Prevalence and predictor factors of severe venous obstruction after cardiovascular electronic device implantation

Long-Term Complications Related to Cardiac Implantable Electronic Devices

Cardiac implantable electronic devices (CIEDs) are commonly used for a number of cardiac-related conditions, and it is estimated that over 300,000 CIEDs are placed annually in the US. With advances in technology surrounding these devices and expanding indications, CIEDs can remain implanted in patients for long periods of time. Although the safety profile of these devices has improved over time, both the incidence and prevalence of long-term complications are expected to increase. This review highlights pertinent long-term complications of CIEDs, including lead-related issues, device-related arrhythmias, inappropriate device therapies, and device-related infections. We also explore key clinical aspects of each complication, including common presentations, patient-specific and non-modifiable risk factors, diagnostic evaluation, and recommended management strategies. Our goal is to help spread awareness of CIED-related complications and to empower physicians to manage them effectively.

New Diseases Related to Cardiac Implantable Electronic Devices (CIEDs): An Overview

The widespread use of Cardiac Implantable Electronic Devices (CIEDs) has transformed the management of cardiac arrhythmias, improving survival and quality of life for millions. However, this progress has introduced a range of device-related complications, which can significantly impact patient outcomes. This review examines "new diseases" linked to CIEDs, categorizing them into physical (e.g., infections, venous obstruction, lead failure, and device recalls) and functional complications (e.g., arrhythmias, pacemaker syndrome, and left ventricular dysfunction). Prevention and management strategies are emphasized. Emerging technologies, such as leadless devices, quadripolar leads, and remote monitoring systems, hold promise in reducing risks and enhancing patient care. Future directions include integrating artificial intelligence for real-time monitoring, improving device durability, and exploring novel materials to minimize infections and mechanical failures. Understanding CIED-related complications is essential for healthcare providers to balance the benefits and risks of these life-saving technologies.

Percutaneous balloon venoplasty for symptomatic lead-related venous stenosis

BACKGROUND

Lead-related venous stenosis (LRVS) is common after transvenous lead implantation and generally diagnosed incidentally. Symptomatic LRVS, causing discomfort and swelling, is less common.

OBJECTIVE

We report on the management and outcomes of patients with symptomatic LRVS after percutaneous balloon venoplasty.

METHODS

We included patients with symptomatic LRVS unresponsive to >30 days of anticoagulation who underwent venoplasty at the Hospital of the University of Pennsylvania between 2014 and 2020. Transvenous lead extraction (TLE) was performed first if the lesion could not be crossed with a wire.

RESULTS

Eighteen patients (mean age, 62 ± 10 years; 44% female) underwent 27 venoplasty procedures. Symptoms included arm swelling in 9 (50%), facial/neck swelling in 1 (6%), and both in 8 (44%). Venography revealed LRVS in the axillary/subclavian veins in 10 (56%), the brachiocephalic vein in 6 (33%), and the superior vena cava in 4 (11%). Most patients (83%) required TLE before venoplasty, and only 5 of 18 (28%) remained with leads crossing the stenosed segment. Thirteen patients (72%) had complete symptom resolution, 4 (22%) had partial resolution due to secondary lymphedema, and 1 showed no improvement. Patients with complete resolution had shorter times from symptom onset to intervention (195 vs 690 days; P = .02).

CONCLUSION

LRVS can affect any part of the venous system and may be manifested with swelling of the arm, face/neck, or both. Balloon venoplasty is safe and effective, often requires TLE, and is particularly durable when leads no longer cross the stenosed region. Venoplasty is less effective for secondary lymphedema, highlighting the need for timely intervention.

Implantable Cardioverter Defibrillator and Resynchronization Therapy in Patients With Overt Chronic Kidney Disease: JACC State-of-the-Art Review

Heart failure and chronic kidney disease are common and clinically important conditions that regularly coexist. Electrophysiologic changes of advanced heart failure often result in abnormal conduction, causing dyssynchronous contraction, and development of ventricular arrhythmias, which can lead to sudden cardiac arrest. In the last 2 decades, implantable cardioverter-defibrillator and cardiac resynchronization therapy devices have been developed to address these complications. However, when the coexisting chronic kidney disease is advanced, the associated pathophysiologic cardiovascular changes can alter the efficacy and safety of those interventions and complicate the management. This review explores the impact of comorbid advanced heart failure and advanced chronic kidney disease on the efficacy and safety of implantable cardioverter-defibrillator and cardiac resynchronization therapy, the currently available evidence, and potential future directions.

Perioperative Considerations for Modern Leadless Pacemakers

Since their initial approval by the Food and Drug Administration in 2016, leadless pacemakers have become increasingly prevalent. This growth has been driven by an improved adverse effect profile when compared to traditional pacemakers, including lower rates of infection, as well as eliminated risk of pocket hematoma and lead complications. More recently, technology enabling leadless synchronized atrioventricular pacing in patients with atrioventricular block has vastly expanded the indications for these devices. Anesthesiologists will increasingly be relied upon to safely care for patients with leadless pacemakers undergoing non-electrophysiology procedures and surgery. This article provides an overview of the technology, evidence base, current indications, and unique perioperative considerations for leadless pacemakers.

Imaging in patients with cardiovascular implantable electronic devices: part 2-imaging after device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC

Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation-both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1).

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

Incidence, Treatment, and Outcomes of Symptomatic Device Lead-Related Venous Obstruction

BACKGROUND

The incidence and clinical impact of lead-related venous obstruction (LRVO) among patients with cardiovascular implantable electronic devices (CIEDs) is poorly defined.

OBJECTIVES

The objectives of this study were to determine the incidence of symptomatic LRVO after CIED implant; describe patterns in CIED extraction and revascularization; and quantify LRVO-related health care utilization based on each type of intervention.

METHODS

LRVO status was defined among Medicare beneficiaries after CIED implant from October 1, 2015, to December 31, 2020. Cumulative incidence functions of LRVO were estimated by Fine-Gray methods. LRVO predictors were identified using Cox regression. Incidence rates for LRVO-related health care visits were calculated with Poisson models.

RESULTS

Among 649,524 patients who underwent CIED implant, 28,214 developed LRVO, with 5.0% cumulative incidence at maximum follow-up of 5.2 years. Independent predictors of LRVO included CIEDs with >1 lead (HR: 1.09; 95% CI: 1.07-1.15), chronic kidney disease (HR: 1.17; 95% CI: 1.14-1.20), and malignancies (HR: 1.23; 95% CI: 1.20-1.27). Most patients with LRVO (85.2%) were managed conservatively. Among 4,186 (14.8%) patients undergoing intervention, 74.0% underwent CIED extraction and 26.0% percutaneous revascularization. Notably, 90% of the patients did not receive another CIED after extraction, with low use (2.2%) of leadless pacemakers. In adjusted models, extraction was associated with significant reductions in LRVO-related health care utilization (adjusted rate ratio: 0.58; 95% CI: 0.52-0.66) compared with conservative management.

CONCLUSIONS

In a large nationwide sample, the incidence of LRVO was substantial, affecting 1 of every 20 patients with CIEDs. Device extraction was the most common intervention and was associated with long-term reduction in recurrent health care utilization.

Efficacy of CRT upgrade in pacemaker-induced cardiomyopathy in an outpatient clinic - Results of a prospective registry

PURPOSE

The aim of this prospective, monocentric registry study was to investigate whether upgrading to cardiac resynchronization therapy (CRT) in pacemaker-induced cardiomyopathy (PICM) can improve left ventricular function in typical outpatient clinical patients.

METHODS

We screened for PICM in a pacemaker outpatient clinic between 2017 and 2021. The follow-up period was 6 months. The primary endpoint was decreased left ventricular end systolic volume (LVESV), and the responder criterion was decreased LVESV >15%. Secondary endpoints were LVEF, NYHA class, device-associated complications and death.

RESULTS

66 patients were newly diagnosed with PICM. 55 of them received a CRT upgrade. For the primary endpoint, LVESV decreased from 101.6 ± 48.2 ml to 75.9 ± 35.8 ml (p < 0.001). Secondary endpoints were: a) LVEF increased from 31.5 ± 5.4% to 46.1 ± 7.6% (p < 0.001) and b) NYHA class improved by an average of one class in both groups (p < 0.001). The overall complication rate was 1.8%.

CONCLUSIONS

CRT upgrade in outpatient clinic patients with PICM improves left ventricular function and functional capacity and is associated with an acceptable complication rate.

Occluded vein as a predictor for complications in non-infectious transvenous lead extraction

Background

The use of cardiovascular implantable electronic device (CIED) is steadily increasing, and complications include venous occlusion and fractured leads. Transvenous lead extraction (TLE) can facilitate the re-implantation of new leads.

Aims

This study aims to explore predictors and complications of non-infectious TLE.

Methods

This study involves a retrospective analysis and comparison of characteristics, complications, and outcomes of patients with and without occluded veins (OVs) undergoing TLE at our center.

Results

In total, eighty-eight patients underwent TLE for non-infectious reasons. Indications for TLE were lead malfunction (62; 70.5%) and need for CIED upgrade (22; 25%). Fourteen patients referred due to lead malfunction had an OV observed during venography. The OV group (36 patients) were significantly older (65.7 ± 14.1 vs. 53.8 ± 15.9, p = 0.001) and had more comorbidities. Ejection fraction (EF) was significantly lower for the OV group (27.5 vs. 57.5%, p = 0.001) and had a longer lead dwelling time (3,226 ± 2,324 vs. 2,191 ± 1,355 days, p = 0.012). Major complications were exclusive for the OV group (5.5% vs. none, p = 0.17), and most minor complications occurred in the OV group as well (33.3 vs. 4.1%, p < 0.001). Laser sheath and mechanical tools for TLE were frequently used for OV as compared to the non-occluded group (94.4 vs. 73.5%, respectively, p = 0.012). Procedure success was higher in the non-occluded group compared to the OV group (98 vs. 83.3%, respectively, p = 0.047). Despite these results, periprocedural mortality was similar between groups.

Conclusion

Among the TLE for non-infectious reasons, vein occlusion appears as a major predictor of complex TLE tool use, complications, and procedural success. Venography should be considered prior to non-infectious TLE to identify high-risk patients.

The usefulness of balloon occlusive left ventricular lead delivery in combination with the quadripolar active fixation lead for a patient with complex coronary venous morphology

Complex coronary vein morphology impedes the insertion of the left ventricular (LV) lead and reduces the effectiveness of cardiac resynchronization therapy (CRT). A 77-year-old woman underwent dual-chamber pacemaker implantation via the left subclavian approach for a complete atrioventricular block 17 years previously. She was hospitalized due to decompensated heart failure, and her cardiac rhythm completely depended on ventricular pacing at that time. Transthoracic echocardiography showed thinning of the ventricular septum in the basal region and pacing-induced dyssynchrony. She was clinically diagnosed with cardiac sarcoidosis with severe LV systolic dysfunction. She was referred for an upgrade to CRT. Given that prior contrast venography showed occlusion of the left subclavian vein, an additional LV lead was inserted through the right subclavian vein. Coronary venography showed a lateral vein that branched from the great cardiac vein with an acute angle and had multiple tortuosities in the peripheral branches. Since the LV lead placement was unsuccessful with the conventional method, we attempted the lead placement using the balloon occlusion technique (BOT). Lead delivery into the anatomical optimal lateral vein was successful by using BOT, and LV pacing from the most delayed basal region was achieved in combination with the active fixation LV lead.

<Learning objective: The balloon occlusion technique in cardiac resynchronization therapy implantation has been introduced to achieve left ventricular (LV) lead insertion into the coronary vein with a complex morphology. A quadripolar active fixation LV lead, which has been recently developed, has a low dislodgement rate and enables lead placement to the desired location. Application of conventional techniques in combination with the active fixation LV lead is expected to improve the success rate of optimal LV pacing in patients with complex coronary vein morphology.>

Should they stay, or should they go: do we need to remove the old cardiac implantable electronic device if a new system is required on the contralateral side?

Background

Ipsilateral approach in patients requiring cardiac implantable electronic device (CIED) revision or upgrade may not be feasible, primarily due to vascular occlusion. If a new CIED is implanted on the contralateral side, a common practice is to explant the old CIED to avoid device interaction.

Objective

The purpose of this study was to assess a conservative approach of abandoning the old CIED after implanting a new contralateral device.

Methods

We used an artificial intelligence algorithm to analyze postimplant chest radiographs to identify those with multiple CIEDs. Outcomes of interest included device interaction, abandoned CIED elective replacement indicator (ERI) behavior, subsequent programming changes, and explant of abandoned CIED. Theoretical risk of infection with removal of abandoned CIED was estimated using a validated scoring system.

Results

Among 12,045 patients, we identified 40 patients with multiple CIEDs. Occluded veins were the most common indication for contralateral implantation (n = 27 [67.5%]). Fifteen abandoned CIEDs reached ERI, with 4 reverting to VVI 65. One patient underwent explant due to device interaction, and 2 required device reprogramming. Of 32 patients with an implantable cardioverter-defibrillator, 8 (25%) had treated ventricular arrhythmia. There were no failed or inappropriate therapies due to interaction. Eighteen patients (45%) had hypothetical >1% annual risk of hospitalization for device infection if the abandoned CIED had been explanted.

Conclusion

In patients requiring new CIED implant on the contralateral side, abandoning the old device is feasible. This approach may reduce the risk of infection and concerns regarding abandoned leads and magnetic resonance imaging scans. Knowledge of ERI behavior is essential to avoid device interactions.

Lead-Related Venous Obstruction in Patients With Implanted Cardiac Devices: JACC Review Topic of the Week

Cardiac implantable electronic device implantation rates have increased in recent decades. Venous obstruction of the subclavian, brachiocephalic, or superior vena cava veins represents an important complication of implanted leads. These forms of venous obstruction can result in significant symptoms as well as present a barrier to the implantation of additional device leads. The risk factors for the development of these complications remain poorly understood, and diagnosis relies on clinical recognition and cross-sectional imaging. Anticoagulation remains the mainstay of treatment, and thrombus debulking, lead extraction, venoplasty, and stenting are all important therapeutic interventions. This review provides a multidisciplinary-based approach to the evaluation and management of cardiac implantable electronic device lead-associated venous obstruction.

Outcomes of temporary pacing using active fixation leads and externalized permanent pacemakers in patients with cardiovascular implantable electronic device infection and pacemaker dependency

INTRODUCTION

The incidence of cardiac implantable electronic device (CIED) infections is increasing. Complete device and lead removal are recommended for all patients with definite CIED system infection. In patients with pacemaker dependency, temporary pacing before reimplantation is necessary. In this study, temporary pacing using active fixation leads (TPAFL) was evaluated.

METHODS

We reviewed data from consecutive patients implanted with TPAFL after transvenous lead extraction at our center between November 2014 and October 2020.

RESULTS

TPAFL were placed in 334 patients. The mean age was 64.5 ± 16.4 years and 76.3% were males. Two hundred and forty (72%) were treated due to local pocket infection and 94 (28%) systemic infection. The indication for temporary pacing was sick sinus syndrome in 135 (40.4%) patients and complete or high-grade atrioventricular (AV) block in 199 (59.6%) patients. The most common access site for lead implantation was the ipsilateral subclavian or axillary vein (78.9%). A new permanent CIED was reimplanted at 10.3 ± 9.2 days (median 10, range: 2-70) after implantation of the temporary pacing. There were five (1.5%) adverse events related to the temporary pacing during hospitalization. The median follow-up duration was 23.1 months (interquartile range [IQR], 7.2-43.4 months). Only one patient (0.3%) developed recurrent CIED infection.

CONCLUSION

TPAFL is safe and effective in pacemaker-dependent patients after infected CIED removal. The rate of temporary pacing-related complications, including lead dislodgment and reinfection of CIED is relatively low.

Upper Extremity Deep Vein Thrombosis and Asymptomatic Vein Occlusion in Patients With Transvenous Leads: A Systematic Review and Meta-Analysis

Aims: The presence of transvenous leads for cardiac device therapy may increase the risk of venous thromboembolisms. The epidemiology of these complications has not yet been determined systematically. Therefore, this study aims to determine (I) the incidence of symptomatic upper extremity deep vein thrombosis (UEDVT) and (II) the prevalence of asymptomatic upper extremity vein occlusion in patients with transvenous leads, both after the initial 2 months following lead implantation.

Methods: PubMed, EMBASE, and Cochrane Library were searched until March 31, 2020 to identify studies reporting incidence of UEDVT and prevalence of asymptomatic vein occlusion after the initial 2 months after implantation in adult patients with transvenous leads. Incidence per 100 patient years of follow-up (PY) and proportions (%) were calculated to derive pooled estimates of incidence and prevalence.

Results: Search and selection yielded 20 and 24 studies reporting on UEDVT and asymptomatic vein occlusion, respectively. The overall pooled incidence of UEDVT was 0.9 (95% CI 0.5–1.4) per 100PY after 2 months after lead implantation. High statistical heterogeneity was present among studies (I² = 82.4%; P = < 0.001) and only three studies considered to be at low risk of bias. The overall pooled prevalence of asymptomatic upper extremity vein occlusion was 8.6% (95% CI 6.0–11.5) with high heterogeneity (I² = 81.4%; P = <0.001). Meta-regression analysis showed more leads to be associated with a higher risk of UEDVT.

Conclusion: Transvenous leads are an important risk factor for symptomatic UEDVT, which may occur up to multiple years after initial lead implantation. Existing data on UEDVT after lead implantation is mostly of poor quality, which emphasizes the need for high quality prospective research. Asymptomatic vein occlusion is present in a substantial proportion of patients and may complicate any future lead addition.

Clinical Trial Registration: (URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178136, Identifier: PROSPERO 2020 CRD42020178136).

Long-term incidence of upper extremity venous obstruction in implantable cardioverter defibrillator patients

BACKGROUND

Very little is known about the long-term prevalence of severe venous obstruction and occlusion in patients with transvenous implantable cardioverter-defibrillator leads. The objective of the current investigation was to elucidate the incidence and prevalence and to identify predisposing conditions in an ICD cohort over a long follow-up period.

METHODS

Based on a prospective database, we analyzed consecutive patients who received an ICD implantation in our hospital between 06/1988 and 2009 as well as all corresponding follow-up data until 02/2018. Cavographies were used for analysis, and all patients with at least one device replacement and one follow-up cavography were included.

RESULTS

Over a mean follow-up period of 94 ± 50 months, severe venous obstruction was found in 147 (33%) of 448 patients. Kaplan-Meier analysis shows a severe obstruction or occlusion in 50% of patients after a period of 14.3 years. The total number of leads (p < .001, HR 2.01, CI 2.000-2.022), an advanced age (p = .004, HR 1.023 per year, CI 1.022-1.024) and the presence of dilated cardiomyopathy (p = .035, HR 1.49, CI 1.47-1.51) were predictive of venous obstruction whereas the presence of anticoagulation was not.

CONCLUSION

Severe obstruction of the access veins after ICD implantation occurs frequently and its prevalence shows a nearly linear increase over long-time follow-up. Multiple leads, an advanced age and DCM as underlying disease are associated with an increased risk of venous obstruction while the role of anticoagulation to prevent venous obstruction in ICD patients is unclear.

Cardiac Implantable Electronic Devices in Hemodialysis and Chronic Kidney Disease Patients-An Experience-Based Narrative Review

Cardiovascular implantable electronic devices (CIEDs) are a standard therapy utilized for different cardiac conditions. They are implanted in a growing number of patients, including those with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Cardiovascular diseases, including heart failure and malignant arrhythmia, remain the leading cause of mortality among CKD patients, especially in ESKD. CIED implantation procedures are considered minor surgery, typically with transvenous leads inserted via upper central veins, followed by an impulse generator introduced subcutaneously. A decision regarding optimal hemodialysis (HD) modality and the choice of permanent vascular access (VA) could be particularly challenging in CIED recipients. The potential consequences of arteriovenous access on the CIED side are related to (1) venous hypertension from lead-related central vein stenosis and (2) the risk of systemic infection. Therefore, when creating permanent vascular access, the clinical scenario may be complicated by the CIED presence on one side and the lack of suitable vessels for arteriovenous fistula on the contralateral arm. These factors suggest the need for an individualized approach according to different clinical situations: (1) CIED in a CKD patient; (2) CIED in a patient on hemodialysis CIED; and (3) VA in a patient with CIED. This complex clinical conundrum creates the necessity for close cooperation between cardiologists and nephrologists.

Mechanical extraction of cardiac implantable electronic devices leads with long dwell time: Efficacy and safety of the step up approach

The aim of this study was to evaluate the efficacy and safety of the stepwise mechanical transvenous lead extraction approach in a patient population with chronically implanted transvenous leads with a long dwell time. From January 2014 till December 2018, all lead extractions with lead dwell time ≥5 years performed at our tertiary centre were retrospectively analysed. A total of 173 leads, from 78 patients (median age 68 years; 81% male) with a median dwell time of 9 years (interquartile range [IQR] 5) were extracted, with three or more leads in 42% of the patients. Right atrial leads: 41%; right ventricular pacing leads: 16%; implantable cardioverter-defibrillator (ICD) leads: 31% (72% dual coil); coronary sinus leads: 12%. The majority (75%) of the leads had an active fixation. Most frequent indication for extraction was pocket infection/erosion (76%). Overall clinical success was 97%, and complete procedural success was 93%. Venous patency, assessed with venous angiography, was well preserved in 93% of the cases. The overall procedural complication rate was 3.8% (2.6% major and 1.3% minor). Despite the complexity of the population and a very long dwell time (median 9 years), a clinical success rate of 97% was achieved with the stepwise mechanical approach. Analysis of impeding progression of pectoral extraction suggests that dense fibrosis and sharp lead curvature in the transvenous trajectory pose a challenge. Complication rate was low, and acute venous patency was generally well preserved.

Efficacy and safety of transvenous lead extraction using a liberal combined superior and femoral approach

Purpose

During transvenous lead extraction (TLE), the femoral snare has mainly been used as a bail-out procedure. The purpose of the present study is to evaluate the efficacy and safety of a TLE approach with a low threshold to use a combined superior and femoral approach.

Methods

This is a single-center observational study including all TLE procedures between 2012 till 2019.

Results

A total of 264 procedures (median age 63 (51–71) years, 67.0% male) were performed in the study period. The main indications for TLE were lead malfunction (67.0%), isolated pocket infection (17.0%) and systemic infection (11.7%). The median dwelling time of the oldest targeted lead was 6.8 (4.0–9.7) years. The techniques used to perform the procedure were the use of a femoral snare only (30%), combined rotational powered sheath and femoral snare (25%), manual traction only (20%), rotational powered sheath only (17%) and locking stylet only (8%). The complete and clinical procedural success rate was 90.2% and 97.7%, respectively, and complete lead removal rate was 94.1% of all targeted leads. The major and minor procedure-related complication rates were 1.1% and 10.2%, respectively. There was one case (0.4%) of emergent sternotomy for management of cardiac avulsion. Furthermore, there were 5 in-hospital non-procedure-related deaths (1.9%), of whom 4 were related to septic shock due to a Staphylococcus aureus endocarditis after an uncomplicated TLE with complete removal of all leads.

Conclusion

An effective and safe TLE procedure can be achieved by using the synergy between a superior and femoral approach.

State of the art: leadless ventricular pacing : A national expert consensus of the Austrian Society of Cardiology

Background

Cardiac pacing has been shown to improve quality of life and prognosis of patients with bradycardia for almost 60 years. The latest innovation in pacemaker therapy was miniaturization of generators to allow leadless pacing directly in the right ventricle. There is a long history and extensive experience of leadless ventricular pacing in Austria. However, no recommendations of national or international societies for indications and implantation of leadless opposed to transvenous pacing systems have been published so far.

Results

A national expert panel of skilled implanters gives an overview on the two utilized leadless cardiac pacing systems and highlights clinical advantages as well as current knowledge of performance and complication rates of leadless pacing. Furthermore, a national consensus for Austria is presented, based on recent studies and current know-how, specifically including indications for leadless pacing, management of infection, suggestions for qualification, and training of the operators and technical standards.

Conclusions

Leadless pacing systems can be implanted successfully with a low complication rate, if suggestions for indications and technical requirements are followed.

Condensed abstract

An overview of the two utilized leadless cardiac pacing systems is given, specifically highlighting clinical advantages as well as current knowledge of performance and complication rates. Furthermore, a national consensus for Austria is presented, specifically including indications for leadless pacing, management of infection, and suggestions for qualification and technical standards.

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.

The role of hemostatic markers as venous stenosis or occlusion predictors following first transvenous cardiac device implantation

BACKGROUND

Among patients with an implanted cardiac implantable electronic device (CIED), ipsilateral upper extremity vein stenosis or occlusion (VSO) is observed more frequently than in the general population. However, there are no data available concerning the relationship between hemostatic markers (and their dynamics) and the occurrence of VSO. The aim of this study was to assess the predictive value of beta-thromboglobulin, the von Willebrand factor (vWF), fibrynogen and D-dimer for VSO development among first time CIED recipients.

METHODS

This is a single-center, prospective study of consecutive first time CIED recipients without upper extremity VSO in baseline ultrasound examination. Biochemical data were collected from all the patients before CIED implantation (first measuring), up to 7 days subsequent (second measuring) and 6 months after the operation (third measuring). Primary endpoint was defined as the presence of upper extremity VSO at the implantation site during the ultrasound examination 6 months after the operation.

RESULTS

The study included 71 patients (mean age 73.1 ± 10.5 years; 39 [55%] male). The incidence of VSO within 6-months follow up was 21.1%. Average concentrations of hemostatic markers increased significantly in all patients immediately after CIED implantation. Serial hemostatic marker concentrations were similar in patients who met or did not meet the primary endpoint, apart from vWF. The mean concentration was significantly elevated in the group of 15 patients who reached the primary endpoint (p = 0.032).

CONCLUSIONS

A significant increase in vWF concentration at 6 months post implantation may be a marker for VSO occurrence.

Is ventricular sensing always right, when it is left?

BACKGROUND

Ventricular sensing in transvenous cardiac implantable electronic devices (CIEDs) occurs conventionally from the right ventricular (RV) channel, though it evolved from epicardial sensing both in pacemakers and implantable cardioverter-defibrillators (ICDs).

HYPOTHESIS

The objective of this study was to observe the reliability of left ventricular (LV) sensing by transvenous leads placed in coronary veins.

METHODS

LV leads were used for sensing and arrhythmia detection in clinical situations where placement of an RV lead across the tricuspid valve was either not preferred or not feasible, or RV signal was unsuitable for arrhythmia detection, or in the event of sensing failure of an RV lead under advisory in cardiac resynchronization therapy defibrillator (CRTD) recipients.

RESULTS

Thirty-seven patients had an IS-1 LV lead connected to the RV port of CIEDs (17 pacemakers, 5 cardiac resynchronization therapy pacemaker [CRTP], 2 ICDs, and 13 CRTDs). Along a median 41 (25-67) months follow-up, lead performance remained stable; there were neither undersensing nor oversensing of non-cardiac signals. VT/VF were correctly detected and terminated by ATP and shocks (one and three patients, respectively); no inappropriate arrhythmia detection. Device reprogramming occurred in four CRTD recipients because of transient counting the QRS (short intervals) when paced in LV-only, and in two with T-wave oversensing.

CONCLUSIONS

Ventricular sensing by an LV lead is feasible in transvenous devices. Sensing programmability is an unmet need: to fix RV lead sensing issues in cardiac resynchronization therapy (CRT) recipients at no risk of infection (no pocket opening); to avoid interaction with the tricuspid valve; to avoid lead redundancy in the vasculature. Moreover, it will be mandatory owing to the loss of lead interchangeability due to the adoption of DF-4 and quadripolar leads.

Lead failure in transvenous implantable cardioverter defibrillator: a new opportunity for an effective management

In case of transvenous defibrillator lead failure, a subcutaneous defibrillator may be implanted and the lead may be abandoned in order to avoid particular risk situations. For patients who require pacing and with an operational atrial lead, the transvenous ICD may be also maintained to ensure antibradycardia support.

Balloon venoplasty opens the road for an implantable defibrillator patient with complex stenosis

There is an increasing need for physicians to handle venous obstructions in pacemaker/implantable cardioverter-defibrillator implants. Venoplasty performed by an experienced operator is a simple, safe, and fast way to manage this situation and proceed to implant. Compared to other approaches, this strategy may offer particular advantages.