1255Comprehensive analysis of pacemaker patients with and without abandoned leads undergoing transvenous lead extraction: A GALLERY subgroup analysis

OnBehalf

GALLERY investigators

Background

The number of cardiac implantable electronic device (CIED)-associated complications such as infection, lead dysfunction or thrombotic events is continuously rising and thus making transvenous lead extraction (TLE) an ever more needed procedure in clinical practice today. Patients with abandoned leads represent a special cohort with a potentially higher susceptibility to CIED-related infections and vascular complications. Moreover, according to literature abandoned leads seem to be associated with more procedural complications and mortality during TLE. 

Aim

 

The aim of this study was to provide an insight on safety, procedural outcome and risk prediction on pacemaker patients with abandoned leads undergoing TLE from the largest national laser-sheath registry to date.

Methods + Results:

We conducted a retrospective analysis of the GALLERY database, which collected 2533 patients undergoing TLE in Germany between 2013 and 2017. Out of 903 pacemaker patients, who underwent TLE, 226 patients (25.0%) with abandoned leads were identified. Those patients had a higher number of leads per patient (3.2 ± 0.8 vs. 1.9 ± 0.3; ns) and longer lead dwell-times (168.0 ± 89.7 vs. 123.0 ± 69.2 months; p < 0.0001) compared to pacemaker patients without abandoned leads. There were no differences in age (71.5 vs. 72.3 years; ns), body mass index (26.5 ± 4.5 vs. 26.78 ± 4.8 kg/m2; ns) or gender distribution (69.0 vs. 66.5% male; ns). Leading indication for TLE was device infection with no difference between groups (79.7 vs 77.8 %; ns). There were no differences in terms of pacemaker dependency, length of hospitalization or comorbidities. Patients with abandoned leads had longer procedure times (112.0 ± 69.0 vs. 86.4 ± 53.0 minutes; p < 0.0001) and a higher incidence of procedural complications (6.6 vs. 3.1%; p = 0.03), but there were no differences in neither procedural and clinical success rates (96.5 vs. 97.3%; ns), nor all-cause mortality (1.33 vs. 2.66%; ns). Multivariate logistic regression revealed abandoned leads (OR 2.1, CI 1.0-4.4, p = 0.04) and female gender (OR 2.4, CI 1.2-4.9, p = 0.02) as independent predictors for procedural complications. Systemic infection (OR 5.4, CI 2.0-14.8, p = 0.001) and chronic kidney disease (OR 4.0, CI 1.5-10.7, p = 0.007) were strong predictors for all-cause mortality in patients with indwelling pacemaker. Patient age > 75 years (OR 3.9, CI 2.7-5.6, p < 0.0001) and a lead dwell-time > 10 years (OR 1.6, CI 1.1-2.2, p = 0.01) were identified as risk factors for an infectious cause for TLE. 

Conclusion

Abandoned leads are frequently encountered in pacemaker patients undergoing TLE and pose an important risk factor for procedural complications. Systemic CIED-related infections are the strongest driver of mortality in this patient cohort and urgently call for further improvements in early diagnosis and prevention.

The wearable cardioverter defibrillator as a bridge to reimplantation in patients with ICD or CRT-D-related infections

Background

The approach to treat device infection in patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) is a challenging procedure. Optimal treatment is complete extraction of the infected device. To protect these patients from sudden cardiac arrest while waiting for reimplantation and to avoid recurrent infection, a wearable cardioverter defibrillator (WCD) seems to be a valuable solution.

Therefore, we investigated the management and outcome of patients with ICD or CRT-D infections using the WCD as a bridge to re-implantation after lead extraction procedures.

Methods

We conducted a retrospective study on consecutive patients who underwent ICD or CRT-D removal due to device-related local or systemic infections. All patients were prescribed a WCD at our center between 01/2012 and 10/2015. All patients returned to our outpatient clinic for regular ICD or CRT-D monitoring initially 1 and 3 months after reimplantation followed by 6-months intervals.

Results

Twenty-one patients (mean age 65.0 ± 8.0 years, male 76.2%) were included in the study. Complete lead extraction was achieved in all patients. While waiting for reimplantation one patient experienced a symptomatic episode of sustained ventricular tachycardia. This episode was converted successfully into sinus rhythm by a single 150 J shock.

Mean follow-up time 392 ± 206 days, showing survival rate of 100% and freedom from reinfection in all patients.

Conclusion

The WCD seems to be a valuable bridging option for patients with ICD or CRT-D infections, showing no recurrent device infection.

Quantification of mechanical ventricular dyssynchrony: direct comparison of velocity-encoded and cine magnetic resonance imaging

PURPOSE

The preoperative assessment of mechanical dyssynchrony can help to improve patient selection in candidates for cardiac resynchronization therapy (CRT). The present study compared the performance of velocity-encoded (VENC) MRI to cine-magnetic resonance imaging (MRI) for quantifying mechanical ventricular dyssynchrony.

MATERIALS AND METHODS

VENC-MRI and cine-MRI were performed in 20 patients with heart failure NYHA class III and reduced ejection fraction (median: 24 %, interquartile range: 18 - 28 %) before CRT device implantation. The interventricular mechanical delay (IVMD) was assessed by VENC-MRI as the temporal difference between the onset of aortic and pulmonary flow. Intraventricular dyssynchrony was quantified by cine-MRI, using the standard deviation of time to maximal wall thickening in sixteen left ventricular segments (SDt-16). The response to CRT was assessed in a six-month follow-up.

RESULTS

14 patients (70 %) clinically responded to CRT. A similar accuracy was found to predict the response to CRT by measurements of the IVMD and SDt-16 (75 vs. 70 %; p = ns). The time needed for data analysis was significantly shorter for the IVMD at 1.69 min (interquartile range: 1.66 - 1.88 min) compared to 9.63 min (interquartile range: 8.92 - 11.63 min) for the SDt-16 (p < 0.0001).

CONCLUSION

Measurements of the IVMD by VENC-MRI and the SDt-16 by cine-MRI provide a similar accuracy to identify clinical responders to CRT. However, data analysis of the IVMD is significantly less time-consuming compared to data analysis of the SDt-16.