Efficacy and mortality of rotating sheaths versus laser sheaths for transvenous lead extraction: a meta-analysis

BACKGROUND

Rotating and laser sheaths are both routinely used in transvenous lead extraction (TLE) which can lead to catastrophic complications including death. The efficacy and risk of each approach are uncertain. To perform a meta-analysis to compare success and mortality rates associated with rotating and laser sheaths.

METHODS

We searched electronic academic databases for case series of consecutive patients and randomized controlled trials published 1998-2017 describing the use of rotating and laser sheaths for TLE. Among 48 studies identified, rotating sheaths included 1,094 patients with 1,955 leads in 14 studies, and laser sheaths included 7,775 patients with 12,339 leads in 34 studies. Patients receiving rotating sheaths were older (63 versus 60 years old) and were more often male (74% versus 72%); CRT-P/Ds were more commonly extracted using rotating sheaths (12% versus 7%), whereas ICDs were less common (37% versus 42%), p > 0.05 for all. Infection as an indication for lead extraction was higher in the rotating sheath group (59.8% versus 52.9%, p = 0.002). The mean time from initial lead implantation was 7.2 years for rotating sheaths and 6.3 years for laser sheaths (p > 0.05).

RESULTS

Success rates for complete removal of transvenous leads were 95.1% in rotating sheaths and 93.4% in laser sheaths (p < 0.05). There was one death among 1,094 patients (0.09%) in rotating sheaths and 66 deaths among 7,775 patients (0.85%) in laser sheaths, translating to a 9.3-fold higher risk of death with laser sheaths (95% CI 1.3 to 66.9, p = 0.01).

CONCLUSIONS

Laser sheaths were associated with lower complete lead removal rate and a 9.3-fold higher risk of death.

Alterations in atrial electrogram amplitude as steady sinus rhythm transitions to paroxysmal atrial fibrillation during continuous monitoring in patients with implantable cardiac devices: Insights from the IMPACT study

OBJECTIVES

We aimed to evaluate whether device measured amplitudes of atrial electrogram (AEGM) would change when measured in sinus rhythm (SR) transitioning to paroxysmal atrial fibrillation (AF) from previous steady SR, and significance of such change.

METHODS

From the IMPACT trial's database we selected two groups; (A) those who developed AF (n = 164), and (B) propensity-matched control (n = 459) who stayed in SR during continuous Home Monitoring (HM) to compare AEGMs amplitudes at baseline SR and transition phase.

RESULTS

During 420.0 ± 349.2 days (mean ± SD) from first postenrollment HM transmission to AF event transmission in Group A, and corresponding 515.3 ± 407.0 days in Group B, baseline and transition AEGM amplitude were 2.88 ± 1.146 and 2.74 ± 1.186 mV, respectively, for Group A (p = .1), and 2.88 ± 1.155 and 2.79 ± 1.145, respectively, for Group B (p < .005). Comparison of differences of AEGM amplitude, 0.14 ± 1.072 mV in Group A and 0.09 ± 0.893 mV in Group B were insignificant (p = .3). Age, sex, and hypertension identified as confounders had no association to AEGM changes (p = NS).

CONCLUSIONS

Independent of age, sex, and hypertension, AEGMs amplitudes decline over a long period of time in patients with defibrillators and substrate for AF. The significance of such change remains unclear as it occurs whether patients develop AF or not, but raises a possibility of progressive atrial myopathy that patients with substrate for AF may be predisposed to.

Comparison of Measured Data between Pre- and Post-Radiotherapy in a Patient with Cardiac Resynchronization Therapy Defibrillator

Although some researches proved the influence of radiation therapy (RT) on pacemakers and implantable cardioverter defibrillators, little has been reported on cardiac resynchronization therapy defibrillators (CRTDs). We experienced a case of RT on CRTD and had a new finding.A patient with CRTD implanted for dilated cardiomyopathy was diagnosed with lung squamous cell carcinoma and started receiving RT. All the implanted devices, including the main body of CRTD, left ventricular lead (LV), right ventricular lead with high-voltage conductor, and right atrial lead, were from the same manufacturer. The radiation targeted the tumor of 67 mm in diameter in the right superior lobe for 5 min per session. The CRTD was outside the radiation field, which is 65 mm, but the leads were inside. Plan 1 used 2 Gy/fr with 8 megavolt photons, and Plan 1 was irradiated at 0° and 180° for 16 RT sessions. The dosage was increased to 3 Gy for Plan 2 for 4 sessions. Plan 3 used 2 Gy with 6 and 8 megavolt photons, and Plan 3 was irradiated at 27.7° and 200.7° for 11 RT sessions. Changes in measured parameters were assessed before and after RT.Changes in impedance of LV and high-voltage lead exceeded prespecified threshold. However, no significant errors were detected in the CRTD on the dosages and energy we used.We hypothesize that the lead insulator could have been affected by radiation.

Cardiac Electronic Devices: Future Directions and Challenges

Cardiovascular implantable electronic devices (CIEDs) are essential management options for patients with brady- and tachyarrhythmias or heart failure with concomitant optimal pharmacotherapy. Despite increasing technological advances, there are still gaps in the management of CIED patients, eg, the growing number of lead- and pocket-related long-term complications, including cardiac device–related infective endocarditis, requires the greatest care. Likewise, patients with CIEDs should be monitored remotely as a part of a comprehensive, holistic management approach. In addition, novel technologies used in smartwatches may be a convenient tool for long-term atrial fibrillation (AF) screening, especially in high-risk populations. Early detection of AF may reduce the risk of stroke and other AF-related complications. The objective of this review article was to provide an overview of novel technologies in cardiac rhythm–management devices and future challenges related to CIEDs.

Infection and migration incidence of cardiac implantable electrical devices in Japan: Web-based survey results

Web-based survey was conducted for experiences of cardiac implantable electrical device (CIED) infection and migration in Japan. A total of 155 cardiologists' answer was collected in January, 2018. CIED includes pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy ICD (CRT-D) and total of 10,499 CIEDs' experiences of within previous twelve months were reported. CIED includes pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy ICD (CRT-D.). The infection rate of PM, ICD, CRT-P, and CRT-D was 0.79%, 0.81%, 0.45%, and 2.0%, respectively, and the device migration rate was 0.68%, 0.64%, 0.45%, and 0.93%, respectively. The overall infection rate was 0.85% and migration rate was 0.68%.

Telecardiology during the Covid-19 pandemic: past mistakes and future hopes

Covid-19 has caused a striking global impact on public health services. The inevitable suspension of all scheduled visits without urgency and non-urgent hospitalizations has resulted in relevant modifications in our management of cardiac patients. Our goal should be to maintain high standards in the treatment of cardiovascular diseases, reducing the risk of esposure to Covid-19 for patients and healthcare professionals. Our Division of Cardiology follows 300 patients in a Heart Failure Ambulatory and almost all of these, as CIEDs' carriers, are monitored by remote monitoring; in addition, we follow more than 2000 CIEDs' carriers using remote monitoring. The purpose of telemedicine, using telecommunications technology, must be to optimize the clinical management of heart failure patients at home, in order to improve their quality of life, reducing hospitalization and emergency department access, also promoting self-management. The evolution of technology has led to the development and refinement of telemedicine and remote monitoring and even more in pandemic times these methods are to be considered a cornerstone. So that telemedicine can really become a well-structured reality, the following are fundamental: the uniform recognition of a reimbursement for this type of medical service, the creation of an organizational model with an adequately structured team, a valid integration with the territorial reality.

Cybersecurity in cardiac implantable electronic devices

INTRODUCTION

Cardiac implantable electronic devices (CIEDs) integrate numerous automatic and monitor functions. Nowadays, most CIEDs are connected to the Internet (via Wi-Fi, Bluetooth or smartphone) to ensure remote monitoring of technical and clinical data: despite the importance of such a monitoring, especially from a clinical point of view, concerns have been raised about information (IT) security in terms of both privacy and security for CIEDs' carriers.

AREAS COVERED

This review will provide an outline of remote monitoring of CIEDs, main IT security issues that have affected them so far, main cybervulnerabilities and possible solutions.

EXPERT OPINION

Although there is no evidence that cyber-attacks have been carried out against any CIED so far, they may occur in the future. Cyber-attacks are usually aimed at stealing sensitive information or granting access to the IT systems to which CIEDs are connected; the possibility of an active reprogramming of CIEDs by cyber-attacks is extremely low. Political, regulatory, scientific, and clinical integration is essential to provide not only effective IT solutions for CIEDs and their carriers, but also for the development of educational programs; it should also promote cooperation between stakeholders in order to reduce the risk of CIEDs' cybervulnerability and increase patient safety.