Outcomes of transvenous lead extraction in octogenarians using bidirectional rotational mechanical sheaths

BACKGROUND

Outcomes of transvenous lead extraction (TLE) are well reported in the general population, However, data on safety, efficacy of TLE in octogenarians with a long lead dwell time, using powered extraction tools are limited. The aim of this multicenter study was to evaluate the safety, effectiveness of TLE in octogenarians using the bidirectional rotational mechanical sheaths and mid-term outcome after TLE.

METHODS

The study population comprised 83 patients (78.3% male; mean age 85 ± 3 years; [range 80-94 years]) with 181 target leads. All the leads (mean implant duration 112 ± 77 months [range 12-377]) were extracted exclusively using the Evolution RL sheaths (Cook Medical, Bloomington, IN, USA).

RESULTS

The main indication for TLE was infection in 84.3% of cases. Complete procedural success rate, clinical success rate, per lead were 93.9% and 98.3%, respectively. Failure of lead extraction was seen in 1.7% of leads. The additional use of a snare was required in 8.4% of patients. Major complications occurred in one patient (1.2%). Thirty-day mortality after TLE was 6%. During a mean time follow-up of 22 ± 21 months, 24 patients (29%) died. No procedure-related mortality occurred. Predictors of mortality included ischemic cardiomyopathy (HR 4.35; 95% CI 1.87-10.13; p = .001), left ventricularejection fraction ≤35% (HR 7.89; 95% CI 3.20-19.48; p < .001), and TLE for systemic infection (HR 4.24; 95% CI 1.69-10.66; p = .002).

CONCLUSIONS

At experienced centers bidirectional rotational mechanical sheaths combined with different mechanical tools and femoral approach allowreasonable success and safety in octogenarian with long lead dwell time. Patient's age should not influence the decision to extract or not the leads, although the 30-day and mid-term mortality are significant, especially in the present of specific comorbidities.

Outcomes of transvenous lead extraction of very old leads using bidirectional rotational mechanical sheaths: Results of a multicentre study

INTRODUCTION

Lead dwell time >10 years is a recognized predictor for transvenous lead extraction (TLE) failure and complications. Data on the efficacy and safety of TLE using the bidirectional rotational mechanical sheaths in patients with very old leads are lacking. In this multicenter study, we reported the outcomes of transvenous rotational mechanical lead extraction in patients with leads implanted for ≥10 years.

METHODS

A total of 441 leads (median: 159 months [135-197]; range: 120-487) in 189 consecutive patients were removed with the Evolution RL sheaths (Cook Medical, Bloomingtom, IN, USA) and mechanical ancillary tools supporting the procedures.

RESULTS

The main indication for TLE was infection in 74% of cases. Complete procedural success rate, clinical success rate, per lead were 94.8% and 98.2%, respectively. Failure of lead extraction was seen in 1.8% of leads. The additional use of a snare via the femoral approach was required in 9% of patients. Lead dwell time was the only predictor of incomplete led removal (odds ratio: 1.009; 95% confidence interval [CI]: 1.003-1.014; p = .002). Four major complication (2%) were encountered. During a mean time follow-up of 31 ± 27 months, 21 patients (11%) died. No procedure-related mortality occurred. Predictors of mortality included severe left ventricular systolic dysfunction (hazard ratio [HR]: 8.06; 95% CI: 2.99-21.73; p = .001), TLE for infection (HR: 8.0; 95% CI: 1.04-62.5; p = .045), diabetes (HR: 3.7; 95% CI: 1.48-9.5; p = .005), and previous systemic infection (HR: 3.1; 95% CI: 1.17-8.24; p = .022). Incomplete lead removal or failure lead extraction did not impact on survival during follow-up.

CONCLUSION

Our findings demonstrated that the use of bidirectional rotational TLE mechanical sheaths combined with different mechanical tools and femoral approach allows reasonable success and safety in patients with very old leads at experienced specialized centers.

P382 FOLLOW–UP OF PATIENTS SUBMITTED TO TRANSVENOUS LEAD EXTRACTION FOR ENDOCARDITIS OR SEPTIC SHOCK AND THEN RE–IMPLANTED WITH LEADLESS PACEMAKER: SINGLE CENTER’S EXPERIENCE

Introduction

With increasing of complications associated with pacemakers and defibrillators implants, the number of patients that undergo transvenous lead extraction following an infection increased. Often in pacemaker–dependent patients there is the problem of having to make an early re–implanting after extraction. This study aims to evaluate the incidence of reinfection in patients implanted with leadless PM following extraction.

Materials and Methods

From January 2016 to December 2021, 132 extractions have been performed in our center. Of these post–extracted patients, 21 were then implanted with a leadless. Among the remaining, in 25 were re–implanted with a traditional PM, 27 with a defibrillator, 2 with a loop recorder, 3 are protected with Life Vest waiting for re–implant; 54 are patients who, after cardiological revaluation, or have not re–implanted a new device or have been redirected to the first implant’s center waiting to complete antibiotic therapy. To evaluate the technical efficiency of leadless in post–extracted patients, a comparison was made between these and the leadless PM implanted “de novo”. To demonstrate the reduction of reinfection recurrences, the post–operative of patients re–implanted with leadless has been compared to those re–implanted with traditional PM. To test the patient‘s level of approval to the new implanted device, a questionnaire was administered to the two samples.

Results

A first analysis of the follow–up of the above classes from 2016 to today shows that in patients who have implanted a leadless PM in no case a recurrence of infection has occurred; in patients who have implanted a traditional device, we have seen how some of these had already suffered a revision of pocket, an extraction or leads’ abandonment. The statistics of electrical parameters have demonstrated the effectiveness of the leadless in both classes of patients compared. Finally, the rating index questionnaire has shown greater acceptance of the new implanted device and a better patient–device relationship in patients re–implanted with leadless.

Conclusions

The implant of Leadless Pacemaker in post–extracted patients, when we have eligible patients to implant this device, has proved to be an effective choice in reducing reinfection recurrences.

C21 ACTIVE STAND TEST IN ALTERNATIVE TO HEAD UP TILT TEST AS NEUROMEDIATE SYNCOPE’S PREDICTOR IN COVID–19 PANDEMIC’S ERA: EXPERIENCE OF SINGLE CENTER

Introduction

The Head Up Tilt Test is an exam that, with prolonged orthostatic stress, allows you to diagnose neuromediated syncope, but has the drawback of being a test that requires time, space and dedicated equipment. During the Covid pandemic, our Syncope Unit was limited both in terms of space and access. Not being able to perform the HUTT, it was decided to replace it with the Active Stand Test, a test that allows you to evaluate changes in blood pressure and ECG in a few minutes.

The purpose of this study is to evaluate the effectiveness of the Active Stand Test as an alternative to HUTT in situations where the latter cannot be performed. Material and Method: In the period 2020–2021, 53 patients were treated for syncope at our center. These patients underwent initial evaluation, Active Stand Test and carotid sinus massage. The Active Stand Test was positive in 8 patients. In order to have a long–distance follow–up, a remote–controlled loop recorder was implanted in all patients. Two categories of patients were thus identified: asymptomatic patients for syncope, in whom no relevant symptoms or arrhythmias were found, and symptomatic patients for syncope. The first were followed only with remote control and telephone follow–up, symptomatic patients were reconvened for clinical re–evaluation.

Results

Of the total 53 patients, 34 were asymptomatic patients with syncope and with no significant arrhythmia recordings and 19 were symptomatic patients with syncope. Of these, 5 were symptomatic for paroxysmal AVB and were implanted with PM, 1 for NSVT was protected with Life Vest; the 13 symptomatic without AVB (syncope of unknown origin) continued the follow–up. Among the latter we find the 8 patients who tested positive when performing the Active Stand Test carried out upon enrollment. The 34 patients asymptomatic for syncope were subsequently recalled to perform a HUTT.

Conclusions

The emergence of the Covid–19 pandemic has led to a greater enhancement of the function of the Syncope Unit, making it the place of choice for the etiological diagnosis of syncope. This allowed for an important selection of the tests necessary to arrive at an etiological diagnosis of syncope. In a situation where the execution of the HUTT is difficult, the Active Stand Test made it possible to manage patients for the diagnosis of neuromediated syncopes.

P8 TRANSVENOUS LEAD EXTRACTION AS LIFE–SAVING PROCEDURE IN SEPTIC SHOCK

Introduction

With the increase of implant centers and the related procedures also increased the complications associated with the pacemakers and defibrillators implant. Transvenous lead extraction, saving procedure in presence of sepsis or septic shock, is the best therapy for leads’ infections because medical treatment alone is not effective to eradicating the infection.

Materials and Methods

In May 2021 was sent to our O.U. from the ER a 61–year–old patient for symptomatic Afib with rapid ventricular response. In 2014 the patient received an ICD implantation for obstructive hypertrophic cardiomyopathy, later found to be an amyloidosic infiltrative cardiomyopathy. The TEE reported EF 30%, thrombus filling left and right atrial appendage and vegetations all over the lead. Despite the patient was apyretic, laboratory tests showed neutrophilic leukocytosis and an increase in inflammation indices. The series of blood cultures were instead negative. However, for the occurrence of septic state, has been set up an antibiotic therapy and DOACs therapy on the advice of an infectious disease specialist. PET TAC confirmed an infection along leads. For a progressive clinical improvement, the patient started a cardiological rehabilitation cycle. Six days later, due to the onset of hyperpyressia and septic shock, the patient was intubated bacause of an acute respiratory failure and transferred urgently in intensive care. For the onset of MOF by sepsis on an endocarditic basis, has been indicated an extraction procedure.

Results

After performing the extraction procedure, it was found an immediate improvement of both the clinical conditions and laboratory parameters. In fact the next day it was possible to proceed to the extubation. Laboratory tests showed a progressive normalization of inflammation and leukocytosis indices; TEE confirmed the absence of vegetations and thrombotic material in the atrial appendage. The patient, apyretic, was sent to cardiological rehabilitation to complete the antibiotic–therapy cycle and, subsequently, at home with Life Vest. After cardiological revaluation and in absence of sepsis signs, the patient was re–implanted with a contralateral ICD.

Conclusions

In accordance with guidelines and literature, transvenous leads extraction constitutes, despite the potential risks associated with the procedure, the true resolutive therapy in device infections.

C22 SYNCOPE UNIT AND REMOTE CONTROL IN THE ERA OF COVID–19 PANDEMIC: EXPERIENCE OF A SINGLE CENTER

Introduction

During the pandemic, many Syncope Units were closed due to inclusion of them and staff in Covid departments. In our experience, in order to meet the numerous requests of patients suffering from syncope, the care strategy was chosen to carry out all outpatient procedures within a single access. The use of this protocol made it possible to satisfy user requests, breaking down all barriers, including the fear of Covid–19.

Materials and Methods

The procedural process used in this period at our O.U. was: initial evaluation, execution of Active Stand Test, carotid sinus massage and implantation of loop recorder in a single access. Immediately after implantation, the patient was equipped with remote monitoring. Patients without events were followed only remotely and underwent telephone follow–up approximately every 3 months to update the center on their general state of health and any symptoms. In patients with events, the individual events were examined by the cardiologist and, by telephone follow–up, the presence of symptoms was assessed, correlating the recorded event with the reported symptom. These were subsequently summoned to the clinic.

Results

With this operating model in the years 2020/2021 we managed 53 patients in the Syncope Unit. Of these, 5 underwent PM implantation for loop recorder’s remote monitoring of the paroxysmal AVB, and one patient, for the detection of major ventricular arrhythmias, was protected with Life Vest pending completion of cardiological screening. The remaining patients, thanks to the remote control, are constantly followed at home and monitored with periodic telephone follow–up.

Conclusions

In line with the literature, also in our ER there was a notable reduction in accesses for syncope. Our operating model was virtuous as it served to decongest the ER and the wards, concentrating all patients with syncope in our Syncope Unit and also reducing the number of tests necessary to arrive at an etiological diagnosis of syncope. The Covid–19 pandemic has accelerated the transformation process of the Syncope Unit which is no longer just an elective place for the diagnosis of syncope, but also a fundamental reference for the remote control of ICM wearers.

P6 MICRA AV AS AN INNOVATIVE THERAPEUTIC OPPORTUNITY IN PATIENTS WITH A PAROXYSMAL ATRIOVENTRICULAR BLOCK OR AN ADVANCED OR PERSISTENT TYPE II 2ND–DEGREE ATRIOVENTRICULAR BLOCK

Introduction

Micra AV is the technological evolution of Micra VR. It’s a monocameral leadless pacemaker that works like a VDD PM, synchronizing atrial activity with the ventricular one. The purpose of the study is to evaluate the response of Micra AV in patients with a paroxysmal atrioventricular block, in which a low percentage of stimulation is expected, and in patients with AVB with normal atrial activity.

Materials and Method

From August 2020 to June 2021 in our center were implanted 11 Micra AV: 4 for advanced AVB, 3 for a paroxysmal AVB and 4 post–extraction. To all patients it was given remote monitoring to guarantee a constant remote follow–up. For each one, were analyzed the values measured at the implant’s moment and those of periodic remote follow–ups, paying particular attention at the device’s percentage of stimulation. Furthermore, a questionnaire was submitted to detect the psychophysical condition, the way in which the device interferes in everyday life, any physical pain, the emotional state, always correlating post–operative with the pre–operative. Particular attention was paid to the decrease in the incidence of adverse events or post–operative complications. In this way, it was possible to focus the study on 3 aspects: technician, quality of post–implant life and the device’s approval.

Results

All patients no longer presented syncopes during a follow–up ranging from a minimum of 5 to a maximum of 10 months. About the analysis made on the percentage of stimulation, the results were obtained by dividing patients into 2 groups based on the nature of the block. Almost all patients with advanced AVB presents a percentage of stimulation that doesn’t exceed 20%; in subjects with paroxysmal AVB this remains below 2%. The results of the questionnaire instead show how the leadless PMs are more appreciated both for a lower aesthetic impact, and for minor functional consequences linked to the lack of catheters who often limit the patient. This results in a better patient–device relationship and better acceptance of the leadless device.

Conclusions

The use of a Leadless PM in patients with syncope is still to be deepened and for this we will have to follow these patients over time to have a wider cases. A certain data is that these PMs are more appreciated as they have less impact on the quality of patients’ life.

Remote assessment of QT interval: A new perspective for implantable cardiac monitors

BACKGROUND

There is an unmet need for simple tools for monitoring QT intervals. The feasibility of measuring the QT interval on the single‑lead subcutaneous electrocardiogram (subECG) recorded and transmitted by implantable cardiac monitors (ICMs) has never been tested.

METHODS

We performed a standard ECG in patients who had already been implanted with a long sensing vector ICM (BIOMONITOR, Biotronik SE&Co.) to calculate the corrected QT interval in lead II (QTc ECG). The QTc was then evaluated on the subECG provided by ICM both by using the programmer printout (QTc subECG) and the snapshot transmitted via home monitoring (QTc HM). Values were compared with Bland-Altman analyses.

RESULTS

The study cohort consisted of 23 ICM recipients (age 58 ± 19 years, 35% female) implanted mainly for unexplained syncope (78%). The mean QTc ECG interval was 404 ± 31 ms. The T-wave was visible and QTc could be calculated in all patients using the ICM programmer printout and in 21 (91%) patients remotely. The QTc subECG and QTc HM were 405 ± 34 and 406 ± 32 ms. Compared to the QTc ECG, Bland-Altman analyses revealed a bias of -0.9 (95% confidence interval: -6.8/4.9) ms and 0.1 (-12.7/12.9) ms for QTc subECG and QTc HM, respectively.

CONCLUSIONS

The QTc interval can be reliably estimated on in-person and remote subECG in most patients without bias compared to the ECG lead II assessment. This technology has the potential to facilitate remote QT interval monitoring.