Lead extraction with the "pisa technique" - experience of a portuguese tertiary care center

Funding Acknowledgements

Type of funding sources: None.

Background

The "Pisa Technique" (PT) is an increasingly used method of lead extraction (LE) that has shown excellent results in terms of clinical (Cs) and radiological success (Rs) associated with the lowest rate of complications reported in ELECTRa Registry.

Purpose

To characterize the adult population submitted to LE with the PT and evaluate its short-term results.

Methods

A single-center prospective study of consecutive procedures (P) of LE using the PT between February 2013 and October 2019. Demographic, clinical, and P related variables, mortality (M) and reimplantation (R) data were assessed.

Results

320 electrodes (E) were removed in a total of 171 Ps and 159 patients (pts). 80.7% of these P’s were due to CIED infection (55.1% due to pocket site infection, 18.8% to occult bacteremia with probable CIED infection and 26.1% due to both local and systemic infection, with 44% of pts presenting with valvular/ lead vegetation) and the remainder due to E dysfunction or venous occlusion. Pts averaged 67.7 years of age, 71.9% were male with a mean left ventricular ejection fraction of 47.8%.

19.3% presented coronary artery disease, 42.1% overt heart failure and 43.9% atrial fibrillation. 29 pts had cardiac resynchronization devices, 20 pts implantable cardioverter-defibrillator devices and 110 pts pacemaker systems (mostly DDD). The mean "age" of the extracted E’s was 83.2 months, 244 of which were atrial or ventricular pacing, 26 pacing E’s via the coronary sinus and 50 shock E’s. In 31.0% of the cases, the E’s were of active fixation, with 42.7% of the pts being pacing dependent. 14% of pts had a previous attempt of LE, 37.4% had already been submitted to generator replacement and a third to CIED upgrade. In 66.7% of pts, a new contralateral CIED was implanted during the hospital stay - H -(mean time for R of 6 days) and in 19% of R’s an antibacterial envelope was used. The Rs and Cs rates were 91.2% and 98.3%, respectively. There was 1 case of cardiac tamponade during LE, which was stabilized by pericardiocentesis and 2 pocket site hematomas requiring surgical drainage. There were no deaths during the P. During a mean follow-up (FU) of 33 months, 11 pts had to undergo a new P, 5 of them due to pocket reinfections. The M rate during FU was 24.2% (37 pts), with 8 pts (5.0%) dying during H, mostly due to septic shock, and 19 pts during the first year post-P.

Conclusion

Our center’s experience with the PT confirms the method’s high efficacy and safety in the percutaneous extraction of E’s in pts with CIED.

Predictors of pacemaker dependency after transcatheter aortic valve replacement

Funding Acknowledgements

Type of funding sources: None.

Background

Conduction disturbances after transcatheter aortic valve replacement (TAVR) are common with a variable risk of long-term pacemaker dependency (PD), being influenced by patient- and procedure-specific factors. As pacemaker (PM) implantation is associated with potential complications, our aim was to assess predictors of PD requirement after TAVR.

Methods

Retrospective analysis of consecutive patients (P) who underwent TAVR with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. Cumulative percentage of ventricular pacing (%Vp) was determined from stored PM data. P with a PM implanted previous to TAVR were excluded. PM implantation post-TAVR was defined as a device implant performed during hospital stay in the context of TAVR or during the first month after discharge. PD was defined as a %Vp > 80% at one-year follow-up. Multivariate analysis for the prediction of PD was done using Cox regression.

Results

A total of 474 P (57% male, age 81.7±6.5 years, left ventricular ejection fraction 51.5±14.6%) were analysed. Mean follow-up was 18.7 months. Mean baseline gradient was 51.7 mmHg with a mean aortic valve area of 0.71 cm2. One hundred and four P (21.9%) required PM implantation after TAVR, with a mean %Vp of 65.3±43.4%, presenting PD in 60% of the cases at one-year follow-up. A glomerular filtration rate > 60 ml/min (OR 0.87, CI 95% 0.74-0.96, p=0.021) and mean aortic annulus perimeter (OR 0.89, CI 95% 0.80-0.98, p=0.029) were independent predictors of a PD < 5%. Arterial hypertension (OR 7.00, CI 95% 1.31-37.40, p=0.023), baseline right bundle branch block (OR 10.2, CI 95% 1.21-18.45, p=0.033), and the EUROSCORE II (OR 1.05, CI 95% 1.01-1.10, p=0.044) were predictors of PD > 80%. Baseline left bundle branch block, implantation depth and aortic valve calcium score were not predictors of PD.

Conclusion

Predictors of PD after TAVR may influence PM implantation, as well as device selection and programming. P with a higher aortic annulus perimeter and preserved kidney function may undergo a more expectant management, as PD rates are low after 1 year follow-up.

Impact of anticoagulation therapy on outcomes in patients undergoing transvenous lead extraction

Funding Acknowledgements

Type of funding sources: None.

Background

Oral anticoagulation (OAC) is essential for patients (pts) at high risk for thromboembolism. However,uninterrupted anticoagulation and bridging with enoxaparin increases the risk of pocket hematoma (PH) andinfection (I).

Aim

To evaluate the impact of OAC in the rate of PH and outcomes in pts undergoing lead extraction (LE) usingthe Pisa Technique (PT).

Methods

A single centre prospective study of consecutive procedures (Pr) of LE using the PT between February2013 and October 2019. Demographic, clinical, device and procedure related variables, morbidity and mortality(M) data were compared between pts without OAC (O0) and pts with AC (O1).

Results

320 electrodes (E) were removed in a total 171 Pr in 159 pts (mean age - 67.7 years, mean LVEF - 48%,male - 72%). The LE were from the following implanted systems: pacemaker – 110 pts, cardiac resynchronizationtherapy – 29 pts, cardioverter-defibrillator – 20 pts. The radiological success rate was 91.2% and the clinicalsuccess rate was 98.3%. There were 14 cases of PH. During a mean follow-up (FU) of 33 months, 11 pts had toundergo a new Pr, 5 of them due to pocket I. 8 pts (5.0%) died during hospital stay, and 19 pts during the firstyear post-Pr. There were no deaths during the Pr. O1 included 56 pts (35.4%), of which 51.9% were under vitaminK antagonists (AVK) and 48.1% under direct oral anticoagulants (DOAC). 11 pts were receiving OAC due toprosthetic mechanical valve, and the remainder due to atrial fibrillation (AF). Pts in O1 were significantly older(p=0.026), presented a lower LVEF (p=0.001), a higher prevalence of valvular heart disease - VHD -(p=0.002),overt heart failure (p=0.006), AF (p<0.001) and previous cardiac surgery - CS - (p<0.001). OAC was associatedwith a higher rate of PH (OR 2,44, IC 95% 1.02-5,84, p=0.046) and pts with PH presented a significantlyprolonged hospital stay (22.7 vs 9.8 days, p=0.031). These pts also presented a higher hospitalization rate duringthe first year post-Pr (OR 2,48, IC95% 1.27-4.88, p=0.009). There was no difference in all-cause hospital M(p=0.522), all-cause M during first year of follow-up (p=0.551) or need for reintervention (p=0.375). Among pts inO1, pts under AVK presented a significantly higher rate of PH (OR 18,67, IC95% 2,23-156,17, p=0.007).

Conclusion

Pts receiving OAC, particularly pts under AVK, presented a higher rate of PH after LE. PerioperativeOAC management is crucial to reduce the morbidity rate in this population.

Evaluation of RV-arterial coupling in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

The ratio of echocardiography-derived tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP) - TAPSE/PASP ratio - is a noninvasive measure of RV-arterial coupling. TAPSE/PASP ratio is a potent independent predictor of prognosis in heart failure and pulmonary arterial hypertension, with a prognostic cutoff value of 0.36 mm/mmHg.

Objective

To assess the prognostic impact of TAPSE/PASP ratio in a population of advanced HF patients.

Methods

Prospective evaluation of adult patients with advanced HFrEF referred to our Institution for evaluation with HF team and possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 2 years for the primary endpoint of cardiac death and HT. Echocardiographically determined TAPSE/PASP ratio was used to assess RV-arterial coupling and a survival analysis was performed to evaluate the prognostic impact of the suggested cutoff of 0.36 mm/mmHg.

Results

A total of 450 Heart Failure with Reduced Ejection Fraction (HFrEF) patients with a mean age of 56 ± 12 years, of which 80% are male, and with a mean LVEF of 29 ± 4%, mean TAPSE of 19 ± 3 mm and PASP of 38 ± 11mmHg. The mean TAPSE/PASP was 0.80 ± 0.28. Fifty-four patients (12%) met the primary endpoint. Patients with RV-arterial uncoupling (TAPSE/PASP < 0.36 mm/mmHg) were more likely to have a non-ischaemic etiology for HF (66.7% vs 40%, p = 0.047), had a lower prevalence of diabetes (53.3% vs 77.9%, p = 0.041), a higher prevalence of moderate-to-severe mitral regurgitation (33.3% vs 13.0%, p = 0.035), a lower LVEF (26.2 ± 6.1 vs 29.9 ± 5.9, p = 0.038), a higher prevalence of RV dysfunction (73.3% vs 26.7%, p < 0.001) and worse cardiopulmonary fitness (pVO2: 12.7 ± 5.1 vs 15.8 ± 6.0 ml/kg/min, p = 0.047; VE/VCO2 slope: 49.5 ± 17.2 vs 37.6 ± 9.7, p < 0.001; cardiorespiratory optimal point: 36.9 ± 11.3 vs 29.0 ± 6.4, p < 0.001). More patients in the group of TAPSE/PASP < 0.36 mm/mmHg met the primary endpoint (33.3% vs 9.6%, p = 0.034) and more patients underwent urgent HT (13.3% vs 1.4%, p = 0.44). RV-arterial coupling was associated with a lower survival free of events during follow-up (log-rank p = 0.010).

Conclusion

RV-arterial coupling predicts a worse prognosis in advanced HF patients, with those below a cutoff of 0.36 mm/mmHg having lower survival. This variable may improve risk stratification in this setting. Abstract Figure.

Prognostic impact of right ventricular function in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

In patients with heart failure with reduced ejection fraction (HFrEF), the presence of coexistent right ventricular (RV) systolic dysfunction is associated with a worse functional capacity and outcome. However, the measurement of RV function is often overshadowed by its left counterpart.

Purpose

To assess the prognostic impact of RV dysfunction in a population of advanced HF patients.

Methods

Prospective evaluation of adult patients with advanced HFrEF referred to our Institution for evaluation with HF team for possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 1 year for the primary endpoint of cardiac death and HT. RV systolic dysfunction was defined by a tricuspid annular plane systolic excursion (TAPSE) < 17 mm and/ or fractional area change (FAC) < 35%. A survival analysis was performed to evaluate the prognostic impact of RV dysfunction and survival curves were compared using the log-rank test.

Results

A total of 450 HFrEF patients (mean age of 56 ± 12 years, 80% male, mean LVEF of 29 ± 4%, mean TAPSE of 19 ± 3 mm and RV FAC of 37 ± 6%), of which 30.4% had RV dysfunction. Thirty patients (6.7%) met the primary endpoint. Patients with RV dysfunction had a higher NT-proBNP value (3278.9 ± 296.7 pg/mL, p = 0.005) and a lower LVEF (26.7 ± 6.4 vs 31.4 ± 5.1, p < 0.001), as well as a worse cardiopulmonary fitness (CPET duration: 7.2 ± 3.8 vs 8.6 ± 4.1, p = 0.019; pVO2: 13.6 ± 4.9 vs 16.2 ± 6.1 ml/kg/min, p = 0.006; VE/VCO2 slope: 41.8 ± 11.9 vs 37.0 ± 10.6, p = 0.015; cardiorespiratory optimal point: 33.0 ± 8.9 vs 28.4 ± 6.2, p < 0.001). RV dysfunction was associated with a lower survival free of events during the first follow-up year (log-rank p = 0.046).

Conclusion

RV is associated with a poor survival in advanced HF patients and it may improve risk stratification in this population. Abstract Figure.

Functional mitral regurgitation in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Moderate-to-severe functional mitral regurgitation (fMR) is present in about one-third of patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (HFrEF) and contributes to progression of the symptoms of HF and is and independent predictor of worse clinical outcomes.

Objective

To characterize the population of advanced HF patients with severe fMR and assess its prognostic impact.

Methods

Prospective evaluation of adult patients with advanced HFrEF were referred to our Institution for evaluation with HF team and possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 1 year for the primary endpoint of cardiac death and HT. Severe fMR was defined by an EROA ≥ 20 mm2 and/or a regurgitant volume (RVol) ≥ 30 mL either taken from TTE or TOE. A survival analysis was performed to evaluate the prognostic impact of fMR and survival curves were compared using the log-rank test.

Results

A total of 450 HFrEF patients (mean age of 56 ± 12 years, 80% male, mean LVEF of 29 ± 4%) of which 14.4% had severe fMR, with a mean EROA of 29.2 ± 3.1 mm2 and a mean RVol of 43.6 ± 4.7 mL. Thirty patients (6.7%) met the primary endpoint. Patients with severe fMR were more likely to be female (69.2% vs 81.5%, p = 0.026) and to have atrial fibrillation (27.0% vs 14.1%, p = 0.028), had a higher NT-proBNP value (3625.8 ± 496.9 vs 1940 ± 212.4 pg/mL, p = 0.001), a lower LVEF (25.9 ± 6.8 vs 29.0 ± 6.7, p = 0.001), more dilated LV (LV end-diastolic diameter: 72.8 ± 13.3 vs 66.9 ± 9.0 P = 0.036), a lower HFSS value (8.1 ± 1.0 vs 8.6 ± 1.0). There was no difference regarding HF etiology, NYHA class or cardiopulmonary fitness (pVO2: 16.6 ± 5.6 vs 16.5 ± 6.3 ml/kg/min, p = 0.19; VE/VCO2 slope: 35.4 ± 9.9 vs 34.0 ± 9.7, p = 0.328). EROA was an independent predictor of the primary outcome (OR 1.23, 95% CI 1.08-1.54, p = 0.039) and patients with severe fMR had a lower survival free of events during the first follow-up year (log-rank p = 0.012).

Conclusion

Severe fMR was associated with worse clinical outcomes in advanced HF population. Abstract Figure.

Right atrial strain by speckle-tracking echocardiography as a prognostic predictor in a pulmonary hypertension cohort

Funding Acknowledgements

Type of funding sources: None.

Background

Right atrial (RA) strain is as a promising technique for assessment of RA function and several studies have suggested it is a powerful prognostic marker in pulmonary hypertension (PH) patients (pts). Our aim was to assess the prognostic power of RA strain in Pulmonary Arterial Hypertension (PAH) and Chronic Thromboembolic Pulmonary Hypertension (CTEPH) pts.

Methods

Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). Correlation between RA strain and other variables was tested with Pearson"s correlation analysis. Regression and survival analysis were performed to assess the combined endpoint of all-cause mortality or hospitalization in the first follow-up year (MH1).

Results

A total of 51 PH pts (mean age 54 ± 46 years, 33.3% male, baseline BNP of 342.4 ± 439.9pg/mL and baseline pulmonary artery systolic pressure – PASP - of 78 ± 26mmHg), of which 64.7% had PAH and 35.3% presented CTEPH. 19 ots (37.3%) met the primary endpoint. The mean RA strain was -21.9 ± -4.9%, with no significant difference between groups (-23.4% vs -17.8%, p = 0.150), however male pts had a significantly lower RA strain (-15.9% vs -25.1%, p = 0.014). There was a statistically significant (p < 0.05) correlation between RA strain and age (r = -0.287), indexed RA area (r = -0.539), index RA volume (r = -0.522) and right ventricular strain (r = -0.453). There was no correlation between RA strain and BNP value (p = 0.150), 6MWT distance (p = 0.145) or PASP (p = 0.072). RA strain was a predictor of MH1 (OR = 0.94, 95% CI: 0.894-0.998, p = 0.048). Pts who met the primary endpoint had a significantly worse RA strain (-17.0 vs -24.6%, p = 0.032). Those with a RA strain worse than -19% presented a significantly lower survival free of events during the first follow-up year (log rank p = 0.022).

Conclusion

RA strain is a powerful predictor of adverse events in a PH population and should be systematically assessed in order to improve risk stratification.

Abstract Figure.