Cardiac resynchronization therapy after coronary sinus lead extraction: feasibility and mid-term outcome of transvenous reimplantation in a tertiary referral centre

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His-bundle pacing to treat an unusual case of chest pain after pacemaker implant

A 63-year-old man with hypertension and 3-vessel coronary artery disease previously treated with coronary artery bypass graft was admitted to our emergency room complaining of chest pain. He had undergone pacemaker implant 5 months before due to paroxysmal advanced atrioventricular block. Electrocardiography and troponin testing were unremarkable. Echocardiography and chest X-ray ruled out lead displacement and perforation. Interrogation showed normal parameters [right atrium: impedance 550 Ohm bipolar, sensing 2.4 mV bipolar; threshold 0.50 V/0.4 ms bipolar; right ventricle (RV): impedance 580 Ohm bipolar, sensing > 25 mV bipolar; threshold 1.5 V/0.4 ms bipolar and 0.4 V/0.4 ms unipolar]. Pain was evoked only during RV pacing. An electrophysiology study demonstrated painful RV pacing from multiple sites. We hypothesized that pain was associated with pacing-induced dyssynchrony. His-bundle pacing (HBP) was considered as a solution. We achieved HBP with a bipolar fixed-screw catheter connected to a cardiac resynchronization therapy pacemaker generator. During HBP above threshold (4.00 V/1.00 ms) the patient did not complain of any pain. He was discharged 3 days later pain-free with His-bundle lead amplitude set at 5.00 V/1.00 ms. After 6 months the patient was asymptomatic, with the device showing normal functioning. This is the first clinical experience of painful RV pacing treated with HBP. Learning objective: Painful right ventricular pacing in the absence of perforation is a rare but potentially underdiagnosed condition. Ventricular dyssynchrony could represent the underlying mechanism. Physiological electromechanical activation achieved via His-bundle pacing could represent an effective therapeutic option

A Modified Transvenous Single Mechanical Dilatation Technique to Remove a Chronically Implanted Active-Fixation Coronary Sinus Pacing Lead

We described a 77-year-old patient, previously implanted with a dual-chamber pacemaker later upgraded to a cardiac resynchronization therapy-defibrillator (CRT-D) device with an active-fixation coronary sinus pacing lead, who underwent a transvenous mechanical extraction procedure for a device-related systemic infection. All leads were removed successfully with a transvenous approach. With regard to the coronary sinus (CS) lead (Attain 4195 StarFix, Medtronic Inc., Minneapolis, MN, USA), manual traction was ineffective and extraction required long and challenging mechanical dilatation up to distal CS using either conventional sheaths or modified CS lead delivery. (PACE 2011; 34: e66-e69

Mechanical transvenous extraction of endocardial implantable cardioverter defibrillator leads: feasibility, safety and determinants of success in the pisa experience

Introduction: Transvenous extraction of implantable electric devices is a well known procedure, almost described and documented for pacing leads, with small series for implantable cardioverter defibrillator (ICD) leads. Aim of our study was to describe a large single center experience in implantable cardioverter defibrillator (ICD) leads extraction by transvenous mechanical technique. Methods: Since 1997 to June 2010, 352 consecutive patients (309 men, mean age 62.1 years, range 8-92) with 378 ventricular ICD leads (mean implantation time 42.2 months, range 1-204) underwent a mechanical transvenous removal. System features included almost left side implanted systems (92%) with passive fixation (76%) and dual coil (74%) leads. The most common indication for lead extraction was local infection (174 patients, 49%), followed by sepsis (95 patients, 27%) and lead malfunction (83 patients, 24%). Results: Removal was feasible with a complete success in all the approached leads (100%). 23 leads (6%) were removed by manual traction, 355 by mechanical dilatation, whose 321 (85%) using the venous entry site approach and 34 (9 %) by the transvenous jugular approach crossover. Mean extraction time was 21±31.7 min (range 1-210). No major complications occurred. Dual coil compared with single coil leads showed an higher rate of fibrous adherences at the innominate vein (69% vs 52%, respectively) and superior vena cava (70% vs 51 %, respectively), without differences in the other sites. Comparing the easy ("traction" group) with the complex approach ("transjugular" group), all baseline patient and leads features resulted comparable (p =NS), with the only exception for the lead implantation time that resulted statistically longer in the second group (10.4±10.3 vs 64.3±36.7 min, p<0.01, respectively). Conclusions: Our large experience shows that transvenous ICD leads removal is a feasible, safe procedure with an high success rate. However, even if the mean dwell time is usually lower than pacing leads, manual traction is rare effective and often transjugular approach may be required