Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Evaluation of a second-generation intercostal extravascular implantable cardioverter defibrillator lead with a pectoral pulse generator for sensing, defibrillation, and anti-tachycardia pacing

AIMS

Intercostal extravascular implantable cardioverter defibrillator (EV-ICD) leads may work better in contact with the pericardium thereby directing pacing and defibrillation energy towards excitable myocytes. We report 3-month safety and performance outcomes with a second-generation intercostal EV-ICD lead paired with standard, commercially available ICD pulse generators (PGs).

METHODS AND RESULTS

Subjects undergoing a transvenous ICD (TV-ICD) procedure received a concomitant intercostal EV-ICD lead system. The intercostal EV-ICD lead was connected sequentially to a PG in a left pectoral and then a left mid-axillary location. Extravascular ICD lead assessment included sensing and defibrillation of induced ventricular arrhythmias and pacing capture. The intercostal EV-ICD system was followed in a 'recording-only' mode and the control TV-ICD system in 'therapy delivery' mode to compare stored events. Devices were evaluated prior to hospital discharge, 2 weeks, 1 month, 2 months, and 3 months post-implant. Defibrillation testing was repeated prior to lead removal; 20/20 (100%) were successfully implanted (median implant time of 9 min). Two major lead complications were reported over a mean of 82 days: (i) lead movement and (ii) infection of both the TV-ICD and EV-ICD systems. Intraoperative pacing capture was achieved with the integrated bipolar configuration in 19 of 20 (95%) subjects. Pacing capture with the EV-ICD system was tolerated in all subjects, with over 90% feeling no pain after a 1-month recovery from the procedure. Induced VF episodes were sensed in all subjects and defibrillated successfully in 17 of 17 patients (100%) with a left mid-axillary PG and 19 of 20 patients (95%) with a left pectoral PG. Sensing and defibrillation were successful in 18 of 18 (100%) tested prior to lead removal.

CONCLUSION

In this pilot experience with a second-generation intercostal EV-ICD lead implantation, sensing and defibrillation of induced VF were successful when paired with a standard ICD PG from either a left mid-axillary or pectoral pocket.

CLINICAL TRIAL REGISTRATION

NCT number: NCT05791032; URL: https://clinicaltrials.gov/study/NCT05791032.

Gram-Negative Bacterial Infections in Cardiac Implantable Electronic Devices: Insights from a Retrospective Analysis of Multidrug-Resistant and Non-Multidrug-Resistant Isolates

Cardiac implantable electronic device (CIED) infections caused by Gram-negative bacteria are uncommon but potentially life-threatening. This study examined patients with Gram-negative CIED infections, investigating the clinical characteristics of patients harboring multidrug-resistant (MDR), versus non-MDR, isolates. A retrospective observational analysis was conducted at two tertiary Greek University Hospitals from 2015 to 2020. Patients were identified through microbiological cultures from device-related sites (pocket, lead, generator), with infections classified as MDR or non-MDR based on antimicrobial susceptibility profiles. Comprehensive data were collected, including demographic characteristics, clinical parameters, procedural details-on both the last device procedure and subsequent extraction procedure-infection-related findings, and microbiological profiles. In total, 18 patients were identified, with an equal distribution of 9 MDR and 9 non-MDR cases. The study population had a median age of 78 years, with 33.3% female patients, and a median Charlson Comorbidity Index of four. Pseudomonas aeruginosa was the most prevalent isolated species. Comparative analysis revealed that MDR patients had higher median SOFA (Sequential Organ Failure Assessment) scores (2 vs. 0, p = 0.07), longer time to device extraction (50% vs. 88.9% extracted within one month, p = 0.079), and higher blood culture positivity (80% vs. 37.5%, p = 0.135). Despite similar demographic characteristics, MDR infections demonstrated more complex clinical profiles, with a trend towards increased disease severity.

Clinical performance of subcutaneous vs. transvenous implantable defibrillator in patients with ischemic cardiomyopathy: data from Monaldi Rhythm Registry

INTRODUCTION

Subcutaneous ICD (S-ICD) is an alternative to a transvenous implantable cardioverter-defibrillator (TV-ICD) system in selected patients not in need of pacing or resynchronization. Currently, little is known about the effectiveness and safety of S-ICD in patients with ischemic cardiomyopathy (ICM). The aim of our study was to describe the clinical features and the drivers of S-ICD implantation among patients with ICM, as well as the clinical performance of S-ICD vs. TV-ICD among this subset of patients during a long-term follow-up.

MATERIALS AND METHODS

All ICM patients with both S-ICD and TV-ICD implanted and followed at Monaldi Hospital from January 1, 2015, to January 1, 2024, were evaluated; among them, only ICD recipients with no pacing indication were included. We collected clinical and anamnestic characteristics, as well as ICD inappropriate therapies, ICD-related complications and infections.

RESULTS

A total of 243 ICM patients (mean age 63.0 ± 11.0, male 86.0%) implanted with TV-ICD (n: 129, 53.1%) and S-ICD (n: 114, 46.9%) followed at our center for a median follow-up of 66.9 [39.4-96.4] months were included in the study. Kaplan-Meier analysis revealed no significant difference in the risk of inappropriate ICD therapies (log-rank p = 0.137) or ICD-related complications (log-rank p = 0.055) between S-ICD and TV-ICD groups. TV-ICD patients showed a significantly higher risk of ICD-related infections compared to those in the S-ICD group (log-rank p = 0.048). At multivariate logistic regression analysis, the only independent predictors of S-ICD implantation were female sex [OR: 52.62; p < 0.001] and primary prevention [OR: 17.60; p < 0.001].

CONCLUSIONS

Among patients with ICM not in need of pacing or resynchronization (CRT), the decision to implant an S-ICD was primarily influenced by female gender and primary prevention indications. No significant differences in inappropriate ICD therapies and complications were found; in contrast, the S-ICD group showed a numerically reduced risk of ICD-related infections.

Fifteen years of subcutaneous implantable cardioverter-defibrillator therapy: Where do we stand, and what will the future hold?

The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a feasible alternative to the transvenous ICD in the treatment of ventricular tachyarrhythmias in patients without indications for pacing or cardiac resynchronization therapy. Since its introduction, numerous innovations have been made and clinical experience has been gained, leading to its adoption in current practice and preference in certain populations. Moreover, emerging technologies like the extravascular ICD and the combination of the S-ICD with the leadless pacemaker offer new possibilities for the future. These advancements underscore the evolving role of the S-ICD in management of ventricular tachyarrhythmias. This review outlines implantation considerations, patient selection, and troubleshooting advancements in the last 15 years and provides insights into future perspectives.

Cardiovascular Implantable Electronic Device Infections: A Contemporary Review

Infections associated with cardiac implantable electronic devices (CIEDs) are increasing and are a cause of significant morbidity and mortality. This article summarizes the latest updates with respect to the epidemiology, microbiology, and risk factors for CIED-related infections. It also covers important considerations regarding the diagnosis, management, and prevention of these infections. Newer technologies such as leadless pacemakers and subcutaneous implantable cardioverters and defibrillators are discussed.

Cardiac Device Implantation: Techniques and Best Practices

Transvenous leads continue to be the standard means to deliver bradyarrhythmia and tachyarrhythmia device therapy. Risk factors for cardiac implantable electronic devices (CIED) infection or complications of transvenous lead extraction (TLE) and mortality represent a complex interplay between non-modifiable patient-related factors and actionable implant-related characteristics or adverse events. Careful attention to patient screening, infection mitigation, lead selection, and implant technique may enhance safety of the index procedure and subsequent clinical management.

Cardiac implantable electronic device infection awareness - A European survey amongst implanting physicians

BACKGROUND AND AIMS

Cardiac Implantable Electronic Device (CIED) infections pose significant mortality and morbidity despite optimal treatment. This survey aimed to understand whether and how the risk of CIED infection is assessed and mitigated in clinical practice in Europe, and to detect gaps with respect to EHRA recommendations.

METHODS

An Expert Group of 8 European cardiologists with specific expertise across CIED therapy designed and distributed electronically a survey to a number of European Cardiologists.

RESULTS

302 physicians from 18 European countries responded to the survey. 288/302 (95%) physicians agreed that CIED-related infections represent a burden on healthcare resources and are associated with significant morbidity and mortality. 285/302 respondents (94%) primarily assess the risk of CIED infections by only evaluating the patient's clinical profile (137/302, 46%) or with the support of a risk score (148/302, 49%). Intravenous antibiotic prophylaxis is used by 282/302 (93%), followed by the implantation of the lowest number of leads possible (182/302, 60%), and by the use of an antibacterial envelope (173/302, 57%). 230/302 respondents (76%) declared that there is need for clear and concise guidelines and more sensitive risk-scores for CIED infection, to maximize the chances of preventative strategies.

CONCLUSIONS

This survey demonstrates a high level of awareness about the multifaceted issue of CIED infection, however, it also highlights an incomplete penetration of scoring systems for risk stratification owing to their perceived limitations, and detects a strong commitment to increase the effectiveness of preventative strategies.

Improved outcomes with leadless vs. single-chamber transvenous pacemaker in haemodialysis patients

AIMS

Cardiac conduction disorders are common in haemodialysis patients, with a relatively high rate of pacemaker implantations. Pacemaker-related complications, especially lead infections and central venous stenosis, pose significant challenges in this population. This study aims to compare single-chamber leadless pacemaker to single-chamber transvenous pacemakers in terms of survival and related complications in haemodialysis patients.

METHODS AND RESULTS

This retrospective study included adult haemodialysis patients who received a first single-chamber transvenous or leadless pacemaker between January 2017 and December 2020. Data were obtained from the French national REIN registry matched to the national health databases (Système National des Données de Santé). Propensity score matching was used to balance baseline characteristics. Survival and complications were compared between groups by Cox regression and by competitive risk models, respectively. One hundred and seventy-eight patients were included after propensity score matching, with 89 patients in each group. The median follow-up time was 24 (range 7-37) months. Leadless pacemakers were associated with significantly lower all-cause mortality rates compared to transvenous pacemakers [hazard ratio (HR) = 0.68, 95% confidence interval (CI) (0.47-0.99)]. Device-related infections are significantly lower with leadless pacemakers throughout the follow-up period (HR 0.43, 95% CI 0.21-0.86). Leadless pacemaker recipients also required fewer vascular access interventions [odds ratio 0.53, 95% CI (0.33-0.68)] on arteriovenous fistula.

CONCLUSION

With the limitations of its observational design, this study suggests that leadless pacemakers are associated with a lower rate of complications and better survival as compared with transvenous VVI pacemakers in haemodialysis patients, supporting to consider their preferential use in this population.

One-year Impact of Clinical and Echocardiographic Parameters in Cardiac Implantable Electronic Device Infection after Transvenous Extraction

Introduction

Cardiac implantable electronic device infection (CIEDi) represents a serious complication with a poor prognosis. Many studies have underlined the importance of comorbidities on prognosis, but less is known about the impact of echocardiographic parameters. The aim of our study was to evaluate the clinical and echocardiographic characteristics of patients hospitalized for CIEDi submitted to transvenous extraction and their impact on 1-year follow-up.

Materials and Methods

This is a retrospective cohort study that evaluated patients hospitalized for CIEDi in 2019 in two high-volume centers (Cotugno Hospital of Napoli and University Hospital of Pisa).

Results

Sixty-eight patients (72 ± 12 years, 24% females) were included. Isolated pocket infection was present in 30 patients (44%), whereas systemic infection in 38 (56%). In 24 patients (35%), it was possible to identify responsible germ, with a higher prevalence of Staphylococcus epidermidis (24%) and Staphylococcus aureus (16%). The mean ejection fraction (EF) was 45 ± 14%, 44% of patients had one vegetation (11.0 ± 8.0 mm), and 19% had multiple. Transthoracic echocardiography (TTE) failed to identify vegetation in 16 patients, whereas transesophageal echocardiography (TEE) was diagnostic. All patients underwent transvenous extraction of infected devices. After the procedure, echocardiographic ghosts were found in six patients (9%). At 1-year follow-up, all-cause mortality was 16%, mortality for cardiovascular cause was 12%, and no reinfection was recorded. Patients with EF ≤40% showed a significantly higher incidence of all-cause mortality (32% vs. 5%, P = 0.003) and mortality for cardiovascular causes (25% vs. 3%, P = 0.005). At adjusted Cox regression model, reduced EF ≤40% (adjusted hazard ratio [AdjHR] = 9.887, confidence interval [CI] =1.782-54.863; P = 0.009) and diabetes (AdjHR = 5.687, CI = 1.243-26.011; P = 0.025) were strong independent predictors of all-cause mortality. Moreover, reduced EF ≤40% (AdjHR = 17.382, CI = 1.379-219.037; P = 0.027), the presence of ghost (AdjHR = 14.584, CI = 1.465-145.197; P = 0.022), and diabetes (AdjHR = 11.334, CI = 1.506-85.315; P = 0.018) were strong independent predictors of mortality for cardiovascular cause.

Conclusions

Echocardiography (TTE and TEE) is a fundamental tool for the diagnosis and follow-up of CIEDi. In our population, diabetes mellitus and echocardiographic-derived parameters as reduced EF ≤40% and the presence of ghosts were strongly associated with 1-year mortality.

What Important Information Does Transesophageal Echocardiography Provide When Performed before Transvenous Lead Extraction?

Background: Transesophageal echocardiography (TEE) is mandatory before transvenous lead extraction (TLE), but its usefulness remains underestimated. This study aims to describe the broad range of TEE findings in TLE candidates, as well as their influence on procedure complexity, major complications (MCs) and long-term survival. Methods: Preoperative TEE was performed in 1191 patients undergoing TLE. Results: Lead thickening (OR = 1.536; p = 0.007), lead adhesion to heart structures (OR = 2.531; p < 0.001) and abnormally long lead loops (OR = 1.632; p = 0.006) increased the complexity of TLE. Vegetation-like masses on the lead (OR = 4.080; p = 0.44), lead thickening (OR = 2.389; p = 0.049) and lead adhesion to heart structures (OR = 6.341; p < 0.001) increased the rate of MCs. The presence of vegetations (HR = 7.254; p < 0.001) was the strongest predictor of death during a 1-year follow-up period. Conclusions: TEE before TLE provides a lot of important information for the operator. Apart from the visualization of possible vegetations, it can also detect various forms of lead-related scar tissue. Build-up of scar tissue and the presence of long lead loops are associated with increased complexity of the procedure and risk of MCs. Preoperative TEE performed outside the operating room may have an impact on the clinical decision-making process, such as transferring potentially more difficult patients to a more experienced center or having the procedure performed by the most experienced operator. Moreover, the presence of masses or vegetations on the leads significantly increases 1-year and all-cause mortality.

Long- and short-term outcomes after transvenous lead extraction in a large single-centre patient cohort using the clinical frailty scale as a risk assessment tool

BACKGROUND AND AIMS

The rate of cardiac implantable electronic device (CIED) implantations and the need for transvenous lead extraction (TLE) are growing worldwide. This study examined a large Swedish cohort with the aim of identifying possible predictors of post-TLE mortality with special focus on systemic infection patients and frailty.

METHODS

This was a single centre study. Records of patients undergoing TLE between 2010 and 2018 were analysed. Statistical analyses were conducted to compare baseline characteristics of patients with different indications and identify risk factors of 30-day and 1-year mortality.

RESULTS

A total of 893 patients were identified. Local infection was the dominant indication and pacemaker was the most common CIED. The mean age was 65 ± 16 years, 73 % were male and median follow-up was 3.9 years. Heart failure was the most common comorbidity. Patients with systemic infection were significantly older, frailer and had significantly higher levels of comorbidities. 30-day mortality and 1-year mortality rates were 2.5 % and 9.9 %, respectively. Systemic infection and chronic kidney disease (CKD) were independently associated with 30-day and 1-year mortality. Clinical frailty scale (CFS) 5-7 correlated independently with 1-year mortality in the entire cohort and specifically in systemic infection patients. CKD, cardiac resynchronization therapy and CFS 5-7 were significant risk factors for long-term mortality (death >1 year after TLE) in multivariable analysis.

CONCLUSIONS

Systemic infection, kidney failure in addition to the novel parameter of frailty were associated with post-TLE all-cause mortality. These risk factors should be considered during pre-procedure risk stratification to improve post-TLE outcomes.

Risk of VF Undersensing in Extra-Vascular ICD Due to Concomitant Leadless Pacing

Extravascular implantable cardioverter-defibrillators (EV-ICD) offer defibrillation, anti-tachycardia pacing (ATP), and backup pacing, packaged in a unit comparable to traditional transvenous ICDs in size, shape, and longevity. However, the pacing capabilities of EV-ICD are restricted to ATP, pause prevention and post-shock pacing. For EV-ICD patients who develop the need for pacing, having a concomitant leadless pacemaker such as Micra could provide the needed pacing support. This research examines the potential interference between Micra's pacing pulses and EV-ICD's arrhythmia detection functions. Specifically, we investigate the impact of pacing amplitudes and pulse widths on the detection of ventricular fibrillation (VF) by the EV-ICD. Our findings indicate that pacing pulses with amplitudes not exceeding 1.3 times the amplitude of VF should not confound VF detection. In our VF database, this threshold corresponds to pacing amplitudes of approximately 0.99±0.56 mV in the sensing electrogram (EGM) vector. Additionally, our analysis identifies pulse width as a critical factor, with widths greater than 0.24 ms, significantly impairing VF detection. These results underscore the importance of proper pacing parameters configuration to optimize the functionality of EV-ICD when combined with a leadless pacemaker.

18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations From ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multisocietal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multifocal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

Percutaneous Mechanical Aspiration in Infective Endocarditis: Applications, Technical Considerations, and Future Directions

In recent years, there has been a shift in the epidemiology of patients with infective endocarditis (IE). This has been characterized by an alarming increase in IE in patients who inject drugs, cardiac implantable electronic device-related IE, and those with comorbid conditions and high surgical risk. This unmet need has mandated a reevaluation of complex management strategies in these patients and introduction of unconventional approaches in treatment. Percutaneous mechanical aspiration has emerged as both a diagnostic and therapeutic option in selected patients with IE. In this review, the authors discuss the gaps in care of IE, rationale, device armamentarium, procedural, and technical considerations and applications of percutaneous mechanical aspiration in IE.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

The BLISTER Score: A Novel, Externally Validated Tool for Predicting Cardiac Implantable Electronic Device Infections, and Its Cost-Utility Implications for Antimicrobial Envelope Use

BACKGROUND

Antimicrobial envelopes reduce the incidence of cardiac implantable electronic device infections, but their cost restricts routine use in the United Kingdom. Risk scoring could help to identify which patients would most benefit from this technology.

METHODS

A novel risk score (BLISTER [Blood results, Long procedure time, Immunosuppressed, Sixty years old (or younger), Type of procedure, Early re-intervention, Repeat procedure]) was derived from multivariate analysis of factors associated with cardiac implantable electronic device infection. Diagnostic utility was assessed against the existing PADIT score (Prior procedure, Age, Depressed renal function, Immunocompromised, Type of procedure) in both standard and high-risk external validation cohorts, and cost-utility models examined different BLISTER and PADIT score thresholds for TYRX (Medtronic; Minneapolis, MN) antimicrobial envelope allocation.

RESULTS

In a derivation cohort (n=7383), cardiac implantable electronic device infection occurred in 59 individuals within 12 months of a procedure (event rate, 0.8%). In addition to the PADIT score constituents, lead extraction (hazard ratio, 3.3 [95% CI, 1.9-6.1]; P<0.0001), C-reactive protein >50 mg/L (hazard ratio, 3.0 [95% CI, 1.4-6.4]; P=0.005), reintervention within 2 years (hazard ratio, 10.1 [95% CI, 5.6-17.9]; P<0.0001), and top-quartile procedure duration (hazard ratio, 2.6 [95% CI, 1.6-4.1]; P=0.001) were independent predictors of infection. The BLISTER score demonstrated superior discriminative performance versus PADIT in the standard risk (n=2854, event rate: 0.8%, area under the curve, 0.82 versus 0.71; P=0.001) and high-risk validation cohorts (n=1961, event rate: 2.0%, area under the curve, 0.77 versus 0.69; P=0.001), and in all patients (n=12 198, event rate: 1%, area under the curve, 0.8 versus 0.75, P=0.002). In decision-analytic modeling, the optimum scenario assigned antimicrobial envelopes to patients with BLISTER scores ≥6 (10.8%), delivering a significant reduction in infections (relative risk reduction, 30%; P=0.036) within the National Institute for Health and Care Excellence cost-utility thresholds (incremental cost-effectiveness ratio, £18 446).

CONCLUSIONS

The BLISTER score (https://qxmd.com/calculate/calculator_876/the-blister-score-for-cied-infection) was a valid predictor of cardiac implantable electronic device infection, and could facilitate cost-effective antimicrobial envelope allocation to high-risk patients.

Emerging Technologies in Cardiac Pacing

Cardiac pacing to treat bradyarrhythmias has evolved in recent decades. Recognition that a substantial proportion of pacemaker-dependent patients can develop heart failure due to electrical and mechanical dyssynchrony from traditional right ventricular apical pacing has led to development of more physiologic pacing methods that better mimic normal cardiac conduction and provide synchronized ventricular contraction. Conventional biventricular pacing has been shown to benefit patients with heart failure and conduction system disease but can be limited by scarring and fibrosis. His bundle pacing and left bundle branch area pacing are novel techniques that can provide more physiologic ventricular activation as an alternative to conventional or biventricular pacing. Leadless pacing has emerged as another alternative pacing technique to overcome limitations in conventional transvenous pacemaker systems. Our objective is to review the evolution of cardiac pacing and explore these new advances in pacing strategies.

Long-Term Atrioventricular Block Following Valve Surgery: Electrocardiographic and Surgical Predictors

BACKGROUND

Bradyarrhythmia requiring pacemaker implantation among patients undergoing valve surgery may occur even after several years, with unclear predictors. Our aim was to investigate the incidence of pacemaker implantation at different follow-up times and identify associated predictors.

METHODS

We conducted a retrospective study evaluating 1046 consecutive patients who underwent valve surgery at the Cardiac Surgery Division of Bologna University Hospital from 2005 to 2010.

RESULTS

During 10 ± 4 years of follow-up, 11.4% of these patients required pacemaker implantation. Interventions on both atrioventricular valves independently predicted long-term pacemaker implantation (SHR 2.1, 95% CI 1.2-3.8, p = 0.014). Preoperative atrioventricular conduction disease strongly predicted long-term atrioventricular block, with right bundle branch block as the major predictor (SHR 7.0, 95% CI 3.9-12.4, p < 0.001), followed by left bundle branch block (SHR 4.9, 95% CI 2.4-10.1, p < 0.001), and left anterior fascicular block (SHR 3.9, 95% CI 1.8-8.3, p < 0.001).

CONCLUSION

Patients undergoing valvular surgery have a continuing risk of atrioventricular block late after surgery until the 12-month follow-up, which was clearly superior to the rate of atrioventricular block observed at long-term. Pre-operative atrioventricular conduction disease and combined surgery on both atrioventricular valves are strong predictors of atrioventricular block requiring pacemaker implantation.

The Micra Transcatheter Pacing System: past, present and the future

Leadless permanent pacemakers represent an important innovation in cardiac device developments. Although transvenous permanent pacemakers have become indispensable in managing bradyarrhythmia and saving numerous lives, the use of transvenous systems comes with notable risks tied to intravascular leads and subcutaneous pockets. This drawback has spurred the creation of leadless cardiac pacemakers. Within this analysis, we compile existing clinical literature and proceed to evaluate the efficacy and safety of the Micra Transcatheter Pacing System. We also delve into the protocols for addressing a malfunctioning or end-of-life Micra as well as device extraction. Lastly, we explore prospects in this domain, such as the emergence of entirely leadless cardiac resynchronization therapy-defibrillator devices.

Simultaneous subcutaneous implantable cardioverter-defibrillator and leadless pacemaker implantation for patients at high risk of infection: a retrospective case series report

BACKGROUND

The subcutaneous implantable cardioverter defibrillator (S-ICD) and leadless pacemaker (LP) are alternative options for patients at high risk of infection requiring ICD and pacing therapy. In this analysis, we described the simultaneous implantation of S-ICD and LP in patients with high infectious risk.

METHODS

The study cohort comprised patients referred to our institution for ICD implantation due to high-risk factors of infection.

RESULTS

Between 2018 and 2022, 13 patients were referred, including 11 with infected ICD and 2 for first ICD implantation in the presence of high-risk factors. In cases of infected ICD, successful extraction was performed using a mechanical dilatation technique. Reimplantation was delayed until resolution of infection with antibiotic therapy. The devices were implanted during a single procedure, with S-ICD implantation following LP placement for verification of sensing adequacy through surface ECG screening. Suitable vectors for sensing during inhibited and ventricular pacing were identified in all patients. Defibrillation testing was effective, and no issues with double counting or undersensing were observed. The postoperative period was uneventful, and during a median follow-up of 35 months, no complications or infections were reported. The median ventricular pacing percentage was 5%, and a single inappropriate shock episode due to myopotential interference was reported and resolved by reprogramming the sensing vector.

CONCLUSION

Simultaneous implantation of S-ICD and LP is feasible and safe in patients at high risk of infection requiring both ICD and pacing therapy. This combined approach provides an effective solution for these patients.

Safety and success of transvenous lead extraction using excimer laser sheaths: a meta-analysis of over 1700 patients

AIMS

While numerous studies have demonstrated favourable safety and efficacy of the excimer laser sheath for transvenous lead extraction (TLE) in smaller cohorts, comprehensive large-scale investigations with contemporary data remain scarce. This study aims to evaluate the safety and performance of laser-assisted TLE through a meta-analysis of contemporary data.

METHODS AND RESULTS

A systematic literature search was conducted to identify articles that assessed the safety and performance of the spectranetics laser sheath (SLS) II and GlideLight Excimer laser sheaths in TLE procedures between 1 April 2016 and 31 March 2021. Safety outcomes included procedure-related death and major/minor complications. Performance outcomes included procedural and clinical success rates. A random-effects, inverse-variance-weighting meta-analysis was performed to obtain the weighted average of the evaluated outcomes. In total, 17 articles were identified and evaluated, including 1729 patients with 2887 leads. Each patient, on average, had 2.3 ± 0.3 leads with a dwell time of 7.9 ± 3.0 years. The TLE procedural successes rate was 96.8% [1440/1505; 95% CI: (94.9-98.2%)] per patient and 96.3% [1447/1501; 95% CI: (94.8-97.4%)] per lead, and the clinical success rate per patient was 98.3% [989/1010, 95% CI: (97.4-99.0%)]. The procedure-related death rate was 0.08% [7/1729, 95% CI: (0.00%, 0.34%)], with major and minor complication rates of 1.9% [41/1729; 95% CI: (1.2-2.8%)] and 1.9% [58/1729; 95% CI: (0.8-3.6%)], respectively.

CONCLUSION

This meta-analysis demonstrated that excimer laser sheath-assisted TLE has high success and low procedural mortality rates. It provides clinicians with a reliable and valuable resource for extracting indwelling cardiac leads which require advanced extraction techniques.

Heart failure is associated with increased risk of all-cause mortality after transvenous lead extraction: A systematic review and meta-analysis

Background

Transvenous lead extraction (TLE) is increasingly considered in cardiac implantable electronic device management. Heart failure (HF) might be associated with mortality risks after the TLE procedure. This study aims to assess mortality risk in HF patients undergoing TLE.

Method

We searched MEDLINE and Embase databases from inception to June 2022 to identify articles that included patients with and without HF who underwent TLE, which reported mortality in both groups. The pooled effect size was calculated with a random-effects model and 95% CI to compare post-TLE mortality between the two groups.

Results

Eleven studies were included in the analysis. Each left ventricular ejection fraction (LVEF) increased by 1% was associated with reduced mortality by 2% (HR = 0.98, 95% CI: 0.97-0.99, I 2 = 74.9%, p < .01). The presence of HF compared to those without HF was associated with higher mortality rates (OR: 3.04, 95% CI: 2.56-3.61, I 2 = 0.0%, p < .531). There was a significant increase in the mortality rates in patients with New York Heart Association (NYHA) function class III (OR: 2.29, 95% CI: 1.29-4.06, I 2 = 0.0%, p = .498) and NYHA IV (OR: 8.5, 95% CI: 2.98-24.3, I 2 = 0.0%, p = .997).

Conclusions

Our study found that post-TLE mortality decreases by 2% as LVEF increases by 1%, also mortality is higher in patients with NYHA III and IV.

Initial Experience With Intercostal Insertion of an Extravascular ICD Lead Compatible With Existing Pulse Generators

BACKGROUND

This study assessed safety and feasibility of a novel extravascular implantable cardioverter defibrillator (ICD) lead when inserted anteriorly through a rib space and connected to various commercially available ICD pulse generators (PGs) placed in either a left mid-axillary or left pectoral pocket. Currently available or investigational, extravascular-ICDs include a subcutaneous or subxiphoid lead connected to customized extravascular-ICD PGs.

METHODS

This novel extravascular-ICD (AtaCor Medical Inc, San Clemente, CA) employs a unique intercostal implant technique and is designed to function with commercial DF-4 ICD PGs. In this nonrandomized, single-center, acute study, 36 de novo or replacement ICD (transvenous ICD) patients enrolled to receive a concomitant extravascular-ICD lead inserted through an intercostal space along the left parasternal margin. extravascular-ICD leads were connected to DF-4 compatible ICD PGs positioned in either a left mid-axillary or pectoral pocket for acute sensing and defibrillation testing. Defibrillation testing started at 30 Joules (J) and stepped up or down in 5 to 10 joule increments depending on the success and limitations of the generator used.

RESULTS

Successful acute defibrillation using ≤35 J was noted in 100% of left mid-axillary PG subjects (n=27, mean 16.3±8.6 J) and 83% of left pectoral PG subjects (n=6, mean 21.0±8.4 J). Furthermore, 24 of 27 (89%) of patients tested with a left, mid-axillary intermuscular PG had successful VF conversion with defibrillation energies at least 10 J below the maximum delivered output of the device. All evaluable episodes (n=93) were automatically sensed, detected, and shocked. No serious device-related intraoperative adverse events were observed.

CONCLUSIONS

This first-in-human study documented the safe and reliable placement of a novel extravascular ICD lead with effective sensing and defibrillation of induced ventricular fibrillation using commercial DF-4 ICD PGs.

Utility of a multipurpose catheter for transvenous extraction of old broken leads: A novel technique for fragile leads

BACKGROUND

Transvenous lead extraction has been possible since the 1980s. However, complications during lead extraction, such as the distal end fragment of the lead remaining in the myocardium or venous system and injury to the veins or heart, have been reported.

OBJECTIVE

The purpose of this study was to examine our method for complete removal of a separated lead, as extraction of long-term implanted devices is difficult using standard methods and may require additional procedures. The removal of leads with inner conductor coil and lead tip separated from outer insulation, conductor coil, and proximal ring electrode using a multipurpose catheter is reported.

METHODS

In total, 345 consecutive patients who underwent transvenous lead extraction (TLE) from April 2014 to March 2021 were retrospectively analyzed. Lead characteristics, device type, and indications for extraction were further analyzed in 20 patients who developed separation of the proximal ring electrode and outer conductor coil from the inner conductor and distal tip at the time of extraction.

RESULTS

Extractions were performed using an excimer laser sheath laser and a Byrd polypropylene telescoping sheath (n = 15); laser, Byrd polypropylene telescoping sheath, and Evolution RL (n = 2); laser and Evolution RL (n = 3); Byrd polypropylene telescoping sheath and Evolution RL (n = 1); Byrd polypropylene telescoping sheath only (n = 4); and Evolution RL only (n = 2). Twenty-seven leads implanted for more than 10 years had lead separation. A multipurpose catheter was used to protect the fragile leads from further damage. All leads were completely extracted.

CONCLUSION

All distal tip-to-proximal ring electrode separated leads were successfully removed using laser and other sheaths with the assistance of a multipurpose catheter, without any part of the leads remaining in the heart.

Complicated Pocket Infection in Patients Undergoing Lead Extraction: Characteristics and Outcomes

Cardiac implantable electronic device (CIED) infection can present with pocket or systemic manifestations, both necessitating complete device removal and pathogen-directed antimicrobial therapy. Here, we aim to characterize those presenting with both pocket and systemic infection. A retrospective analysis of CIED extraction procedures included 300 patients divided into isolated pocket (n = 104, 34.7%), complicated pocket (n = 54, 18%), and systemic infection (n = 142, 47.3%) groups. The systemic and complicated pocket groups frequently presented with leukocytosis and fever > 37.8, as opposed to the isolated pocket group. Staphylococcus aureus was the most common pathogen in the systemic and complicated pocket groups (43.7% and 31.5%, respectively), while Coagulase-negative staphylococci (CONS) predominated (31.7%) in the isolated pocket group (10.6%, p < 0.001). No differences were observed in procedural success or complications rates. Kaplan-Meier survival analysis found that at three years of follow-up, the rate of all-cause mortality was significantly higher among patients with systemic infection compared to both pocket groups (p < 0.001), with the curves diverging at thirty days. In this study, we characterize a new entity of complicated pocket infection. Despite the systemic pattern of infection, their prognosis is similar to isolated pocket infection. We suggest that this special category be presented separately in future publications of CIED infections.

Procedure, management, and outcome of subcutaneous implantable cardioverter-defibrillator extraction in clinical practice

AIMS

Subcutaneous implantable cardioverter-defibrillator (S-ICD) therapy is expanding rapidly. However, there are few data on the S-ICD extraction procedure and subsequent patient management. The aim of this analysis was to describe the procedure, management, and outcome of S-ICD extractions in clinical practice.

METHODS AND RESULTS

We enrolled consecutive patients who required complete S-ICD extraction at 66 Italian centres. From 2013 to 2022, 2718 patients undergoing de novo implantation of an S-ICD were enrolled. Of these, 71 required complete S-ICD system extraction (17 owing to infection). The S-ICD system was successfully extracted in all patients, and no complications were reported; the median procedure duration was 40 (25th-75th percentile: 20-55) min. Simple manual traction was sufficient to remove the lead in 59 (84%) patients, in whom lead-dwelling time was shorter [20 (9-32) months vs. 30 (22-41) months; P = 0.032]. Hospitalization time was short in the case of both non-infectious [2 (1-2) days] and infectious indications [3 (1-6) days]. In the case of infection, no patients required post-extraction intravenous antibiotics, the median duration of any antibiotic therapy was 10 (10-14) days, and the re-implantation was performed during the same procedure in 29% of cases. No complications arose over a median of 21 months.

CONCLUSION

The S-ICD extraction was safe and easy to perform, with no complications. Simple traction of the lead was successful in most patients, but specific tools could be needed for systems implanted for a longer time. The peri- and post-procedural management of S-ICD extraction was free from complications and not burdensome for patients and healthcare system.

CLINICAL TRIAL REGISTRATION

URL: http://clinicaltrials.gov/Identifier: NCT02275637.

Subcutaneous versus transvenous implantable cardioverter-defibrillator among drug-induced type-1 ECG pattern Brugada syndrome: a propensity score matching analysis from IBRYD study

No real-world data are available about the complications rate in drug-induced type 1 Brugada Syndrome (BrS) patients with an implantable cardioverter-defibrillator (ICD). Aim of our study is to compare the device-related complications, infections, and inappropriate therapies among drug-induced type 1 BrS patients with transvenous- ICD (TV-ICD) versus subcutaneous-ICD (S-ICD). Data for this study were sourced from the IBRYD (Italian BRugada sYnDrome) registry which includes 619 drug-induced type-1 BrS patients followed at 20 Italian tertiary referral hospitals. For the present analysis, we selected 258 consecutive BrS patients implanted with ICD. 198 patients (76.7%) received a TV-ICD, while 60 a S-ICD (23.4%). And were followed-up for a median time of 84.3 [46.5-147] months. ICD inappropriate therapies were experienced by 16 patients (6.2%). 14 patients (7.1%) in the TVICD group and 2 patients (3.3%) in S-ICD group (log-rank P = 0.64). ICD-related complications occurred in 31 patients (12%); 29 (14.6%) in TV-ICD group and 2 (3.3%) in S-ICD group (log-rank P = 0.41). ICD-related infections occurred in 10 patients (3.88%); 9 (4.5%) in TV-ICD group and 1 (1.8%) in S-ICD group (log-rank P = 0.80). After balancing for potential confounders using the propensity score matching technique, no differences were found in terms of clinical outcomes between the two groups. In a real-world setting of drug-induced type-1 BrS patients with ICD, no significant differences in inappropriate ICD therapies, device-related complications, and infections were shown among S-ICD vs TV-ICD. However, a reduction in lead-related complications was observed in the S-ICD group. In conclusion, our evidence suggests that S-ICD is at least non-inferior to TV-ICD in this population and may also reduce the risk of lead-related complications which can expose the patients to the necessity of lead extractions.

Risk factors associated with higher mortality in patients with cardiac implantable electronic device infection

INTRODUCTION

Cardiac Implantable Electronic Devices (CIEDs) are widely used for the management of advanced heart failure and ventricular arrhythmias. CIED-Infection (CIED-I) has very high mortality, especially in the subsets of patients with limited health-care access and delayed presentation. The purpose of this study is to identify the risk-predictors mortality in subjects with CIED-I.

METHODS

We performed a retrospective cohort study of a regional database in patients presenting with CIED infections to tertiary care medical centers across Western New York, USA from 2012 to 2020. The clinical outcomes included recurrent device infection (any admission for CIED-I after the first hospitalization for device infection), septic complications (pulmonary embolism, respiratory failure, septic shock, decompensated HF, acute kidney injury) and mortality outcomes (death during hospitalization, within 30 days from CIED-I, and within 1 year from CIED-I). We studied associations between categorical variables and hard outcomes using χ2 tests and used one-way analysis of variance to measure between-groups differences.

RESULTS

We identified 296 patients with CIED-I, among which 218 (74%) were male, 237 (80%) were white and the mean age at the time of infection was 69.2 ± 13.7 years. One-third of the patients were referred from the regional facilities. Staphylococcus aureus was responsible for most infections, followed by Enterococcus fecalis. On multivariate analysis, the covariates associated with significantly increased mortality risk included referral from regional facility (OR: 2.0;1.0-4.0), hypertension (Odds ratio, OR: 3.2;1.3-8.8), right ventricular dysfunction (OR: 2.6;1.2-5.1), end-stage renal disease (OR: 2.6;1.1-6.2), immunosuppression (OR: 11.4;2.5-53.3), and septic shock as a complication of CIED-I (OR: 3.9;1.3-10.8).

CONCLUSION

Hypertension, right ventricular dysfunction, immunosuppression, and end-stage renal disease are associated with higher mortality after CIED-I. Disproportionately higher mortality was also noted in subjects referred from the regional facilities. This underscores the importance of early clinical risk-assessment, and the need for a robust referral infrastructure to improve patient outcomes.

Assessment of the Social Security Administration Death Master File for Comparative Analysis Studies of Peripheral Vascular Devices

OBJECTIVES

The objective of this study was to assess the reliability the Social Security Administration Death Master File (SSADMF) for evaluating mortality in comparative peripheral vascular device studies.

METHODS

We leveraged 2 versions of an administrative claims data set that were identical except for the source of mortality data. The SSADMF was the primary source of mortality records in one version. The SSADMF was combined with mortality from Medicare beneficiary records in the other. Our study was set in the context of a comparative effectiveness analysis of recent Food and Drug Administration interest involving peripheral paclitaxel-coated devices. Mortality of patients with Medicare Advantage insurance coverage from 2015 to 2018 who underwent femoropopliteal artery revascularization with a drug-coated device (DCD) or non-DCD was assessed through 2019. Covariate differences between treatment groups were adjusted by inverse propensity treatment weighting. The hazard ratio of DCD to non-DCD mortality was estimated using Cox regression.

RESULTS

The cumulative incidences of mortality differed substantially between versions of the data. Nevertheless, we could not reject the null hypothesis that the hazard ratios of the SSADMF (1.05; 95% confidence interval 0.95-1.17) and the Master Beneficiary Summary File/SSADMF (1.03; 95% confidence interval 0.96-1.11) were the same (P = .63).

CONCLUSIONS

The SSADMF is a common source of mortality records in the United States that can be linked to real-world data sources but is known to underreport mortality rates. We find that the SSADMF provides a reliable source of all-cause mortality for a comparative study assessing the safety of peripheral vascular devices.

Characteristics and outcomes of angiovac-assisted debulking of intracardiac masses, thrombi, and endocarditis

BACKGROUND

Traditional management for right-sided infective endocarditis and other adherent masses centers around balancing the risks and benefits of open surgical removal against medical therapy.

METHODS

Single-center study analysis of 19 patients who underwent vacuum-assisted debulking and/or en bloc removal of right-sided infective endocarditis and other adherent masses between September 2017 and November 2021. Clinical outcomes during the perioperative period, postoperative period, hospital course, and post-discharge were analyzed.

RESULTS

We included 12 male and 7 female patients with an average age 47.4 ± 16.8. Relevant risk factors included 47.4% of patients with active intravenous drug use (IVDU), 21.1% of patients with a history of permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD), and 5.3% of prior malignancy with mediastinal radiation. 31.6% of patients had documented right-sided masses from a non-infectious etiology, while 68.4% of patients were noted to have right-sided infective endocarditis (RSIE). All patients were found to have large, mobile masses or vegetations at high risk for embolization to the pulmonary vasculature. Average in-hospital length of stay was 17.8 ± 12.2 days, blood cultures cleared postoperatively in 8.9 ± 7.3 days, periprocedural mortality was 0%, subsequent open surgical valvular repair during the same admission was 5.3%, and in-hospital mortality was 5.3%. Within 6 weeks of follow-up, 15.8% of patients were readmitted for recurrence of bacteremia, 10.5% of patients were found to have new pulmonary embolism, and 15.8% of patients underwent open surgical valvular repair. Total death after 1-year and 2-years was 15.8% and 5.3%, respectively. Recurrence of bacteremia was 21.1% within 1-year.

CONCLUSION

AngioVac is a viable therapeutic strategy for select patients with intravascular and intracardiac right-sided masses including thrombi, emboli, or infective masses such as endocarditis.

Long-Term Outcome of Infective Endocarditis Involving Cardiac Implantable Electronic Devices: Impact of Comorbidities and Lead Extraction

(1) Background: Management of cardiac implantable electronic device-related infective endocarditis (CIED-IE) hinges on complete hardware removal. We assessed whether long-term prognosis is affected by device removal, considering baseline patient comorbid conditions; (2) Methods: A total of 125 consecutive patients hospitalized for CIED-IE were included in this retrospective analysis. Outcomes were in-hospital, one-year, and long-term mortality. There were 109 patients who underwent device removal, 91 by transvenous lead extraction (TLE) and 18 by open heart surgery (OHS); (3) Results: TLE translated into lower hospital mortality (4.4% vs. 22.5% with OHS; p = 0.03). Septic pulmonary embolism was the only independent predictor of in-hospital mortality (OR:7.38 [1.49-36.6], p = 0.013). One-year mortality was in contrast independently associated to tricuspid valve involvement (p = 0.01) and Charlson comorbidity index (CCI, p = 0.039), but not the hardware removal modality. After a median follow-up of 41 months, mortality rose to 24%, and was significantly influenced only by CCI. Specifically, patients with a higher CCI who were also treated with TLE showed a survival rate not significantly different from those managed with medical therapy only; (4) Conclusions: In CIED-IE, TLE is the strategy of choice for hardware removal, improving early outcomes. Long-term benefits of TLE are lessened by comorbidities. In cases of CIED-IE with high CCI, a more conservative approach might be an option.

Infection in patients with subcutaneous implantable cardioverter-defibrillator: Results of the S-ICD Post Approval Study

BACKGROUND

Early subcutaneous implantable cardioverter-defibrillator (S-ICD) studies included atypical cohorts of patients who were younger with fewer comorbidities. Recent S-ICD studies included patient populations with more comorbidities.

OBJECTIVES

The goals of this study were to determine the incidence and predictors of S-ICD-related infection over a 3-year follow-up period and to use these results to develop an infection risk score.

METHODS

The S-ICD Post Approval Study is a US prospective registry of 1637 patients. Baseline demographic characteristics and outcomes with 3-year postimplantation follow-up were compared between patients with and without device-related infection. A risk score was derived from multivariable proportional hazards analysis of 22 variables.

RESULTS

Infection was observed in 55 patients (3.3%), with 69% of infections occurring within 90 days and a vast majority (92.7%) within 1 year of implantation. Late infections more likely involved device erosion; no infections occurred after year 2. The annual mortality rate postinfection was 0.6%/y. No lead extraction complications or bacteremia related to infection were observed. An infection risk score was created with diabetes, age, prior transvenous ICD implant, and ejection fraction as predictors. Patients with a risk score of ≥3 had an 8.8 hazard ratio (95% confidence interval 2.8-16.3) of infection compared with a 0 risk score.

CONCLUSION

Infection rates in the S-ICD Post Approval Study were similar to other S-ICD populations and not associated with systemic blood-borne infections. Late infection (>1 year) is uncommon and associated with system erosion. A high-risk infection cohort can be identified that may facilitate preventive measures.

Risk factors for cardiac implantable electronic device infections: a nationwide Danish study

AIMS

Cardiac implantable electronic device (CIED) infection is a severe complication to modern management of cardiac arrhythmias. The CIED type and the type of surgery are recognized as risk factors for CIED infections, but knowledge of patient-related risk factors is scarce. This study aimed to identify lifelong patient-related risk factors for CIED infections.

METHODS AND RESULTS

Consecutive Danish patients undergoing a CIED implantation or reoperation between January 1996 and April 2018 were included. The cohort consisted of 84 429 patients undergoing 108 494 CIED surgeries with a combined follow-up of 458 257 CIED-years. A total of 1556 CIED explantations were classified as either pocket (n = 1022) or systemic CIED infection (n = 534). Data were cross-linked with records from the Danish National Patient Registry and the Danish National Prescription Registry. Using multiple-record and multiple-event per subject proportional hazard analysis, specific patient-related risk factors were identified but with several variations amongst the subtypes of CIED infection. CIED reoperations were associated with the highest risk of pocket CIED infection but also CIED type, young age, and prior valvular surgery [hazard ratio (HR): 1.62, 95% confidence interval (CI): 1.29-2.04]. Severe renal insufficiency/dialysis (HR: 2.40, 95% CI: 1.65-3.49), dermatitis (HR: 2.80, 95% CI: 1.92-4.05), and prior valvular surgery (HR: 2.09, 95% CI: 1.59-2.75) were associated with the highest risk of systemic CIED infections. Congestive heart failure, ischaemic heart disease, malignancy, chronic obstructive pulmonary disease, and temporary pacing were not significant at multivariate analysis.

CONCLUSION

Specific comorbidities and surgical procedures were associated with a higher risk of CIED infections but with variations amongst pocket and systemic CIED infection. Pocket CIED infections were associated with CIED reoperations, young age and more complex type of CIED, whereas systemic CIED infections were associated with risk factors predisposing to bacteraemia.

Device-related complications in subcutaneous versus transvenous ICD: a secondary analysis of the PRAETORIAN trial

BACKGROUND

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is developed to overcome lead-related complications and systemic infections, inherent to transvenous ICD (TV-ICD) therapy. The PRAETORIAN trial demonstrated that the S-ICD is non-inferior to the TV-ICD with regard to the combined primary endpoint of inappropriate shocks and complications. This prespecified secondary analysis evaluates all complications in the PRAETORIAN trial.

METHODS AND RESULTS

The PRAETORIAN trial is an international, multicentre, randomized trial in which 849 patients with an indication for ICD therapy were randomized to receive an S- ICD (N = 426) or TV-ICD (N = 423) and followed for a median of 49 months. Endpoints were device-related complications, lead-related complications, systemic infections, and the need for invasive interventions. Thirty-six device-related complications occurred in 31 patients in the S-ICD group of which bleedings were the most frequent. In the TV-ICD group, 49 complications occurred in 44 patients of which lead dysfunction was most frequent (HR: 0.69; P = 0.11). In both groups, half of all complications were within 30 days after implantation. Lead-related complications and systemic infections occurred significantly less in the S-ICD group compared with the TV-ICD group (P < 0.001, P = 0.03, respectively). Significantly more complications required invasive interventions in the TV-ICD group compared with the S-ICD group (8.3% vs. 4.3%, HR: 0.59; P = 0.047).

CONCLUSION

This secondary analysis shows that lead-related complications and systemic infections are more prevalent in the TV-ICD group compared with the S-ICD group. In addition, complications in the TV-ICD group were more severe as they required significantly more invasive interventions. This data contributes to shared decision-making in clinical practice.

Lead-related infective endocarditis with vegetations: Prevalence and impact of pulmonary embolism in patients undergoing transvenous lead extraction

INTRODUCTION

The prevalence and impact of pulmonary embolism (PE) in patients with lead-related infective endocarditis undergoing transvenous lead extraction (TLE) are unknown.

METHODS

Twenty-five consecutive patients with vegetations ≥10 mm at transoesophageal echocardiography were prospectively studied. Contrast-enhanced chest computed tomography (CT) was performed before (pre-TLE) and after (post-TLE) the lead extraction procedure.

RESULTS

Pre-TLE CT identified 18 patients (72%) with subclinical PE. The size of vegetations in patients with PE did not differ significantly from those without (median 20.0 mm [interquartile range: 13.0-30.0] vs. 14.0 mm [6.0-18.0], p = 0.116). Complete TLE success was achieved in all patients with 3 (2-3) leads extracted per procedure. There were no postprocedure complications related to the presence of PE and no differences in terms of fluoroscopy time and need for advanced tools. In the group of positive pre-TLE CT, post-TLE scan confirmed the presence of silent PE in 14 patients (78%). There were no patients with new PE formation. Large vegetations (≥20 mm) tended to increase the risk of post-TLE subclinical PE (odds ratio 5.99 [95% confidence interval (CI): 0.93-38.6], p = 0.059). During a median 19.4 months follow-up, no re-infection of the implanted system was reported. Survival rates in patients with and without post-TLE PE were similar (hazard ratio: 1.11 [95% CI: 0.18-6.67], p = 0.909).

CONCLUSION

Subclinical PE detected by CT was common in patients undergoing TLE with lead-related infective endocarditis and vegetations but was not associated with the complexity of the procedure or adverse outcomes. TLE procedure seems safe and feasible even in patients with large vegetations.

Rate of Cardiovascular Implantable Electronic Device-Related Infection at a Tertiary Hospital in Saudi Arabia: A Retrospective Cohort Study

Introduction

Cardiovascular implantable electronic devices (CIEDs) are long-term cardiac treatments that address a variety of cardiac diseases. In the recent years, a steady growth has been noticed in CIEDs, mainly due to expanding indications for their usage. Possible device-related infection, whether pocket or systemic, which leads to high morbidity and mortality, is one of the most worrying complications. In addition, there are limited studies conducted on the topic of CIED infection rate and their clinical presentation both regionally and locally.

Methods

In this retrospective cohort study, we reviewed the medical records of all patients with CIEDs who presented to our medical center (implanted, followed up, or referred to our hospital) between January 2016 and January 2019.The medical records were extracted from the BestCare electronic medical records system (ezCaretech Co, Seoul, Korea). All consecutive patients were included as we had no exclusion criteria.

Results

During the three years of the study period, a total of 612 patients with CIEDs were identified at our medical center. Among this cohort, 436 subjects (71.2%) were male and 176 (28.8%) were female. Thirty-four patients experienced device-related infections from among the total patient population (n = 612) who presented with CIEDs between January 2016 and January 2019, for a total rate of 5.6%. Of the infected patients, 29 (85%) presented with local infections and five (15%) presented with systemic infections.

Conclusion

The infection rate of 5.6% observed in this study was higher than expected. Therefore, we conclude that action should be taken to reduce infection rates at our medical center to at least that seen in prior studies or below that, if possible. Moreover, we found that CIED infections were often caused by Staphylococcus species and commonly affected the elderly and patients with chronic diseases such as diabetes and hypertension. Most of the identified cases were local infections, although systemic infections were common in those with renal disease. Further studies are needed to control the risk factors and to better understand the role of antibiotics, antiseptic prophylaxis, and other methods in avoiding CIED infection and associated complications.

Risk Factors for Mortality in Cardiac Implantable Electronic Device (CIED) Infections: A Systematic Review and Meta-Analysis

Background: Infections following cardiac implantable electronic device (CIED) implantation can require surgical device removal and often results in significant cost, morbidity, and potentially mortality. We aimed to systemically review the literature and identify risk factors associated with mortality following CIED infection. Methods: Electronic searches (up to June 2021) were performed on PubMed and Scopus. Twelve studies (10 retrospective, 2 prospective cohort studies) were included for analysis. Meta-analysis was conducted with the restricted maximum likelihood method, with mortality as the outcome. The overall mortality was 13.7% (438/1398) following CIED infection. Results: On meta-analysis, the male sex (OR 0.77, 95%CI 0.57–1.01, I² = 2.2%) appeared to have lower odds for mortality, while diabetes mellitus appeared to be associated with higher mortality (OR 1.47, 95%CI 0.67–3.26, I² = 81.4%), although these trends did not reach statistical significance. Staphylococcus aureus as the causative organism (OR 2.71, 95%CI 1.76–4.19, I² = 0.0%), presence of heart failure (OR 1.92, 95%CI 1.42–4.19, I² = 0.0%) and embolic phenomena (OR 4.00, 95%CI 1.67–9.56, I² = 69.8%) were associated with higher mortality. Surgical removal of CIED was associated with lower mortality compared with conservative management with antibiotics alone (OR 0.22, 95%CI 0.09–0.50, I² = 62.8%). Conclusion: We identified important risk factors associated with mortality in CIED infections, including Staphyloccocus aureus as the causative organism, and the presence of complications, such as heart failure and embolic phenomena. Surgery, where possible, was associated with better outcomes.

Device-Related Complications and Inappropriate Therapies Among Subcutaneous vs. Transvenous Implantable Defibrillator Recipients: Insight Monaldi Rhythm Registry

INTRODUCTION

In the context of randomized clinical trials, subcutaneous implantable cardiac defibrillators (S-ICDs) are non-inferior to transvenous ICDs (T-ICDs) concerning device-related complications or inappropriate shocks in patients with an indication for defibrillator therapy and not in need of pacing. We aimed at describing the clinical features of patients who underwent S-ICD implantation in our clinical practice, as well as the ICD-related complications and the inappropriate therapies among S-ICD vs. T-ICD recipients during a long-term follow-up.

MATERIALS AND METHODS

All patients undergoing ICD, both S-ICD and TV-ICD, at Monaldi Hospital from January 1, 2015 to January 1, 2019 and followed up at our institution were included in the present analysis. The clinical variables associated with S-ICD implantation were evaluated by logistic regression analyses. We collected the ICD inappropriate therapies, ICD-related complications (including both pulse generator and lead-related complications), ICD-related infections, appropriate ICD therapies, and overall mortality. Kaplan-Meier (KM) analyses were performed to assess the risk of clinical outcome events between the two subgroups. A time-dependent Cox regression analysis was performed to adjust the results.

RESULTS

Total 607 consecutive patients (mean age 53.8 ± 16.8, male 77.8%) with both TV-ICD (n: 290, 47.8%) and S-ICD (n: 317, 52.2%), implanted and followed at our center for a mean follow-up of 1614 ± 1018 days, were included in the study. At multivariate logistic regression analysis, an independent association between S-ICD implantation and ionic channel disease [OR: 6.01 (2.26-15.87); p < 0.0001] and ischemic cardiomyopathy [OR: 0.20 (0.12-0.35); p < 0.0001] was shown. The KM analysis did not show a significantly different risk of the inappropriate ICD therapies (log rank p = 0.64) between the two subgroups; conversely, a significant increase in the risk of ICD-related complications (log rank p = 0.02) and infections (log rank p = 0.02) in TV-ICD group was shown. The adjusted risk for ICD-related infections [OR: 0.07 (0.009-0.55), p = 0.01] and complications [0.31 (0.12-0.81), p = 0.01] was significantly lower among patients with S-ICD.

CONCLUSIONS

The choice to implant S-ICD was mainly driven by younger age and the presence of ionic channel disease; conversely ischemic cardiomyopathy reduces the probability to use this technology. No significant differences in inappropriate ICD therapies were shown among S-ICD vs. TV-ICD group; moreover, S-ICD is characterized by a lower rate of infectious and non-infectious complications leading to surgical revision or extraction.

Combined Use of S-ICD and Absorbable Antibacterial Envelopes: A Proof-of-concept Study

BACKGROUND

Absorbable antibacterial envelopes (AAEs) are currently recommended in patients undergoing a transvenous ICD implantation in cases at high risk of infection, who are now preferably implanted with a subcutaneous ICD (S-ICD). Nevertheless, experiences using a combined approach with S-ICD and AAE have not been reported. The aim of our study was to evaluate this strategy in patients at very high risk of infection.

METHODS

Twenty-five patients were implanted with the S-ICD+AAE using our combined approach, restricted to patients who would fit our decisional flow algorithm identifying very high-risk patients. Patients were followed up 1 month after discharge and every 6 months thereafter. Complications were defined as device-related events requiring medical or surgical intervention for resolution and/or device reprogramming.

RESULTS

Twenty-five patients (92% males, mean age 58.5±14.1 years) were implanted with the S-ICD device and the AAE using our combined approach. The most common high-infective risk factors were diabetes requiring insulin treatment (80%) and CKD requiring hemodialysis (48%), with 7 (28%) patients presenting with more than 2 risk factors. A single mild early post-operative hematoma was observed that was managed conservatively with a spontaneous resolution. Despite a very high-risk cohort, only a single late pocket infection was detected and solved conservatively with antibiotic therapy.

CONCLUSIONS

The preliminary data of this proof-of-concept study show how a combined deployment of AAE and S-ICD in selected patients at very high risk of infection is a safe and feasible technique and may offer a reliable treatment option in specific and selected clinical settings.

Delayed Improvement of Left Ventricular Function in Newly Diagnosed Heart Failure Depends on Etiology-A PROLONG-II Substudy

In patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF), three months of optimal therapy are recommended before considering a primary preventive implantable cardioverter-defibrillator (ICD). It is unclear which patients benefit from a prolonged waiting period under protection of the wearable cardioverter-defibrillator (WCD) to avoid unnecessary ICD implantations. This study included all patients receiving a WCD for newly diagnosed HFrEF (n = 353) at our center between 2012 and 2017. Median follow-up was 2.7 years. From baseline until three months, LVEF improved in patients with all peripartum cardiomyopathy (PPCM), myocarditis, dilated cardiomyopathy (DCM), or ischemic cardiomyopathy (ICM). Beyond this time, LVEF improved in PPCM and DCM only (10 ± 8% and 10 ± 12%, respectively), whereas patients with ICM showed no further improvement. The patients with newly diagnosed HFrEF were compared to 29 patients with a distinct WCD indication, which is an explantation of an infected ICD. This latter group had a higher incidence of WCD shocks and poorer overall survival. All-cause mortality should be considered when deciding on WCD prescription. In patients with newly diagnosed HFrEF, the potential for delayed LVEF recovery should be considered when timing ICD implantation, especially in patients with PPCM and DCM.