New-generation electronic appliances and cardiac implantable electronic devices: a systematic literature review of mechanisms and in vivo studies

INTRODUCTION

Cardiac implantable electronic device (CIED) functions are susceptible to electromagnetic interference (EMI) from electromagnetic fields (EMF). Data on EMI risks from new-generation electronic appliances (EA) are limited.

OBJECTIVE

We performed a systematic literature review on the mechanisms of EMI, current evidence, and recently published trials evaluating the effect of EMF on CIEDs from electric vehicles (EV), smartphone, and smartwatch technology and summarize its safety data.

METHODS

Electronic databases, including PubMed and EMBASE, were searched for in vivo studies evaluating EMF strength and incidence between CIEDs and commercial EVs, new-generation smartphones, and new-generation smartwatches.

RESULTS

A total of ten studies (three on EVs, five on smartphones, one on smartphones, one on smartphones and smartwatches) were included in our systematic review. There was no report of EMI incidence associated with EVs or smartwatches. Magnet-containing smartphones (iPhone 12) can cause EMI when placed directly over CIEDs - thereby triggering the magnet mode; otherwise, no report of EMI was observed with other positions or smartphone models.

CONCLUSION

Current evidence suggests CIED recipients are safe from general interaction with EVs/HEVs, smartphones, and smartwatches. Strictly, results may only be applied to commercial brands or models tested in the published studies. There is limited data on EMI risk from EVs wireless charging and smartphones with MagSafe technology.

Racial and Ethnic Disparities in Patients Who Underwent Leadless Pacemaker Implantation

Evidence regarding racial disparities in leadless pacemaker (LP) utilization and outcomes is limited. We aimed to explore ethnicity-based disparities in LP utilization and clinical outcomes of patients who underwent LP implantation. All consecutive patients who underwent LP between January 2019 and January 2023 at our institution were included. Charts were reviewed for baseline characteristics and clinical outcomes. The primary outcomes were procedure-related complications, cardiac rehospitalization, worsening heart failure (HF) or HF hospitalization, and all-cause mortality. All statistical analyses were performed using SPSS Statistics 22 (IBM Corp., Armonk, NY). The p <0.05 was considered statistically significant. A total of 196 adult patients underwent LP implantation during the study period (48% Caucasians, 36.2% Hispanic, 8.2% Asians, and 7.7% African-American). The groups were balanced with respect to baseline demographics, clinical characteristics, and procedure-related complications. During the median follow-up of 104 days (interquartile range 24 to 382), no statistically significant differences were observed in worsening HF or HF hospitalization or all-cause mortality among the ethnic groups. After multivariable logistic regression, Asian individuals had higher odds of cardiac readmissions (odds ratio 4.1, 95% confidence interval 1.4 to 12.3, p = 0.01). Patients from racial and ethnic minorities face significant inequities in arrhythmia care, including patients who have undergone LP implantation. Awareness and a system-based approach (understanding cultural preferences, effective application of evidence-based guidelines, and population-based policies) are crucial to lessen disparities in health care among minorities.

Adverse events associated with amplatzer left atrial appendage occlusion delivery system: A Food and Drug Administration MAUDE database study

BACKGROUND

Dual occlusive closure mechanism (disc and lobe type), Amulet device (Abbott; a second-generation device that has replaced Amplatzer Cardiac Plug) was approved by the Food and Drug Administration (FDA) in August 2021 for percutaneous left atrial appendage occlusion (LAAO). However, real-world safety data on the delivery system (Amplatzer Cardiac Plug and Amplatzer Amulet device) are lacking.

OBJECTIVE

We sought to assess the type of adverse events associated with the Amplatzer LAAO delivery system using the FDA Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

A MAUDE database search was conducted on March 31, 2023, for reports received between February 2013 and March 2023 to capture all adverse events.

RESULTS

A total of 59 adverse events were reported, of which 58 were sheath-related events, and one was a wire-related event. The most commonly encountered issue was air embolism (19%, 11 events), followed by sheath thrombosis (13.8%, eight events, two of which were also associated with device thrombosis), kinked sheath (10.3%, six events), and sheath deformation (8.6%, five events). Patient-related adverse events included pericardial effusion requiring pericardiocentesis (22.4%, 13 events), vascular complications (20.7%, 12 events), and device dislodgement (5.2%, three events).

CONCLUSION

LAAO-related adverse events are increasingly being reported using the Amplatzer LAAO delivery sheath. It is anticipated that improvements in device technology, the advent of steerable sheaths, and operator experience will minimize these complications.

Adverse events associated with AveirTM VR leadless pacemaker: A Food and Drug Administration MAUDE database study

BACKGROUND

Leadless pacemaker (LP) offers an innovative approach for treating bradyarrhythmia, thus avoiding pacemaker pocket and lead-related complications. The Food and Drug Administration (FDA) has recently approved the Aveir™ leadless pacing system (screw-in type LP).

METHODS

We queried the FDA MAUDE database to study the safety profile and assess the types of complications with this relatively novel device technology. A MAUDE database search was conducted on January 20, 2023, for reports received post-FDA approval to capture all adverse events.

RESULTS

A total of 98 medical device report were reported for Aveir™ LP. After excluding duplicate, programmer-related, or introducer-sheath-related entries (n = 34), 64 entries were included. The most commonly encountered problem was high threshold/noncapture (28.1%, 18 events), followed by stretched helix (17.2%, 11 events) and device dislodgement (15.6%, ten events-5 intraprocedural, while 5 in the postoperative Day 1). Other reported events included high impedance (14.1%, nine events), sensing issues (12.5%, eight events), bent/broken helix (7.8%, five events), premature separation (4.7%, three events), interrogation problem (3.1%, two events), low impedance (3.1%, two events), premature battery depletion (1.6%, one event) and inadvertent MRI mode switch (1.6%, one event) and miscellaneous (15.6%, n = 10). There were eight serious patient injury events-pericardial effusion requiring pericardiocentesis (7.8%, five events) due to cardiac perforation that resulted in two deaths (3.1%) followed by sustained ventricular arrhythmias (4.6%, n = 3).

CONCLUSION

In our study assessing the real-world safety profile of the Aveir™ LP, serious adverse events have been reported-life-threatening ventricular arrhythmias, pericardial effusion, device explantation/reimplantation, and death.

Clinical outcomes of radiofrequency catheter ablation of ventricular tachycardia in patients with hypertrophic cardiomyopathy

BACKGROUND

Monomorphic ventricular tachycardia (VT) is rare in patients with hypertrophic cardiomyopathy (HCM), management of which is challenging. Limited data exists on the utility of catheter ablation for the treatment of VT in this population.

OBJECTIVES

We aimed to assess clinical outcomes of catheter ablation for VT in HCM patients.

METHODS

A systematic search, without language restriction, using PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov was performed. The meta-analysis was performed using a meta-package for R version 4.0/RStudio version 1.2 and Freeman Tukey double arcsine method to establish the variance of raw proportions. Outcomes measured included (1) acute procedure success (defined as noninducible for clinical VT), (2) freedom from VT at follow-up, (3) mortality.

RESULTS

This systematic review of six studies (three from the United States and three from Japan) incorporated a total of 68 drug-refractory HCM patients who underwent VT radiofrequency catheter ablation (mean age 57.6 ± 13.3 years, mean LVEF 45.8 ± 15.4%, 85% men, maximum septal wall thickness 17.4 ± 4.6 mm, and 32.3% with an apical aneurysm). Acute procedural success was achieved in 84.5% patients (95% confidence interval [CI]: 70.6%-95.2%) with 27.9% patients had recurrent VT requiring multiple ablations (median 1, IQR 1-3). During the follow-up period (18.3 ± 11.7 months), the pooled incidence of freedom from recurrent VT after index procedure was 70.2% (95% CI: 51.9%-86.2%), while after the last ablation was 82.8% (95% CI: 57%-99.2%). There were two deaths during follow-up, one from heart failure and one from SCD 0.8% (95% CI: 0%-5.8%).

CONCLUSION

The results of our pooled analysis demonstrated that catheter ablation for VT in HCM patients was associated with high acute procedural success, and reduced VT recurrence-findings comparable to previously published reports in other disease substrates.

Electromagnetic interference induced ventricular tachycardia in left ventricular assist device

Left ventricular assist devices (LVAD) have been increasingly utilized end-stage heart failure despite guidelinedirected medical therapy (due to limited organ availability) as a bridge to transplant or destination therapy, with improved overall survival.Majority of patients undergoing LVAD implantation have pre-existing implantable cardioverter-defibrillator (ICD) in-situ.We present a case of device-device interaction resulting in EMI inducing recurrent inappropriate device therapies inducing ventricular arrhythmia followed by the inappropriate triggering of noise reversion mode, thereby inhibiting device therapies.With the increase in number of end-stage heart failure patients with ICDs in situ (and limited organ availability) undergoing LVAD implantation, it is imperative to recognize potential device-device interactions to avoid unwarranted invasive interventions.

Intracardiac echocardiography from coronary sinus

Intracardiac echocardiography (ICE) has become an essential tool and is an integral part of percutaneous interventional and electrophysiology (EP) procedures. Intracardiac echocardiography offers real-time, high-quality, near-field evaluation of cardiac anatomy. Standard ICE imaging includes placing the catheter in the right atrium (RA), right ventricle (RV), or left atrium (LA, via the transeptal approach). Coronary sinus echocardiography (CSE) is another alternative, where the ICE catheter is positioned in the coronary sinus (CS). This approach offers better catheter stability and allows operators to visualize cardiac structure with particularly excellent views of the LA, LAA, left ventricle (LV), and mitral annulus. Additionally, CSE is an attractive alternative in cases with unfavorable interatrial septum or fossa ovalis anatomical features that could lead to difficulty advancing ICE catheter in left atrium. In this article focusing on CSE, we provide illustration-based guidance to help operators identify critical cardiac structures from CSE.

Adverse events associated with PentaRay Mapping Catheter – MAUDE database analysis

Background

The 20 pole PentaRay Mapping Catheter is a high-definition mapping catheter with five soft, flexible spines providing better and faster acquisition. Despite its design, the catheter is not without glitches.

Objective

We queried the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database for adverse events related to the use of the PentaRay mapping catheter.

Methods

The Manufacturer and User Facility Device Experience (MAUDE) database was searched for reports received between October 1, 2019, to October 31, 2021, to capture all adverse events associated with PentaRay mapping catheter using the term “PentaRay” in the “brand name” section. The adverse events were adjudicated to various categories based on the review of the event description for each medical device report (MDR).

Results

A total of 159 events were reported in 148 MDRs during the study period. The most common device related issues were: damaged splines 18.2% (n=29), device entrapment 17% (n=27), thrombus on device 15.1% (n=24), foreign material on splines 8.8% (n=14), sensor error 3.8% (n=6). Of the patient related events, 13.8% (n=22) were pericardial effusion, 5% (n=8) cardiac arrest, 1.2% (n=2) coronary vasospasm/STEMI, 0.6% (n=1) heart block, 0.6% (n=1) air embolism, 0.6% (n=1) tear in pulmonary veins. These events lead to procedure abortion 27.7% (n=44) and procedural delay 11.3% (n=18).

Conclusion

Several issues have been reported with the PentaRay mapping catheter leading to to procedure abortion, delay and patients related adverse events. Understanding and troubleshooting may help improve patient outcomes.

Funding Acknowledgement

Type of funding sources: None.

"Catch, Flip, and Remove" Technique for Retrieval of a Hypermobile Detached Leadless Pacemaker: A Case Report and Literature Review

Leadless pacemaker (LP) detachment is a rare but life-threatening complication that may occur during implantation. While different snaring techniques have been described to remove partially or completely detached LPs, there are currently no reports of snaring a hypermobile LP that travels between different cardiac chambers. This report describes a technique to successfully snare a hypermobile detached LP by first “catching” onto the tines for stabilization with the help of a multi-loop snare, followed by using a second snare for the proximal retrieval feature.

Conduction system pacing in prosthetic heart valves

BACKGROUND

There has been increasing interest in physiologic pacing techniques that directly activate the specialized conduction system. We aimed to assess outcomes of conduction system pacing (CSP) in patients with prosthetic heart valves.

METHODS

This systematic review was performed according to PRISMA guidelines. Freeman-Tukey double arcsine transformation with the random-effect model was used to summarize the data. Outcomes studied were 1) implant success (defined as ability to recruit the His-Purkinje system or the distal Purkinje system); (2) lead parameters at implant and follow-up; and (3) procedure-related complications.

RESULTS

This systematic review of 7 studies included 267 unique patients in whom CSP was attempted with either HBP or LBBAP for pacing indications after a prosthetic valve. HBP was attempted in 38% (n = 108), while LBBAP in 62% (n = 175) patients. The overall success rate of CSP was 87%, while in patients post-TAVR, the overall success rate was 83.2%. In the subgroup analysis, LBBAP had a significant higher overall success rate compared to HBP (94.3% vs. 76.5%, p _interaction = 0.02) and post-TAVR patients (94.3 vs. 66.9%, p _interaction < 0.01), respectively. The LBBAP thresholds were significantly lower compared to HBP both at implant (0.67 ± 0.4 @ 0.44 ms vs. 1.35 ± 1 @ 0.85 ms, p _interaction < 0.01) and at a mean follow-up of 12.4 ± 8 months (0.73 ± 0.1 @ 0.44 ms vs. 1.39 ± 1 @ 0.85 ms, p _interaction < 0.01), respectively.

CONCLUSION

CSP is safe and feasible in patients with a prosthetic valve, with a significantly higher success rate and superior lead parameters with LBBAP than HBP, especially in patients post-TAVR.

Surgical left atrial appendage occlusion in patients with left ventricular assist device

BACKGROUND

Thromboembolic (TE) events are among the most common and devastating adverse events in patients with continuous-flow left ventricular assist device (cf-LVAD). Given the high burden of AF among cf-LVAD patients, we sought to evaluate the effect of concomitant surgical LAAO in patients receiving cf-LVAD.

METHODS

A systematic search using electronic databases was performed using the keywords: "left atrial appendage occlusion" and "left ventricular assist device." Statistical analysis was performed using meta-package for R version 4.0 and Rstudio version 1.2. Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data between two groups. The primary outcomes included: (a) stroke; (b) LVAD pump thrombosis; (c) all-cause mortality RESULTS: : Three studies with a total of 305 patients (LAAO=68 and No-LAAO=237) were included in the analysis. HeartMate II (39%) and Heartware (27.5%) were the two most common cf-LVADs utilized, while only 5% received HeartMate III. At a mean follow up of 1.47 years, LAAO group had a lower risk of stroke (8.8% vs 15.2%, RR 0.64; 95% CI 0.28 - 1.49), LVAD pump thrombosis (1.5% vs 3.8%, RR 0.28; 95% CI 0.05 - 1.55) and all-cause mortality (5.9% vs 20.2%, RR 0.69; 95% CI 0.19 - 2.52) when compared with no-LAAO group, but the difference did not reach statistical significance.

CONCLUSION

Concomitant surgical LAAO at the time of cf-LVAD implantation demonstrated a trend towards positive outcomes and was not associated with adverse outcomes during the follow-up period, though the results were not statistically significant This article is protected by copyright. All rights reserved.

Early modified primary closure for treatment of cardiac implantable electronic device pocket infections

BACKGROUND

Guidance for wound management of the vacated generator pocket in cardiac implantable electronic device (CIED) pocket infections after removal of all hardware and tissue debridement is limited. The typical surgical technique for management of a purulent wound is to allow healing by secondary intention. An alternative approach uses negative pressure wound therapy with or without delayed primary closure. While effective in managing infection, these approaches increase hospital length of stay and costs. We present our experience with a third option: modified early primary wound closure over a suction device.

METHODS

All patients with CIED pocket infections who presented to our institution between September 2018 and October 2020 underwent extraction of hardware and modified primary wound closure over a negative pressure Jackson-Pratt drain. Length of hospital and postoperative stay, complications, and recurrent infections were recorded.

RESULTS

During the study period, 14 patients underwent modified primary wound closure for CIED pocket infections. Mean length of hospital stay was 6.64 days ± 4.01 days (standard deviation [SD]). Mean postoperative length of stay was 3.92 ± 2.21 days (SD). Two patients (both on intravenous heparin for mechanical valve prostheses) required re-exploration for bleeding. No patients developed recurrent infection at a mean follow up of 363 ± 245 days (SD).

CONCLUSION

Based on our experience, early modified primary wound closure for CIED pocket infections appears to be safe and allows for prompt discharge with no observed re-infections.

A Multidisciplinary Approach to Electrical Instability and Cardiogenic Shock in Acute Myocardial Infarction

New cardiogenic shock classifications allow prompt recognition and management of complications of acute coronary syndrome. A 59-year-old man presented after a delayed left anterior descending coronary artery ST-segment elevation myocardial infarction in Society of Cardiovascular Angiography and Interventions stage E cardiogenic shock and ventricular tachycardia storm. He underwent revascularization of the left anterior descending artery, percutaneous left ventricular assist device bridged to permanent assist device placement, epicardial and endocardial ventricular tachycardia ablation, and iatrogenic closure of an atrial septal defect. (Level of Difficulty: Beginner.)