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Pokorney SD, Zepel L, Greiner MA, Fowler VG, Black-Maier E, Lewis RK, Hegland DD, Granger CB, Epstein LM, Carrillo RG, Wilkoff BL, Hardy C, Piccini JP. Lead Extraction and Mortality Among Patients With Cardiac Implanted Electronic Device Infection. JAMA Cardiol 2023; 8:1165-1173. [PMID: 37851461 PMCID: PMC10585491 DOI: 10.1001/jamacardio.2023.3379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/05/2023] [Indexed: 10/19/2023]
Abstract
Importance Complete hardware removal is a class I recommendation for cardiovascular implantable electronic device (CIED) infection, but practice patterns and outcomes remain unknown. Objective To quantify the number of Medicare patients with CIED infections who underwent implantation from 2006 to 2019 and lead extraction from 2007 to 2019 to analyze the outcomes in these patients in a nationwide clinical practice cohort. Design, Setting, and Participants This cohort study included fee-for-service Medicare Part D beneficiaries from January 1, 2006, to December 31, 2019, who had a de novo CIED implantation and a CIED infection more than 1 year after implantation. Data were analyzed from January 1, 2005, to December 31, 2019. Exposure A CIED infection, defined as (1) endocarditis or infection of a device implant and (2) documented antibiotic therapy. Main Outcomes and Measures The primary outcomes of interest were device infection, device extraction, and all-cause mortality. Time-varying multivariable Cox proportional hazards regression models were used to evaluate the association between extraction and survival. Results Among 1 065 549 patients (median age, 78.0 years [IQR, 72.0-84.0 years]; 50.9% male), mean (SD) follow-up was 4.6 (2.9) years after implantation. There were 11 304 patients (1.1%) with CIED infection (median age, 75.0 years [IQR, 67.0-82.0 years]); 60.1% were male, and 7724 (68.3%) had diabetes. A total of 2102 patients with CIED infection (18.6%) underwent extraction within 30 days of diagnosis. Infection occurred a mean (SD) of 3.7 (2.4) years after implantation, and 1-year survival was 68.3%. There was evidence of highly selective treatment, as most patients did not have extraction within 30 days of diagnosed infection (9202 [81.4%]), while 1511 (13.4%) had extraction within 6 days of diagnosis and 591 (5.2%) had extraction between days 7 and 30. Any extraction was associated with lower mortality compared with no extraction (adjusted hazard ratio [AHR], 0.82; 95% CI, 0.74-0.90; P < .001). Extraction within 6 days was associated with even lower risk of mortality (AHR, 0.69; 95% CI, 0.61-0.78; P < .001). Conclusions and Relevance In this study, a minority of patients with CIED infection underwent extraction. Extraction was associated with a lower risk of death compared with no extraction. The findings suggest a need to improve adherence to guideline-directed care among patients with CIED infection.
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Affiliation(s)
- Sean D. Pokorney
- Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Lindsay Zepel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Melissa A. Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Vance G. Fowler
- Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Christopher B. Granger
- Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Jonathan P. Piccini
- Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Gabriels JK, Schaller RD, Koss E, Rutkin BJ, Carrillo RG, Epstein LM. Lead management in patients undergoing percutaneous tricuspid valve replacement or repair: a 'heart team' approach. Europace 2023; 25:euad300. [PMID: 37772978 PMCID: PMC10629975 DOI: 10.1093/europace/euad300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 09/30/2023] Open
Abstract
Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads.
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Affiliation(s)
- James K Gabriels
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY, USA
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elana Koss
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | - Bruce J Rutkin
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | | | - Laurence M Epstein
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY, USA
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3
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D'Angelo LA, Arora Y, Diaz MA, Carrillo RG, Guta C, Patton M. Endovascular approach to a complex thrombus in-transit through a patent foramen ovale. J Cardiol Cases 2023; 28:83-85. [PMID: 37521573 PMCID: PMC10382967 DOI: 10.1016/j.jccase.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 08/01/2023] Open
Abstract
Large atrial thrombi can be managed percutaneously. We present a case of a 76-year-old female patient who presented to our emergency room with an acute stroke and was managed with mechanical thrombectomy. Further work-up revealed a large complex thrombus in-transit trapped in a patent foramen ovale with a large mobile portion in the left atrium. Due to contraindications for thrombolysis and poor surgical candidacy, an endovascular approach was favored. The procedure was performed successfully, and the patient recovered uneventfully. Learning objective Endovascular approach with mechanical thrombectomy can be a treatment option for patients that present with large thrombus in-transit when other therapies are contraindicated.
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Affiliation(s)
| | - Yingyot Arora
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Miguel A. Diaz
- Heart Institute at Palmetto General Hospital, Hialeah, FL, USA
| | | | - Cosmin Guta
- Heart Institute at Palmetto General Hospital, Hialeah, FL, USA
| | - Marquand Patton
- Heart Institute at Palmetto General Hospital, Hialeah, FL, USA
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4
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Arora Y, Carrillo RG. CI-545-03 TRANSVENOUS LEAD EXTRACTION FOR THE MANAGEMENT OF TRICUSPID REGURGITATION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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5
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Arora Y, D'Angelo L, Llaneras N, Carrillo RG. B-PO03-058 INJURY PATTERN AND HEMODYNAMIC PRESENTATION OF SVC INJURIES DURING TLE. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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6
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Arora Y, Perez AA, Carrillo RG. Influence of vegetation shape on outcomes in transvenous lead extractions: Does shape matter? Heart Rhythm 2020; 17:646-653. [DOI: 10.1016/j.hrthm.2019.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Indexed: 10/25/2022]
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7
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Oh TS, Le K, Baddour LM, Sohail MR, Vikram HR, Hernandez-Meneses M, Miro JM, Prutkin JM, Greenspon AJ, Carrillo RG, Danik SB, Naber CK, Blank E, Tseng CH, Uslan DZ, Peacock JE. Cardiovascular implantable electronic device infections due to enterococcal species: Clinical features, management, and outcomes. Pacing Clin Electrophysiol 2019; 42:1331-1339. [PMID: 31424091 DOI: 10.1111/pace.13783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/31/2019] [Accepted: 08/15/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Enterococcal cardiovascular implantable electronic device (CIED) infections are not well characterized. METHODS Data from the Multicenter Electrophysiologic Device Infection Cohort, a prospective study of CIED infections, were used for descriptive analysis of adults with enterococcal CIED infections. RESULTS Of 433 patients, 21 (4.8%) had enterococcal CIED infection. Median age was 71 years. Twelve patients (57%) had permanent pacemakers, five (24%) implantable cardioverter defibrillators, and four (19%) biventricular devices. Median time from last procedure to infection was 570 days. CIED-related bloodstream infections occurred in three patients (14%) and 18 (86%) had infective endocarditis (IE), 14 (78%) of which were definite by the modified Duke criteria. IE cases were classified as follows: valvular IE, four; lead IE, eight; both valve and lead IE, six. Vegetations were demonstrated by transesophageal echocardiography in 17 patients (81%). Blood cultures were positive in 19/19 patients with confirmed results. The most common antimicrobial regimen was penicillin plus an aminoglycoside (33%). Antibiotics were given for a median of 43 days. Only 14 patients (67%) underwent device removal. There was one death during the index hospitalization with four additional deaths within 6 months (overall mortality 24%). There were no relapses. CONCLUSIONS Enterococci caused 4.8% of CIED infections in our cohort. Based on the late onset after device placement or manipulation, most infections were likely hematogenous in origin. IE was the most common infection syndrome. Only 67% of patients underwent device removal. At 6 months follow-up, no CIED infection relapses had occurred, but overall mortality was 24%.
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Affiliation(s)
- Timothy S Oh
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Katherine Le
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - M Rizwan Sohail
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Holenarasipur R Vikram
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Marta Hernandez-Meneses
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jordan M Prutkin
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
| | - Arnold J Greenspon
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Roger G Carrillo
- Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, Florida
| | - Stephen B Danik
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Chi-Hong Tseng
- Department of Biostatistics, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Daniel Z Uslan
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - James E Peacock
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Abstract
Background:
A history of open-heart surgery has been a heavily debated topic in transvenous lead extraction. This study evaluates the impact of prior sternotomy on transvenous lead extraction outcomes.
Methods:
Data for all patients undergoing transvenous lead extraction at a tertiary referral center were prospectively gathered from 2004 to 2017. Relevant clinical information was compared between patients with a history of sternotomy before transvenous lead extraction and those without. After considering baseline differences, multivariate regression, and propensity-matched analysis were performed. Outcome variables included major and minor complication rates, clinical success, and in-hospital mortality as defined by the 2017 Heart Rhythm Society consensus statement.
Results:
Of 1480 patients in the study period, 455 had a prior sternotomy. When compared with patients with no prior sternotomy, those with prior sternotomy were more likely to be older, male, and present with more comorbidities and leads targeted for extraction. No statistical differences were identified in major and minor complication rates (
P
=0.75,
P
=0.41), clinical success rate (
P
=0.26), and in-hospital mortality (
P
=0.08). In patients with prior sternotomy, there were no instances of pericardial effusion after extraction. Prior sternotomy was not an independent predictor of clinical or procedural outcomes. No associations were elucidated after propensity-matched analysis.
Conclusions:
In a large, single-center series, no differences in clinical or procedural outcomes were elucidated between patients with a history of sternotomy and those without. Patients with sternotomies before lead extraction who experienced vascular or cardiac perforations clinically presented with hemothoraces rather than pericardial effusions.
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Affiliation(s)
- Darren C. Tsang
- University of Miami Miller School of Medicine, FL (D.C.T., A.A.P., T.A.B.)
| | - Adryan A. Perez
- University of Miami Miller School of Medicine, FL (D.C.T., A.A.P., T.A.B.)
| | - Thomas A. Boyle
- University of Miami Miller School of Medicine, FL (D.C.T., A.A.P., T.A.B.)
| | - Roger G. Carrillo
- Division of Cardiothoracic Surgery, The Heart Institute at Palmetto General Hospital, Hialeah, FL (R.G.C.)
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9
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Reis VS, Tsang DC, Williams DB, Carrillo RG. Symptomatic Aortic Valve Mass - Cardiac Work-Up Challenges and Role of Computed Tomography Angiography: A Case Report. Braz J Cardiovasc Surg 2019; 34:499-502. [PMID: 31454208 PMCID: PMC6713383 DOI: 10.21470/1678-9741-2018-0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Cardiac papillary fibroelastoma are rare, benign cardiac tumors that may lead to
lethal complications from embolization or valvular dysfunction if left
untreated. When working up symptomatic tumors with concomitant angina,
traditional diagnostic studies such as cardiac catheterization may predispose
the patient to embolic complications if the mass is located in the path of the
catheter. Newer, non-invasive diagnostic testing, such as cardiac magnetic
resonance imaging or dynamic computed tomography angiography, may be considered
in lieu of invasive approaches to avoid potentially devastating complications.
We herein present a case report of a 77-year-old female with a symptomatic
aortic valve tumor and describe our diagnostic strategy and management.
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Affiliation(s)
- Victor S Reis
- University of Miami Miller School of Medicine Division of Cardiothoracic Surgery Miami Florida Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Darren C Tsang
- University of Miami Miller School of Medicine Division of Cardiothoracic Surgery Miami Florida Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Donald B Williams
- University of Miami Miller School of Medicine Division of Cardiothoracic Surgery Miami Florida Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Roger G Carrillo
- University of Miami Miller School of Medicine Division of Cardiothoracic Surgery Miami Florida Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Azarrafiy R, Tsang DC, Wilkoff BL, Carrillo RG. Endovascular Occlusion Balloon for Treatment of Superior Vena Cava Tears During Transvenous Lead Extraction. Circ Arrhythm Electrophysiol 2019; 12:e007266. [DOI: 10.1161/circep.119.007266] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon.
Methods:
We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration–maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality.
Results:
From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used (
P
=0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04–0.40;
P
<0.001).
Conclusions:
From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.
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Affiliation(s)
- Ryan Azarrafiy
- University of Miami Miller School of Medicine, FL (R.A., D.C.T.)
| | - Darren C. Tsang
- University of Miami Miller School of Medicine, FL (R.A., D.C.T.)
| | - Bruce L. Wilkoff
- Department of Cardiovascular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH (B.L.W.)
| | - Roger G. Carrillo
- Division of Cardiothoracic Surgery, The Heart Institute at Palmetto General Hospital, Hialeah, FL (R.G.C.)
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Baquero GA, Azarrafiy R, Marchena EJ, Carrillo RG. Hybrid off‐pump coronary artery bypass grafting surgery and transaortic transcatheter aortic valve replacement: Literature review of a feasible bailout for patients with complex coronary anatomy and poor femoral access. J Card Surg 2019; 34:591-597. [DOI: 10.1111/jocs.14082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 04/27/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Giselle A. Baquero
- Department of Medicine, Division of CardiologySouthern Illinois University School of MedicineSpringfield Illinois
| | - Ryan Azarrafiy
- Department of Medicine, Division of CardiologyUniversity of Miami Miller School of MedicineMiami Florida
| | - Eduardo J. Marchena
- Department of Medicine, Division of CardiologyUniversity of Miami Miller School of MedicineMiami Florida
| | - Roger G. Carrillo
- Division of Cardiothoracic SurgeryThe Heart Institute at Palmetto General HospitalHialeah Florida
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Azarrafiy R, Carrillo RG. Minimally Invasive Techniques to Avoid Sternotomy in Complex Lead Extraction Cases. J Innov Card Rhythm Manag 2019; 10:3515-3521. [PMID: 32494411 PMCID: PMC7252869 DOI: 10.19102/icrm.2019.100201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/17/2018] [Indexed: 11/06/2022] Open
Abstract
Cardiac device lead extractions have increased in frequency over the past several years. Although most of these procedures are successfully performed through a percutaneous approach, certain cases may be unmanageable using conventional methods. The traditional approach for such complex cases has been median sternotomy. However, four surgical techniques offer a less-invasive alternative. These include the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy. In the present study, we reviewed data from patients who underwent minimally invasive, surgical lead extraction at our institution from January 2003 to October 2017 using an ongoing, prospective registry. Summary statistics were generated for age, sex, device extracted, lead dwell time (years), procedure indication, major/minor complications and procedural success as defined by the 2017 Heart Rhythm Society consensus statement, and survival at discharge. Between January 2003 and October 2017, 14 cases at our center were managed via a transatrial approach, whereas 11 involved the subxiphoid approach, 19 involved a left minithoracotomy or thoracoscopy, and one involved a ministernotomy. For the transatrial approach, all cases were classified as procedural successes and all patients were discharged alive. Additionally, for the subxiphoid approach, all cases were deemed procedural successes, whereas survival at discharge was 90.9%. For the left minithoracotomy/thoracoscopy, all cases were procedural successes and survival at discharge was 94.7%. Lastly, the ministernotomy was successfully used to remove an infected, retained lead fragment from the innominate vein. In conclusion, at our institution, the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy were used as minimally invasive, surgical approaches that represent fairly safe and effective alternatives to median sternotomy in complex cases unamenable to management via conventional, percutaneous approaches to lead extraction.
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Affiliation(s)
- Ryan Azarrafiy
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Roger G Carrillo
- The Heart Institute at Palmetto General Hospital, Hialeah, FL, USA
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13
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Abstract
The rise in indications for cardiac implantable electronic devices has necessitated the development of tools for removal of the electrodes that connect the heart to these externally located pacemakers and defibrillators. After implant of a cardiac electrode, variable but progressive fibrous adhesion occurs. Removal of these adhesions can cause devastating complications with high risk of mortality if not treated surgically in a highly expeditious and appropriate manner. This article describes the incidence, risk factors, and diagnosis of these injuries followed by discussion of recent evidence for use of superior vena cava balloon occlusion, and conventional surgical repair of these injuries.
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Affiliation(s)
- Jamil Bashir
- University of British Columbia, St. Paul's Hospital, Room 458, 4th Floor, Burrard Building, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.
| | - Roger G Carrillo
- University of Miami, Miller School of Medicine, 1295 Northwest 14 Street, Suite H, Miami, FL 33125, USA
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14
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Oh TS, Peacock JE, Le K, Sohail MR, Baddour LM, Vikram HR, Miro JM, Prutkin JM, Greenspon AJ, Carrillo RG, Danik SB, Naber CK, Blank E, Tseng CH, Uslan DZ. 1085. Enterococcal Cardiac Implantable Electronic Device (CIED) Infections: Clinical Features and Outcomes. Open Forum Infect Dis 2018. [PMCID: PMC6253554 DOI: 10.1093/ofid/ofy210.920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Unlike enterococcal native and prosthetic valve infective endocarditis (IE), enterococcal CIED infections are not well described. Methods Data from the Multicenter Electrophysiologic Device Infection Collaboration (MEDIC), a prospective, observational, multinational cohort study of CIED infections, were used to provide a descriptive analysis of adult patients with CIED infections due to enterococcal species. Results Of 433 patients, 21 (4.8%) were diagnosed with enterococcal CIED infection. Specific data on enterococcal species and antimicrobial susceptibilities were not recorded. The mean age was 70.8 years. No patient had previous CIED infection. Twelve patients (57%) had permanent pacemakers, 5 (24%) had implantable cardioverter defibrillators, and 4 (19%) had biventricular devices. Among the 21 infections, 3 (14%) were categorized as CIED-related bloodstream infections and 18 (86%) as IE; no patient had isolated pocket infection. Of the IE cases, four were valvular IE, eight were lead IE, and six were both. Fourteen cases of IE (78%) were definite by the modified Duke criteria. Median time from last device procedure to infection was 510 days (range 37–2,952 days). The most common presenting symptom was fever (48%); five patients (24%) exhibited local signs of pocket infection. All 21 patients underwent TEE with vegetations demonstrated in 17 (81%). Blood cultures grew enterococci from all patients. The most common antimicrobial regimen was a penicillin plus aminoglycoside (38%); two patients (9.5%) received ampicillin + ceftriaxone. Antibiotics were given for a median of 43 days. Only 14 patients (67%) had complete device removal; the seven patients retaining their device were judged to be at high risk for extraction. There was one death during the index hospital stay with four additional patients dying over the 6 months after therapy (overall mortality 24%); two of the seven patients retaining their CIED died. Conclusion Enterococci caused 4.8% of all CIED infections in our cohort. Most infections appeared to be hematogenous in origin with late onset. IE was the most common infectious syndrome. A penicillin plus aminoglycoside, given for 6 weeks, was the most frequent therapy. Only 67% of patients underwent device removal. At 6 months follow-up, no relapses had occurred but overall mortality was 24%. Disclosures J. E. Peacock Jr., Pfizer, Inc.: Shareholder, Owns common stock in Pfizer which was inherited and held in a trust. M. R. Sohail, TyRx Inc.: Investigator, Research support. Medtronic Inc.: Investigator, Research support. Medtronic Inc.: Consultant, Speaker honorarium. Spectranetics: Consultant, Speaker honorarium. Boston Scientific Corp: Consultant, Speaker honorarium. L. M. Baddour, UpToDate: Collaborator, Royalty payment. J. M. Miro, Abbvie: Consultant and Grant Investigator, Consulting honoraria and Research grant. Bristol-Myers Squibb: Consultant and Grant Investigator, Consulting honoraria and Research grant. Genentech: Consultant and Grant Investigator, Consulting honoraria and Research grant. Medtronic: Consultant and Grant Investigator, Consulting honoraria and Research grant. Novartis: Consultant and Grant Investigator, Consulting honoraria and Research grant. Gilead Sciences: Consultant and Grant Investigator, Consulting honoraria and Research grant. Pfizer: Consultant and Grant Investigator, Consulting honoraria and Research grant. ViiV Healthcare: Consultant and Grant Investigator, Consulting honoraria and Research grant. A. J. Greenspon, Medtronic: Consultant, Speaker honorarium. Boston Scientific: Consultant, Speaker honorarium. St. Jude: Consultant, Speaker honorarium. R. G. Carrillo, St. Jude Medical Group: Speaker’s Bureau, Research support. Spectranetics: Consultant, Speaker honorarium. Sorin Group: Speaker’s Bureau, None. Boston Scientific Corp: Speaker’s Bureau, None. D. Z. Uslan, Medtronic: Investigator, Research support. Boston Scientific: Consultant, Speaker honorarium.
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Affiliation(s)
- Timothy S Oh
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James E Peacock
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Katherine Le
- Mayo Clinic College of Medicine, Rochester, Minnesota
| | | | | | | | | | | | | | | | | | | | | | - Chi-Hong Tseng
- David Geffen School of Medicine, Los Angeles, California
| | - Daniel Z Uslan
- David Geffen School of Medicine, Los Angeles, California
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15
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Abstract
Surgical and hybrid lead extraction has developed considerably over the past several decades. Although transvenous lead extraction is the standard approach to remove infected or malfunctioning cardiac implantable electronic device leads, surgical approaches may be necessary in complex cases not amenable to transvenous lead extraction or in cases that involve concomitant pathologies, such as tricuspid valve regurgitation. We describe our experience with 4 minimally invasive surgical approaches to lead extraction as well as our experience with hybrid open heart surgery and transvenous lead extraction as an option for patients who present with concomitant conditions.
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Affiliation(s)
- Ryan Azarrafiy
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Roger G Carrillo
- The Heart Institute at Palmetto General Hospital, 7150 West 20th Avenue, Suite 615, Hialeah, FL 33016, USA.
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16
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Perez AA, Woo FW, Tsang DC, Carrillo RG. Transvenous Lead Extractions: Current Approaches and Future Trends. Arrhythm Electrophysiol Rev 2018; 7:210-217. [PMID: 30416735 PMCID: PMC6141917 DOI: 10.15420/aer.2018.33.2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/16/2018] [Indexed: 12/11/2022] Open
Abstract
The use of cardiac implantable electronic devices (CIEDs) has continued to rise along with indications for their removal. When confronted with challenging clinical scenarios such as device infection, malfunction or vessel occlusion, patients often require the prompt removal of CIED hardware, including associated leads. Recent advancements in percutaneous methods have enabled physicians to face a myriad of complex lead extractions with efficiency and safety. Looking ahead, emerging technologies hold great promise in making extractions safer and more accessible for patients worldwide. This review will provide the most up-to-date indications and procedural approaches for lead extractions and insight on the future trends in this novel field.
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Affiliation(s)
- Adryan A Perez
- University of Miami Miller School of Medicine Miami, FL, USA
| | - Frank W Woo
- University of Miami Miller School of Medicine Miami, FL, USA
| | - Darren C Tsang
- University of Miami Miller School of Medicine Miami, FL, USA
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17
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Damluji AA, Murman M, Byun S, Moscucci M, Resar JR, Hasan RK, Alfonso CE, Carrillo RG, Williams DB, Kwon CC, Cho PW, Dijos M, Peltan J, Heldman AW, Cohen MG, Leroux L. Alternative access for transcatheter aortic valve replacement in older adults: A collaborative study from France and United States. Catheter Cardiovasc Interv 2018; 92:1182-1193. [DOI: 10.1002/ccd.27690] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/20/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Abdulla A. Damluji
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
- Division of Cardiology; Johns Hopkins University; Baltimore Maryland
| | - Magdalena Murman
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Seunghwan Byun
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
| | - Mauro Moscucci
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
| | - Jon R Resar
- Division of Cardiology; Johns Hopkins University; Baltimore Maryland
| | - Rani K. Hasan
- Division of Cardiology; Johns Hopkins University; Baltimore Maryland
| | - Carlos E. Alfonso
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Roger G. Carrillo
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Donald B. Williams
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Christopher C. Kwon
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
- Division of Cardiac Surgery, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
| | - Peter W. Cho
- Beverly and Jerome Fine Cardiac Valve Center, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
- Division of Cardiac Surgery, Sinai Hospital of Baltimore; LifeBridge Health Cardiovascular Institute; Baltimore Maryland
| | | | | | - Alan W. Heldman
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Mauricio G. Cohen
- Multidisciplinary Structural Heart Disease Program, the Elaine and Sydney Sussman Cardiac Catheterization Laboratory; University of Miami-Miller School of Medicine; Miami Florida
| | - Lionel Leroux
- Department of Interventional Cardiology, Hôpital Cardiologique du Haut-Lévêque; Université Victor Segalen Bordeaux II; Bordeaux France
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18
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Peacock JE, Stafford JM, Le K, Sohail MR, Baddour LM, Prutkin JM, Danik SB, Vikram HR, Hernandez-Meneses M, Miró JM, Blank E, Naber CK, Carrillo RG, Greenspon AJ, Tseng CH, Uslan DZ. Attempted salvage of infected cardiovascular implantable electronic devices: Are there clinical factors that predict success? Pacing Clin Electrophysiol 2018. [PMID: 29518265 DOI: 10.1111/pace.13319] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Published guidelines mandate complete device removal in cases of cardiovascular implantable electronic device (CIED) infection. Clinical predictors of successful salvage of infected CIEDs have not been defined. METHODS Data from the Multicenter Electrophysiologic Device Infection Collaboration, a prospective, observational, multinational cohort study of CIED infection, were used to investigate whether clinical predictors of successful salvage of infected devices could be identified. RESULTS Of 433 adult patients with CIED infections, 306 (71%) underwent immediate device explantation. Medical management with device retention and antimicrobial therapy was initially attempted in 127 patients (29%). "Early failure" of attempted salvage occurred in 74 patients (58%) who subsequently underwent device explantation during the index hospitalization. The remaining 53 patients (42%) in the attempted salvage group retained their CIED. Twenty-six (49%) had resolution of CIED infection (successful salvage group) whereas 27 patients (51%) experienced "late" salvage failure. Upon comparing the salvage failure group, early and late (N = 101), to the group experiencing successful salvage of an infected CIED (N = 26), no clinical or laboratory predictors of successful salvage were identified. However, by univariate analysis, coagulase-negative staphylococci as infecting pathogens (P = 0.0439) and the presence of a lead vegetation (P = 0.024) were associated with overall failed salvage. CONCLUSIONS In patients with definite CIED infections, clinical and laboratory variables cannot predict successful device salvage. Until new data are forthcoming, device explantation should remain a mandatory and early management intervention in patients with CIED infection in keeping with existing expert guidelines unless medical contraindications exist or patients refuse device removal.
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Affiliation(s)
- James E Peacock
- Section on Infectious Diseases, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeanette M Stafford
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Katherine Le
- Division of Infectious Diseases, Department of Medicine, and the Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Muhammad Rizwan Sohail
- Division of Infectious Diseases, Department of Medicine, and the Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, and the Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Jordan M Prutkin
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Stephan B Danik
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Holenarasipur R Vikram
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Marta Hernandez-Meneses
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José M Miró
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Elisabeth Blank
- Ärztin im Studienzentrum Kardiologie, Contilia Heart and Vascular Center, Essen, Germany
| | - Christoph K Naber
- Klinik für Kardiologie und Angiologie, Contilia Heart- and Vascular Center, Elisabeth-Krankenhaus, Essen, Germany
| | - Roger G Carrillo
- Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Arnold J Greenspon
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, CA, USA
| | - Daniel Z Uslan
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, CA, USA
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19
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Harper MW, Uslan DZ, Greenspon AJ, Baddour LM, Carrillo RG, Danik SB, Tolosana JM, Le K, Miro JM, Naber CK, Peacock J, Sohail MR, Vikram HR, Prutkin JM. Clinical presentation of CIED infection following initial implant versus reoperation for generator change or lead addition. Open Heart 2018; 5:e000681. [PMID: 29632673 PMCID: PMC5888434 DOI: 10.1136/openhrt-2017-000681] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 02/01/2018] [Accepted: 03/06/2018] [Indexed: 11/11/2022] Open
Abstract
Objective To explore differences in clinical manifestations and outcomes in those patients who develop infection after undergoing initial implantation versus reoperation. Methods We compared cases of cardiac implantable electronic device (CIED) infection based on initial implantation versus reoperation from 11 centres. Results There were 432 patients with CIED infection, 178 occurring after initial device placement and 254 after repeat reoperation. No differences were seen in age, sex or device type. Those with infection after initial implant had a higher Charlson Comorbidity Score (median 3 (IQR 2–6) vs 2 (IQR 1–4), p<0.001), shorter time since last procedure (median 8.9 months (IQR 0.9–33.3) vs 19.5 months (IQR 1.1–62.9), p<0.0001) and fewer leads (2.0±0.6vs 2.5±0.9, p<0.001). Pocket infections were more likely to occur after a reoperation (70.1%vs48.9%, p<0.001) and coagulase negative staphylococci (CoNS) was the most frequently isolated organism in this group (p=0.029). In contrast, initial implant infections were more likely to present with higher white cell count (10.5±5.1 g/dL vs 9.5±5.4 g/dL, p=0.025), metastatic foci of infection (16.9%vs8.7%, p=0.016) and sepsis (30.9%vs19.3%, p=0.006). There were no differences in in-hospital (7.9%vs5.2%, p=0.31) or 6-month mortality (21.9%vs14.0%, p=0.056). Conclusions CIED infections after initial device implant occur earlier, more aggressively, and often due to Staphylococcus aureus. In contrast, CIED infections after reoperation occur later, are due to CoNS, and have more indolent manifestations with primary localisation to the pocket.
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Affiliation(s)
- Mariko W Harper
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Daniel Z Uslan
- Division of Infectious Diseases, Department of Medicine, UCLA, Los Angeles, California, USA
| | - Arnold J Greenspon
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Roger G Carrillo
- Division of Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Stephan B Danik
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jose M Tolosana
- Infectious Diseases Service, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Katherine Le
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Christoph K Naber
- Klinik für Kardiologie und Angiologie, Elisabeth Krankenhaus, Essen, Germany
| | - James Peacock
- Section on Infectious Diseases, Department of Medicin, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Muhammad Rizwan Sohail
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Holenarasipur R Vikram
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jordan M Prutkin
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
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20
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Boyle T, Carrillo RG. P1237An artificial neural network for predicting outcomes in lead extraction. Europace 2018. [DOI: 10.1093/europace/euy015.718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- T Boyle
- University of Miami Leonard M. Miller School of Medicine, Miami, United States of America
| | - R G Carrillo
- University of Miami Leonard M. Miller School of Medicine, Miami, United States of America
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21
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Azarrafiy R, Albuquerque FN, Carrillo RG, Cohen MG. Coil embolization to successfully treat annular rupture during transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2018; 92:1205-1208. [PMID: 29469984 DOI: 10.1002/ccd.27546] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 01/27/2018] [Indexed: 11/10/2022]
Abstract
Aortic annular rupture is one of the most feared complications of transcatheter aortic valve replacement (TAVR). This complication often presents as sudden cardiac tamponade with hypotension and requires urgent intervention. The traditional rescue strategy for such cases is emergency surgical intervention, yet the mortality remains high considering most patients who undergo TAVR are not candidates for open heart surgery. As such, there is a need for percutaneous alternatives to treat this critical complication. Here, we describe a case of annular rupture during TAVR that was successfully treated with coil embolization at the rupture site. This case illustrates the use of coil embolization as a treatment strategy in patients with acute aortic annular rupture who are at high-risk for surgical intervention.
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Affiliation(s)
- Ryan Azarrafiy
- Elaine and Sydney Sussman Catheterization Laboratories, University of Miami Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Felipe N Albuquerque
- Elaine and Sydney Sussman Catheterization Laboratories, University of Miami Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Roger G Carrillo
- Elaine and Sydney Sussman Catheterization Laboratories, University of Miami Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Mauricio G Cohen
- Elaine and Sydney Sussman Catheterization Laboratories, University of Miami Hospital, University of Miami Miller School of Medicine, Miami, Florida
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22
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Boyle TA, Uslan DZ, Prutkin JM, Greenspon AJ, Baddour LM, Danik SB, Tolosana JM, Le K, Miro JM, Peacock JE, Sohail MR, Vikram HR, Carrillo RG. Impact of Abandoned Leads on Cardiovascular Implantable Electronic Device Infections: A Propensity Matched Analysis of MEDIC (Multicenter Electrophysiologic Device Infection Cohort). JACC Clin Electrophysiol 2017; 4:201-208. [PMID: 29749938 DOI: 10.1016/j.jacep.2017.09.178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/14/2017] [Accepted: 09/21/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to evaluate the impact of abandoned cardiovascular implantable electronic device (CIED) leads on the presentation and management of device-related infections. BACKGROUND Device infection is a serious consequence of CIEDs and necessitates removal of all hardware for attempted cure. The merits of extracting or retaining presumed sterile but nonfunctioning leads is a subject of ongoing debate. METHODS The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled patients with CIED infections at 10 institutions in the United States and abroad between January 1, 2009, and December 31, 2012. Within a propensity-matched cohort, relevant clinical information was compared between patients who had 1 or more abandoned leads at the time of infection and those who had none. RESULTS Matching produced a cohort of 264 patients, including 176 with no abandoned leads and 88 with abandoned leads. The groups were balanced with respect to Charlson comorbidity index, oldest lead age, device type, sex, and race. At the time of admission, those with abandoned leads were less likely to demonstrate systemic signs of infection, including leukocytosis (p = 0.023) and positive blood cultures (p = 0.005). Conversely, patients with abandoned leads were more likely to demonstrate local signs of infections, including skin erosion (p = 0.031) and positive pocket cultures (p = 0.015). In addition, patients with abandoned leads were more likely to require laser extraction (p = 0.010). CONCLUSIONS The results of a large prospective registry of CIED infections demonstrated that patients with abandoned leads may present with different signs, symptoms, and microbiological findings and require laser extraction more than those without abandoned leads.
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Affiliation(s)
- Thomas A Boyle
- Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Miami, Florida.
| | - Daniel Z Uslan
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Jordan M Prutkin
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Arnold J Greenspon
- Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Larry M Baddour
- Department of Medicine, Divisions of Infectious Diseases and Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Stephan B Danik
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jose M Tolosana
- Cardiology and Infectious Disease Services, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Katherine Le
- Department of Medicine, Divisions of Infectious Diseases and Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Jose M Miro
- Cardiology and Infectious Disease Services, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - James E Peacock
- Department of Medicine, Section of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Muhammad R Sohail
- Department of Medicine, Divisions of Infectious Diseases and Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | | | - Roger G Carrillo
- Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Miami, Florida.
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23
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Pokorney SD, Mi X, Lewis RK, Greiner M, Epstein LM, Carrillo RG, Zeitler EP, Al-Khatib SM, Hegland DD, Piccini JP. Outcomes Associated With Extraction Versus Capping and Abandoning Pacing and Defibrillator Leads. Circulation 2017; 136:1387-1395. [DOI: 10.1161/circulationaha.117.027636] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 07/31/2017] [Indexed: 11/16/2022]
Abstract
Background:
Lead management is an increasingly important aspect of care in patients with cardiac implantable electronic devices; however, relatively little is known about long-term outcomes after capping and abandoning leads.
Methods:
Using the 5% Medicare sample, we identified patients with de novo cardiac implantable electronic device implantations between January 1, 2000, and December 31, 2013, and with a subsequent lead addition or extraction ≥12 months after the de novo implantation. Patients who underwent extraction for infection were excluded. Using multivariable Cox proportional hazards models, we compared cumulative incidence of all-cause mortality, device-related infection, device revision, and lead extraction at 1 and 5 years for the extraction versus the cap and abandon group.
Results:
Among 6859 patients, 1113 (16.2%) underwent extraction, whereas 5746 (83.8%) underwent capping and abandonment. Extraction patients tended to be younger (median, 78 versus 79 years;
P
<0.0001), were less likely to be male (65% versus 68%;
P
=0.05), and had shorter lead dwell time (median, 3.0 versus 4.0 years;
P
<0.0001) and fewer comorbidities. Over a median follow-up of 2.4 years (25th, 75th percentiles, 1.0, 4.3 years), the overall 1-year and 5-year cumulative incidence of mortality was 13.5% (95% confidence interval [CI], 12.7–14.4) and 54.3% (95% CI, 52.8–55.8), respectively. Extraction was associated with a lower risk of device infection at 5 years relative to capping (adjusted hazard ratio, 0.78; 95% CI, 0.62–0.97;
P
=0.027). There was no association between extraction and mortality, lead revision, or lead extraction at 5 years.
Conclusions:
Elective lead extraction for noninfectious indications had similar long-term survival to that for capping and abandoning leads in a Medicare population. However, extraction was associated with lower risk of device infections at 5 years.
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Affiliation(s)
- Sean D. Pokorney
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Xiaojuan Mi
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Robert K. Lewis
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Melissa Greiner
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Laurence M. Epstein
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Roger G. Carrillo
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Emily P. Zeitler
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Sana M. Al-Khatib
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Donald D. Hegland
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
| | - Jonathan P. Piccini
- From Duke University Medical Center, Durham, NC (S.D.P., R.K.L., E.P.Z., S.M.A.-K., D.D.H., J.P.P.); Duke Clinical Research Institute, Durham, NC (S.D.P., X.M., M.G., E.P.Z., S.M.A.-K., J.P.P.); Brigham and Women’s Hospital, Boston, MA (L.M.E.); and University of Miami, FL (R.G.C.)
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24
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Tsang DC, Carrillo RG. A case of symmetrical peripheral gangrene associated with transvenous lead extraction. HeartRhythm Case Rep 2017; 3:436-439. [PMID: 28948150 PMCID: PMC5602803 DOI: 10.1016/j.hrcr.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Darren C Tsang
- Department of Surgery, Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Roger G Carrillo
- Department of Surgery, Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Azarrafiy R, Tsang DC, Boyle TA, Wilkoff BL, Carrillo RG. Compliant endovascular balloon reduces the lethality of superior vena cava tears during transvenous lead extractions. Heart Rhythm 2017; 14:1400-1404. [DOI: 10.1016/j.hrthm.2017.05.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Indexed: 10/19/2022]
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Tsang DC, Azarrafiy R, Pecha S, Reichenspurner H, Carrillo RG, Hakmi S. Long-term outcomes of prophylactic placement of an endovascular balloon in the vena cava for high-risk transvenous lead extractions. Heart Rhythm 2017; 14:1833-1838. [PMID: 28797678 DOI: 10.1016/j.hrthm.2017.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Many clinicians use the strategy of prophylactically placing an endovascular balloon before transvenous lead extraction, yet there are no data regarding this practice. OBJECTIVE This study assesses long-term outcomes of prophylactic placement of an endovascular balloon in the venae cavae of patients during transvenous lead extraction. METHODS From April 1, 2016 to March 31, 2017 data were prospectively collected at 2 international cardiovascular centers on patients who had the balloon prophylactically placed in the venae cavae. Patients were monitored for a minimum of 3 months to capture any associated adverse events. RESULTS Twenty-one patients had the balloon prophylactically placed in the venae cavae during lead extraction. Sixteen patients were male (76%); the mean age was 57.6 ± 18.7 years; and the mean body mass index was 26.1 ± 4.4 kg/m2. The mean lead dwell time was 11.2 ± 8.3 years, with an average of 2.2 ± 1.1 leads per case, and most indications for extraction were noninfectious (62%). Two minor complications (10%, pocket hematomas) and 1 major complication (5%, cardiac tamponade) occurred during the procedure. All cases (100%) were procedural successes, and all patients (100%) were discharged alive. On follow-up (6.8 ± 3.7 months), all patients were alive and reported no adverse events related to prophylactic balloon placement, such as pulmonary emboli or deep venous thrombi. CONCLUSION During the study period, we observed no acute or long-term adverse outcomes associated with prophylactic placement of an endovascular balloon in the venae cavae of patients undergoing transvenous lead extraction.
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Affiliation(s)
- Darren C Tsang
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Ryan Azarrafiy
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Simon Pecha
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | | | - Roger G Carrillo
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, FL.
| | - Samer Hakmi
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
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Boyle TA, Uslan DZ, Prutkin JM, Greenspon AJ, Baddour LM, Danik SB, Tolosana JM, Le K, Miro JM, Peacock J, Sohail MR, Vikram HR, Carrillo RG. Reimplantation and Repeat Infection After Cardiac-Implantable Electronic Device Infections: Experience From the MEDIC (Multicenter Electrophysiologic Device Infection Cohort) Database. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004822. [PMID: 28292753 DOI: 10.1161/circep.116.004822] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 02/03/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infection is a serious complication of cardiovascular-implantable electronic device implantation and necessitates removal of all hardware for optimal treatment. Strategies for reimplanting hardware after infection vary widely and have not previously been analyzed using a large, multicenter study. METHODS AND RESULTS The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with cardiovascular-implantable electronic device infections at multiple institutions in the United States and abroad between 2009 and 2012. Reimplantation strategies were evaluated overall, and every patient who relapsed within 6 months was individually examined for clinical information that could help explain the negative outcome. Overall, 434 patients with cardiovascular-implantable electronic device infections were prospectively enrolled at participating centers. During the initial course of therapy, complete device removal was done in 381 patients (87.8%), and 220 of them (57.7%) were ultimately reimplanted with new devices. Overall, the median time between removal and reimplantation was 10 days, with an interquartile range of 6 to 19 days. Eleven of the 434 patients had another infection within 6 months, but only 4 of them were managed with cardiovascular-implantable electronic device removal and reimplantation during the initial infection. Thus, the repeat infection rate was low (1.8%) in those who were reimplanted. Patients who retained original hardware had a 11.3% repeat infection rate. CONCLUSIONS Our study findings confirm that a broad range of reimplant strategies are used in clinical practice. They suggest that it is safe to reimplant cardiac devices after extraction of previously infected hardware and that the risk of a second infection is low, regardless of reimplant timing.
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Affiliation(s)
- Thomas A Boyle
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.).
| | - Daniel Z Uslan
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Jordan M Prutkin
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Arnold J Greenspon
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Larry M Baddour
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Stephan B Danik
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Jose M Tolosana
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Katherine Le
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Jose M Miro
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - James Peacock
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Muhammad R Sohail
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Holenarasipur R Vikram
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.)
| | - Roger G Carrillo
- From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.).
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Al-Khatib SM, Yancy CW, Solis P, Becker L, Benjamin EJ, Carrillo RG, Ezekowitz JA, Fonarow GC, Kantharia BK, Kleinman M, Nichol G, Varosy PD. 2016 AHA/ACC Clinical Performance and Quality Measures for Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes 2017; 10:e000022. [DOI: 10.1161/hcq.0000000000000022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Cohen JA, Govea A, Carrillo RG. Clinical Outcomes of Patients with HIV Undergoing Lead Extraction for Infectious and Noninfectious Indications. Pacing Clin Electrophysiol 2015; 39:122-7. [PMID: 26514095 DOI: 10.1111/pace.12773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 08/17/2015] [Accepted: 10/13/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND With the increasing prevalence of human immunodeficiency virus positive (HIV+) patients in the United States, and the association between HIV and cardiovascular morbidity and mortality, the use of cardiac implantable electronic devices (CIEDs) in patients with HIV has become more common. With the increasing incidence of device-related complications, lead extraction is becoming a topic of importance in this population. As the use of implantable devices increases in the HIV+ population, complications are to be expected; therefore, lead extraction in the HIV population must be addressed. METHODS From January 2004 to May 2013, 1,018 patients requiring lead extraction were referred to a single, high-volume tertiary cardiovascular center. Within this group of patients, 10 were HIV+. We retrospectively reviewed the charts of this cohort and reported clinical variables of interest. RESULTS Infection was the most common indication for lead extraction and device removal. Four patients were in advanced heart failure, and the overall average ejection fraction of the sample population was 32.7 ± 16.3%. In addition, the majority of patients had one or more medical comorbidities. Devices removed, in order of frequency, were implantable cardioverter defibrillators, permanent pacemakers, and cardiac resynchronization therapy devices. On average, 35.6 ± 41.6 months elapsed from implantation of the oldest lead to the date of extraction. There were no major or minor complications and all procedures were clinically successful. CONCLUSIONS Laser lead extraction is both safe and effective in patients with HIV. This study sets a level of clinical precedent regarding the management of CIED infection or malfunction in patients with HIV.
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Affiliation(s)
- Joshua A Cohen
- University of Miami Miller School of Medicine, Miami, Florida
| | - Alayn Govea
- University of Miami Miller School of Medicine, Miami, Florida
| | - Roger G Carrillo
- University of Miami Miller School of Medicine, Miami, Florida.,Department of Cardiothoracic Surgery, University of Miami Hospital, Miami, Florida
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Healy CA, Carrillo RG. Wearable cardioverter-defibrillator for prevention of sudden cardiac death after infected implantable cardioverter-defibrillator removal: A cost-effectiveness evaluation. Heart Rhythm 2015; 12:1565-73. [PMID: 25839113 DOI: 10.1016/j.hrthm.2015.03.061] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prevention of sudden cardiac arrest (SCA) after removal of an infected implantable cardioverter-defibrillator (ICD) is a challenging clinical dilemma. The cost-effectiveness of the wearable cardioverter-defibrillator (WCD) in this setting remains uncertain. OBJECTIVE The purpose of this study was to compare the cost-effectiveness of the WCD with discharge home, discharge to a skilled nursing facility, or inpatient monitoring for the prevention of SCA after infected ICD removal. METHODS A decision model was developed to compare the cost-effectiveness of use of the WCD to several different strategies for patients who undergo ICD removal. One-way and 2-way sensitivity analyses were performed to account for uncertainties. RESULTS In the base-case analysis, the incremental cost-effectiveness of the WCD strategy was $20,300 per life-year (LY) or $26,436 per quality-adjusted life-year (QALY) compared to discharge home without a WCD. Discharge to a skilled nursing facility and in-hospital monitoring resulted in higher costs and worse clinical outcomes. The incremental cost-effectiveness ratio was as low as $15,392/QALY if the WCD successfully terminated 95% of SCA events and exceeded the $50,000/QALY willingness-to-pay threshold if the efficacy was <69%.The WCD strategy remained cost-effective, assuming 5.6% 2-month SCA risk, as long as the time to reimplantation was at least 2 weeks. CONCLUSION The WCD likely is cost-effective in protecting patients against SCA after infected ICD removal while waiting for ICD reimplantation compared to keeping patients in the hospital or discharging them home or to a skilled nursing facility.
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Affiliation(s)
- Christopher A Healy
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida.
| | - Roger G Carrillo
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Maytin M, Wilkoff BL, Brunner M, Cronin E, Love CJ, Grazia Bongiorni M, Segreti L, Carrillo RG, Garisto JD, Kutalek S, Subzposh F, Fischer A, Coffey JO, Gangireddy SR, Saba S, Mittal S, Arshad A, O’Keefe RM, Henrikson CA, Belott P, John RM, Epstein LM. Multicenter experience with extraction of the Riata/Riata ST ICD lead. Heart Rhythm 2014; 11:1613-8. [DOI: 10.1016/j.hrthm.2014.05.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Indexed: 12/21/2022]
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Greenspon AJ, Le KY, Prutkin JM, Sohail MR, Vikram HR, Baddour LM, Danik SB, Peacock J, Falces C, Miro JM, Naber C, Carrillo RG, Tseng CH, Uslan DZ. Influence of Vegetation Size on the Clinical Presentation and Outcome of Lead-Associated Endocarditis. JACC Cardiovasc Imaging 2014; 7:541-9. [DOI: 10.1016/j.jcmg.2014.01.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/23/2014] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
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Affiliation(s)
- Bryan R. Wilner
- University of Miami Miller School of Medicine; Miami Florida
| | - Roger G. Carrillo
- Department of Cardiac Surgery; University of Miami Miller School of Medicine; Miami Florida
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Wilner BR, Coffey JO, Mitrani R, Carrillo RG. Perforated tricuspid valve leaflet resulting from defibrillator leads: a review of the literature. J Card Surg 2014; 29:470-2. [PMID: 24803079 DOI: 10.1111/jocs.12352] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tricuspid valve (TV) perforation is a rare complication after implantable cardioverter defibrillator (ICD) and permanent pacemaker implantation. In reported cases of lead-related TV perforations, patients' present with symptoms months to years postimplantation. We describe a case where a patient presented with signs of severe TV regurgitation secondary to traumatic perforation of the septal leaflet two weeks after ICD implantation and review of the literature associated with this complication.
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Affiliation(s)
- Bryan R Wilner
- Department of Cardiac Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Welch M, Uslan DZ, Greenspon AJ, Sohail MR, Baddour LM, Blank E, Carrillo RG, Danik SB, Del Rio A, Hellinger W, Le KY, Miro JM, Naber C, Peacock JE, Vikram HR, Tseng CH, Prutkin JM. Variability in clinical features of early versus late cardiovascular implantable electronic device pocket infections. Pacing Clin Electrophysiol 2014; 37:955-62. [PMID: 24665867 DOI: 10.1111/pace.12385] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Revised: 12/31/2013] [Accepted: 02/14/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cardiovascular implantable electronic device (CIED) pocket infections are often related to recent CIED placement or manipulation, but these infections are not well characterized. The clinical presentation of CIED pocket infection, based on temporal onset related to last CIED procedure, deserves further study. METHODS The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with CIED infection. Subjects were stratified into those whose infection occurred <12 months (early) or ≥ 12 months (late) since their last CIED-related procedure. RESULTS There were 132 subjects in the early group and 106 in the late group. There were more females (P = 0.009) and anticoagulation use (P = 0.039) in the early group. Subjects with early infections were more likely to have had a generator change or lead addition as their last procedure (P = 0.03) and had more prior CIED procedures (P = 0.023). Early infections were more likely to present with pocket erythema (P < 0.001), swelling (P < 0.001), and pain (P = 0.007). Late infections were more likely to have pocket erosion (P = 0.005) and valvular vegetations (P = 0.009). In bacteremic subjects, early infections were more likely healthcare-associated (P < 0.001). In-hospital and 6-month mortality were equivalent. CONCLUSION A total of 45% of patients with CIED pocket infection presented >12 months following their last CIED-related procedure. Patients with early infection were more likely to be female, on anticoagulation, and present with localized inflammation, whereas those with late infection were more likely to have CIED erosion or valvular endocarditis.
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Affiliation(s)
- Mariko Welch
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
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Tanawuttiwat T, O'Neill BP, Cohen MG, Chinthakanan O, Heldman AW, Martinez CA, Alfonso CE, Mitrani RD, Macon CJ, Carrillo RG, Williams DB, O'Neill WW, Myerburg RJ. New-onset atrial fibrillation after aortic valve replacement: comparison of transfemoral, transapical, transaortic, and surgical approaches. J Am Coll Cardiol 2014; 63:1510-9. [PMID: 24486264 DOI: 10.1016/j.jacc.2013.11.046] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 10/10/2013] [Accepted: 11/19/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study sought to determine the incidence of new-onset atrial fibrillation (AF) associated with different methods of isolated aortic valve replacement (AVR)-transfemoral (TF), transapical (TA), and transaortic (TAo) catheter-based valve replacement and conventional surgical approaches. BACKGROUND The relative incidences of AF associated with the various access routes for AVR have not been well characterized. METHODS In this single-center, retrospective cohort study, we evaluated a total of 231 consecutive patients who underwent AVR for degenerative aortic stenosis (AS) between March 2010 and September 2012. Patients with a history of paroxysmal, persistent, or chronic AF, with bicuspid aortic valves, and patients who died within 48 h after AVR were excluded. A total of 123 patients (53% of total group) qualified for inclusion. Data on documented episodes of new-onset AF, along with all clinical, echocardiographic, procedural, and 30-day follow-up data, were collated. RESULTS AF occurred in 52 patients (42.3%). AF incidence varied according to the procedural method. AF occurred in 60% of patients who underwent surgical AVR (SAVR), in 53% after TA-TAVR, in 33% after TAo-TAVR cases, and 14% after TF-TAVR. The episodes occurred at a median time interval of 53 (25th to 75th percentile, 41 to 87) h after completion of the procedure. Procedures without pericardiotomy had an 82% risk reduction of AF compared with those with pericardiotomy (adjusted odds ratio: 0.18; 95% confidence interval: 0.05 to 0.59). CONCLUSIONS AF was a common complication of AVR with a cumulative incidence of >40% in elderly patients with degenerative AS who underwent either SAVR or TAVR. AF was most common with SAVR and least common with TF-TAVR. Procedures without pericardiotomy were associated with a lower incidence of AF.
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Affiliation(s)
- Tanyanan Tanawuttiwat
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Brian P O'Neill
- Temple Heart and Vascular Center, Temple University, Philadelphia, Pennsylvania (formerly at Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida)
| | - Mauricio G Cohen
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Orawee Chinthakanan
- Department of Obstetrics and Gynecology, Chiang Mai University, Chiang Mai, Thailand
| | - Alan W Heldman
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Claudia A Martinez
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Carlos E Alfonso
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Raul D Mitrani
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Conrad J Macon
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Roger G Carrillo
- Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Donald B Williams
- Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - William W O'Neill
- Center of Structural Heart Disease, Henry Ford Hospital and Medical Group, Detroit, Michigan
| | - Robert J Myerburg
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.
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Tanawuttiwat T, Garisto JD, Salow A, Glad JM, Szymkiewicz S, Saltzman HE, Kutalek SP, Carrillo RG. Protection from outpatient sudden cardiac death following ICD removal using a wearable cardioverter defibrillator. Pacing Clin Electrophysiol 2013; 37:562-8. [PMID: 24762055 DOI: 10.1111/pace.12319] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 10/07/2013] [Accepted: 10/13/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND An implantable cardioverter defibrillator (ICD) is effective in preventing sudden cardiac death (SCD). Once an ICD is removed and reimplantation is not feasible, a wearable cardioverter defibrillator (WCD) may be an alternative option. We determined the effectiveness of WCD for SCD prevention in patients who were discharged after ICD removal. METHODS A retrospective study was conducted on all WCD (LifeVest, ZOLL, Pittsburgh, PA, USA) patients who underwent ICD removal due to cardiac device infections (CDIs) at two referral centers between January 1, 2005 and December 31, 2009. Clinical characteristics, device information, and WCD data were analyzed. Sudden cardiac arrest was defined as all sustained ventricular tachycardia (VT) and ventricular fibrillation occurring within a single 24-hour period. RESULTS Ninety-seven patients (mean age 62.8 ± 13.3, male 80.4%) were included in the study. The median duration of antibiotic use was 14.7 days (interquartile range [IQR] 10-30). The median daily WCD use was 20 hours/day and the median length of use was 21 days (IQR 5-47). A total of three patients were shocked by WCD. Two patients had four episodes of sustained VT, successfully terminated by the WCD. A third patient experienced two inappropriate treatments due to oversensitivity of the signal artifact. Three patients experienced sudden death outside the hospital while not wearing the device. Five patients died while hospitalized. CONCLUSION WCD can prevent SCD, until ICD reimplantation is feasible in patients who underwent device removals for CDI. However, patient compliance is essential for the effective use of this device.
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Affiliation(s)
- Tanyanan Tanawuttiwat
- Division of Cardiovascular Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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Epstein LM, Love CJ, Wilkoff BL, Chung MK, Hackler JW, Bongiorni MG, Segreti L, Carrillo RG, Baltodano P, Fischer A, Kennergren C, Viklund R, Mittal S, Arshad A, Ellenbogen KA, John RM, Maytin M. Superior Vena Cava Defibrillator Coils Make Transvenous Lead Extraction More Challenging and Riskier. J Am Coll Cardiol 2013; 61:987-9. [DOI: 10.1016/j.jacc.2012.12.014] [Citation(s) in RCA: 394] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 12/02/2012] [Accepted: 12/09/2012] [Indexed: 11/25/2022]
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Maytin M, Carrillo RG, Baltodano P, Schaerf RHM, Bongiorni MG, Di Cori A, Curnis A, Cooper JM, Kennergren C, Epstein LM. Multicenter experience with transvenous lead extraction of active fixation coronary sinus leads. Pacing Clin Electrophysiol 2012; 35:641-7. [PMID: 22432739 DOI: 10.1111/j.1540-8159.2012.03353.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVE Active fixation coronary sinus (CS) leads limit dislodgement and represent an attractive option to the implanter. Although extraction of passive fixation CS leads is a common and frequently uncomplicated procedure, data regarding extraction of chronically implanted active fixation CS leads are limited. METHODS We performed a retrospective cohort study of patients undergoing active fixation CS lead extraction at six centers. Patient and procedural characteristics, indications for extraction, use of extraction sheath (ES) assistance, and outcomes are reported. RESULTS Between January 2009 and February 2011, 12 patients underwent transvenous lead extraction (TLE) of Medtronic StarFix® lead (Medtronic Inc., Minneapolis, MN, USA). The cohort was 83% male with mean age 71 ± 14 years. Average implant duration was 14.2 ± 5.7 months (2.3-23.6). All leads but one were removed for infectious indications (67% systemic infection). At the time of explant, the fixation lobes were completely retracted in only one of the 12 cases and ES assistance was required for lead removal in all cases (58% laser, 25% cutting, 25% mechanical, and 25% femoral). The majority of cases required advancement of the sheath into the CS (75.0%) and often into a branch vessel (41.7%). One lead could not be removed transvenously and required surgical lead extraction. There were no major complications. Examination of the leads after extraction frequently revealed significant tissue growth into the fixation lobes. CONCLUSIONS Although TLE of active fixation CS leads can be a safe procedure in select patients and experienced hands, powered sheaths and aggressive techniques are frequently required for successful removal despite relatively short implant durations. This raises significant concern regarding future TLE of active fixation CS leads with longer implant durations.
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Affiliation(s)
- Melanie Maytin
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Rodriguez Y, Greenspon AJ, Sohail MR, Carrillo RG. Cardiac device-related endocarditis complicated by spinal abscess. Pacing Clin Electrophysiol 2011; 35:269-74. [PMID: 22150338 DOI: 10.1111/j.1540-8159.2011.03288.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infective endocarditis is the most serious manifestation of cardiac device infection and metastatic seeding of distant sites has been reported. However, the association between device-related endocarditis and spinal abscess has not been fully described. METHODS We reviewed hospital records at three high-volume cardiovascular referral centers from January 2005 to October 2010. Device-related endocarditis was confirmed in all cases with positive blood cultures and transesophageal echocardiogram revealing lead and/or valvular vegetations. Six patients with spinal abscesses in association with device-related endocarditis were identified. RESULTS A total of 384 patients met the clinical criteria for device-related endocarditis. Among these, infection was complicated by spinal abscess formation in six (1.5%) cases. The mean age of patients was 69.3 ± 11.8 years (47-82 years). The predominant clinical manifestations in these six patients included a recent history of fever (six), malaise (four), and neurological or meningeal signs (five). Spinal abscesses were diagnosed by magnetic resonance imaging in two and computed tomography scans in four of the cases. The causative pathogens were methicillin-resistant Staphylococcus aureus (three), methicillin-sensitive S. aureus (one), coagulase-negative Staphylococci (two), and Enterococcus fecalis (one). All patients underwent complete device removal with no procedure-related complications. Two patients died in the hospital, two were discharged with permanent neurological deficits, and the remaining two recovered with no permanent neurologic sequelae. CONCLUSION Device-related endocarditis must be considered in patients who present with a spinal abscess and bacteremia. Early recognition of this scenario is imperative in order to avoid permanent neurological sequelae and patient mortality. Early imaging, appropriate parenteral antimicrobial therapy, and expedited removal of all cardiac hardware are pivotal for optimal management.
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Affiliation(s)
- Yasser Rodriguez
- Department of Cardiothoracic Surgery, University of Miami, Miami, FL, USA
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Rodriguez Y, Garisto J, Carrillo RG. Management of cardiac device-related infections: a review of protocol-driven care. Int J Cardiol 2011; 166:55-60. [PMID: 22033126 DOI: 10.1016/j.ijcard.2011.09.071] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 09/09/2011] [Accepted: 09/17/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND The prevalence of cardiac device-related infections (CDIs) has mirrored the unprecedented increase in device usage. CDIs are currently one of the leading indications for extraction. Despite this, there is limited data regarding the clinical trends, management and outcomes associated with this complication. METHODS A review of a prospective registry of all patients undergoing device extraction between January 1, 2004, and June 15, 2009, at a single high-volume tertiary referral center was performed. RESULTS A total of 506 consecutive patients were identified. From these, 350 patients were identified as having a CDI (205 ICD, 145 PPM). The mean age was 69.9 ± 13.7. Although most patients presented clinically with signs of a pocket infection (PI) (42%), the most common final diagnosis was cardiac device infective endocarditis (CDIE) (57%). The two most common pathogens were methicillin-resistant Staphylococcus aureus (27%) and methicillin-resistant Staphylococcus epidermidis (23%); they accounted for 69% of all deaths. Cultures taken from pocket tissue as opposed to exudates displayed higher concordance with lead-tip cultures (56% and 31% respectively). The mean time from explantation to device reimplantation for PIs, bacteremia and CDIE was 6.7 ± 4.7, 10.25 ± 4.7 and 11.39 ± 16.6 days respectively. CONCLUSION CDIs are a serious complication associated with device usage. Diagnosis and management protocols for CDIs should feature transesophageal echocardiography; complete hardware extraction; broad-spectrum antibiotics that cover methicillin-resistant Staphylococci and cultures derived from lead-tips and preferably pocket tissue. Immediate device reimplantation is possible in noninfectious cases; several factors should be considered regarding reimplantation in cases involving CDIs.
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Affiliation(s)
- Yasser Rodriguez
- University of Miami Miller School of Medicine, Miami, FL, United States.
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Affiliation(s)
- Yasser Rodriguez
- From the Department of Cardiothoracic Surgery, University of Miami Hospital, Miller School of Medicine, Miami, FL
| | - Juan D. Garisto
- From the Department of Cardiothoracic Surgery, University of Miami Hospital, Miller School of Medicine, Miami, FL
| | - Roger G. Carrillo
- From the Department of Cardiothoracic Surgery, University of Miami Hospital, Miller School of Medicine, Miami, FL
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Affiliation(s)
- Yasser Rodriguez
- From the Department of Cardiothoracic Surgery, University of Miami Hospital, Miller School of Medicine, Miami, FL
| | - Juan D. Garisto
- From the Department of Cardiothoracic Surgery, University of Miami Hospital, Miller School of Medicine, Miami, FL
| | - Roger G. Carrillo
- From the Department of Cardiothoracic Surgery, University of Miami Hospital, Miller School of Medicine, Miami, FL
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Koruth JS, Dukkipati S, Carrillo RG, Coffey J, Teng J, Eby TB, Reddy VY, D'Avila A. Safety and efficacy of high-intensity focused ultrasound atop coronary arteries during epicardial catheter ablation. J Cardiovasc Electrophysiol 2011; 22:1274-80. [PMID: 21676047 DOI: 10.1111/j.1540-8167.2011.02084.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coronary arterial injury continues to be a limitation of epicardial catheter ablation using currently available energy sources. Application of high intensity focused ultrasound (HIFU) energy may avoid such injury due to its theoretical ability to focus energy beyond the ablation element and create lesions at depth. OBJECTIVE This study evaluated the safety of HIFU applications delivered directly over the left anterior descending (LAD) artery in an open-chest swine model. METHODS Ten swine underwent median sternotomy. A prototype HIFU probe was placed atop the LAD. Forty-three therapies along the LAD (60-seconds/6 watt) were analyzed. Three, 3, and 4 swine were studied at 2, 4, and 8 weeks and subsequently sacrificed. Lesions were scored (0-4) depending on the percent circumferential involvement of arteries. RESULTS Lesion area increased minimally from 54.5 ± 18.0 mm(2) at 2 weeks to 56.9 ± 20.6 mm(2) at 8 weeks, and depth increased moderately from 13.2 ± 2.5 mm to 15.5 ± 3.4 mm. At 2, 4, and 8 weeks, the mean injury score of the LAD was 0.8 ± 0.3, 1.5 ± 0.9, and 2.0 ± 0.7. No/minimal arterial injury was seen in 64% of all sections. However, a progressive increase in injury resulted in 89% of all sections showing any injury at 8 weeks. One animal developed occlusion of the distal LAD. CONCLUSIONS HIFU has the potential to create deep ventricular lesions with relative sparing of the LAD. The incremental arterial damage noted over time warrants further evaluation to support the viability of focusing ultrasound energy beyond vulnerable critical structures to ablate deeper targets.
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Affiliation(s)
- Jacob S Koruth
- Helmsley Cardiac Arrhythmia Service, Mount Sinai Medical Center, New York, New York, USA
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Maytin M, Love CJ, Fischer A, Carrillo RG, Garisto JD, Bongiorni MG, Segreti L, John RM, Michaud GF, Albert CM, Epstein LM. Reply. J Am Coll Cardiol 2011. [DOI: 10.1016/j.jacc.2010.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Maytin M, Love CJ, Fischer A, Carrillo RG, Garisto JD, Bongiorni MG, Segreti L, John RM, Michaud GF, Albert CM, Epstein LM. Multicenter Experience With Extraction of the Sprint Fidelis Implantable Cardioverter-Defibrillator Lead. J Am Coll Cardiol 2010; 56:646-50. [DOI: 10.1016/j.jacc.2010.03.058] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Revised: 02/17/2010] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
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Carrillo RG, Garisto JD, Salman L, Merrill D, Asif A. Contamination of Transvenous Pacemaker Leads Due to Tunneled Hemodialysis Catheter Infection: A Report of 2 Cases. Am J Kidney Dis 2010; 55:1097-101. [DOI: 10.1053/j.ajkd.2010.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2009] [Accepted: 01/08/2010] [Indexed: 11/11/2022]
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Wazni O, Epstein LM, Carrillo RG, Love C, Adler SW, Riggio DW, Karim SS, Bashir J, Greenspon AJ, DiMarco JP, Cooper JM, Onufer JR, Ellenbogen KA, Kutalek SP, Dentry-Mabry S, Ervin CM, Wilkoff BL. Lead extraction in the contemporary setting: the LExICon study: an observational retrospective study of consecutive laser lead extractions. J Am Coll Cardiol 2010; 55:579-86. [PMID: 20152562 DOI: 10.1016/j.jacc.2009.08.070] [Citation(s) in RCA: 417] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 07/13/2009] [Accepted: 08/03/2009] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This study sought to examine the safety and efficacy of laser-assisted lead extraction and the indications, outcomes, and risk factors in a large series of consecutive patients. BACKGROUND The need for lead extraction has been increasing in direct relationship to the increased numbers of cardiovascular implantable electronic devices. METHODS Consecutive patients undergoing transvenous laser-assisted lead extraction at 13 centers were included. RESULTS Between January 2004 and December 2007, 1,449 consecutive patients underwent laser-assisted lead extraction of 2,405 leads (20 to 270 procedures/site). Median implantation duration was 82.1 months (0.4 to 356.8 months). Leads were completely removed 96.5% of the time, with a 97.7% clinical success rate whereby clinical goals associated with the indication for lead removal were achieved. Failure to achieve clinical success was associated with body mass index <25 kg/m(2) and low extraction volume centers. Procedural failure was higher in leads implanted for >10 years and when performed in low volume centers. Major adverse events in 20 patients were directly related to the procedure (1.4%) including 4 deaths (0.28%). Major adverse effects were associated with patients with a body mass index <25 kg/m(2). Overall all-cause in-hospital mortality was 1.86%; 4.3% when associated with endocarditis, 7.9% when associated with endocarditis and diabetes, and 12.4% when associated with endocarditis and creatinine > or =2.0. Indicators of all-cause in-hospital mortality were pocket infections, device-related endocarditis, diabetes, and creatinine > or =2.0. CONCLUSIONS Lead extraction employing laser sheaths is highly successful with a low procedural complication rate. Total mortality is substantially increased with pocket infections or device-related endocarditis, particularly in the setting of diabetes, renal insufficiency, or body mass index <25 kg/m(2). Centers with smaller case volumes tended to have a lower rate of successful extraction.
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Affiliation(s)
- Oussama Wazni
- Department of Cardiovascular Disease, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Garisto JD, Medina A, Williams DB, Carrillo RG. Surgical management of a giant ascending aortic pseudoaneurysm. Tex Heart Inst J 2010; 37:710-713. [PMID: 21224953 PMCID: PMC3014128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Aortic pseudoaneurysm is a rare, life-threatening complication after cardiac or aortic root surgery. When a pseudoaneurysm has eroded bony structures in the chest, the surgeon's challenge is to choose the safest approach for sternotomy. Herein, we report the case of a 74-year-old woman who presented with a giant pseudoaneurysm of the ascending aorta, 8 years after undergoing aortic valve replacement. The 8.9×5.8-cm formation arose in the anterior aortic sinus, extended to the retrosternal region, exerted mass effect on the main pulmonary artery, and eroded the bony structures of the sternum and medial upper chest. A new aortic valved tissue conduit was placed, and the coronary arteries were reimplanted. The patient recovered without neurologic sequelae. We discuss the characteristics of this case and explain our surgical decisions.
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Affiliation(s)
- Juan D Garisto
- Department of Cardiothoracic Surgery, University of Miami Hospital, Miller School of Medicine, Miami, Florida 33125, USA.
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Carrillo RG, Garisto JD, Salman L, Merrill D, Asif A. A Novel Technique for Tethered Dialysis Catheter Removal Using the Laser Sheath. Semin Dial 2009; 22:688-91. [DOI: 10.1111/j.1525-139x.2009.00646.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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