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.

Leads dislodged into the pulmonary vascular bed in patients with cardiac implantable electronic devices

Introduction : Spontaneous lead dislodgement into the pulmonary circulation is a rare complication of permanent pacing with unproven harmfulness and an indication of controversial class for transvenous lead extraction (TLE). Aim: To assess TLE safety in patients with leads dislodged into the pulmonary artery. Material and methods: A retrospective analysis of a 9-year-old database of transvenous lead extraction procedures comprising 1767 TLEs was carried out, including a group of 19 (1.1%) patients with leads dislodged into the pulmonary artery (LDPA). Results: Under univariate analysis the factors that increased the likelihood of the presence of an electrode in the pulmonary artery were mean lead dwelling time (increase of risk by 9% per year), total number of leads in the heart before TLE (increase of risk by 66% for one lead) and the number of abandoned leads (increase of risk by 119%). The presence of LDPA was associated with frequent occurrence of intracardiac lead abrasion (increase by 316%) and isolated lead-related infective endocarditis (LRIE) (increase by 500%). There were no statistically significant differences in clinical (p = 0.3), procedural (p = 0.94) or radiological (p = 0.31) success rates in compared (LDPA and non-LDPA) groups. Long-term mortality after TLE was comparable in both groups. Conclusions : As the effectiveness and safety of TLE in patients with LDPA are comparable to those in standard TLE procedures, in our opinion, such patients should be considered TLE candidates

Analysis of Risk Factors for Major Complications of 1500 Transvenous Lead Extraction Procedures with Especial Attention to Tricuspid Valve Damage

Background: Transvenous lead extraction (TLE) is a relatively safe procedure, but it may cause severe complications such as cardiac/vascular wall tear (CVWT) and tricuspid valve damage (TVD). Methods: The risk factors for CVWT and TVD were examined based on an analysis of data of 1500 extraction procedures performed in two high-volume centers. Results: The total number of major complications was 33 (2.2%) and included 22 (1.5%) CVWT and 12 (0.8%) TVD (with one case of combined complication). Patients with hemorrhagic complications were younger, more often women, less often presenting low left ventricular ejection fraction (LVEF) and those who received their first cardiac implantable electronic device (CIED) earlier than the control group. A typical patient with CVWT was a pacemaker carrier, having more leads (including abandoned leads and excessive loops) with long implant duration and a history of multiple CIED-related procedures. The risk factors for TVD were similar to those for CVWT, but the patients were older and received their CIED about nine years earlier. Any form of tissue scar and technical problems were much more common in the two groups of patients with major complications. Conclusions: The risk factors for CVWT and TVD are similar, and the most important ones are related to long lead dwell time and its consequences for the heart (various forms of fibrotic scarring). The occurrence of procedural complications does not affect long-term survival in patients undergoing lead extraction

A Study of Major and Minor Complications of 1500 Transvenous Lead Extraction Procedures Performed with Optimal Safety at Two High-Volume Referral Centers

Background: Transvenous lead extraction (TLE) is the preferred management strategy for complications related to cardiac implantable electronic devices. TLE sometimes can cause serious complications. Methods: Outcomes of TLE procedures using non-powered mechanical sheaths were analyzed in 1500 patients (mean age 68.11 years; 39.86% females) admitted to two high-volume centers. Results: Complete procedural success was achieved in 96.13% of patients; clinical success in 98.93%, no periprocedural death occurred. Mean lead dwell time in the study population was 112.1 months. Minor complications developed in 115 (7.65%), major complications in 33 (2.20%) patients. The most frequent minor complications were tricuspid valve damage (TVD) (3.20%) and pericardial effusion that did not necessitate immediate intervention (1.33%). The most common major complication was cardiac laceration/vascular tear (1.40%) followed by an increase in TVD by two or three grades to grade 4 (0.80%). Conclusions: Despite the long implant duration (112.1 months) satisfying results without procedure-related death can be obtained using mechanical tools. Lead remnants or severe tricuspid regurgitation was the principal cause of lack of clinical and procedural success. Worsening TR(Tricuspid regurgitation) (due to its long-term consequences), but not cardiac/vascular wall damage; is still the biggest TLE-related problem; when non-powered mechanical sheaths are used as first-line tools