Cardiac implantable electronic devices and lead removal, single center experience

Introduction: Over the past couple of decades, the use of cardiac implantable electronic devices (CIEDs) has increased significantly. Because of that and because of increased life expectancy of patients, this has led to an increase in the number of the device and lead complications. Consequently, there is a growing need to perform lead removal. Today, lead removal is a specialized procedure with well-defined indications. Indication for lead removal can be infection (infective endocarditis, pocket infection, pocket erosion, bacteremia), lead-related (fracture, insulation defect, dislocation-if the lead cannot be repositioned, dysfunction-for reasons other than lead fracture and insulation defect, CIED upgrade/ need for additional lead(s), perforation) and chronic pain due to a periosteal reaction1. Lead removal can be explantation (removal of leads with a dwell time of less than 1 year and using simple traction), extraction (removal of leads with a dwell time of more than 1 year or with the use of specialized equipment (locking stylets, snares, cutting tools, telescoping and laser sheats) regardless of implant time) and cardiothoracic surgical procedure. Patients and Methods: We retrospectively analyzed the characteristics, types of devices, and indications for lead removal in 70 patients at University Hospital Centre Zagreb between January 2014 and July 2019. Results: Average patient age was 67.6 years and most patients were male (74.3%). 78.6% of patients were on anticoagulation or antiplatelet therapy, and 50% had chronic renal failure or diabetes mellitus. Two most common indications for lead removal were lead dislocation (28 patients) and pocket infection/ erosion (20 patients). Average lead dwelling time was 27.4 months. 38 explantations, 30 extractions, and 2 surgical removals were performed. Total of 99 leads was removed, 1.28 per procedure. Conclusion: The procedure was successful in all patients. There was no recurrence of infection after infected device extraction. Besides 2 cases of pericardial effusion (which were not hemodynamically significant), no other major complication (cardiac tamponade, cardiac avulsion, SVC tear, death) were observed. LITE RATURE 1. Bongiorni MG, Burri H, Deharo JC, Starck C, Kennergren C, Saghy L, et al; ESC Scientific Document Group.2018 EHRA expert consensus statement on lead extraction: recommendations on definitions, endpoints, research trial design, and data collection requirements for clinical scientific studies and registries: endorsed by APHRS/HRS/LAHRS. Europace. 2018 Jul 1;20(7):1217. https://doi.org/10.1093/europace/euy050 Arrhythmias and Electrophysiology Extended Abstrac

Preporuke za perioperacijski postupak kod bolesnika koji imaju ugrađene kardiovaskularne implantabilne elektroničke uređaje

Four thousand cardiac implantable electronic devices (CIED) are implanted yearly in Croatia with constant increase. General anesthesia and surgery carry some specific risk for the patients with implanted CIEDs. Since most of the surgical procedures are performed in institutions without reprogramming devices available, or in the periods when they are unavailable, these guidelines aim to standardize the protocol for perioperative management of these patients. With this protocol, most of the procedures can be performed easily and, more importantly, safely in the majority of surgical patients.U Republici Hrvatskoj na godinu se implantira oko 4000 kardiovaskularnih implantabilnih uređaja i taj broj je u stalnom porastu. Anestezija i kirurški zahvati kod bolesnika s ugrađenim implantabilnim uređajima nose određene rizike. Ove smjernice su nastale zato što se većina zahvata izvodi u ustanovama bez mogućnosti testiranja i reprogramiranja navedenih uređaja ili u vrijeme kada to nije dostupno. Cilj je standardizirati perioperacijsku skrb ovih bolesnika te učiniti kirurške zahvate dostupnima i sigurnima za veliku većinu ovih kirurških bolesnika u svim ustanovama u Hrvatskoj

Gender differences in response to CRTD therapy in patients with valvular regurgitation

Introduction: Patients with symptomatic chronic heart failure (sCHF) and implanted cardiac resynchronization device (CRTD) were included in this retrospective study in order to evaluate possible differences in mitral (MR) and tricuspid (TR) valvular regurgitation severity, NYHA class and left ventricle ejection fraction (LVEF) between male and female CRTD patients during follow up of 6 months after CRTD implantation. Patients and Methods: We included 135 patients (89 men, 46 women) with sCHF due to any cause with implanted CRTD according to guidelines with optimal medical therapy regardless of atrial fibrillation or in sinus rhythm. Clinical (NYHA class) and echocardiographic data (valve pathology, LVEF) were assessed before and 6 months after CRTD implantation. Using color and continuous wave Doppler, PISA, regurgitation volume and vena contracta measurements, mitral regurgitation (MR) and tricuspid regurgitation (TR) were stratified in 3 grades. Echocardiography was recorded always by the same echo-technician to avoid inter-observer variability. Results: Mean age of patients was 60 (±10) years. The results showed improvement in LVEF from 25% up to 36% (p=0.006) in all patients regardless of sex and age, as well as worsening of TR (p<0.001) and no difference in MR (p=0.195). In male patients (N=89), significant worsening in MR and TR was present (p<0.05) while there was no significant worsening in MR (p=0.42) nor TR (p=0.06) in female patients (N=46). In patients older than 60 years (N=82, female 27 (33%), male 55 (67%)), as well as younger than 60 years (N=53; female 19 (36%), male 34 (64%)) significant worsening of TR grade was observed (p<0.05), while the grade of MR remained the same (p=0.255 and p=0.534). An improvement in NYHA class was observed in 75 patients (71%), no change in 25 patients (24%) and worsening in 5 patients (5%). Overall improvement in NYHA class was statistically significant (p<0.001). Conclusion: Six months after CRTD implantation the severity of MR and TR remained the same in female patients while significant worsening of MR and TR severity was found in male patients. TR worsening might be due to implanted electrodes. The age of patients had no impact on LVEF, TR and MR change. Despite improvement in clinical status and NYHA class, the echocardiography results did not meet our expectations.1-4 Due to limited number of patients the results were not divided according to the etiology of CHF

Primjena ručne metode intrakrdijalnih elektrograma odgovarajuća je zamjena ehokardiografskoj atrioventrikulskoj i inter-ventrikulskoj optimizaciji resinkronizacijskoga elektrostimulatora srca

Some manufacturers do not provide automated intracardiac electrogram method (IEGM) systems for atrioventricular (AV) and interventricular (VV) delay optimization in cardiac resynchronization therapy (CRT). We aimed to evaluate the accuracy of manual IEGM method in 48 patients previously implanted with Medtronic Syncra CRT. All patients underwent standard device interrogation followed by CRT optimization by IEGM method and by echocardiography one month after implantation. The patient mean age was 60.7±11.8 years and there were 33 (68.8%) males. After CRT implantation, the left ventricular ejection fraction increased from 28.0±7.9% to 39.1±11.0% (p<0.001). Optimal aortic flow Velocity Time Integral (aVTI) was obtained when VV was set to 20-50 ms left ventricular pre-activation. There was a strong correlation between VV values determined by echocardiography and IEGM (R=0.823, p<0.001). We found no significant difference in AV, VV and aVTI values between echocardiography and IEGM method. However, IEGM was significantly less time-consuming than echocardiography [20 (10-28) vs. 40 (35-60) minutes, p<0.001]. Manual IEGM method may be good alternative to echocardiography and automated IEGM method. It also emphasizes the need for implementation of automated IEGM systems in as many CRT devices as possible.Neki proizvođači nemaju automatski sustav intrakardijalnog elektrokardiograma (IEGM) za atrioventrikulsku (AV) i in-terventrikulsku (VV) optimizaciju u srčanoj resinkronizacijskoj terapiji (CRT). Cilj ovoga istraživanja bio je procijeniti točnost ručnog namještanja IEGM kod bolesnika s ugrađenom CRT. U istraživanje je bilo uključeno 48 bolesnika kojima je prethodno ugrađen Medtronic Syncra CRT. Jedan mjesec nakon ugradnje svim bolesnicima je učinjena standardna kontrola elektrostimulatora, nakon čega je učinjena optimizacija CRT, prvo metodom IEGM, a potom ultrazvučno. Srednja dob ­bolesnika bila je 60,7±11,8 godina; bila su 33 (68,8%) muškarca. Nakon ugradnje CRT, ejekcijska frakcija lijeve klijetke ­narasla je s 28,0±7,9% na 39,1±11,0% (p<0,001). Najveći integral brzine protoka nad aortnom valvulom (aVTI) dobiven je pri VV intervalu od 20-50 ms lijeve preekscitacije. Utvrđena je snažna korelacija između trajanja VV intervala dobivenog ultrazvučno i IEGM (R=0,823, p<0,001). Nismo našli statistički značajnu razliku između vrijednosti AV, VV i aVTI ­dobivenih ultrazvučno i metodom IEGM. Ipak, metoda IEGM zahtijeva bitno manje vremena od ultrazvučne metode [20 (10-28) prema 40 (35- 60) minuta, p<0,001]. Naše istraživanje pokazuje da ručna metoda IEGM može biti dobra alter-na­tiva ehokardiografskoj optimizaciji i automatskoj metodi IEGM. Također ukazuje na potrebu omogućavanja automatske IEGM optimizacije kod što više CRT uređaja

Recommendations for Perioperative Management of Patients with Cardiac Implantable Electronic Devices

Four thousand cardiac implantable electronic devices (CIED) are implanted yearly in Croatia with constant increase. General anesthesia and surgery carry some specific risk for the patients with implanted CIEDs. Since most of the surgical procedures are performed in institutions without reprogramming devices available, or in the periods when they are unavailable, these guidelines aim to standardize the protocol for perioperative management of these patients. With this protocol, most of the procedures can be performed easily and, more importantly, safely in the majority of surgical patients