Procedural outcome and risk prediction in patients with implantable cardioverter-defibrillator (ICD) undergoing transvenous lead extraction: a GALLERY subgroup analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Device complications, such as infection or lead dysfunction necessitating transvenous lead extraction (TLE) are continuously rising amongst patients with indwelling 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 1- and 2-chamber ICD patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for procedural failure and all-cause mortality were assessed.

Results

A total of 854 patients with ICD undergoing TLE were identified, who were younger (62.9±13.8 vs. 70.7±13.0 years; p<0.001), less likely to be female (20.8 vs. 27.1%; p<0.001) and had a higher proportion of patients with coronary artery disease (51.5 vs. 38.6%; p<0.001) and highly reduced ejection fraction (32.0 vs. 23.0%; p>0.001), when compared to non-ICD patients. Leading extraction indication was lead dysfunction (48.0 vs. 21.9%; p<0.001), followed by device-related infection (45.6 vs. 73.0%; p<0.001). There were no differences in overall procedural complications (4.3 vs. 4.3%; p=0.980), clinical success rate (97.9 vs. 97.8%; p=0.861) or procedure-related (0.8 vs. 0.5%; p=0.292) and all-cause mortality (3.4 vs. 3.7%; 0.742) between groups. Multivariate analysis revealed lead age≥10 years (OR:5.75, 95%CI:2.0-16.2; p=0.001) as independent predictor for procedural failure. Systemic infection as extraction indication (OR:9.57, 95%CI:2.2-42.4; p=0.003) and procedural complications (OR:8.0, 95%CI:2.8-23.3; p<0.001) were identified as risk factors for all-cause mortality. Predictors for systemic infection in ICD patients were atrial fibrillation (OR: 2.22, 95%CI: 1.51-3.27; p<0.001), diabetes mellitus (OR: 2.28, 95%CI: 1.59-3.25; p<0.001) and chronic kidney disease (OR: 2.0, 95%CI: 1.39-2.89; p<0.001).

Conclusions

Transvenous lead extraction 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.

1255Comprehensive analysis of pacemaker patients with and without abandoned leads undergoing transvenous lead extraction: A GALLERY subgroup analysis

OnBehalf

GALLERY investigators

Background

The number of cardiac implantable electronic device (CIED)-associated complications such as infection, lead dysfunction or thrombotic events is continuously rising and thus making transvenous lead extraction (TLE) an ever more needed procedure in clinical practice today. Patients with abandoned leads represent a special cohort with a potentially higher susceptibility to CIED-related infections and vascular complications. Moreover, according to literature abandoned leads seem to be associated with more procedural complications and mortality during TLE. 

Aim

 

The aim of this study was to provide an insight on safety, procedural outcome and risk prediction on pacemaker patients with abandoned leads undergoing TLE from the largest national laser-sheath registry to date.

Methods + Results:

We conducted a retrospective analysis of the GALLERY database, which collected 2533 patients undergoing TLE in Germany between 2013 and 2017. Out of 903 pacemaker patients, who underwent TLE, 226 patients (25.0%) with abandoned leads were identified. Those patients had a higher number of leads per patient (3.2 ± 0.8 vs. 1.9 ± 0.3; ns) and longer lead dwell-times (168.0 ± 89.7 vs. 123.0 ± 69.2 months; p < 0.0001) compared to pacemaker patients without abandoned leads. There were no differences in age (71.5 vs. 72.3 years; ns), body mass index (26.5 ± 4.5 vs. 26.78 ± 4.8 kg/m2; ns) or gender distribution (69.0 vs. 66.5% male; ns). Leading indication for TLE was device infection with no difference between groups (79.7 vs 77.8 %; ns). There were no differences in terms of pacemaker dependency, length of hospitalization or comorbidities. Patients with abandoned leads had longer procedure times (112.0 ± 69.0 vs. 86.4 ± 53.0 minutes; p < 0.0001) and a higher incidence of procedural complications (6.6 vs. 3.1%; p = 0.03), but there were no differences in neither procedural and clinical success rates (96.5 vs. 97.3%; ns), nor all-cause mortality (1.33 vs. 2.66%; ns). Multivariate logistic regression revealed abandoned leads (OR 2.1, CI 1.0-4.4, p = 0.04) and female gender (OR 2.4, CI 1.2-4.9, p = 0.02) as independent predictors for procedural complications. Systemic infection (OR 5.4, CI 2.0-14.8, p = 0.001) and chronic kidney disease (OR 4.0, CI 1.5-10.7, p = 0.007) were strong predictors for all-cause mortality in patients with indwelling pacemaker. Patient age > 75 years (OR 3.9, CI 2.7-5.6, p < 0.0001) and a lead dwell-time > 10 years (OR 1.6, CI 1.1-2.2, p = 0.01) were identified as risk factors for an infectious cause for TLE. 

Conclusion

Abandoned leads are frequently encountered in pacemaker patients undergoing TLE and pose an important risk factor for procedural complications. Systemic CIED-related infections are the strongest driver of mortality in this patient cohort and urgently call for further improvements in early diagnosis and prevention.

P2869Role of PDE8 in cAMP dynamics in human atrial fibrillation

Background

Cardiac arrhythmias, such as atrial fibrillation (AF), are often related to remodeling of membrane receptors and alterations in cAMP-dependent regulation of Ca2+ handling mechanisms. For instance, decreased L-type calcium current (ICa,L) density but upregulated RyR2 are major hallmarks of AF. These inhomogeneous AF-associated changes of protein phosphorylation point to a local regulation of PKA activity within these intracellular compartments. Local cAMP compartmentation and the role of phosphodiesterase (PDEs) have ben extensively studied in ventricular myocytes from animals. However, only a few studies have evaluated the contribution of PDEs to the pathophysiology of AF and the reason for the persistent AF-associated hypophosphorylation of the L-type calcium channel (LTCC) is currently unknown. The aim of this study was to investigate whether a change in the expression level of PDE8 in human atrium may affects cAMP nearby LTCC promoting the reduction of the ICa,L observed in persistent AF.

Methods

Atrial myocytes were isolated from tissue of 47 patients in sinus rhythm (SR) and with AF. Cells were then transfect with an adenovirus (Epac1-camps or pm-Epac1-camps) in order to express the (cytosolic or membrane, respectively) FRET-based cAMP sensor and cultured during 48 hours. Föster-resonance energy transfer (FRET) was used to measure cAMP in 232 isolated human atrial myocytes. Ro-20-1724 (10 μM), Cilostamide (1 μM) and PF-04957325 (30 nM) and IBMX (100 μM) were used as PDE4, PDE3, PDE8 and non-selective phosphodiesterases (PDEs) inhibitor respectively.

Results

Effects of PDE4 and especially PDE3 inhibition on cytosolic [cAMP] are reduced in AF. Pharmacological PDE8 inhibition induces only a small increase in basal intracellular [cAMP] in AF but it showed a big synergic effect when PDE4 was inhibit at the same time. By contrast, PDE8 inhibition dramatically increased basal [cAMP] in the subsarcolemmal compartment in AF while PDE3 or PDE4 inhibition had a smaller effect that didn't change between SR and AF.

Conclusions

PDE8 controls basal cytosolic cAMP levels in human atrial myocytes from patients with persistent AF while PDE3 effects tends to be reduced in these patients. Furthermore, PDE8 is the main PDE in controlling cAMP levels at the membrane in persistent AF. Thus, our study may provide a clue for the reported reduction of the ICa,L in persistent AF.

The wearable cardioverter defibrillator as a bridge to reimplantation in patients with ICD or CRT-D-related infections

Background

The approach to treat device infection in patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) is a challenging procedure. Optimal treatment is complete extraction of the infected device. To protect these patients from sudden cardiac arrest while waiting for reimplantation and to avoid recurrent infection, a wearable cardioverter defibrillator (WCD) seems to be a valuable solution.

Therefore, we investigated the management and outcome of patients with ICD or CRT-D infections using the WCD as a bridge to re-implantation after lead extraction procedures.

Methods

We conducted a retrospective study on consecutive patients who underwent ICD or CRT-D removal due to device-related local or systemic infections. All patients were prescribed a WCD at our center between 01/2012 and 10/2015. All patients returned to our outpatient clinic for regular ICD or CRT-D monitoring initially 1 and 3 months after reimplantation followed by 6-months intervals.

Results

Twenty-one patients (mean age 65.0 ± 8.0 years, male 76.2%) were included in the study. Complete lead extraction was achieved in all patients. While waiting for reimplantation one patient experienced a symptomatic episode of sustained ventricular tachycardia. This episode was converted successfully into sinus rhythm by a single 150 J shock.

Mean follow-up time 392 ± 206 days, showing survival rate of 100% and freedom from reinfection in all patients.

Conclusion

The WCD seems to be a valuable bridging option for patients with ICD or CRT-D infections, showing no recurrent device infection.