2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14:e503-e551. [PMID: 28919379 DOI: 10.1016/j.hrthm.2017.09.001]

Computed Tomography-Guided Risk Assessment in Percutaneous Lead Extraction

OBJECTIVES

The aim of this study was to assess if pre-procedural computed tomography (CT) could identify high-risk operative features and predict increased procedural complexity.

BACKGROUND

Unpredictable lead adhesions can make lead extraction complicated. Adhesions are known to affect leads with longer indwelling time but can unpredictably affect newer leads.

METHODS

Consecutive patients who had CTs performed ≤90 days before their planned lead extraction (LE) were included. CTs were reviewed blinded to outcome according to a preset checklist. The outcome was a combined endpoint of procedural complexity and major complications.

RESULTS

Between January 1, 2015 and July 1, 2018, 143 patients underwent CT and LE. Median age was 68 years (interquartile range [IQR]: 54.4 to 76.5), and 35% were female. Median age of extracted leads was 111 months, and 126 (43%) were >10 years. CT detected lead perforation ≥5 mm (n = 13), <5 mm (n = 55), severe lead adhesions (n = 65), leads touching vessel wall >1 cm (n = 102), lead fracture (n = 8), and severe ipsilateral venous stenosis/occlusion (n = 36). The procedure was complex in 63 cases. There were 2 deaths, and 6 major complications. Patients with severe lead adhesions had more complex procedures (n = 36 vs 29; p = 0.04), whereas none of the other findings on CT were significantly associated with worse outcome. In patients with leads that had an indwelling time <10 years (n = 72), severe lead adhesions on CT was associated with worse outcome in multivariable analysis (odds ratio: 6.4; 95% confidence interval: 1.4 to 30.2; p = 0.02).

CONCLUSIONS

Pre-procedural CT can be used to locate severe lead adhesions in patients planned for lead extraction. In patients with indwelling leads <10 years, pre-procedural CT aids in identifying patients prone to complex extractions.

Cardiac magnetic resonance imaging in a patient with temporary external pacemaker: a case report

Background 

Magnetic resonance imaging (MRI) is increasingly becoming the imaging modality of choice for many clinical disorders due to superior image quality and absence of radiation. However, access to MRI remains limited for most patients with cardiac implantable electronic devices due to potential safety concerns. In line with guidelines, there is no absolute contraindication to perform MRI, but warrants careful risk-benefit assessment.

Case summary 

A 59-year-old man was admitted with a 5-day history of central chest pain and few week’s history of general malaise, dry cough, and breathlessness. Electrocardiogram confirmed complete atrioventricular block (CAVB). A slight increase in cardiac enzyme was noted. Coronary angiogram revealed atheromatous changes, but no obstructive coronary lesion. A temporary transvenous pacemaker was inserted. Transthoracic echocardiogram confirmed a dilated left ventricle with severely reduced left ventricular function. To facilitate diagnosis (hence prognosis), management and mobilization, investigation with cardiovascular magnetic resonance (CMR) was warranted but contraindicated by the temporary transvenous pacemaker. An active fixation pacemaker lead was therefore placed in the right ventricle via percutaneous puncture of the right subclavian vein and connected to a pulse generator, both secured to the skin with sutures and adhesive medical dressing. Appropriate device programming and close patient monitoring ensured that CMR could be performed without any adverse effects. A diagnosis of acute myocarditis was confirmed. Regular device interrogation during an extended 3-week period with temporary pacing ruled out any device failure. As there was no resolution of CAVB, the patient received a dual-chamber pacemaker.

Discussion 

Cardiovascular magnetic resonance was feasible and safely performed on a patient with a temporary permanent external pacemaker system using a standard screw-in pacing lead and a regular pulse generator fixed to the skin. Although more studies are needed for generalizability, CMR may be used in highly selected patients with a temporary pacemaker.

Transfemoral extraction of pacemaker and implantable cardioverter defibrillator leads using Needle's Eye Snare: a single-center experience of more than 900 leads

The femoral approach with the Needle's Eye Snare (NES) is often used for bailout after failure of the superior approach for transvenous lead extraction (TLE). The safety and efficacy of the NES as a first-line tool for TLE remain unclear. The medical records of patients who underwent TLE via the femoral approach utilizing the NES from May 2014 to June 2019 in Peking University People's Hospital were retrospectively reviewed. Nine hundred and eighty-five leads were extracted in 492 patients (369 men; mean age 72.8 ± 29.0 years). The median (range) number of leads extracted per patient was 2 (1-6). The mean indwelling time of all extracted leads was 112.6 ± 52.0 months. The complete procedure success rate, clinical success rate, and failure rate were 94.1% (463/492), 97.8% (481/492), and 1.1% (11/492), respectively. Major complications including death occurred in nine patients (1.9%), of whom eight developed cardiac tamponade. Among these eight patients, emergency pericardiocentesis followed by rescue surgical repair if necessary was successful in 6 (75.0%) and failed in 2 (25.0%). No significant differences were found in the clinical success rate or major complications rate between patients with pacemakers and implantable cardioverter defibrillators, or between patients with infected and uninfected leads. A femoral approach with the NES is safe and effective for TLE of both pacing and defibrillator leads and could be considered a first-line approach. Cardiac tamponade was the most frequent cardiovascular complication. A strategy of emergency pericardiocentesis followed by a rescue surgical approach seems to be reasonable technique to treat a cardiac tamponade.

Thrombocytopenia and end stage renal disease are key predictors of survival in patients with cardiac implantable electronic device infections

INTRODUCTION

Cardiac implantable electronic device (CIED) infections are associated with a high mortality. Our aim was to identify key predictors of survival in patients with CIED infections as to be able to detect high-risk patients and possibly affect modifiable factors.

METHODS AND RESULTS

In this observational study, we collected data from 277 patients with CIED infections treated in our department between 2001 and 2017; predictors of survival were evaluated. The median time since the last CIED procedure was 0.83 years (interquartile range [IQR]: 0.25-3.01), median time since initial CIED implant was 4.79 years (IQR: 0.90-11.0 years). Survival at 30 days was 94.9% (95% confidence interval [CI]: 92.3-97.5) and survival at 1 year was 80.9% (CI: 76.4-85.7). Age (odds ratio [OR]: 1.05, CI: 1.01-1.09; P = .009), end stage renal disease (ESRD) with dialysis (OR: 5.14, CI: 1.87-14.11; P = .001), positive blood cultures (OR: 2.19, CI: 1.08-4.45; P = .030), and thrombocytopenia (OR: 2.3, CI, 1.03-5.15; P = .042) were identified as predictors of death within 1 year of treatment of CIED infection.

CONCLUSION

Patients with CIED infection with prior ESRD with dialysis or preoperative thrombocytopenia are at an increased risk of 1-year mortality. We suggest that these patients be evaluated critically and resources be allocated to these patients more liberally. A greater understanding of the role of platelets in immunity may improve treatment of advanced infection in the future.

Safety and effectiveness of coronary sinus leads extraction - single high-volume centre experience

Introduction

Transvenous leads extraction (TLE) of permanently implanted coronary sinus (CS) leads is widely believed to present greater risks than the removal of other leads.

Aim

To assess the safety and efficacy of CS leads extraction based on large research material obtained by one operator performing procedures in two TLE centres.

Material and methods

We extracted 408 CS leads from 389 patients, and the results were compared to a control group of 2465 patients who underwent non-CS lead TLE procedures.

Results

There were no significant differences in the clinical success rate (97.9% vs. 98.0%) or the major complication rate (2.1% vs. 1.8%) between the CS and control group. CS lead destination (LV/LA pacing) and tip location (CS ostium/mid CS /CS tributaries) influenced the procedural and radiological success rates and procedural complexity but not the complications. CS lead extraction did not affect the necessity for a cardiosurgical intervention or presence of procedure-related death.

Conclusions

TLE of CS leads can be achieved with a high procedural success rate. The major complication rate is not higher than that seen in non-CS lead extraction patients. More than half of CS leads cannot be removed by simple traction and the use of mechanical sheaths may be necessary. The detachment of CS leads from connective tissue scars in the venous and atrial areas up to the CS ostium is generally sufficient for further removal of the lead using simple traction.

The Diagnosis and Treatment of Pacemaker-Associated Infection

BACKGROUND

Approximately 105 000 cardiac electronic devices are newly implanted in Germany each year. Germany has the highest implantation rate with respect to population of any European country. Infections in cardiac implants are serious complications, with an associated in-hospital mortality of 5-15%. It is thus very important to optimize the diagnostic and therapeutic strategies by which such infections can be detected early and treated effectively.

METHODS

This review is based on pertinent publications retrieved by a search in PubMed, with special attention to the current recommendations of international medical specialty societies.

RESULTS

According to the international literature, the incidence of device-associated infection is 1.7% (in six months) for implanted defibrillators and 9.5% (in two years) for resynchronization devices. No absolute figures on infection rates are available for Germany. Infection can involve either the site where the impulse generator is implanted or the intravascular portion of the electrodes. The most important elements of the diagnostic evaluation are: assessment of the local findings; pathogen identification by culture of peripheral blood, swabs of the infected site, or material recovered at surgery; and transesophageal echocardiography to detect endocarditic deposits on the electrodes or cardiac valves. The treatment consists of appropriate antibiotic administration and the complete removal of all foreign material. These special extractions are generally performed via the transvenous route. With the aid of various sheath systems, the procedure can be carried out safely and effectively, with a success rate above 95% and a complication rate below 3%. The indications for the implantation of a new device after eradication of the infection should be critically reassessed.

CONCLUSION

Untreated infection carries a high mortality. Evaluation and treatment according to a standardized clinical algorithm facilitate correct and timely diagnosis and the choice of an appropriate therapeutic strategy.

Lead-Related Infective Endocarditis in Latvia: A Single Centre Experience

Background and Objectives: Over the last five decades cardiac implantable electronic devices (CIED) have become established as the mainstay for the treatment of permanent bradycardias, chronic heart failure and dangerous heart rhythm disturbances. These devices improve survival and quality of life in many patients. However, infections associated with CIED implantation, particularly lead-related infective endocarditis (LRIE), can offset all benefits and make more harm than good for the patient. To date, there are no other studies in Latvia, addressing patients with lead-related infective endocarditis. The objective of this study was to identify the most common pathogens associated with LRIE and their antimicrobial resistance and to identify possible risk factors of patients who present with LRIE. Materials and Methods: The study was performed retrospectively at Pauls Stradins Clinical University Hospital (PSCUH). The study included patients who were referred to PSCUH due to LRIE for lead extraction. Patients were identified from procedural journals. Information about isolated microorganisms, patient comorbidities and visual diagnostics data was taken from patient records. Results: Forty-nine patients with CIED related infective endocarditis were included in the study, 34 (69.4%) were male, median age of all patients was 65.0 (50.5-73.0) years, median hospital stay was 15.5 (22.0-30.5) days. Successful and complete lead extraction was achieved in all patients. Thirty-two (65.3%) had received antibiotics prior to blood sample. Only in 31 (63.3%) positive culture results were seen. The most common isolated pathogens were Staphylococcus aureus (23.5%) and coagulase negative staphylococci (23.5%). Other bacteria were isolated considerably less often. The atrial lead was most common location for lead vegetations, seen in 50.0% of cases. Five (10.2%) patients have died due to the disease. Conclusions: Lead-related infective endocarditis is a major complication of cardiac implantable electronic devices with considerable morbidity and mortality, which in our study was as high as 10.2%.

Timing of device reimplantation and reinfection rates following cardiac implantable electronic device infection: a systematic review and meta-analysis

OBJECTIVES

Initial management of cardiac implantable electronic device (CIED) infection requires removal of the infected CIED system and treatment with systemic antibiotics. However, the optimal timing to device reimplantation is unknown. The aim of this study was to quantify the incidence of reinfection after initial management of CIED infection, and to assess the effect of timing to reimplantation on reinfection rates.

DESIGN

Systematic review and meta-analysis.

INTERVENTIONS

A systematic review and meta-analysis was performed of studies published up to February 2018. Inclusion criteria were: (a) documented CIED infection, (b) studies that reported the timing to device reimplantation and (c) studies that reported the proportion of participants with device reinfection. A meta-analysis of proportions using a random effects model was performed to estimate the pooled device reinfection rate.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the rate of CIED reinfection. The secondary outcome was all-cause mortality.

RESULTS

Of the 280 screened studies, 8 met inclusion criteria with an average of 96 participants per study (range 15-220 participants). The pooled incidence rate of device reinfection was 0.45% (95% CI, 0.02% to 1.23%) per person year. A longer time to device reimplantation >72 hours was associated with a trend towards higher rates of reinfection (unadjusted incident rate ratio 4.8; 95% CI 0.9 to 24.3, p=0.06); however, the meta-regression analysis was unable to adjust for important clinical covariates. There did not appear to be a difference in reinfection rates when time to reimplantation was stratified at 1 week. Heterogeneity was moderate (I²=61%).

CONCLUSIONS

The incident rate of reinfection following initial management of CIED infection is not insignificant. Time to reimplantation may affect subsequent rates of device reinfection. Our findings are considered exploratory and significant heterogeneity limits interpretation.

PROSERO REGISTRATION NUMBER

CRD4201810960.

Lead extraction for cardiac implantable electronic device infection: comparable complication rates with or without abandoned leads

AIMS

Abandoned leads are often linked to complications during lead extraction, prompting pre-emptive extraction if leads become non-functional. We examined their influence on complications when extracted for device-related infection.

METHODS AND RESULTS

All patients undergoing lead extraction for device-related infection from 2006 to 2017 in our hospital were included. The primary endpoint was major complications. Out of 500 patients, 141 had abandoned leads, of whom 75% had only one abandoned lead. Median cumulative implant times were 24.2 (interquartile range 15.6-38.2) and 11.6 (5.6-17.4), respectively years with or without abandoned leads. All leads were extracted only with a femoral approach in 50.4% of patients. Mechanical rotational tools were introduced in 2014 and used in 22.2% of cases and replacing laser sheaths that were used in 5% of patients. Major complications occurred in 0.7% of patients with abandoned leads compared with 1.7% of patients with only active leads (P = 0.679). Failure to completely remove all leads was 14.9% and 6.4%, respectively with or without abandoned leads (P = 0.003), and clinical failure was 6.4% and 2.2% (P = 0.028), respectively. Procedural failure dropped to 9.2% and 5.7% (P = 0.37), respectively after the introduction of mechanical rotational tools. The only independent predictor of procedural and clinical failure in multivariate analysis was the cumulative implant duration.

CONCLUSION

Despite longer implant times, patients with abandoned leads did not have more major complications during lead extraction. Therefore, preventive extraction of non-functional leads to avoid complications at a later stage is not warranted.

Effect of Prior Sternotomy on Outcomes in Transvenous Lead Extraction

Background:

A history of open-heart surgery has been a heavily debated topic in transvenous lead extraction. This study evaluates the impact of prior sternotomy on transvenous lead extraction outcomes.

Methods:

Data for all patients undergoing transvenous lead extraction at a tertiary referral center were prospectively gathered from 2004 to 2017. Relevant clinical information was compared between patients with a history of sternotomy before transvenous lead extraction and those without. After considering baseline differences, multivariate regression, and propensity-matched analysis were performed. Outcome variables included major and minor complication rates, clinical success, and in-hospital mortality as defined by the 2017 Heart Rhythm Society consensus statement.

Results:

Of 1480 patients in the study period, 455 had a prior sternotomy. When compared with patients with no prior sternotomy, those with prior sternotomy were more likely to be older, male, and present with more comorbidities and leads targeted for extraction. No statistical differences were identified in major and minor complication rates ( P =0.75, P =0.41), clinical success rate ( P =0.26), and in-hospital mortality ( P =0.08). In patients with prior sternotomy, there were no instances of pericardial effusion after extraction. Prior sternotomy was not an independent predictor of clinical or procedural outcomes. No associations were elucidated after propensity-matched analysis.

Conclusions:

In a large, single-center series, no differences in clinical or procedural outcomes were elucidated between patients with a history of sternotomy and those without. Patients with sternotomies before lead extraction who experienced vascular or cardiac perforations clinically presented with hemothoraces rather than pericardial effusions.

Bradyarrhythmias for the Internist

In this article, the authors review the different types of sinus node and atrioventricular node diseases that lead to bradyarrhythmias with their associated symptoms, the diagnostic investigations needed to assess the degree of disease, and the therapeutic management, including the indications for permanent pacing.

Cardiac resynchronization therapy coronary venous left ventricular lead removal and reimplantation: Experience from a single center in China

The present study aimed to investigate the success rate, methods and associated complications of left ventricular lead (LVL) extraction and venous pathway reimplantation in patients with cardiac resynchronization therapy device/defibrillator (CRT/CRTD). A retrospective analysis was performed in the patients who underwent CRT/CRTD extraction and reimplantation at our hospital from January 2012 to October 2018. The methods, patient complications and success rate of extraction and reimplantation of LVL were analyzed. A total of 54 patients underwent CRT/CRTD removal (pacemaker infection, n=51; LVL dysfunction, n=3; CRT/CRTD, 34/20). A total of 54 LVLs were removed (3 active electrodes and 51 passive electrodes). The average implantation duration of the LVL was 53.5 months (range, 1-204 months), whereas the success rate of the LVL extraction was 100% (94% completely removed and 6% clinically removed. A total of 6 patients (11%) were treated only by manual traction, whereas the remaining patients had their LVL successfully removed using extraction tools. In the peri-operative period, one fatality occurred (2%). The highest complication rate of the lead extraction was 2% and no minor complications were observed. A total of 36 patients were reimplanted on the right side, which was successful in 31 cases (success rate, 86.1%), whereas 3 cases were successfully reimplanted on the left side. The total success rate of LVL reimplantation was 87.2%. The procedure of the LVL removal and reimplantation exhibited a high success rate and a lower incidence of complications compared with that in patients with cardiac devices.

Trends of Cardiovascular Implantable Electronic Device Infection in 3 Decades: A Population-Based Study

OBJECTIVES

This study assessed trends in the incidence of cardiovascular implantable electronic device (CIED) infection in the last 3 decades using a population-based records linkage study.

BACKGROUND

Infection remains an important issue associated with increased implantation rate and dwell time of CIEDs.

METHODS

We identified a cohort of all adults with CIEDs who resided in Olmsted County, Minnesota, from 1988 to 2015, using the medical linkage system of the Rochester Epidemiology Project. Standardized criteria were used to identify all CIED infection cases. The cumulative rate of CIED infection was estimated using the Kaplan-Meier method, and the trends of CIED infection incidence were calculated with person-years of follow-up after device implantation.

RESULTS

The cumulative probabilities of overall CIED infection were 6.2% (95% confidence interval [CI]: 4.0% to 8.4%) at 15 years and 11.7% (95% CI: 6.8% to 17.3%) at 25 years of follow-up. The incidence of CIED infection every 7 years from 1988 to 2015 was 1.3, 5.7, 4.1, and 4.7 per 1,000-person years, respectively. The 15-year cumulative probabilities of CIED infection after the initial, second, and third procedures were 2.6% (95% CI: 1.4% to 3.8%), 2.7% (95% CI: 1.2% to 4.2%), and 24.1% (95% CI: 3.8% to 44.4%), respectively. Generator changes (hazard ratio [HR]: 3.91; 95% CI: 1.47 to 10.37; p = 0.006) and upgrades (HR: 3.08; 95% CI: 1.24 to 7.62; p = 0.02) were significantly associated with infection.

CONCLUSIONS

The incidence of CIED infection had a trend of increasing in the past 2 decades. Contemporary implantable cardioverter-defibrillator and cardiac resynchronization therapies and repeated manipulation of device pockets introduced a greater risk of CIED infection.

Lead Removal Without Extraction Tools: A Single-Center Experience

Introduction

Indications for cardiac devices have been increasing as well as the need for lead extractions as a result of infections, failed leads and device recalls. Powered laser sheaths, with a global trend towards the in-creasingly technological tools, meant to improve the procedure’s outcome but have economic implications.

Objective

The aim of this study is to demonstrate the experience of a Bra-zilian center that uses simple manual traction in most lead removals per-formed annually, questioning the real need for expensive and technically challenging new devices.

Methods

This retrospective observational study included 35 patients who had a transvenous lead extraction in the period of a year between January 1998 and October 2014 at Hospital de Messejana Dr. Carlos Alberto Studart Gomes, in Fortaleza, CE, Brazil. Data were collected through a records review. They were evaluated based on age, type of device, dwelling time, indication for removal, technique used and immediate outcomes.

Results

The median dwelling time of the devices was 46.22 months. Infec-tion, lead fracture and device malfunction were the most common indica-tions. Simple traction was the method of choice, used in 88.9% of the pro-cedures. Manual traction presented high success rates, resulting in com-plete removal without complications in 90% of the cases.

Conclusion

This article suggests that lead extraction by simple manual traction can still be performed effectively in countries with economic diffi-culties as a first attempt, leaving auxiliary tools for a second attempt in case of failure or contraindications to the simple manual traction technique.

Fever and neck pain after pacemaker lead extraction: A case report

BACKGROUND

Venous thrombosis (VT) is one of the minor complications of pacemaker lead extraction. It is often found due to the swelling of the limbs after the extraction. It is easy to be neglected or even misdiagnosed in the absence of typical clinical symptoms. The incidence, risk factors, and long-term impact of this complication are still unclear. Herein, we report a case of deep VT caused by transvenous lead extraction, which is easily misdiagnosed.

CASE SUMMARY

A 66-year-old woman underwent a pacemaker lead extraction at our hospital because of a pacemaker pocket infection. After the extraction, she began to experience intermittent fever accompanied by sweating. The highest body temperature recorded was 37.9 °C. Additionally, she reported migratory pain that made her uncomfortable. The pain was mistakenly thought to be caused by operation trauma. At first, the pain radiated from the left chest to the mandible. Then, the pain in the left chest was alleviated, but pain in the left neck and throat appeared. Finally, the pain was confined to the mandible and a submandibular mass was palpated with no other abnormalities upon physical examination. Computed tomography venography and angiography finally indicated that the fever and pain were the symptoms of thrombophlebitis caused by lead extraction. The patient was then treated with rivaroxaban for more than three months and has shown no symptoms since she left the hospital.

CONCLUSION

The possibility of thrombosis should be considered when pain and recurrent fever occur after pacemaker lead extraction.

Endovascular Occlusion Balloon for Treatment of Superior Vena Cava Tears During Transvenous Lead Extraction

Background:

Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon.

Methods:

We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration–maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality.

Results:

From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used ( P =0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04–0.40; P <0.001).

Conclusions:

From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.

Clinical practice and implementation of guidelines for the prevention, diagnosis and management of cardiac implantable electronic device infections: results of a worldwide survey under the auspices of the European Heart Rhythm Association

AIMS

Cardiac implantable electronic device (CIED) infection rates are increasing. Worldwide compliance and disparities to published guidelines for the prevention, diagnosis and management of these conditions are not well elucidated. The purpose of this survey, therefore, was to clarify these issues through an inquiry to arrhythmia-related associations and societies worldwide.

METHODS AND RESULTS

A questionnaire comprising 15 questions related to CIED infections was distributed among members of seven arrhythmia societies worldwide. A total of 234 centres in 62 countries reported implantation rates of which 159 (68.0%) performed more than 200 device implantations per year and 14 (6.0%) performed fewer than 50 implantations per year. The reported rates of CIED infections for 2017 were ≤2% in 78.7% of the centres, while the infection rates exceeded 5% in 7.8% of the centres. Preventive measures for CIED infection differed from published recommendations and varied among different regions mainly in terms of pocket irrigation and administering post-operative antimicrobial therapy the use of which was reported by 39.9% and 44% of the respondents, respectively. Antibacterial envelopes were used by 37.7% of the respondents in selected circumstances. In terms of pocket infection management, 62% of the respondents applied complete system removal as an initial step. Diagnostic pocket needle aspiration and pocket surgical debridement were reported by 15.8% and 11.8% of centres, respectively.

CONCLUSION

Clinical practices for prevention and management of CIED do not fully comply with current recommendations and demonstrate considerable regional disparities. Further education and programmes for improved implementation of guidelines are mandatory.

Successful percutaneous femoral extraction of a detached tricuspid valve-in-valve balloon delivery system

We shall discuss a patient who underwent a tricuspid valve-in-valve implantation for a failing bioprosthetic valve replacement. The procedure was complicated by detachment of the valve deployment apparatus which was removed in its entirety, using percutaneous extraction techniques. We believe this was the first ever case to report such a complication.

Femoral extraction of transvenous leads and leadless pacemakers-A review of the data, tools, and procedural steps

Extraction of transvenous leads via the femoral route might be needed when extraction via the implant vein fails or when retained lead fragments exist. The skill set required for this procedure is unique as it relies on the ability to snare and the use of a variety of shelf tools. In this era of leadless pacing, this skill set might be called upon more frequently. In this article, we review the data, tools, and procedural steps of femoral lead extraction and retrieval/extraction of leadless pacemakers.

Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity

Cephalosporins are among the most commonly prescribed antibiotic classes due to their wide clinical utility and general tolerability, with approximately 1-3% of the population reporting a cephalosporin allergy. However, clinicians may avoid the use of cephalosporins in patients with reported penicillin allergies despite the low potential for cross-reactivity. The misdiagnosis of β-lactam allergies and misunderstanding of cross-reactivity among β-lactams, including within the cephalosporin class, often leads to use of broader spectrum antibiotics with poor safety and efficacy profiles and represents a serious obstacle for antimicrobial stewardship. Risk factors for cephalosporin allergies are broad and include female sex, advanced age, and a history of another antibiotic or penicillin allergy; however, cephalosporins are readily tolerated even among individuals with true immediate-type allergies to penicillins. Cephalosporin cross-reactivity potential is related to the structural R1 side chain, and clinicians should be cognizant of R1 side chain similarities when prescribing alternate β-lactams in allergic individuals or when new cephalosporins are brought to market. Clinicians should consider the low likelihood of true cephalosporin allergy when clinically indicated. The purpose of this review is to provide an overview of the role of cephalosporins in clinical practice, and to highlight the incidence of, risk factors for, and cross-reactivity of cephalosporins with other antibiotics.

Effectiveness and safety of transvenous extraction of single- versus dual-coil implantable cardioverter-defibrillator leads at single-center experience

The available literature lacks data concerning direct comparison of the effectiveness and safety of single- versus dual-coil implantable cardioverter-defibrillator (ICD) leads transvenous extraction. Certainly, additional shocking coil in superior vena cava adds to the amount of metal in the vascular system. Adhesions developing around the superior vena cava coil add to the difficulty of extraction of ICD lead if lead removal is required. The aim of the study was to assess the effectiveness and safety of single- and dual-coil ICD leads transvenous extraction using mechanical systems. We performed transvenous lead extraction (TLE) of 197 ICD leads in 196 patients. There were 46 (23.3%) dual-coil leads removed from 46 (23.5%) patients. Cardiovascular implantable electronic device-related infection was an indication for TLE in 25.0% of patients. The following extracting techniques were used: manual direct traction, mechanical telescopic sheaths, controlled-rotation mechanical sheaths, and femoral approach. Complete ICD lead removal and complete procedural success in both groups were similar (99.3% in single-coil vs 97.8% in dual-coil, P = .41 and 99.3% in single-coil vs 97.8% in dual-coil, P = 0.41, respectively). We did not find significant difference between major and minor complication rates in both groups (2.0% in single-coil vs 4.3% in dual-coil, and 0.7% in single-coil vs 0.0% in dual-coil, P = .58, respectively). There was 1 death associated with the TLE procedure of single-coil lead.This study shows that extraction of dual-coil leads seems to be comparably safe and effective to extraction of single-coil leads. On the other hand, it requires longer fluoroscopy time and frequent utilization of advanced tools.

EHRA White Paper: knowledge gaps in arrhythmia management-status 2019

Clinicians accept that there are many unknowns when we make diagnostic and therapeutic decisions. Acceptance of uncertainty is essential for the pursuit of the profession: bedside decisions must often be made on the basis of incomplete evidence. Over the years, physicians sometimes even do not realize anymore which the fundamental gaps in our knowledge are. As clinical scientists, however, we have to halt and consider what we do not know yet, and how we can move forward addressing those unknowns. The European Heart Rhythm Association (EHRA) believes that scanning the field of arrhythmia / cardiac electrophysiology to identify knowledge gaps which are not yet the subject of organized research, should be undertaken on a regular basis. Such a review (White Paper) should concentrate on research which is feasible, realistic, and clinically relevant, and should not deal with futuristic aspirations. It fits with the EHRA mission that these White Papers should be shared on a global basis in order to foster collaborative and needed research which will ultimately lead to better care for our patients. The present EHRA White Paper summarizes knowledge gaps in the management of atrial fibrillation, ventricular tachycardia/sudden death and heart failure.

Prognosis after lead extraction in patients with cardiac implantable electronic devices infection: Comparison of lead-related infective endocarditis with pocket infection in a Japanese single-center experience

Background

The increase in the use of cardiac implantable electronic devices (CIEDs) has been associated with an increase in CIED-related infections. Transvenous lead extraction is safe and effective for patients with CIED-related infections; however, the mortality rate in these patients is high. The prognosis after transvenous lead extraction in Japanese patients, especially those with lead-related infective endocarditis, has not been evaluated. Then, the purpose of this study is to clarify the prognosis after transvenous lead extraction in Japanese patients with CIED-related infections at a single Japanese center.

Methods

A total of 107 patients who underwent transvenous lead extraction were retrospectively reviewed. The patients were divided into a lead-related infective endocarditis group (n = 32) and a pocket infection group (n = 75). Procedure success rate and prognosis after lead extraction were evaluated between the two groups.

Results

Procedure success rate was not significantly different between the groups. There were no deaths associated with the procedure or with infection. The survival rate was not significantly different at 1 year or at a median of 816 days (lead-related infective endocarditis vs pocket infection; 93.7% vs 94.7%, P = 1.000; 78.1% vs 81.3%, P = 0.791) Time to reimplantation and duration of hospital stay and antibiotics therapy were significantly longer for patients with lead-related infective endocarditis.

Conclusion

In this study, the prognosis for patients with lead-related infective endocarditis after transvenous lead extraction was favorable. Thus, extraction should be strongly recommended, even if the general condition of the patient is poor.

Transvenous Lead Extraction in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy

OBJECTIVES

This study aimed to evaluate the effectiveness and safety of transvenous lead extraction (TLE) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC).

BACKGROUND

ARVC is an increasingly diagnosed cardiomyopathy that often requires device implantation to prevent sudden death. Little is known about TLE in this setting, which has potential challenges and risks, primarily due to right ventricular (RV) wall thinning and fragility.

METHODS

All consecutive patients with ARVC who underwent TLE at our institution between 1996 and 2016 were included. When extraction tools were used, sheaths were advanced to the RV with countertraction at the lead tip. Success and complications were defined in concordance with Heart Rhythm Society guidelines.

RESULTS

Twenty-two TLE procedures in patients with ARVC involved extraction of 27 leads (22 defibrillators and 5 pacemakers). TLEs were performed due to evidence of lead malfunction (n = 17; 77%) or device infection (n = 5; 23%). Twenty-four leads (89%) were RV, and 3 leads (11%) were right atrial. The median age of the oldest extracted lead was 1,691 days (interquartile range [IQR]: 1,168 to 2,726 days). Specialized extraction tools were required in 20 procedures (91%). None required the use of a snare or a femoral workstation. The median procedural and fluoroscopic times were 152 min (IQR: 129 to 185 min) and 11 min (IQR: 6 to 18 min), respectively. Complete procedural success with removal of all leads was achieved in all cases. There were no major complications.

CONCLUSIONS

In a high-volume center, TLE in patients with ARVC was associated with a high success rate and a low rate of complications when guideline-established techniques and tools were used.

Effect of fibrotic capsule debridement during generator replacement on cardiac implantable electronic device infection risk

BACKGROUND

Cardiovascular implantable electronic device (CIED) replacement is increasingly common. It has been proposed that capsule removal at the time of CIED replacement may reduce infection rates. In this study, we aimed to assess how pocket capsule removal impacted infection rates in patients undergoing CIED replacement.

METHODS

We retrospectively reviewed the medical records of patients who underwent CIED replacement from 2006 to 2016 at a single centre. We retrieved patient data, procedure details, and clinical outcomes. To evaluate the relationship between capsule removal and CIED infection, we used the Cox proportional hazard model, with adjustment for multiple variables.

RESULTS

During the study period, 773 patients underwent device replacement. Of these patients, 194 (25%) underwent capsule debridement during the replacement procedure. The mean patient age was 75 ± 15 years, and 281 (36.3%) were females. The replaced CIEDs included DDD pacemakers (32%), VDD pacemakers (15%), VVI/AAI pacemakers (13%), defibrillators (22%), and cardiac resynchronization therapy devices (CRT-D/P) (17%). During an average follow-up of 3.6 years, 42 (5%) patients experienced a CIED infection. Multivariate analysis revealed that patients who underwent capsule removal had a significantly lower risk of CIED infection, with a hazard ratio of 0.32 (95% confidence interval, 0.12-0.83; P = 0.019).

CONCLUSIONS

Capsule debridement during CIED replacement was associated with a significant reduction of CIED infection risk. There is a need for randomized controlled studies to confirm these findings.

The role of transvenous lead extraction in the management of redundant or malfunctioning pacemaker and defibrillator leads post ELECTRa

Cardiac implantable electronic devices implantation rates have increased over the past decade due to broader indications and an ageing population. Similarly, device and lead complications have also risen. The management of pacemaker/defibrillator leads that are no longer required (redundant) or malfunctioning, can be contentious. There is a need to balance the risk of transvenous lead extraction (TLE) against those of lead abandonment. The recently published European Lead Extraction ConTRolled Registry (ELECTRa) study provides contemporary outcomes for TLE across Europe with important implications for the management of redundant and/or malfunctioning leads. This review article discusses the potential complications for each interventional approach when managing redundant or malfunctioning pacemaker leads.

Methicillin-resistant Staphylococcus aureus in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice review the epidemiology, diagnosis, prevention, and management of methicillin-resistant Staphylococcus aureus (MRSA) infections in solid organ transplantation. Despite an increasing armamentarium of antimicrobials active against MRSA, improved diagnostic tools, and overall declining rates of infection, MRSA infections remain a substantial cause of morbidity and mortality in solid organ transplant recipients. Pre- and post-transplant MRSA colonization is a significant risk factor for post-transplant MRSA infection. The preferred initial treatment of MRSA bacteremia remains vancomycin. Hand hygiene, chlorhexidine bathing in the ICU, central-line bundles that focus on reducing unnecessary catheter use, disinfection of patient equipment, and the environment along with antimicrobial stewardship are all aspects of an infection prevention approach to prevent MRSA transmission and decrease healthcare-associated infections.

Micra pacemaker implant after cardiac implantable electronic device extraction: feasibility and long-term outcomes

Aims

We aimed at investigating the feasibility and outcome of Micra implant in patients who have previously undergone transvenous lead extraction (TLE), in comparison to naïve patients implanted with the same device.

Methods and results

Eighty-three patients (65 males, 78.31%; 77.27 ± 9.96 years) underwent Micra implant at our centre. The entire cohort was divided between ‘post-extraction’ (Group 1) and naïve patients (Group 2). In 23 of 83 patients (20 males, 86.96%; 73.83 ± 10.29 years), Micra was implanted after TLE. Indication to TLE was an infection in 15 patients (65.21%), leads malfunction in four (17.39%), superior vena cava syndrome in three (13.05%), and severe tricuspid regurgitation in one case (4.35%). The implant procedure was successful in all patients and no device-related events occurred at follow-up (median: 18 months; interquartile range: 1–24). No differences were observed between groups in fluoroscopy time (13.88 ± 10.98 min vs. 13.15 ± 6.64 min, P = 0.45), single device delivery (Group 1 vs. Group 2: 69.56% vs. 55%, P = 0.22), electrical performance at implant and at 12-month follow-up (Group 1 vs. Group 2: pacing threshold 0.48 ± 0.05 V/0.24 ms vs. 0.56 ± 0.25 V/0.24 ms, P = 0.70; impedance 640 ± 148.83 Ohm vs. 583.43 ± 99.7 Ohm, P = 0.27; and R wave amplitude 10.33 ± 2.88 mV vs. 12.62 ± 5.31 mV, P = 0.40). A non-apical site of implant was achievable in the majority of cases (72.3%) without differences among groups (78.26% vs. 70%; P = 0.42).

Conclusion

Micra implant is an effective and safe procedure in patients still requiring a ventricular pacing after TLE, with similar electrical performance and outcome compared with naïve patients at long-term follow-up.

Concurrent Epicardial Cardiac Resynchronization at Time of Complicated Biventricular Device Extraction: A Potentially Life-Saving Option

A 60-year-old man with cardiac resynchronization therapy defibrillator (CRT-D) lead endocarditis underwent transvenous lead extraction that was complicated by coronary sinus laceration and tamponade. Severe left ventricular dysfunction and unstable hemodynamic parameters persisted after emergent sternotomy, drainage, and repair. Reinstitution of cardiac resynchronization therapy with an epicardial device resulted in immediate hemodynamic improvement. Our case illustrates the potentially life-saving nature of single-stage extraction and reimplantation in resynchronization responders.