Coronary Sinus Lead Removal: A Comparison between Active and Passive Fixation Leads

<div><p>Background</p><p>Implantation of coronary sinus (CS) leads may be a difficult procedure due to different vein anatomies and a possible lead dislodgement. The mode of CS lead fixation has changed and developed in recent years.</p><p>Objectives</p><p>We compared the removal procedures of active and passive fixation leads.</p><p>Methods</p><p>Between January 2009 and January 2014, 22 patients at our centre underwent CS lead removal, 6 active and 16 passive fixation leads were attempted using simple traction or lead locking devices with or without laser extraction sheaths. Data on procedural variables and success rates were collected and retrospectively analyzed.</p><p>Results</p><p>The mean patient age was 67.2 ± 9.8 years, and 90.9% were male. The indication for lead removal was infection in all cases. All active fixation leads were Medtronic^® Attain StarFix^™ Model 4195 (Medtronic Inc., Minneapolis, MN, USA). The mean time from implantation for the active and passive fixation leads was 9.9 ± 11.7 months (range 1.0–30.1) and 48.7 ± 33.6 months (range 5.7–106.4), respectively (p = 0.012). Only 3 of 6 StarFix leads were successfully removed (50%) compared to 16 of 16 (100%) of the passive fixation CS leads (p = 0.013). No death or complications occurred during the 30-day follow-up.</p><p>Conclusion</p><p>According to our experience, removal of the Starfix active fixation CS leads had a higher procedural failure rate compared to passive.</p></div

Re-implantation status.

<p>Re-implantation status.</p

Chest-X-Ray with abandoned LV Lead fragment after extraction failure.

<p>Chest-X-Ray with abandoned LV Lead fragment after extraction failure.</p

Left Atrial Appendage Closure Guided by Integrated Echocardiography and Fluoroscopy Imaging Reduces Radiation Exposure

<div><p>Aims</p><p>To investigate whether percutaneous left atrial appendage (LAA) closure guided by automated real-time integration of 2D-/3D-transesophageal echocardiography (TEE) and fluoroscopy imaging results in decreased radiation exposure.</p><p>Methods and Results</p><p>In this open-label single-center study LAA closure (Amplatzer^TM Cardiac Plug) was performed in 34 consecutive patients (8 women; 73.1±8.5 years) with (n = 17, EN+) or without (n = 17, EN-) integrated echocardiography/fluoroscopy imaging guidance (EchoNavigator^® [EN]; Philips Healthcare). There were no significant differences in baseline characteristics between both groups. Successful LAA closure was documented in all patients. Radiation dose was reduced in the EN+ group about 52% (EN+: 48.5±30.7 vs. EN-: 93.9±64.4 Gy/cm²; p = 0.01). Corresponding to the radiation dose fluoroscopy time was reduced (EN+: 16.7±7 vs. EN-: 24.0±11.4 min; p = 0.035). These advantages were not at the cost of increased procedure time (89.6±28.8 vs. 90.1±30.2 min; p = 0.96) or periprocedural complications. Contrast media amount was comparable between both groups (172.3±92.7 vs. 197.5±127.8 ml; p = 0.53). During short-term follow-up of at least 3 months (mean: 8.1±5.9 months) no device-related events occurred.</p><p>Conclusions</p><p>Automated real-time integration of echocardiography and fluoroscopy can be incorporated into procedural work-flow of percutaneous left atrial appendage closure without prolonging procedure time. This approach results in a relevant reduction of radiation exposure.</p><p>Trial Registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT01262508?term=NCT01262508&rank=1" target="_blank">NCT01262508</a></p></div

Overview of integrated echocardiography and fluoroscopy imaging.

<p>The image acquisition angles during transseptal puncture are depicted in the lower right corner of each image. A+B) Concordant views of TEE and fluoroscopy images. C) In the “Free view” echocardiographic images can be rotated and zoomed independently from the echocardiographer by using a tableside control. D) Conventional echocardiographic view using the x-plane mode for identification of the preferred transseptal puncture site (Septum, blue). Sheath with transseptal needle; Pigtail cath. = pigtail catheter; RV cath. = catheter in the right ventricle.</p

CONSORT flow chart.

<p>CONSORT flow chart.</p

Evaluation of adequate device position and stability by using 3D-TEE and fluoroscopy.

<p>After LAA occluder release correct positioning is verified simultaneously by rotation and zoom of the 3D-TEE image and angiography. The LAA occluder is shown in the 3D-TEE “Free view” (A) by using the tableside control and the fluoroscopy (B) demonstrating the relationship to surrounding structures (LCX, crista). Note the relatively large crista which could not be fully covered by the disc of the LAA occluder, while contrast agent injection demonstrated good LAA sealing.</p

Baseline characteristics.

<p>ACE: angiotensin converting enzyme; AF: atrial fibrillation; INR: international normalized ratio; PCI: percutaneous coronary intervention; SD: standard deviation.</p

Angiotensin II-induced atrial fibrosis was reduced in CD11b^−/− mice.

<p><b>(A)</b> Percentage of fibrotic area in atrial sections of WT and CD11b^−/− mice upon vehicle or Ang II treatment. *  =  p<0.05, ***  =  p<0.001. <b>(B, C)</b> Representative images of Trichrome stained atrial sections with fibrotic tissue stained in light blue merged from 6 individual images with 10× magnification <b>(B)</b>, scale bar  =  200 µm and with 40× magnification <b>(C)</b>, scale bar  =  40 µm.</p

CD11b-deficiency diminished AF vulnerability and preserved conduction velocity following angiotensin II treatment.

<p>(A, B) Number and total time of AF-episodes during an electrophysiological stimulation procedure in WT and CD11b^−/− mice upon vehicle or Ang II application. *  =  p<0.05. (C) Example electrical tracings of surface and intracardiac leads from Ang II treated WT and CD11b^−/− mice during electrophysiological burst stimulation with cycle length of 20 ms. (D) Electrical conduction velocity in propagation direction as assessed by epicardial mapping of Langendorff-perfused hearts of WT and CD11b^−/− mice. ***  =  p<0.001. (E) Representative examples of conduction properties of epicardial activation mapping.</p