Safety and effectiveness of transvenous lead extraction in elderly patients

Background: There is a considerable controversy regarding safety of transvenous lead extraction (TLE) in elderly patients due to their potentially worse general condition, more concomitant diseases, more difficult sedation or analgesia. Moreover, the present experience is not relevant. The aim of the study was the comparison of safety and feasibility of TLE in elderly and middle-aged patients.Methods: We have extracted an ingrown pacemaker (PM)/implantable cardioverter-defibrillator (ICD) leads from 1,060 adult patients (21–70 years) and 192 octogenarians (mean age 83.4 ± 3.1 years) using standard mechanical systems within the last 7 years. We compared effectiveness and complications of the TLE procedures in the two mentioned groups of patients.Results: There were more women in octogenarians referred for TLE (45.3% vs. 36.9%). In addition, more pocket infections (37.0% vs. 24.5%), less non-infective indications for PM (46.9% vs. 57.7%) and ICD systems (7.3% vs. 28.8%) TLE were observed in this group. Leads body dwelling time was similar (76.4 ± 56.8 vs. 83.5 ± 63.0) in both groups. Procedure efficacy (full radiological success 97.4% vs. 94.6%, partial radiological success 2.6% vs. 4.34%), safety measures (major complications 1.6% vs. 1.51%, minor complications 1.0% vs. 1.9%) were similar in both compared groups.Conclusions: Old age does not influence TLE effectiveness. Therefore, TLE can be safely and successfully performed in octogenarians

Infection-related complications in patients with end stage renal failure dialyzed through a permanent catheter

Objectives Progression of renal failure leads to an increase in the number of patients who require forming dialysis access. Old age and a rising morbidity make it impossible to form a native arteriovenous fistula and a permanent catheter becomes the first choice. The presence of a catheter frequently generates complications, including infections, which may result in a higher mortality rate. Patients and methods A retrospective analysis data has been conducted, involving 398 patients who had permanent catheters implanted from 2010 to 2016. Out of this group, 65 patients who suffered infection-related complications have been identified. Risk factors for infection and a survival rate of the population have been estimated. Results Between 2010 and 2016, 495 catheters were implanted for 398 patients aged 68.73(13.26) years on average. 92 catheter-related infections (23.1%) were recorded in 65 patients. A higher risk of infection has been noted among younger patients, with coronary disease and heart failure. Patients affected by infection had 35.38% survivability as against 38.14% for those with no infection: p= 0.312. A higher mortality risk was identified among patients suffering catheter-related infections with cardiac implants and vascular prostheses. Unfavourable prognosis was for infections occurring together with hypotension, high leucocytosis, a low number of platelets and a high leukocyte/platelet ratio. Conclusion Dialysis patients who use permanent catheters run a high risk of infection-related complications, especially younger patients suffering from coronary conditions and heart failure. Severe catheter-related infections lead to a high mortality rate, therefore it is necessary to limit this form of access

Lead dependent tricuspid dysfunction: Analysis of the mechanism and management in patients referred for transvenous lead extraction

Background: Lead-dependent tricuspid dysfunction (LDTD) is one of important complicationsin patients with cardiac implantable electronic devices. However, this phenomenon isprobably underestimated because of an improper interpretation of its clinical symptoms. Theaim of this study was to identify LDTD mechanisms and management in patients referred fortransvenous lead extraction (TLE) due to lead-dependent complications.Methods: Data of 940 patients undergoing TLE in a single center from 2009 to 2011 wereassessed and 24 patients with LDTD were identifi ed. The general indications for TLE, pacingsystem types and lead dwell time in both study groups were comparatively analyzed. Theradiological and clinical effi cacy of TLE procedure was also assessed in both groups with precisionestimation of clinical status patients with LDTD (before and after TLE). Additionally,mechanisms, concomitant lead-dependent complications and degree (severity) of LDTD beforeand after the procedure were evaluated. Telephone follow-up of LDTD patients was performedat the mean time 1.5 years after TLE/replacement procedure.Results: The main indications for TLE in both groups were similar (apart from isolatedLDTD in 45.83% patients from group I). Patients with LDTD had more complex pacing systemswith more leads (2.04 in the LDTD group vs. 1.69 in the control group; p = 0.04). Therewere more unnecessary loops of lead in LDTD patients than in the control group (41.7% vs.5.24%; p = 0.001). There were no signifi cant differences in average time from implantationto extraction and the number of preceding procedures. Signifi cant tricuspid regurgitation(TR-grade III–IV) was found in 96% of LDTD patients, whereas stenosis with regurgitationin 4%. The 10% frequency of severe TR (not lead dependent) in the control group patients wasobserved. The main mechanism of LDTD was abnormal leafl et coaptation caused by: loop ofthe lead (42%), septal leafl et pulled toward the interventricular septum (37%) or too intensivelead impingement of the leafl ets (21%). LDTD patients were treated with TLE and reimplantationof the lead to the right ventricle (87.5%) or to the cardiac vein (4.2%), or surgery procedure with epicardial lead placement following ineffective TLE (8.3%). The radiological and clinicaleffi cacy of TLE procedure was very high and comparable between the groups I and II (91.7%vs. 94.2%; p = 0.6 and 100% vs. 98.4%; p = 0.46, respectively). Repeated echocardiographyshowed reduced severity of tricuspid valve dysfunction in 62.5% of LDTD patients. The follow--up interview confi rmed clinical improvement in 75% of patients (further improvement aftercardiosurgery in 2 patients was observed).Conclusions: LDTD is a diagnostic and therapeutic challenge. The main reason for LDTDwas abnormal leafl et coaptation caused by lead loop presence, or propping, or impingementthe leafl ets by the lead. Probably, TLE with lead reimplantation is a safe and effective optionin LDTD management. An alternative option is TLE with omitted tricuspid valve reimplantation.Cardiac surgery with epicardial lead placement should be reserved for patients withineffective previous procedures

Complications of permanent cardiac pacing in patients with persistent left superior vena cava

Background: Persistent left superior vena cava (PLSVC) is present in about 0.3–0.5% of the general population and in about 12% of patients with other abnormalities. This congenital anomaly is usually asymptomatic and does not cause any physiological problems. However, it may become a significant problem in multiple clinical situations. Various complications related to PLVSC are encountered in anesthesiological, nephrological, oncological and cardiological procedures. The presence of PLSVC is usually incidentally detected during placement of pacemaker (PM), implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) leads. Technical difficulties during lead positioning (especially ventricular leads) are commonly known and often described in the literature. The purpose of the present study was to evaluate the specific methods used for implantation of increasingly complicated pacing systems, finding an optimal strategy in patients with PLSVC, especially with electrotherapy complications.Methods: We performed a single-center retrospective analysis of 11 patients (7 women and 4 men, mean age 60.4 ± 13 years) with PLSVC hospitalized in single Cardiology Department between 2000 and 2012. The clinical characteristic, indications for PM/ICD/CRT implantation, technique of implantation and complications were evaluated.Results: In PLSVC patients, different indications for pacing or resynchronization therapy were represented: sick sinus syndrome (SSS) in 4 patients, 3rd degree atrio-ventricular (AV) block in 4 patients, dilated cardiomyopathy with left bundle branch block in 2 patients, dilated cardiomyopathy and non-sustained ventricular tachycardia episodes in 1 patient. In patients no. 1, 3, 4 and 10 the complications necessitated the change of leads or type of pacing. Transvenous lead extraction was successfully performed in patient no. 1 and 10 with re-implantation of new leads via PLSVC in patient no. 1 and via right superior vena cava in patient no. 10. Patient no. 3 received an additional ventricular lead via PLSVC because of 2nd degree AV block (formerly atrial lead implanted due to SSS). In patient no. 4 with left atrial pacing (lead in coronary sinus), prosthetic mitral valve replacement was combined with epicardial ventricular lead placement. Patients no. 2 and 7 received a CRT device, without technical problems in patient no. 7, whereas in patient no. 2 due to difficulties with left ventricular lead positioning a hybrid approach to epicardial lead pacing was used. In patient no. 8 an ICD was implanted with difficulty in placing defibrillator lead. Patient no. 5 received 2 atrial leads via PLSVC with successful biatrial pacing; patient no. 6 with the necessity of DDD pacing had a (ventricular) lead for left atrial pacing and a typical right ventricular lead. In patients no. 9 and 11 typical DDD pacing was used with contralateral placement of the leads due to anatomical and technical differences. After 12 years of follow-up the survival is 90.9%. Late electrotherapy complications have developed only in patient no. 8 (problems with the defibrillator lead).Conclusions: Patients with PLSVC are a very heterogeneous group with different indications for pacing, therefore individualization of therapy is required. Technical complications connected with pacing of the right heart chambers are commonly known, hence transvenous left atrialor left ventricular lead implantation should be attempted. In case of difficulties in transvenous positioning of the lead, a hybrid or isolated cardiac surgery technique should be considered. Because of the increasing number of electrotherapy complications, these problems are also present in PLSVC patients. Transvenous lead extraction with re-implantation of a pacing system has not been reported yet. For this reason a thorough evaluation of the venous system is required in PLSVC patients before intervention.

Zespół Twiddlera: nowe oblicze starego powikłania

Twiddler’s syndrome (TS) is the well known late electrotherapy complication. The typical TS develops as a result of the pulse generator rotation with retraction of the leads and consequent interruption of pacing. We reported 2 cases illustrating late TS without spontaneous old, ingrown lead extraction and very different leads damage

Walka z powikłaniami elektroterapii — dlaczego wciąż jest taka trudna? Analiza dwóch złożonych przypadków klinicznych

We present two cases of diagnostics and treatment difficulties developing after pacemaker implantation. Lead dependentinfective endocarditis in the aftermath of mechanical complications was observed in both cases

Ten-year study of late electrotherapy complications. Single-centre analysis of indications and safety of transvenous leads extraction

Background: An increase in the number of cardiac implantable electronic device (CIED) implantations is associated with a higher frequency of electrotherapy complications.Aim: The aim of the study was to determine the risk factors for late electrotherapy complications and to evaluate the effectiveness of transvenous lead extraction (TLE) and survival after TLE.Methods: We analysed the clinical data of 225 patients with electrotherapy complications referred for TLE in a single centre in the years 2006 to 2015. Indications for TLE, risk factors for infectious complications, effectiveness of TLE, and survival after the procedure were assessed.Results: In the study group, non-infectious indications for TLE predominated (78.2%). Analysis of risk for infectious complications demonstrated the important role of chronic renal failure (hazard ratio [HR] 1.842, p = 0.034) and a greater number of CIED-related procedures (HR 4.768, p < 0.001). High effectiveness of TLE and significantly higher long-term mortality of patients with infectious complications compared with the remainder (50% vs. 20%, p < 0.05) were documented.Conclusions: The study demonstrated a high rate of patients with non-infectious complications referred for TLE and very high effectiveness of the procedure. The worse long-term survival of patients with infectious complications, as well as increased risk for such complications due to the greater number of prior procedures, should prompt the consideration of early referral for TLE in the case of lead dysfunctions

Discontinuation of cardiac implantable electronic device therapy after transvenous lead extraction

Background: Patients with cardiac implantable electronic devices (CIEDs) may no longer be eligible for continued therapy.Aims: The study aimed to assess the circumstances under which CIED reimplantation may not be necessary after transvenous lead extraction (TLE).Methods: A retrospective analysis of 3646 TLE procedures was performed with assessment of indications for device reimplantation.Results: Reimplantation was not performed immediately after TLE in 169 (4.6%) and, in long-term follow-up, in 146 (4.0%) of patients. No further need for CIED reimplantation was mostly associated with establishment of stable sinus rhythm (2.4%), conversion of sinus node dysfunction to chronic atrial fibrillation (AF; 1.4%), or improvement in left ventricular ejection fraction (LVEF) (0.9%). Independent prognostic factors were in the pacing groups: LVEF (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01–1.05; P <0.001), AF (OR, 3.8; 95% CI, 2.4–15.7; P <0.001), patients’ age during first CIED implantation (OR, 0.97; 95% C, 0.96–0.98; P <0.001), and New York Heart Association (NYHA) class (OR, 0.616; 95% CI, 0.43–0.86; P <0.01); in the cardioverter-defibrillator group: LVEF (OR, 1.06; 95% CI, 1.04–1.09; P <001). Non-reimplanted patients had more complex procedures and more frequent complications, but survival after TLE was better in this group of patients.Conclusions: Reassessment of the need for continuation of CIED therapy should be considered in all patients following lead extraction and also before planned device replacement as TLE delay increases implant duration, complexity, and procedural risk. The predictors of non-reimplantation are a younger age during the first CIED implantation, lower NYHA class, presence of AF, and higher LVEF in pacemaker carriers, and, in the defibrillator group, only higher LVEF. A decision not to reimplant does not negatively affect the long-term prognosis