Lead extraction: The road to successful cardiac resynchronization therapy

Background: Still increasing life expectancy in patients with implanted devices and large number of leads more and more often induce the need to cure the treatment complications or to change especially to cardiac resynchronization therapy (CRT). In order to prevent further complications, the possibility of damaged or redundant leads extraction should be taken into consideration. The aim of the paper was to assess the effectiveness and safety of transvenous lead extraction (TLE) with co-implantation of resynchronization systems. Methods and results: Between 2008 and March 2013, the system removal with TLE was conducted in 246 patients. In 38 patients (11 women, 28.9%), aged 43–79 (mean 65 years), it was combined with co-implantation of CRT-pacemaker or defibrillator (CRT-P/D). Indica­tions for TLE covered: lead failure in 21 (55.3%) patients, redundant leads in 6 (15.8%), and the occluded venous system in 7 (18.4%). The up-grade of the pacemaker or defibrillator system to CRT-D was performed in 19 cases, CRT-P/D revision in next 19. Together 32 defibrillation leads and 42 pacing leads (27 left ventricular leads, and 1 epicardial lead) were implanted. The intended clinical target — an effective resynchronization therapy — was obtained in all patients. There was no case of death or severe complications. In 2 cases of venous occlusion, the implantation on the contralateral side was required. Conclusions: TLE enables effective resynchronization therapy also in the case of the presence of too many leads, occlusion of the venous system or lead failure. Significant technical problems can occur especially in patients with venous system occlusion

The effectiveness of transvenous leads extractions implanted more than 10 years before

Background: The increasing number of patients with cardiac implantable electronic devices (CIEDs) causes a rise in the absolute percentage of individuals qualifying for a transvenous lead extraction (TLE) due to infectious, vascular or lead failure related indications. As the survival time prolongs, TLE procedures more and more often concern the electrodes of long- -term functioning. Authors provide a retrospective analysis of the effectiveness and safety of TLE performed on leads implanted at least 10 years before the extraction. Methods: Between 2008 and 2012 we performed TLE of 364 electrodes in 217 patients. Out of these, 66 (18.1%) leads in 43 (19.8%) patients had been implanted for at least 10 years. The mean dwelling time for electrodes was 161 months (120 to 330). In 62% of cases CIED-related infection was an indication for TLE. The following extracting techniques were used: manual direct traction, device traction, mechanical telescopic sheaths, autorotational cutting sheaths and femoral approach. Results: Fifty-eight pacemakers and 8 defibrillating leads were extracted. Sixty-three (95%) completely, in the remaining 3 cases the clinical success was achieved with the small portion of the lead left into the vascular space. No major procedure complications were observed; minor complications were found in 3 (6%) patients. Conclusions: TLE with the use of various endovascular techniques is an effective and safe method for treating infectious, vascular and mechanical complications of long-lasting CIEDs therapy.

Occurrence and extraction of implantable cardioverter-defibrillator leads with conductor externalization

   Background: The increasing number of patients with implantable cardioverter-defibrillators (ICD) contributes to the rising number of patients qualifying for a transvenous lead extraction (TLE) due to infection, vascular or lead failure related indications. The purpose of this study was to perform a retrospective analysis of the occurrence of conductor externalization in TLE patients and to assess the success rate in the extraction of these leads. Methods: TLE procedure was performed between 2012 and 2014 of 428 electrodes in 259 patients. Out of these, 143 (33.4%) leads in 138 (52.9%) patients were ICD leads. The indications for the TLE in ICD patients were: infection in 37 patients, lead failure in 84 patients, and others in 17 patients. Conductor externalization was observed in 8 ICD leads (5.6%) in 8 (5.8%) patients. The mean dwell­ing time for externalized leads was 87.9 (55 to 132) months compared to 60.1 (3 to 246) months of the remaining 135 ICD leads (p = 0.0329). All externalized leads were successfully and completely extracted using device traction, mechanical telescopic sheaths and/or autorotational cutting sheaths. No complica­tions of lead extraction procedures were observed in 8 patients with externalization. Results: Patients with lead externalization were often in a better New York Heart Association func­tional class (I or II) compared to those in the rest of the study group (p = 0.0212). Conclusions: Conductor externalization is a rare finding in patients undergoing TLE. This occurs with different manufacturers and lead types. In this complication transvenous lead extraction with the mechanical extraction tools can be safely performed.

Clinical, echocardiographic, and pacing parameters affecting atrial fibrillation burden in patients with tachycardia-bradycardia syndrome

Background: The influence of various factors on atrial fibrillation (AF) development in the population of tachycardia-bradycardia syndrome (TBS) patients remains unclear. There are no data on the impact of different right ventricular pacing percentage (RVp%) profiles. Aim: The purpose of the study was to evaluate the relationship between the AF burden (AFB) and various clinical, echocardiographic, and pacing parameters in TBS patients. Methods: We performed a prospective, one-year registry of TBS patients with documented AF referred for dual-chamber pacemaker (DDD) implantation. Results: The data of 65 patients were analysed. The median 12-month RVp% and AFB was 9.4% and 1.0%, respectively. During the follow-up 14% of patients had no AF (p = 0.003), and the withdrawal of AF symptoms was observed in 49% of patients (p < 0.0001). The AFB was related to the left atrium diameter (r = 0.31, p = 0.02), especially in the subjects with left ventricular ejection fraction < 60% (r = 0.44, p = 0.04). Based on the relative change of RVp%, three groups of various RVp% profile were established: stable, decreasing, and increasing RVp%. In the stable RVp% group (n = 21) there was a quadratic correlation between the 12-month RVp% and AFB (r = 0.71, p = 0.0003). In the stable RVp% > 20% subgroup there was a significant increase of AFB in comparison to the RVp% ≤ 20% subgroup (ΔAFB 1.8% vs. 0.0%, p = 0.03, respectively). In the increasing RVp% group (n = 28) the AFB increased whereas in the decreasing RVp% (n = 16) it remained stable (ΔAFB 0.67% vs. 0.0%, p = 0.034, respectively). Conclusions: DDD implantation in TBS patients is related to a significant reduction in AF symptoms, and left atrial diameter correlates with cumulative AFB in the mid-term observation. Stable RVp% > 20% is associated with AF progression whereas lower stable RVp% may stabilise AF development. Increasing RVp% may be associated with the AFB increase in comparison to the decreasing RVp% subgroup in which AFB remains stable.Background: The influence of various factors on atrial fibrillation (AF) development in the population of tachycardia-bradycardia syndrome (TBS) patients remains unclear. There are no data on the impact of different right ventricular pacing percentage (RVp%) profiles. Aim: The purpose of the study was to evaluate the relationship between the AF burden (AFB) and various clinical, echocardiographic, and pacing parameters in TBS patients. Methods: We performed a prospective, one-year registry of TBS patients with documented AF referred for dual-chamber pacemaker (DDD) implantation. Results: The data of 65 patients were analysed. The median 12-month RVp% and AFB was 9.4% and 1.0%, respectively. During the follow-up 14% of patients had no AF (p = 0.003), and the withdrawal of AF symptoms was observed in 49% of patients (p < 0.0001). The AFB was related to the left atrium diameter (r = 0.31, p = 0.02), especially in the subjects with left ventricular ejection fraction < 60% (r = 0.44, p = 0.04). Based on the relative change of RVp%, three groups of various RVp% profile were established: stable, decreasing, and increasing RVp%. In the stable RVp% group (n = 21) there was a quadratic correlation between the 12-month RVp% and AFB (r = 0.71, p = 0.0003). In the stable RVp% > 20% subgroup there was a significant increase of AFB in comparison to the RVp% ≤ 20% subgroup (ΔAFB 1.8% vs. 0.0%, p = 0.03, respectively). In the increasing RVp% group (n = 28) the AFB increased whereas in the decreasing RVp% (n = 16) it remained stable (ΔAFB 0.67% vs. 0.0%, p = 0.034, respectively). Conclusions: DDD implantation in TBS patients is related to a significant reduction in AF symptoms, and left atrial diameter correlates with cumulative AFB in the mid-term observation. Stable RVp% > 20% is associated with AF progression whereas lower stable RVp% may stabilise AF development. Increasing RVp% may be associated with the AFB increase in comparison to the decreasing RVp% subgroup in which AFB remains stable

Subcutaneous implantable cardioverter-defibrillator therapy in Poland: Results of the Polish S-ICD Registry

Background: The use of a subcutaneous implantable cardioverter-defibrillator (S-ICD) has been expanding in Poland since 2014. The Polish Registry of S-ICD Implantations was held by the Heart Rhythm Section of the Polish Cardiac Society between May 2020 and September 2022 to monitor the implementation of that therapy in Poland. Aims: To investigate and present the state-of-the-art of S-ICD implantation in Poland. Methods: Implanting centers reported clinical data of patients undergoing S-ICD implantations and replacements, including: age, gender, height, weight, underlying disease, history of pacemaker and defibrillator implantations, indications for S-ICD, electrocardiographical parameters, procedural techniques, and complications. Results: 440 patients undergoing S-ICD implantation (411) or replacement (29) were reported by 16 centers. Most patients were in New York Heart Association class II (218 patients, 53%) or I (150 patients, 36.5%). Left ventricular ejection fraction was 10-80%, median (IQR) 33% (25%‒55%). Primary prevention indications were present in 273 patients (66.4%). Non-ischemic cardiomyopathy was reported in 194 patients (47.2%). The main reason for the choice of S-ICD were: young age (309, 75.2%), risk of infective complications (46, 11.2%), prior infective endocarditis (36, 8.8%), hemodialysis (23, 5.6%), and immunosuppressive therapy (7, 1.7%). Electrocardiographic screening was performed in 90% of patients. The rate of adverse events was low (1.7%). No surgical complications were observed. Conclusions: Qualification for S-ICD in Poland was slightly different when compared to the rest of Europe. The implantation technique was mostly consistent with the current guidelines. S-ICD implantation was safe, and the complication rate was low