admitted to our cardiac center for TLE from January 2014 to January 2021 were included in this study. The patient information, device baseline characteristics, procedure-related information, complications and outcomes were recorded. Independent predictors of TLE related adverse events were identified by univariate, LASSO and multivariate analysis. A nomogram for predicting these adverse events was developed based on these independent predictors. Calibration and decision curve analysis were conducted to evaluate the nomogram.

RESULTS

One thousand and one hundred patients were included in this study, 778 (70.7%) were male and the median age was 68 years old. A total of 2,208 leads were extracted and 2.01±0.74 leads were extracted per procedure. Fifty-five patients (5%) developed adverse events including minor complications (2.4%), major complications (2.3%) and death (0.27%). Seven independent predictors for TLE related adverse events were identified and selected to establish the nomogram including BMI, female gender, hypoalbuminemia, number of extracted leads>3, longest dwell time of the extracted leads and manual traction. The area under the receiver operating characteristic (ROC) curve (AUC) for the prediction model was 0.774. Calibration curve and decision curve analysis showed that the nomogram had good prediction performance.

CONCLUSION

TLE related adverse events are some of the key issues that concern clinicians. We have identified seven independent factors and established a predictive model that may help clinicians identify at-risk patients and create better plans for lead extraction.

Anesthetic Considerations in the Electrophysiology Laboratory: A Comprehensive Review

Catheter ablation procedures for arrhythmias or implantation and/or extraction of cardiac pacemakers can present many clinical challenges. It is imperative that there is clear communication and understanding between the anesthesiologist and electrophysiologist during the perioperative period regarding the mode of ventilation, hemodynamic considerations, and various procedural complications. This article provides a comprehensive narrative review of the anesthetic techniques and considerations for catheter ablation procedures, ventilatory modes using techniques such as high-frequency jet ventilation, and strategies such as esophageal deviation and luminal temperature monitoring to decrease the risk of esophageal injury during catheter ablation. Various hemodynamic considerations, such as the intraprocedural triaging of cardiac tamponade and fluid administration during catheter ablation, also are discussed. Finally, this review briefly highlights the early research findings on pulse-field ablation, a new and evolving ablation modality.

Surgical extraction of cardiac implantable electronic device leads based on a heart team approach

BACKGROUND

As cardiac implantable electronic devices, such as pacemakers, cardioverter defibrillators, and cardiac resynchronization therapies, have become more popular, device extraction has become more frequent. At our institution, individual treatment strategies are discussed at a heart team meeting. Transvenous lead extraction (TVLE) is a first-line treatment; however, surgical lead extraction (SLE) is sometimes selected as a primary choice to provide optimal treatment and maintain the medical safety policy. This study aimed to investigate the validity of this heart team decision-making.

METHODS

From 2013 to 2021, 384 consecutive patients underwent lead extraction at our institution.

RESULTS

SLE was proposed as the primary intervention for 21 patients who had high risk of bleeding, difficult TVLE conditions, large vegetations, and other concomitant cardiac diseases. Of the 363 TVLE patients, 10 patients required surgical intervention; 5 had TVLE difficulty followed by SLE and 5 had excessive bleeding. SLE was performed in 26 patients, 19 of whom required valve surgery, and 8 required plication of the great veins. In 4 of the 17 hybrid procedures with SLE and TVLE, excessive bleeding occurred due to laceration of the superior vena cava and innominate vein. Operative mortality was not observed in SLE patients but was observed in 1 of the 4 TVLE patients who required emergent open-chest hemostasis.

CONCLUSIONS

The heart team discussion was essential to provide optimal treatment and maintain medical safety policies for each patient. SLE should be selected for patients with high risk of TVLE or other cardiac complications such as tricuspid valve incompetence.

Assessment of the impact of organisational model of transvenous lead extraction on the effectiveness and safety of procedure: an observational study

OBJECTIVES

To estimate the impact of the organisational model of transvenous lead extraction (TLE) on effectiveness and safety of procedures.

DESIGN

Post hoc analysis of patient data entered prospectively into a computer database.

SETTING

Data of all patients undergoing TLE in three centres in Poland between 2006 and 2021 were analysed.

PARTICIPANTS

3462 patients including: 985 patients undergoing TLE in a hybrid room (HR), with cardiac surgeon (CS) as co-operator, under general anaesthesia (GA), with arterial line (AL) and with transoesophageal echocardiography (TEE) monitoring (group 1), 68 patients-TLE in HR with CS, under GA, without TEE (group 2), 406 patients-TLE in operating theatre (OT) using 'arm-C' X-ray machine with CS under GA and with TEE (group 3), 154 patients-TLE in OT with CS under GA, without TEE (group 4), 113 patients-TLE in OT with anaesthesia team, using the 'arm-C' X-ray machine, without CS (group 5), 122 patients-TLE in electrophysiology lab (EPL), with CS under intravenous analgesia without TEE and AL (group 6), 1614 patients-TLE in EPL, without CS, under intravenous analgesia without TEE and AL (group 7).

KEY OUTCOME MEASURE

Effectiveness and safety of TLE depending on organisational model.

RESULTS

The rate of major complications (MC) was higher in OT/HR than in EPL (2.66% vs 1.38%), but all MCs were treated successfully and there was no MC-related death. The use of TEE during TLE increased probability of complete procedural succemss achieving about 1.5 times (OR=1.482; p<0.034) and were connected with reduction of minor complications occurrence (OR=0.751; p=0.046).

CONCLUSIONS

The most important condition to avoid death due to MC is close co-operation with cardiac surgery team, which permits for urgent rescue cardiac surgery. Continuous TEE monitoring plays predominant role in immediate decision on rescue sternotomy and improves the effectiveness of procedure.

Reduced fibrous capsule elastic fibers from biologic ECM-enveloped CIEDs in minipigs, supported with a novel compression mechanics model

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.

Same-day discharge after transvenous lead extraction: feasibility and outcomes

AIMS

Same-day discharge (SDD) is safe for patients undergoing electrophysiology procedures. There is no existing data regarding SDD for patients undergoing transvenous lead extraction (TLE). We report our experience with SDD for patients undergoing TLE.

METHODS AND RESULTS

The study group included patients undergoing TLE between February 2020 and July 2021 without an infectious indication. A modified SDD protocol for device implants/ablations was applied to TLE patients. Patient characteristics, extraction details, outcomes, and complications were reviewed. Of 239 patients undergoing TLE, 210 were excluded (94 infections and 116 did not meet SDD criteria). Of the remaining 29 patients, seven stayed due to patient preference and 22 were discharged home the same day. The SDD group had an average age of 65.9 ± 12 (47-84), 41% female, and LVEF of 52.2 ± 18% (10-80). The indication for TLE was malfunction (20), upgrade (4), advisory lead (2), and magnetic resonance imaging compatibility (1). Extractions included four implantable cardioverter-defibrillators (ICDs), 17 pacemakers (PPM), and one cardiac resynchronization therapy (CRT)-P system. The leads were 9.6 years (1.5-21.7) old, and 1.8 leads were removed per patient (1-3); the lead extraction difficulty (LED) score was 11.6 ± 7. Twenty underwent cardiovascular implantable electronic device (CIED) re-implantation (2 ICD, 3 CRT-D, 13 PPM, and 2 CRT-P). For CIED re-implants, patients sent a remote transmission the next day, and all patients received a next-day call. There were no procedure or device-related issues, morbidities, or mortalities in the 30 days after discharge.

CONCLUSION

Same-day discharge after TLE for non-infectious aetiologies is safe and feasible in a select group of patients with early procedure completion who meet strict SDD criteria.

Synchronous atrioventricular sequential pacing utilizing conventional and leadless pacemakers in an elderly patient: a case report

Background

Leadless pacemakers present a viable alternative to conventional transvenous devices to mitigate the risk of lead- and/or pocket-related complications. In elderly patients who have encountered ventricular lead failures with transvenous pacemakers, this option may enable the delivery of atrioventricular synchronous pacing therapy, while obviating the requirement for lead extraction and lead-based pacemaker re-implantation.

Case summary

This case report describes the successful implantation of a leadless pacemaker in a 90-year-old who had undergone two dual-chamber permanent pacemaker implantation procedures with a failure of three of four previously implanted leads. Atrioventricular synchronous pacing was achieved, as the leadless device was able to track the atrial-paced rhythm from the pre-existing right-sided device.

Discussion

In elderly patients who have encountered issues with transvenous pacemakers, alternative approaches should be considered to mitigate the risk of future complications. Leadless pacemakers may offer a low-risk solution, enabling the delivery of atrioventricular synchronous pacing therapy in such patient groups. Future studies should be designed to delineate whether these devices could be utilized as a first-line approach in certain situations.

Causes of Early Mortality After Transvenous Lead Removal

BACKGROUND

Recognition of the causes of early mortality (≤30 days) after transvenous lead removal (TLR) is an essential step for the development of quality improvement programs.

OBJECTIVES

This study sought to determine the causes of early mortality after TLR and to further understand the circumstances surrounding death after TLR.

METHODS

A retrospective analysis was performed of all patients undergoing TLR from January 1, 2001, to January 1, 2021, at the Mayo Clinic (Rochester, Minnesota; Phoenix, Arizona; and Jacksonville, Florida). Causes of death were identified through a detailed chart review of the electronic health record from within the Mayo Clinic system and outside records when available. The causes of death were further characterized based on whether it was related to the TLR procedure.

RESULTS

A total of 2,319 patients were included in the study. The overall 30-day all-cause mortality rate was 3% (n = 69). Among all 30-day deaths, infection was the most common primary cause of death (42%). This was followed by decompensated heart failure (17%), procedure-related death (10%), sudden cardiac arrest (7%), and respiratory failure (6%). The 30-day mortality rate directly due to complications associated with the TLR procedure was 0.3%. One-third of deaths (33%) occurred after discharge from the index hospitalization; among these, 43% were readmitted before their death, 35% died at home or at a nursing facility, and 22% were discharged on comfort care and died in hospice. The main reasons for readmission before death were sepsis and decompensated heart failure.

CONCLUSIONS

The majority (90%) of 30-day mortality after TLR was not due to complications associated with TLR procedures. The primary causes were infection and decompensated heart failure. This highlights the importance of increased emphasis on postprocedure management of infection and heart failure to reduce postoperative mortality, including after hospital discharge.

Strategies and outcomes of patients with severely reduced ejection fraction (≤15%) undergoing transvenous lead extraction: A single-center experience

BACKGROUND

Patients with severely reduced ejection fraction (SREF ≤15%) are deferred from transvenous lead extraction (TLE) owing to fear of intraoperative hemodynamic collapse. When these patients require lead extraction, their management options are limited, and they suffer from high morbidity and mortality. Left ventricular (LV) assist devices provide intraoperative hemodynamic support and facilitate TLE, enabling lifesaving interventions.

OBJECTIVE

We present our experience of performing TLE in 245 patients with SREF. Additionally, we report outcomes of 8 patients who received LV support during TLE.

METHODS

Between January 2008 and January 2022, we performed TLE in 245 patients with stage D heart failure, SREF, and class I or II indications for extraction. Primary (clinical success and in-hospital mortality) and secondary (length of stay and procedure-associated complications) outcomes were compared between patients with SREF and patients in our registry undergoing extraction with EF < 15%. A subgroup analysis was performed in the SREF group to evaluate outcomes of 8 patients who underwent extraction with LV assist devices.

RESULTS

In patients with SREF, clinical success was high (97.6%) and mortality was low (5.3%). There were no statistically significant differences in primary outcomes between groups. Similarly, there were no significant differences in procedural complications between groups. In the SREF group, there were no significant differences in outcomes between the 8 patients undergoing TLE with LV assist devices and patients that did use LV assist devices.

CONCLUSION

Lead extraction in patients with SREF can be performed safely and effectively. Adopting a few simple steps, including the early initiation of LV support, can overcome myocardial impairment in patients who decompensate.

Repeat Transvenous Lead Extraction-Predictors, Effectiveness, Complications and Long-Term Prognostic Significance

BACKGROUND

Data regarding repeat transvenous lead extraction (TLE) are scarce. The aim of study was to explore the frequency of repeat TLE, its safety, predisposing factors, as well as effectiveness of repeat procedures.

METHODS

Retrospective analysis of a large single-center database of 3654 TLEs.

RESULTS

Repeat TLE was a rare occurrence (193, i.e., 5,28% among 3654 TLEs). Subsequent re-extractions occurred in 12.21% of the patients. Lead failure was the most common cause of re-extraction (51.16%). Cox regression analysis showed that patients who were older at first implantation [HR = 0.987; p = 0.003], had infection-related TLE [HR = 0.392; p < 0.001] and complete procedural success [HR = 0.544; p = 0.034] were less likely to undergo repeat TLE. Functional leads left in place for continuous use [HR = 1.405; p = 0.012] or superfluous leads left in place (abandoned) [HR = 2.370; p = 0.011] were associated with an increased risk of undergoing a repeat procedure. Overall mortality in patients with repeat TLE and subsequent re-extraction in the entire FU period was similar to that in patients without a history of re-extraction [HR = 0.949; p = 0.480].

CONCLUSIONS

Repeat TLE was a rare occurrence (5.28%) among TLEs. Left of both active and nonactive leads during TLE increased the risk of re-extraction. Re-extraction has no effect on the long-term mortality.

Transvenous Lead Extraction in Adult Patient with Leads Implanted in Childhood-Is That the Same Procedure as in Other Adult Patients?

BACKGROUND

Lead management in children and young adults is still a matter of debate.

METHODS

To assess the course of transvenous lead extraction (TLE) in adults with pacemakers implanted in childhood (CIP) we compared 98 CIP patients with a control group consisting of adults with pacemakers implanted in adulthood (AIP).

RESULTS

CIP patients differed from AIP patients with respect to indications for TLE and pacing history. CIP patients were four-eight times more likely to require second-line or advanced tools. Furthermore, CIP patients more often than AIP were prone to developing complications: major complications (MC) (any) 2.6 times; hemopericardium 3.2 times; severe tricuspid valve damage 4.4 times; need for rescue cardiac surgery 3.7 times. The rate of procedural success was 11% lower because of 4.8 times more common lead remnants and 3.1 times more frequent permanently disabling complications.

CONCLUSIONS

Due to system-related risk factors TLE in CIP patients is more difficult and complex. TLE in CIP is associated with an increased risk of MC and incomplete lead removal. A conservative strategy of lead management, acceptable in very old patients seems to be less suitable in CIP because it creates a subpopulation of patients at high risk of major complications during TLE in the future.

A Unique Case of Central Line Fracture Due to Laser Lead Extraction

Transvenous laser-assisted lead extraction is successful, with a low procedural complication rate for a wide range of indications. Here, we report a case of right internal jugular triple-lumen central venous catheter fracture and subsequent embolism to the right pulmonary artery during laser lead extraction that was successfully retrieved with a gooseneck snare. (Level of Difficulty: Advanced.).

Outcomes of Transvenous Extraction of Leads Older Than 20 and 30 Years-A Large Cohort Study

BACKGROUND

There is limited knowledge on outcome of transvenous lead extraction (TLE) of leads being 20 and 30 years old.

METHODS

Retrospective single center large database analysis containing 3673 TLE procedures performed from 2006 to 2020 was analysed. We aimed to compare procedure complexity and the incidence of the TLE major complications (MC) in groups where extracted leads were under 10 years, 10-20 years, 20-30 years (old) and over 30 years (very old).

RESULTS

Rate of removal of old and very old leads almost doubles with successive five-year periods (3-6-10%). In patients with old and very old leads there is an accumulation of risk factors for major complications of TLE (young age, female, multiple and/or abandoned leads, multiple previous procedures). The removal of old and very old leads was more labour-consuming, more difficult, and much more often required second-line (advanced) tools and complex techniques. Incidence of all MC grew parallel to age of removed leads from 0.6 to 18.2%; haemopericardium-from 0.3 to 12.1%, severe tricuspid valve damage-from 0.2 to 2.1%, need for rescue cardiac surgery-from 0.4 to 9.1%. Notably, there was no procedure-related death when old or very old lead was extracted. The percentages of clinical and procedural success decreased with increasing age of the removed leads from 99.2 and 97.8% to 90.9 and 81.8%. The risk of MC during extraction of leads aged 10-20 years increases 6.7 times, aged 20-30 years-14.3 times (amounting to 8.4%), and aged 30 and more years-20.4 times, amounting to 18.2%. Removal of ventricular leads is associated with a greater complexity of the procedure but not with more frequent MC. Removal of the atrial leads is associated with a higher incidence of MC, especially haemopericardium, regardless of the age of the leads, although the tendency becomes less pronounced with the oldest leads.

CONCLUSIONS

1. Extraction of old and very old leads is a rising challenge, since the rate of removal of leads aged 20-and-more years almost doubles with successive five-year periods. 2. Procedure difficulty, complexity and the risk of major complications increases along with the age of extracted lead. TLE is more time-consuming, difficult and much more often requires advanced tools and complex techniques. 3. TLE of old (≥20 years) or very old (≥30 years) leads can be performed with satisfactory success rate and safety profile when conducted at high-volume centre by an experienced operator under optimal safety conditions.

Usefulness of the controlled-rotation dilator sheath "Evolution RL" for extraction of old leads in two Japanese centers - An experience in use

BACKGROUND

Transvenous lead extraction (TLE) is an established procedure for the management of cardiovascular implantable electronic devices. However, some difficulties and risks of complications still exist, especially in old and adhered leads. Evolution RL (Cook Medical, Bloomington, IN, USA) is a newly introduced device for TLE; however, no clinical results have been reported in Japan, and the results with older leads are unknown. We investigated the efficacy and safety of Evolution RL and its usefulness for old leads at two TLE centers in Japan.

METHODS

A total of 27 consecutive patients who underwent lead extraction using Evolution RL at Shinshu University Hospital and Tokyo Women's Medical University Hospital from September 2017 to December 2019 were retrospectively enrolled. We examined the backgrounds of the patients and leads and investigated the efficacy and safety of the procedures. We divided the leads into two groups according to the number of years of implantation (10 years) and compared the results.

RESULTS

Among the 27 patients, 20 (74.1%) were men, and the median age was 62 (14-91) years. The total number of leads was 58, and the median implantation duration was 136 months (8-448). We achieved clinical success in all patients and complete procedural success in 24 patients (88.9%). In three patients, the broken tip of the lead remained in the heart. No major complications were noted. Of the 58 leads, there were 34 leads with more than 10 years of implantation, with significantly more Evolution RLs used (94.1% vs. 54.2%, p = 0.001) and significantly higher percentages of Evolution 11Fr, 13Fr, and steady sheaths used (79.4% vs. 33.3%, p = 0.001, 52.9% vs. 16.7%, p = 0.006, and 64.7% vs. 20.8%, p = 0.001, respectively).

CONCLUSIONS

In two TLE centers in Japan, Evolution RL was shown to be safe and effective, even in leads older than 10 years.

Triple access transvenous lead extraction: Pull-through of a lead from subclavian to jugular access to facilitate extraction

A 39-years old ventricular lead of a right-sided single-chamber pacemaker required extraction for infection. Angulation at the right subclavian-superior vena cava junction coupled with calcified fibrotic encapsulating tissue prevented advancement of a rotational dissecting sheath. To straighten the lead, it was pulled from the subclavian and out of the right internal jugular vein, whilst the Needle's-Eye Snare via the femoral access provided counter-traction. A 13-french rotational dissecting sheath was successfully advanced over the lead via the jugular access to complete the lead extraction without any complication.

Subcutaneous Versus Transvenous Implantable Defibrillator Therapy: A Systematic Review and Meta-Analysis of Randomized Trials and Propensity Score-Matched Studies

Background

Subcutaneous implantable cardioverter‐defibrillators (S‐ICDs) have been of great interest as an alternative to transvenous implantable cardioverter‐defibrillators (TV‐ICDs). No meta‐analyses synthesizing data from high‐quality studies have yet been published.

Methods and Results

An electronic literature search was conducted to retrieve randomized controlled trials or propensity score–matched studies comparing S‐ICD against TV‐ICD in patients with an implantable cardioverter‐defibrillator indication. The primary outcomes were device‐related complications and lead‐related complications. Secondary outcomes were inappropriate shocks, appropriate shock, all‐cause mortality, and infection. All outcomes were pooled under random‐effects meta‐analyses and reported as risk ratios (RRs) and 95% CIs. Kaplan–Meier curves of device‐related complications were digitized to retrieve individual patient data and pooled under a 1‐stage meta‐analysis using Cox models to determine hazard ratios (HRs) of patients undergoing S‐ICD versus TV‐ICD. A total of 5 studies (2387 patients) were retrieved. S‐ICD had a similar rate of device‐related complications compared with TV‐ICD (RR, 0.59 [95% CI, 0.33–1.04]; P=0.070), but a significantly lower lead‐related complication rate (RR, 0.14 [95% CI, 0.07–0.29]; P<0.0001). The individual patient data–based 1‐stage stratified Cox model for device‐related complications across 4 studies yielded no significant difference (shared‐frailty HR, 0.82 [95% CI, 0.61–1.09]; P=0.167), but visual inspection of pooled Kaplan–Meier curves suggested a divergence favoring S‐ICD. Secondary outcomes did not differ significantly between both modalities.

Conclusions

S‐ICD is clinically superior to TV‐ICD in terms of lead‐related complications while demonstrating comparable efficacy and safety. For device‐related complications, S‐ICD may be beneficial over TV‐ICD in the long term. These indicate that S‐ICD is likely a suitable substitute for TV‐ICD in patients requiring implantable cardioverter‐defibrillator implantation without a pacing indication.