PlasmaBlade versus Electrocautery for Deep Inferior Epigastric Perforator Flap Harvesting in Autologous Breast Reconstruction: A Comparative Clinical Outcome Study

(1) Background: DIEP-based breast reconstruction necessitates wide undermining at the abdominal donor site, creating large wound areas. Flap harvesting is usually conducted using electrosurgical dissection devices. This study sought to compare the clinical outcomes in patients after using the PEAK PlasmaBlade (PPB) versus monopolar electrocautery (MPE). (2) Methods: This retrospective cohort study included 128 patients with DIEP-based breast reconstruction. Patient characteristics and information on the postoperative course were collected and a comparative evaluation was conducted. (3) Results: The MPE group exhibited significantly (p* = 0.0324) higher abdominal drainage volume (351.11 ± 185.96 mL) compared to the PPB group (279.38 ± 183.38 mL). A subgroup analysis demonstrated that PPB significantly reduced postoperative wound fluid in patients with BMI > 30 kg/m2 (p* = 0.0284), without prior neoadjuvant chemotherapy (p** = 0.0041), and among non-smokers (p = 0.0046). Furthermore, postoperative pain was significantly (p**** < 0.0001) lower in the PPB cohort. (4) Conclusions: This study confirms the non-inferiority of the PEAK PlasmaBlade to conventional electrocautery for abdominal flap harvesting. The PPB demonstrated advantages, notably reduced drainage volume and lower postoperative pain levels. Recognizing patient subsets that benefit more from the PPB highlights the importance of personalized device selection based on patient characteristics.

Dissection using pulsed radiofrequency energy device (PlasmaBlade) is safe and efficient in experimental revision neuromodulation implant surgery

BACKGROUND

The use of functional neurosurgical implants has increased over the past 10 years. PlasmaBlade is an innovative electrosurgical appliance harnessing pulsed radiofrequency (RF) energy. Our aim was to assess the risk of damage to neuromodulation hardware during PlasmaBlade dissection.

MATERIALS AND METHODS

A simulated setting with chicken breast threaded with different hardware and PlasmaBlade used in three configurations. . Post dissection, the wires were inspected naked eye and under an operating microscope. The induced current was assessed contemporaneously using an oscilloscope.

RESULTS

Five surgeons tested the PlasmaBlade at different generator settings. Sixty dissections were undertaken. No structural damage or induced current was identified at CUT 3/4, COAG 5. At CUT 6, COAG 5 and during dissection in a perpendicular orientation with prolonged hardware contact, opacification of insulation material occurred in 15/20 dissections. There was no dissolution of insulation even at this setting. On deviation from Medtronic advice, hardware damaged occurred if one was reckless with the PlasmaBlade.

CONCLUSION

When using the recommended settings and operational technique, PlasmaBlade dissection did not cause any damage to implant wiring/tubing in this simulated setting. This report seeks to add to clinical data suggesting PlasmaBlade is safe for dissection around deep brain stimulator (DBS), vagal nerve stimulator (VNS), and spinal cord stimulator (SCS) hardware.

Early Pacemaker Implantation after Transcatheter Aortic Valve Replacement: Impact of PlasmaBlade™ for Prevention of Device-Associated Bleeding Complications

Background and Objectives: Permanent pacemaker implantation (PPI) is frequently required following transcatheter aortic valve replacement (TAVR). Dual antiplatelet therapy (DAPT) or oral anticoagulation therapy (OAK) is often necessary in these patients since they are at higher risk of thromboembolic events due to TAVR implantation, high incidence of coronary artery diseases (CAD) with the necessity of coronary intervention, and high rate of atrial fibrillation with the need of stroke prevention. We sought to evaluate the safety, efficiency, and clinical outcomes of early PPI following TAVR using the PlasmaBlade™ (Medtronic Inc., Minneapolis, MN, USA) pulsed electron avalanche knife (PEAK) for bleeding control in patients under DAPT or OAK. Materials and Methods: This retrospective single-center study included patients who underwent PPI after transfemoral TAVR (TF) at our center between December 2015 and May 2020. All PPI were performed using the PlasmaBlade™ Device. Results: The overall PPI rate was 14.1% (83 of 587 patients; 82.5 ± 4.6 years; 45.8% male). The PPI procedures were used to treat high-grade atrioventricular block (81.9%), severe sinus node dysfunction (13.3%), and alternating bundle branch block (4.8%). At the time of the procedure, 35 (42.2%) patients received DAPT, and 48 (57.8%) patients received OAK (50% with vitamin K antagonist (VKA) and 50% with novel oral anticoagulants (NOAK)). One device-pocket hematoma treated conservatively occurred in a patient (1.2%) receiving NOAK. Two re-operations were necessary in patients due to immediate lead dislocation (2.4%). Conclusions: The results of this study illustrate that the use of PlasmaBlade™ for PPI in patients after a TAVR who require antithrombotic treatment is feasible and might result into lower rates of severe bleeding complications compared to rates reported in the literature. Use of the PlasmaBlade device may be considered in this specific group of patients because of their high risk of bleeding.

Comparative healing of swine skin following incisions with different surgical devices

Background

Electrosurgical technology is widely used in surgical dissection and hemostasis, but the generated heat creates thermal injury to adjacent tissues and delays wound healing. The plasma blade (PB) applies pulsed radiofrequency (RF) to generate electrical plasma along the edge of a thin, flat, insulated electrode, minimizing collateral tissue damage. This study aimed to evaluate wound healing in swine skin following incision with a new surgical system that applies low-temperature plasma (NTS-100), a foreign PB, conventional electrosurgery (ES), and a scalpel blade.

Methods

In vitro porcine skin and an in vivo porcine skin model were used in this study. Full-thickness skin incisions 3 cm in length were made on the dorsum of each animal for each of the 5 surgical procedures at 0, 21, 28, 35, and 42 days. The timing of the surgical procedures allowed for wound-healing data points at 1, 2, 3, and 6 weeks accordingly. Local operating temperature and blood loss were quantified. Wounds were harvested at designated time points, tested for wound tensile strength, and examined histologically for scar formation and tissue damage.

Results

Local operating temperature was reduced significantly with NTS-100 (cut mode 83.12±23.55 °C; coagulation mode 90.07±10.6 °C) compared with PB (cut mode 94.46±11.48 °C; coagulation mode 100.23±6.58 °C, P<0.05) and ES (cut mode 208.99±34.33 °C, P<0.01; coagulation mode 233.37±28.69 °C, P<0.01) in vitro. Acute thermal damage from NTS-100 was significantly less than ES incisions (cut mode: 247.345±42.274 versus 495.295±103.525 µm, P<0.01; coagulation mode: 351.419±127.948 versus 584.516±31.708 µm, P<0.05). Bleeding, histological scoring of injury, and wound strength were equivalent for the NTS-100 and PB incisions.

Conclusions

The local operating temperature of NTS-100 was lower than PB, and NTS-100 had similarly reliable safety and efficacy.

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Clinical application of PEAK PlasmaBlade to remove distal tracheal granulation in patients after tracheostomy

OBJECTIVE

Tracheal granulation is one of the common long term complications in patients after tracheostomy. Hypertrophic tracheal granulation may cause airway obstruction and further operation may be required to recreate an airway. Distal tracheal granulation is clinically challenging because of its position and surgical field limitation. This retrospective case review study evaluated the outcomes of PEAK PlasmaBlade-assisted tracheal surgery in patients with distal tracheal granulation.

METHODS

This study retrospectively reviewed patients with distal tracheal granulation following long-term tracheostomy. All patients received PEAK PlasmaBlade assistance tracheal surgery (PATS) between February 2013 and December 2019. The surgery was performed using the PEAK PlasmaBlade with TnA type tip, powered by a PULSAR Generator, and guided by a 45 ° rigid endoscope. Patients were regularly followed up for a minimum of 12 months.

RESULTS

A total 21 patients had completed PATS. None of the patients experience immediate life-threatening complications during or after the procedure. All the 21 patients were free of recurrent obstructive granulation within 12 months after operation.

CONCLUSION

PATS is practical, effective, and safe for distal tracheal granulation and can be performed by single surgeon. Furthermore, it is technically less demanding than other surgical approaches and it has a rapid learning curve.

Deep brain stimulation and electromagnetic interference

Deep brain stimulation (DBS) has evolved into an approved and efficacious treatment for movement, obsessive-compulsive, and epilepsy disorders that are refractory to medical therapy, with current investigation into other disease conditions. However, there are unintentional and intentional sources of external electromagnetic interference (EMI) that can lead to either malfunctioning or damaged DBS devices, as well as injury to human tissue. Comprehensive studies and guidelines on such topics in the medical literature are scarce. Herein, we review the principles behind EMI, as well as the various potential sources of interference, both unintentional (e.g. stray EMI fields) and intentional (e.g. MRI scans, "brainjacking"). Additionally, we employ the Manufacturer and User Device Facility Experience (MAUDE) database to assess real-world instances of EMI (e.g., airport body scanners, magnetic resonance imaging (MRI), and electrosurgery) affecting DBS devices commonly implanted in the United States (US).

Low-temperature electrocautery reduces adverse effects from secondary cardiac implantable electronic device procedures: Insights from the WRAP-IT trial

BACKGROUND

Cardiac device procedures require tissue dissection to free existing device lead(s). Common techniques include blunt dissection, standard electrocautery, and low-temperature electrocautery (PlasmaBlade, Medtronic); however, data on the type of electrosurgical tool used and the development of procedure- or lead-related adverse events are limited.

OBJECTIVE

The purpose of this study was to determine whether standard or low-temperature electrocautery impacts the development of an adverse event.

METHODS

We evaluated patients enrolled in WRAP-IT (Worldwide Randomized Antibiotic EnveloPe Infection PrevenTion Trial) undergoing cardiac implantable electronic device (CIED) revision, upgrade, or replacement. All adverse events were adjudicated by an independent physician committee. Data were analyzed using Cox proportional hazard regression modeling.

RESULTS

In total, 5641 patients underwent device revision/upgrade/replacement. Electrocautery was used in 5205 patients (92.3%) (mean age 70.6 ± 12.7 years; 28.8% female), and low-temperature electrocautery was used in 1866 patients (35.9%). Compared to standard electrocautery, low-temperature electrocautery was associated with a 23% reduction in the incidence of a procedure- or lead-related adverse event through 3 years of follow up (hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.65-0.91; P = .002). After controlling for the number of active leads, degree of capsulectomy, degree of lead dissection, and renal dysfunction, low-temperature electrocautery was associated with a 32% lower risk of lead-related adverse events (HR 0.68; 95% CI 0.52-0.89; P = .004). These effects were consistent across a spectrum of lead-related adverse event types.

CONCLUSION

This study represents one of the largest assessments of electrocautery use in patients undergoing CIED revision, upgrade, or replacement procedures. Compared to standard electrocautery, low-temperature electrocautery significantly reduces adverse effects from these procedures.

Lead damage after cardiac implantable device replacement procedure: Comparison between electrical plasma tool and electrocautery

BACKGROUND

Lead damage is a complication caused by lead manipulation or heating damage from conventional electrocautery (EC) after cardiovascular implantable electronic device (CIED) replacement. Application of electrical plasma (PEAK PlasmaBlade) is a new technology that reportedly reduces this risk.

OBJECTIVES

This study was designed to compare the effect of EC versus PEAK PlasmaBlade on lead parameters and complications after generator replacement procedures.

METHODS

We retrospectively studied 410 consecutive patients (840 leads) who underwent CIED replacement using EC (EC group) and 410 consecutive patients (824 leads) using PEAK PlasmaBlade (PlamaBlade group). Pacing lead impedance, incidence of lead damage, and complications were compared between both groups.

RESULTS

Lead impedance increased in 393 leads (46.8%) in the EC group versus 282 leads (34.2%) in the PlasmaBlade group (p < .01) with average percent changes of 6.7% and 4.0% (p < .01), respectively. Lead impedance decreased in 438 leads (52.1%) in the EC group versus 507 leads (61.5%) in the PlasmaBlade group (p < .01) with average percent changes of -5.7% and -7.1% (p < .01), respectively. Lead damage requiring lead revision occurred in five leads (0.6%) or after five procedures (1.2%) in the EC group compared to three leads (0.4%, p = .50) or after three procedures (0.7%, p = .48) in the PlasmaBlade group. There were no significant differences in the procedural-related complications between the EC group (nine patients, 2.2%) and the PlasmaBlade group (five patients, 1.2%, p = .28).

CONCLUSION

Conventional electrocautery can potentially damage lead insulations. However, this study shows that when used carefully electrocautery is as safe as the PEAK PlasmaBlade™.

Bilateral reduction mammaplasty with pulsed electron avalanche knife PlasmaBlade™ and conventional electrosurgical surgery: A retrospective, randomised controlled clinical trial

Wound-healing disorders are common complications in bilateral reduction mammaplasty. Traditional electrosurgical devices generate large amounts of thermal energy, often causing extensive thermal-related collateral tissue damage. This study aimed to retrospectively analyse the operative performance of a novel low-thermal plasma dissection device (pulsed electron avalanche knife-PEAK PlasmaBlade™) compared with traditional electrosurgery. Twenty patients with breast hypertrophy were randomly treated with PEAK PlasmaBlade™ on one breast and conventional electrosurgery on the other. Primary outcome measures were resection weight, drain duration, total drainage volume, and drain output on the first postoperative day. Breasts treated with PEAK PlasmaBlade™ had significantly higher resection weights (728.0 ± 460.1 g vs 661.6 ± 463.4 g; P = .038), significantly lower drain output on the first postoperative day (15.9 ± 15.2 mL vs 27.6 ± 23.5 mL; P = .023), and significantly lower drain durations (2.8 ± 1.0 days vs 3.3 ± 1.0 days; P = .030). Mean total drainage volume was lower where breast reduction was performed with PEAK PlasmaBlade™, but this difference was not significant. No major complications occurred, but wound-healing disorders were documented in almost one-third of the patients (35.0%, n = 7). The PEAK PlasmaBlade™ seems to be superior to conventional electrosurgery for bilateral reduction mammaplasty in terms of tissue damage and wound healing.

Utilization of low-temperature helium plasma (J-Plasma) for dissection and hemostasis during carotid endarterectomy

Herein we report nine cases of carotid endarterectomy in which we used a cold atmospheric helium plasma device (J-Plasma; Apyx Medical Corporation, Clearwater, Fla). Although clinical reports are limited, experimental data indicate that this technology could be used for dissection and coagulation during surgery, yielding limited adjacent tissue damage. As a result, it could be extremely useful in procedures like carotid endarterectomy that necessitate careful dissection and coagulation with limited damage of adjacent neurovascular structures.

Comparative analysis on the effect of low-thermal plasma dissection device (PEAK PlasmaBlade) versus conventional electro surgery in post-bariatric body-contouring procedures: A retrospective randomised clinical study

Postoperative wound-healing problems are relatively high in post-bariatric body-contouring procedures, partly because of electrosurgery and the associated thermal tissue damage. This study is a retrospective randomised evaluation of the effect of a low-thermal plasma dissection device (PEAK PlasmaBlade, Medtronic, Minneapolis, Minnesota) in comparison with conventional electrosurgery. A total of 24 patients undergoing upper arm or medial thigh lifting were randomised to PEAK PlasmaBlade on one side and to monopolar electrosurgery on the other side of the same patient. Wounds of 10 patients were examined histologically for acute thermal injury depth. Significantly lower total volume of drain output (61,1 ± 70,2 mL versus 95,1 ± 176,0 mL; P = .04) was found on the PEAK PlasmaBlade side compared with the electrosurgery side. Furthermore, the PEAK PlasmaBlade side showed fewer seromas (no case of seroma versus three seromas in the electrosurgery group) and less thermal damage (40% versus 70%; P = .26). Acute thermal injury depth from the PEAK PlasmaBlade was less than from monopolar electrosurgery (425 ± 171 μm versus 686 ± 1037 μm; P = .631). PEAK PlasmaBlade appears to be superior to traditional monopolar electrosurgery for post-bariatric body-contouring procedures because it demonstrated less tissue damage, lower total volume of drain output, and fewer postoperative seromas resulting in faster wound healing.

Use of pulsed electron avalanche knife (PEAK) PlasmaBlade™ in patients undergoing implantation of subcutaneous implantable cardioverter-defibrillator

Introduction

Surgical implantation of subcutaneous implantable cardioverter-defibrillators (S-ICD) requires preparation of a deeper and larger pocket. Infection and bleeding complications are reported, particularly in patients requiring antiplatelet therapy (APT) or being on oral anticoagulation (OAC), with rates up to 25%. The pulsed electron avalanche knife (PEAK) PlasmaBlade™ has been reported to reduce bleeding complications. The purpose of this study was to evaluate the safety and feasibility of a PEAK guided S-ICD implantation with respect to perioperative complications.

Methods and results

We enrolled 36 consecutive patients (75% male; mean age 52.1 ± 14.4 years) undergoing S-ICD implantation. Periprocedural safety endpoints comprised major complications including pocket hematomas, wound infections, bleeding (BARC ≥2) or events requiring interventions. Patients were divided into three groups according to management of their anticoagulation: i.) APT, n = 15 (41.7%); ii.) OAC, n = 10 patients (27.8%); iii.) none (neither OAC nor APT), n = 11 (30.6%). Mean procedure duration was 33.1 ± 13.4 min. Mean length of hospital stay was 3.3 ± 2.1 days. Overall analysis showed no differences between the 3 groups with respect to major complications, major bleeding episodes or other procedural parameters, beside a trend towards more minor hematomas in the OAC group (OAC: 22.2% vs. APT: 11.4% vs. none: 9.1%; p = 0.15).

Conclusion

The results of our pilot study suggest that intermuscular S-ICD implantation using PEAK is safe and potentially beneficial in patients receiving OAC or APT with respect to prevention of bleeding complications. These results support the rationale for large prospective controlled trials evaluating a beneficial effect of PEAK use in S-ICD implantation procedures.

Preclinical Comparison of Thermal Tissue Effects from Traditional Electrosurgery and a Low-Temperature Electrosurgical Device during Anterior Cervical Discectomy and Fusion

Background

Exposure of the anterior cervical spine requires dissection in proximity to critical neurovascular structures. Monopolar electrosurgical (ES) devices generate heat in contacted tissues, resulting in thermal damage and temperature change. This study examined depth of thermal injury and temperature change associated with use of a low-temperature electrosurgical device (LTD) compared to traditional electrosurgery during a cadaveric anterior cervical discectomy and fusion (ACDF) dissection.

Methods

ACDF was performed, using ES or LTD, on cervical spines (C3-4 and C4-5) from 2 fresh human cadavers with intact neck soft tissues and no history of surgery. Cadavers were maintained at 22-23°C, and fiber-optic temperature sensors (Neoptix, Québec City, Québec, Canada) were placed near relevant structures to measure changes during dissection. Depth of thermal injury was assessed by hematoxylin and eosin and Masson's trichrome histology of fixed tissue specimens.

Results

Use of the LTD resulted in a statistically significant reduction in temperature change at platysma (3.0 ± 1.04 vs. 11.41 ± 3.10°C, P = .003), carotid sheath (7.32 ± 1.13 vs. 15.57 ± 2.56°C, P = .007), and longus colli (6.11 ± 1.32 vs. 12.9 ± 3.62°C, P = .016) compared to ES. Temperature change at the trachea was similar between groups (6.06 ± 1.99 vs. 4.96 ± 1.89°C, P = .528). Histology showed that LTD produced less mean and maximal depth of thermal injury compared to ES (mean: 0.5 vs. 1.2 mm; max: 0.9 vs. 1.8 mm; P < .05).

Conclusions

The results of this pilot study demonstrate that anterior cervical spine exposure using an LTD reduces tissue temperature change and depth of thermal injury compared to ES.

Clinical Relevance

Although exploratory, these results suggest that use of an LTD during ACDF may reduce the extent of thermal tissue injury during dissection. Future studies in live animal models are warranted to determine if thermal injury is a potential cause of common exposure-related complications, such as dysphagia and dysphonia.

Risk of Collateral Lead Damage in Percutaneous Cardiac Implantable Electronic Device Extraction

OBJECTIVES

This study sought to assess the risk of collateral lead damage during cardiac implantable electronic device extraction.

BACKGROUND

With the increasing numbers of cardiovascular implantable electronic devices, there has been an increase in the number of percutaneous device and lead extractions. It is unknown how often collateral damage (defined as the need for unintended lead extraction, or loss of lead's integrity or dislodgement) occurs in the planned retained leads.

METHODS

In this retrospective study, 108 patients who underwent incomplete cardiovascular implantable electronic device removal at the University of California, San Diego from September 2010 to September 2015 were included. The authors established the integrity of previously functioning leads at the end of each procedure as well as on follow-up visits using parameters including lead impedance change, threshold change, drop in P- or R-wave signal amplitude, or presence of lead noise.

RESULTS

Only 4 of 143 leads (2.7%) were found to have collateral damage. One right atrial (RA) lead had a clear insulation break, the second RA lead was found dislodged, and the third RA had a constant noise. The right ventricular lead was found to have a new high pacing threshold. Collateral lead age, extracted lead implantation site, collateral lead implantation site, and mode of lead extraction (laser, traction, or rotational dilator) did not have a significant correlation with the outcome of collateral lead damage.

CONCLUSIONS

Lead extraction can be performed safely; however, there is a small risk of damaging adjacent leads. Close follow-up is needed, especially for the first few months, to assess for the reconnected leads' integrity.

An electrical plasma dissection tool for surgical treatment of chronic ulcers: Results of a prospective randomised trial

Cutaneous ulceration is a difficult medical problem and a major source of morbidity for patients. In the surgical treatment of ulcers, debridement is the first step, and it can be carried out using several surgical tools. Recently, new surgical devices have emerged using plasma-mediated electrical discharges with a lower peak temperature. A prospective single-blind trial was conducted on chronic ulcers not responsive to common non-surgical management. Patients were randomly separated into 2 groups: Group A received surgical debridement with conventional electrocautery, and Group B received surgical debridement using the plasma-mediated device. Histological samples were collected intraoperatively to evaluate the thermal damage during the surgical procedure and 2 weeks after surgery to evaluate the inflammatory response and collagen deposition. The width of coagulation necrosis at the incision margins in Group B was significantly shorter compared with Group A (P = .001). The inflammatory cell infiltration showed a cellular distribution percentage that was quite equal between the 2 groups. The granulation tissue showed an abundant deposition of dense and mature collagen in Group B, compared with Group A, where the mature collagen appeared in small quantities (P < .001). Microbial culture showed a lower incidence of postoperative infections in Group B compared with the control group (P < .05). The study demonstrated, based on the results, that the new technology with the use of a lower temperature electrosurgical device represents an effective therapeutic weapon for the surgical treatment of skin ulcers, both vascular and extravascular types.

Economic assessment of traditional surgical intervention versus use of a new innovative radiofrequency based surgical system in device replacements

Introduction

Intra-operative complications like mechanical damages to the leads, infections and hematomas during generator replacements of implantable pacemakers and defibrillators contribute to additional costs for hospitals. The aim of this study was to evaluate operation room use, costs and budget impact of generator replacements using either a traditional surgical intervention (TSI) with scissors, scalpel and electrocautery vs. a new radiofrequency energy based surgical system, called PEAK PlasmaBlade^TM (PPB).

Materials and methods

We conducted a retrospective analysis of a population including 508 patients with TSI and 254 patients with PPB who underwent generator replacement at the Kepler University Hospital in Linz or the St. Josef Hospital in Braunau, Austria. The economic analysis included costs of resources used for intra-operative complications (lead damages) and of procedure time for TSI vs. PPB.

Results

Proportion of males, mean age and type of generator replaced were similar between the two groups. Lead damages occurred significantly more frequent with TSI than with PPB (5.3% and 0.4%; p< 0.001) and the procedure time was significantly longer with TSI than with PPB (47.9±24.9 and 34.1±18.1 minutes; p<0.001). Shorter procedure time and a lower rate of lead damages with PPB resulted in per patient cost savings of €81. Based on estimated 2,700 patients annually undergoing generator replacement in Austria, the use of PPB may translate into cost savings of €219,600 and 621 saved operating facility hours.

Conclusion

PPB has the potential to minimize the risk of lead damage with more efficient utilization of the operating room. Along with cost savings and improved quality of care, hospitals may use the saved operating room hours to increase the number of daily surgeries.

Pulsed electron avalanche knife (PEAK) PlasmaBlade™ in pacemaker and defibrillator procedures

Background

The pulsed electron avalanche knife (PEAK) PlasmaBlade™ is an innovative electrosurgical device that uses a novel technology to cut tissues. It has been proven to be safe and feasible in ear, nose, and throat surgery, but there are only limited data concerning the use of PlasmaBlade™ instead of conventional electrocautery in cardiac implantable electronic device (CIED) procedures except for generator replacements.

Methods

We conducted a retrospective, single-center study with patients undergoing CIED surgery at our center between December 2015 and March 2017 and evaluate the feasibility and the clinical outcome of the PlasmaBlade™.

Results

282 patients (mean age 70.7 ±  12.9 years; 65.6% male) were included, of which 119 (42.2%) underwent pacemaker implantation, 95 (33.7%) implantable cardioverter defibrillator implantation, and 68 (24.1%) received a generator replacement. At the time of the procedure, 55 patients (19.5%) were on dual antiplatelet therapy, and 109 (38.7%) patients were on oral anticoagulation (30.5% vitamin K antagonists, 8.2% novel oral anticoagulants). The overall perioperative complication rate was 3.9%. Device-pocket hematoma occurred in 9 patients (3.2%) requiring further surgery. No lead damage was seen within a follow-up of 6 months. One patient presented with device-pocket infection 2.9 months after implantation of a cardiac resynchronization therapy defibrillator requiring CIED system extraction.

Conclusions

Replacing conventional electrocautery by PlasmaBlade™ for CIED procedures is feasible with a moderate rate of perioperative complications compared to the literature. Studies comparing the PlasmaBlade™ with conventional electrocautery are necessary to investigate whether PlasmaBlade™ offers an additional benefit over conventional electrocautery.

Methods of hemostasis in abdominal surgery

Hemorrhage is one of the common concomitant conditions during abdominal surgeries, and it is also the main cause of non-planed secondary surgery. There are various methods for abdominal surgical hemostasis. How to adopt reasonable methods to manage intraoperative bleeding promptly and effectively has bothered surgeons for a long time. With the development of minimally invasive technology and surgical instruments, laparoscopy and more hemostasis techniques have been widely used during abdominal surgery. This article summarizes the methods of hemostasis during abdominal surgery.

Global health resource utilization associated with pacemaker complications

AIM

To estimate health resource utilization (HRU) associated with the management of pacemaker complications in various healthcare systems.

METHODS

Electrophysiologists (EPs) from four geographical regions (Western Europe, Australia, Japan, and North America) were invited to participate. Survey questions focused on HRU in the management of three chronic pacemaker complications (i.e. pacemaker infections requiring extraction, lead fractures/insulation breaches requiring replacement, and upper extremity deep venous thrombosis [DVT]). Panelists completed a maximum of two web-based surveys (iterative rounds). Mean, median values, and interquartile ranges were calculated and used to establish consensus.

RESULTS

Overall, 32 and 29 panelists participated in the first and second rounds of the Delphi panel, respectively. Consensus was reached on treatment and HRU associated with a typical pacemaker implantation and complications. HRU was similar across regions, except for Japan, where panelists reported the longest duration of hospital stay in all scenarios. Infections were the most resource-intensive complications and were characterized by intravenous antibiotics days of 9.6?13.5 days and 21.3?29.2 days for pocket and lead infections respectively; laboratory and diagnostic tests, and system extraction and replacement procedures. DVT, on the other hand, was the least resource intensive complication.

LIMITATIONS

The results of the panel represent the views of the respondents who participated and may not be generalizable outside of this panel. The surveys were limited in scope and, therefore, did not include questions on management of acute complications (e.g. hematoma, pneumothorax).

CONCLUSIONS

The Delphi technique provided a reliable and efficient approach to estimating resource utilization associated with chronic pacemaker complications. Estimates from the Delphi panel can be used to generate costs of pacemaker complications in various regions.

Incidence of Bleeding-Related Complications During Primary Implantation and Replacement of Cardiac Implantable Electronic Devices

BACKGROUND

Use of cardiac implantable electronic devices (CIEDs) is increasing. The incidence of bleeding-related complications during CIED procedures and the association with subsequent infection risk have been studied in trial settings but not in nonrandomized "real-world" populations.

METHODS AND RESULTS

This retrospective database analysis of US insurance claims from the Truven MarketScan database (2009-2013) evaluated the incidence of bleeding complications during, or in the 30 days following, a CIED procedure and the association between bleeding and subsequent infection in days 31 to 365 of follow-up. This study identified 42 606 patients who had a primary or replacement CIED procedure and met all inclusion criteria. Incidence of bleeding ranged from 0.58% to 2.81% by type of pharmaceutical therapy. Incidence of infection during days 31 to 365 of follow-up was significantly higher among patients with a bleeding complication in the first 30 days versus those without (6.56% vs 1.24%, P<0.001), with results upheld in multivariate analysis (HR=2.97, 95% CI 1.94-4.54, P<0.001).

CONCLUSIONS

This study provides a lower bound of the real-world incidence of bleeding complications following a CIED procedure within the coding limitations of an insurance claims database. Results confirm the association between bleeding in the pocket and risk of subsequent infection. Further research is needed to precisely identify the costs associated with bleeding in the pocket.

Is capsulectomy a feasible and useful measure in internal pulse generator replacement procedures? A technical note on the use of the PEAK PlasmaBlade(TM)

BACKGROUND

Implantable pulse generator (IPG) replacement is considered a simple procedure, but in case of extension cable damage or IPG pocket infection, it can dramatically affect a patient's quality of life. Higher risk of infection has been reported after IPG replacement procedures rather than after primary deep brain stimulation lead implantation, and some authors suggested that the IPG pocket capsule could play a pivotal role in causing it. In this technical note we present a capsulectomy technique adopted in IPG replacement procedures.

METHODS

Between July and October 2015, we carried out ten outpatient IPG replacement procedures at the chest and abdomen under local anesthesia for battery depletion using the PEAK PlasmaBlade(TM). All patients were followed for at least 2 months to rule out any hardware malfunction and infection.

RESULTS

All ten procedures were uneventful. No extension cable damage occurred. No IPG pocket infection occurred, also not in the follow-up. Mean surgical time was 30 min.

CONCLUSIONS

Complete capsulectomy is not feasible with basic surgical instruments, and the PEAK PlasmaBlade(TM) pencil appears to be a helpful tool in carrying out the procedure.

Incidence and Costs Related to Lead Damage Occurring Within the First Year After a Cardiac Implantable Electronic Device Replacement Procedure

BACKGROUND

Inadvertent damage to leads for transvenous pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy defibrillators is an important complication associated with generator-replacement procedures. We sought to estimate the incidence and costs associated with transvenous lead damage following cardiac implantable electronic device replacement.

METHODS AND RESULTS

Using the Truven Health Analytics MarketScan Commercial Research Database, we identified health care claims between 2009 and 2013 for lead damage following generator replacement. Patients were identified by claims with a procedure code for cardiac implantable electronic device replacement and then evaluated for 1 year. All follow-up visits for lead damage were identified, and incidence, risk factors, and hospitalization costs were determined. A total of 22 557 patients with pacemakers, 20 632 with implantable cardioverter-defibrillators, and 2063 with cardiac resynchronization therapy defibrillators met selection criteria. Incidence of lead damage was 0.46% for pacemaker replacement, 1.27% for implantable cardioverter-defibrillator replacement, and 1.94% for cardiac resynchronization therapy defibrillator replacement procedures (P<0.001). After adjusting for patient characteristics, patients with implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators demonstrated risk of lead damage that was, respectively, double (hazard ratio 2.00, 95% CI 1.57-2.55) and >2.5 times (hazard ratio 2.58, 95% CI 1.73-3.83) that of patients with pacemakers. Lead revision or repair procedures were associated with increased inpatient hospitalization costs (mean $19 959 for pacemaker, $24 885 for implantable cardioverter-defibrillator, and $46 229 for cardiac resynchronization therapy defibrillator; P=0.048, Kruskal-Wallis test).

CONCLUSIONS

These findings establish the first objective assessment of the incidence, risk factors, and economic burden of lead damage following cardiac implantable electronic device replacement in the United States. New care algorithms are warranted to avoid these events, which impose substantial burdens on patients, physicians, and payors.