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Özpak E, Van Heuverswyn F, Timmermans F, De Pooter J. Lead performance of stylet-driven leads in left bundle branch area pacing: Results from a large single-center cohort and insights from in vitro bench testing. Heart Rhythm 2024:S1547-5271(24)00103-6. [PMID: 38307309 DOI: 10.1016/j.hrthm.2024.01.049] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) requires deep septal lead deployment for left-sided conduction stimulation. Advancing leads toward deep septal positions might add mechanical stress on these leads. Concerns about lead performance and reliability remain an unanswered question. OBJECTIVE The purpose of this study was to analyze lead performance and integrity of stylet-driven pacing leads (SDLs) for LBBAP. METHODS This study assessed lead fracture rates of SDL in a large single-center cohort of adult LBBAP patients. Fluoroscopic analysis of lead bending angulations at the septal insertion point and in vitro bench testing of lead preconditioning were performed to simulate clinical use conditions. Lead performance was compared between LBBAP and conventional right ventricular apical pacing (RVp) sites. RESULTS The study included 325 LBBAP patients (66% male; age 71±15 years). During median follow-up of 18 months, 2 patients (0.6%) experienced conductor fracture between tip housing and ring electrode, whereas no such fractures occurred with RVp patients (n = 149; P = .22). X-ray analysis revealed that high lead bending angulations occurred in 1.3% of the patients. Accelerated bench testing of excessive preconditioned leads showcased a higher probability of early conductor fracture compared to standard preconditioned leads. CONCLUSION The incidence of early conductor failure in LBBAP seems higher than with conventional RVp sites. The most vulnerable lead part seems to be the interelectrode space between the tip housing and ring electrode. Excessive angulation and preconditioning might contribute to early fatigue fracture.
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Affiliation(s)
- Emine Özpak
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium.
| | | | - Frank Timmermans
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Jan De Pooter
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
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Kawada S, Nishii N, Mizuno T, Miyamoto M, Nakagawa K, Morita H. Management of sensing issues with a subcutaneous implantable cardioverter-defibrillator in a patient with Brugada syndrome: A case report. HeartRhythm Case Rep 2023; 9:878-882. [PMID: 38204842 PMCID: PMC10774532 DOI: 10.1016/j.hrcr.2023.09.009] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Satoshi Kawada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nobuhiro Nishii
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomofumi Mizuno
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Zhu XY, Tang XH, Huang WY. Pacemaker electrode rupture causes recurrent syncope: A case report. World J Clin Cases 2022; 10:12352-12357. [PMID: 36483839 PMCID: PMC9724526 DOI: 10.12998/wjcc.v10.i33.12352] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Currently, the implantation of permanent cardiac pacemakers entails mostly subclavian vein puncture, which is relatively simpler and easier to master. However, due to individual differences, some patients carry a narrow space between the clavicle and the first rib. If the range of activity of the upper limb is increased, the friction between the electrode wire and the bone gap leads to the breakage of the electrode wire, which is manifested by poor pacemaker perception and pacing.
CASE SUMMARY A 68-year-old woman underwent permanent pacemaker implantation in our hospital because of third-degree atrioventricular block 6 years ago. At that time, the patient was recommended to have a dual-chamber permanent pacemaker implantation, and finally chose a single-chamber permanent pacemaker because she could not afford the cost. The patient has repeatedly lost consciousness for no obvious reason in the past 3 d, and went to our hospital for treatment. The chest X-ray showed that the pacemaker electrode was broken. After the patient was given a pacemaker electrode replacement, the patient did not continue to lose consciousness.
CONCLUSION Because the electrodes implanted in the subclavian approach are close to the clavicle and the first rib, the pacemaker electrodes may wear out. If the patient loses consciousness again after the pacemaker is implanted, we should consider whether there is a pacemaker. The possibility of electrode breakage, and timely help the patient to replace the new pacemaker electrodes.
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Affiliation(s)
- Xiao-Yong Zhu
- Department of Cardiology, Jiujiang University Affiliated Hospital, Jiujiang 332000, Jiangxi Province, China
| | - Xin-Hu Tang
- Department of Cardiology, Jiujiang University Affiliated Hospital, Jiujiang 332000, Jiangxi Province, China
| | - Wen-Yin Huang
- Department of Cardiology, Jiujiang University Affiliated Hospital, Jiujiang 332000, Jiangxi Province, China
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Thaler R, Sinner MF, Joghetaei N, Fichtner S. Early sudden distal conductor fracture of a stylet-driven lead implanted for left bundle branch area pacing. HeartRhythm Case Rep 2022; 9:28-30. [PMID: 36685682 PMCID: PMC9845548 DOI: 10.1016/j.hrcr.2022.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 11/05/2022] Open
Affiliation(s)
- Raffael Thaler
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany,Address reprint requests and correspondence: Dr Raffael Thaler, Department of Cardiology, University Hospital, LMU Munich, Marchionini Street 15, 81377, Munich, Germany.
| | - Moritz F. Sinner
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | | | - Stephanie Fichtner
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany
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Pothineni NVK, Schaller RD. Gradual rise in lead impedance - A "rocky" course. HeartRhythm Case Rep 2021; 7:833-835. [PMID: 34987970 PMCID: PMC8695284 DOI: 10.1016/j.hrcr.2021.09.008] [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: 11/29/2022] Open
Affiliation(s)
- Naga Venkata K. Pothineni
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D. Schaller
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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O’Neill L, Gillis K, Wielandts JY, Hilfiker G, Knecht S, Duytschaever M, Tavernier R, Le Polain De Waroux JB. Flatline on the alternate vector…Is this subcutaneous implantable cardiac defibrillator lead fractured? HeartRhythm Case Rep 2021; 7:758-761. [PMID: 34820275 PMCID: PMC8602115 DOI: 10.1016/j.hrcr.2021.08.008] [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: 11/29/2022] Open
Affiliation(s)
- Louisa O’Neill
- Address reprint requests and correspondence: Dr Louisa O’Neill, Department of Cardiology, AZ Sint-Jan Hospital, Bruges, Belgium.
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Horani G, Hosein K, Kumar R, Shamoon F. A broken lead to an open heart: implantable cardioverter defibrillator vegetations with lead fracture. Radiol Case Rep 2021; 16:3152-6. [PMID: 34484509 DOI: 10.1016/j.radcr.2021.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 07/25/2021] [Accepted: 07/25/2021] [Indexed: 11/22/2022] Open
Abstract
Implantable cardiac devices are widely used devices that serve several purposes. Complications from devices are not uncommon and include localized or systemic infections, device-related endocarditis, and device malfunction leading to serious outcomes, including death. Another possible complication that has been reported in the literature is thrombus formation on the device leads. We present a rare case of large thrombi forming on the leads of an implantable cardioverter defibrillator leading to lead fracture and device malfunction. After the device alerted for malfunction, the patient underwent a transesophageal echocardiogram which demonstrated masses on the right atrium and ventricle. He subsequently had a right atrial exploration and lead extraction which revealed large thrombi on the leads which histologically were identified as sterile vegetations.
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De Vloo P, Vermeulen L, Vandenberghe W, Nuttin B. Open fracture of deep brain stimulation leads with normal electrical impedances. Brain Stimul 2020; 13:1639-1641. [PMID: 33007426 DOI: 10.1016/j.brs.2020.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/21/2020] [Accepted: 09/25/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Experimental Functional Neurosurgery, Research Group of Experimental Neurosurgery and Neuroanatomy, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Lynn Vermeulen
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Wim Vandenberghe
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Parkinson Research, Research Group of Experimental Neurology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Bart Nuttin
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Experimental Functional Neurosurgery, Research Group of Experimental Neurosurgery and Neuroanatomy, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
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Kuschyk J, Müller-Leisse J, Duncker D, Tülümen E, Fastenrath F, Fastner C, Kruska M, Akin I, Liebe V, Borggrefe M, Veltmann C, Rudic B. Comparison of transvenous vs subcutaneous defibrillator therapy in patients with cardiac arrhythmia syndromes and genetic cardiomyopathies. Int J Cardiol 2021; 323:100-5. [PMID: 32871189 DOI: 10.1016/j.ijcard.2020.08.089] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/19/2020] [Accepted: 08/26/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Inherited arrhythmia syndromes and genetic cardiomyopathies attribute in a significant proportion to sudden cardiac death. Implantable cardioverter defibrillators (ICDs) are the cornerstone in the prevention of sudden death in high-risk patients. However, ICD therapy is also associated with high rates of inappropriate shocks and/or device-related complications especially in young patients. OBJECTIVE To determine the outcome of high-risk patients with inherited arrhythmia syndromes and genetic cardiomyopathies comparing two defibrillator technologies. METHOD Between 2010 and 2018, 183 consecutive patients from two large German tertiary care centers were enrolled in the study. The majority of patients (83%) had either cardiac channelopathies or idiopathic ventricular fibrillation without cardiac structural abnormalities, while the remaining 17% had a genetic cardiomyopathy (HCM/ARVC). Eighty-six patients (47%) received a transvenous ICD (TV-ICD), while a subcutaneous ICD (S-ICD) was implanted in another 97 patients (53%). RESULTS During a mean follow-up of 4.3 years, 30 patients had an appropriate ICD therapy (annual rate 3.8%). Fifteen patients experienced an inappropriate shock (annual rate 1.9%). Lead failure occurred in 17 (9%) patients and was less frequent in the S-ICD group (OR 0.48, 95%CI 0.38-0.62). Adverse defibrillator events, defined as a composite of inappropriate shocks and lead failure requiring surgical revision were significantly lower in the S-ICD group as compared to the TV-ICD group (OR 0.55, 95%CI 0.41-0.72). There was a non-significant trend towards lower appropriate shocks in the S-ICD group, that in combination with all-cause shocks yielded in a significantly higher freedom of any shock in the S-ICD group (RR 39%, p = 0.003). No deaths occurred during follow-up. CONCLUSION The present data favor the use of the subcutaneous ICD for patients with inherited arrhythmia syndromes and genetic cardiomyopathies who do not need anti-bradycardia pacing.
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Barakat AF, Cross B, Wertz J, Saba S, Kancharla K. Cardiac implantable electronic device malfunction after deceleration injury without obvious chest trauma. HeartRhythm Case Rep 2019; 5:285-7. [PMID: 31193179 DOI: 10.1016/j.hrcr.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Elsheshtawy M, Yang F, Prabhu S. Dizziness spells: Should one suspect the pacemaker? Am J Emerg Med 2018; 37:563.e1-563.e3. [PMID: 30581029 DOI: 10.1016/j.ajem.2018.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 10/24/2018] [Revised: 11/12/2018] [Accepted: 12/10/2018] [Indexed: 11/20/2022] Open
Abstract
A 52-year-old lady presented to the emergency department with recurrent episodes of dizziness and near-syncope on awakening up or swinging her left arm. Initial rhythm strips demonstrated intermittently non-conducted p waves corresponding to inappropriate pacemaker inhibition and oversensing malfunction. Pacemaker was interrogated in the ED showing ventricular lead noise and decreased lead impedance over a one year period. The patient was diagnosed with pacemaker lead failure supported by correlating pacemaker lead variation with homolateral arm movement. The patient was referred to an electrophysiologist and underwent new right ventricular lead placement with the resolution of symptoms.
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Affiliation(s)
- Moustafa Elsheshtawy
- Department of Medicine, Division of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA 11219; Department of Medicine, Division of Cardiology, Coney Island Hospital, Brooklyn, NY, USA 11235.
| | - Felix Yang
- Department of Medicine, Division of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA 11219
| | - Sudhakar Prabhu
- Department of Medicine, Division of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA 11219; Department of Medicine, Division of Cardiology, Coney Island Hospital, Brooklyn, NY, USA 11235
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El-Chami MF, Rao B, Shah AD, Wood C, Sayegh M, Zakka P, Ginn K, Pallotta L, Evans B, Hoskins MH, Delurgio D, Lloyd M, Langberg J, Leon AR, Merchant FM. Long-term performance of a pacing lead family: A single-center experience. Heart Rhythm 2019; 16:572-8. [PMID: 30366161 DOI: 10.1016/j.hrthm.2018.10.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The performance of Abbott/St. Jude Medical (Sylmar CA) Tendril pacing leads has not been well characterized. OBJECTIVE We sought to assess the performance of Tendril leads as compared with that of different pacing leads. METHODS We retrospectively identified patients implanted with the following leads: Tendril leads 1888 TC, 2088 TC, and 1688 TC, Medtronic (Fridely, MN) 4076 CapSureFix Novus, and Boston Scientific (Natick, MA) FINELINE II Sterox Pacing EZ leads (models 4469, 4470, and 4471). The primary end point was the incidence of lead malfunction assessed by Kaplan-Meier analysis. RESULTS During the study period, 9782 leads were implanted, including 8512 Tendril leads, 731 Medtronic 4076 CapSureFix Novus leads, and 539 FINELINE II leads. A total of 540 leads (5.5%) malfunctioned during a mean follow-up of 3.6 ± 2.9 years. Lead malfunction manifested predominantly as noise and/or low impedance (95%). Lead malfunction rates were significantly higher at 5 years for Tendril vs non-Tendril leads (7.0% vs 2.1%; P < .001). The highest rate of failure at 5 years was seen in the Tendril 1888 TC leads (9.9%), followed by Tendril 1688 (5.7%) and Tendril 2088 (5.2%) leads. In contrast, malfunction rates were significantly lower for the Medtronic 4076 (2.6%) and FINELINE II (1.7%) leads. During follow-up to 10 years, the incidence of lead malfunction for Optim-insulated Tendril leads (models 1888 TC and 2088 TC) was significantly higher than that for the non-Optim-insulated Tendril 1688 TC lead (24.5% vs 7.1%) (P = .008). CONCLUSION Tendril leads appear to have a higher rate of malfunction than do comparator leads. Optim insulation may partly explain the higher failure rate.
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Gul EE, Boles U, Ali FS, Abdollah H. Loss of atrial pacing in a patient with a dual-chamber permanent pacemaker: What is the mechanism? J Arrhythm 2017; 33:159-60. [PMID: 28416988 DOI: 10.1016/j.joa.2016.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/20/2016] [Accepted: 08/08/2016] [Indexed: 11/22/2022] Open
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Tuohy S, Ryan P, Galvin J. Turning a blind eye to the far field: Are we burying the evidence? A case of abrupt catastrophic implantable cardioverter defibrillator lead failure causing sudden death. HeartRhythm Case Rep 2015; 2:6-10. [PMID: 28491620 PMCID: PMC5412663 DOI: 10.1016/j.hrcr.2015.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 11/30/2022] Open
Key Words
- ATP, antitachycardia pacing
- Defibrillator
- EF, ejection fraction
- EGM, electrogram
- ICD therapy
- ICD, implantable cardioverter defibrillator
- LV, left ventricle
- Lead fracture
- RV, right ventricle
- RVLND, right ventricular lead noise discrimination
- SVC, superior vena cava
- Sudden death
- TWOS, T-wave oversensing
- VF, ventricular fibrillation
- VT, ventricular tachycardia
- Ventricular fibrillation
- bpm, beats per minute
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Affiliation(s)
- Stephen Tuohy
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
| | - Paul Ryan
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
| | - Joseph Galvin
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
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Hauser RG, Kallinen Retel LM. Early fatigue fractures in the IS-1 connector leg of a small-diameter ICD lead: value of returned product analysis for improving device safety. Heart Rhythm 2013; 10:1462-8. [PMID: 23871705 DOI: 10.1016/j.hrthm.2013.07.001] [Citation(s) in RCA: 7] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Conductor fractures may affect the performance of implantable cardioverter-defibrillator leads. During routine surveillance of returned product analyses (RPAs) in the Food and Drug Administration's Manufacturers and User Facility Device Experience database, we found a number of conductor fractures in small diameter implantable cardioverter-defibrillator leads manufactured by St Jude Medical, Inc (SJM, Sylmar, CA). OBJECTIVES To determine the location and cause of these fractures and to catalog their clinical signs and consequences. METHODS We searched the FDA's Manufacturers and User Facility Device Experience database on April 11, 2013. SJM provided information and data it collected independently. RESULTS Our search found 59 leads with fractures in the IS-1 leg. Most fractures were in leads implanted in 2008-2009; no fractures were found in leads implanted after 2010. Outer coil conductor fractures accounted for the majority (51 of 59, 86%). Oversensing and noise were common signs, and 81% of the patients received inappropriate shocks. SJM's RPAs found that the fractures were due to inadequate strain relief and redesigned the IS-1 leg by shortening the crimp bore. Younger age and subpectoral implants appeared to be associated with these fractures. SJM stated the incidence is low (0.040%) and has not seen further fractures of this type in leads with the modified crimp. CONCLUSIONS SJM's small diameter leads that were manufactured before 2011 are prone to early outer coil fatigue fractures in the IS-1 leg. The failure mechanism appears to have been mitigated by a design change. RPA is important for improving device safety.
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Affiliation(s)
- Robert G Hauser
- Patient Safety and Advocacy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.
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