Predictors of all-cause mortality for patients undergoing transvenous lead extraction

Background

Risk assessment of TLE patients may be challenging due to incomplete knowledge about possible risk factors for post-TLE outcomes. The aim of this study was to identify predictors of 30-days and 1-year all-cause mortality including the novel parameter frailty in a large retrospective series of patients undergoing TLE at a high-volume centre.

Methods

Medical journals of 893 consecutive patients undergoing TLE between January 1, 2010 and December 31, 2018 were retrogradely analysed. Univariate logistic regression and multivariate analyses were performed to identify risk factors.

Results

A total of 893 patients were identified. Local infection was the dominant indication (41.1%) and pacemaker was the most common device (49.4%). Mean age was 65±16 years and 73.0% were males. The median follow up was 3.9 years (IQR, 4.5 years). Within the systemic infection group, Staphylococcus aureus was the main microorganism in the positive blood cultures (44.4%) and 69.4% of the patients had vegetations. The 30-days and 1 year mortality rates were 2.5% and 9.7%, respectively. Per-procedural mortality occurred in 1 patient. Significant risk factors for 30-days all-cause mortality at univariate analysis were anaemia, systemic infection, clinical frailty scales (CFS) 5–7 and stage 5 chronic kidney disease (CKD). Age, CRT-P/D (vs ICD), reduced ejection fraction, anaemia, BMI <25 kg/m2, CFS 4–7 and CKD stages 3–5 were identified as significant predictors of 1-year all-cause mortality. Within the systemic infection subgroup, leucocytosis and white blood cell count (WBC) 8.8–15x109/L were associated with significant 30-days and 1-year all-cause mortality and CRP 200–300 mg/L and low WBC count correlated with 1-year all-cause mortality. Local infection patients with CRP 100–150 mg/L had an elevated risk for 1-year all-cause mortality. Multivariate analysis identified CKD 5, CFS 5–7 and systemic infection for 30-days all-cause mortality and age, CKD 5, CFS 5–7, systemic infection and BMI <25 kg/m2 for 1-year all-cause mortality as independent risk factors.

Conclusions

Patient-related characteristics, comorbidities and systemic infection independently predicted worse post-TLE prognosis. Several parameters need to be considered when assessing patients for TLE in order to risk stratify the patients and optimize the post-TLE care. Frailty is a novel parameter with significant influence on short and long-term outcome.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Internal funding

Predictors of all-cause mortality for patients undergoing transvenous lead extraction

Funding Acknowledgements

Type of funding sources: None.

Background

Risk assessment of TLE patients may be challenging due to incomplete knowledge about possible risk factors for post-TLE outcomes. The aim of this study was to identify predictors of 30-day and 1-year mortality in a large retrospective series of patients undergoing TLE at a high-volume centre.

Methods

Medical journals of 893 consecutive patients undergoing TLE between January 1, 2010 and December 31, 2018 were analysed. Univariate logistic regression analysis was performed to identify risk factors.

Results

A total of 893 patients were identified. Local infection was the dominant TLE indication (40.5%), and pacemaker was the most common CIED (49.4%). Mean age was 65 + 16 years and 73.0% were males. The median follow up was 3.9 years (IQR, 2.0-6.4 years). Staphylococcus aureus was the most common microorganism found in blood cultures of the systemic infection group (39.9%). A total of 179 (69.4%) systemic infection patients had vegetations on echocardiography, where majority engaged the lead(s). The 30-day and 1 year mortality rates were 2.5% (86.4% had systemic infection) and 9.7% (64.4% had systemic infection), respectively. Per-procedural mortality occurred in 1 patient with systemic infection. Significant predictors of 30-day mortality were low haemoglobin, systemic infection as TLE-indication, clinical frailty scales (CFS) 5-7 and stage 5 chronic kidney disease (CKD). In case of 1-year mortality, age, CRT-P/D (vs ICD), reduced ejection fraction, anaemia, BMI <25 kg/m2, CFS 4-7 and CKD stages 3-5 were identified as significant predictors. In the systemic infection subgroup, elevated white blood cell (WBC) count was associated with 30-day and 1 year mortality. Additionally CRP interval 200-300, low WBC count and WBC interval 8.8-15 correlated signigicantly with 1-year mortality within the systemic infection cohort. In the local infection subgroup, a significant correlation between CRP interval 100-150 and 1-year mortality was found.

Conclusions

Systemic infection as TLE-indication carries a high 30-days post-TLE all-cause mortality rate and is significantly correlated with short and long-term mortality, where elevated inflammatory parameters carried additional mortality risk in this subgroup. Anaemia, chronic kidney disease, CRT compared to ICD, reduced EF and patient-related features as high clinical frailty scale levels and BMI <25 kg/m2 predicted worse prognosis in the entire TLE-cohort.

Incidental finding of ”ghost” on echocardiography after transvenous lead extraction among systemic infection patients

Background

Ghosts are described as cylindrical and oscillating structures diagnosed after transvenous lead extraction (TLE) and may consist of thrombi, vegetations and fibrous sheaths. Presence of ghosts is found to be associated with poor outcomes.

Purpose

The aim of this study was to estimate the proportion of patients with ghosts and to describe the characteristic features of `'ghosts” seen post-TLE in a retrospective series of systemic infection patients.

Methods

Medical journals including echocardiography studies of systemic infection patients undergoing TLE between January 1, 2010 and December 31, 2018 were analysed.

Results

A total of 258 patients (72% males, mean age 71±12 years), underwent TLE due to systemic infection. Staphylococcus aureus was the dominant microorganism isolated in blood cultures (40%). Echocardiography identified ghosts as incidental findings in 15 (6%) patients, 1–23 day(s) (median, 5; mean, 7±6 days) post-TLE and ghosts remained up to 51 days post-TLE. Ghosts were described as tubular, echodense and mobile tissues with variety of dimensions (2–50 mm) on echocardiography, mostly localised in right atrium (40%). Ghosts were visually described by surgeons as vegetations on tricuspid valve, organised thrombotic material in superior/inferior vena cavae and more loose thrombotic materials in right atrium in 2 patients who underwent open heart surgery after TLE. Echocardiography could not certainly differentiate between non-infectious tissue and infectious vegetations, thereby endocarditis treatment was prolonged to at least 12 days (mean, 29±14 days) post-TLE in the ghost group.

Conclusion

Although this was a retrospective analysis and ghosts were incidental findings rather than differential diagnosis, which may have underestimated the proportion ghosts identified, ghosts were relatively common in this cohort. Presence of ghosts caused management challenges for clinicians. There is a great need for large multicentre studies enabling establishment of guidelines for diagnosis and management of this common post-TLE finding.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Histocompatibility leukocyte antigens in Rokitansky-Küster-Hauser syndrome

Histocompatibility leukocyte antigens of 32 patients with Rokitansky-Küster-Hauser syndrome were compared with a control healthy population of 100. For analysis chi 2 with Yates' correction and Bonferroni criterion for multiple comparisons were used. Seven antigens were significant in the chi 2 test, but only three were confirmed in the Bonferroni criterion (Aw19, DRw52, and DQw1) (p < 0.001). The study showed certain associations between Rokitansky-Küster-Hauser syndrome and the major histocompatibility complex.