Andrzej Kutarski

The European Lead Extraction ConTRolled (ELECTRa) study: a European Heart Rhythm Association (EHRA) Registry of Transvenous Lead Extraction Outcomes

Aims The European Lead Extraction ConTRolled Registry (ELECTRa), is a prospective registry of consecutive transvenous lead extraction (TLE) procedures conducted by the European Heart Rhythm Association (EHRA) in order to identify the safety and efficacy of the current practice of TLE. Methods and results European centres performing TLE, invited by the organizing committee on behalf of EHRA, prospectively recruited all consecutive patients undergoing TLE at their institution. The primary endpoint was TLE safety defined by pre-discharge major procedure-related complications including death. Secondary endpoints included clinical and radiological success and overall complication rates. Outcomes were compared between Low Volume (LoV) vs. High Volume (HiV) centers (LoV < 30 and HiV ≥ 30 procedures/year). A total of 3555 consecutive patients (pts) of whom 3510 underwent TLE at 73 centres in 19 European countries were enrolled between November 2012 and May 2014. The primary endpoint of in-hospital procedure-related major complication rate was 1.7% [95% CI 1.3-2.1%] (58/3510 pts) including a mortality of 0.5% [95% CI 0.3-0.8%] (17/3510 pts). Approximately two-thirds (37/58) of these complications occurred during the procedure and one-third (21/58) in the post-operative period. The most common procedure related complications were those requiring pericardiocentesis or chest tube and/or surgical repair (1.4% [95% CI 1.0-1.8%]). Complete clinical and radiological success rates were 96.7% [95% CI 96.1-97.3%] and 95.7% [95% CI 95.2-96.2%], respectively. The all cause in-hospital major complications and deaths were significantly lower in HiV centres vs. LoV centres (2.4% [95% CI 1.9-3.0%] vs. 4.1% [95% CI 2.7-6.0%], P = 0.0146; and 1.2% [95% CI 0.8-1.6%] vs. 2.5% [95% CI 1.5-4.1%] P = 0.0088), although those related to the procedure did not reach statistical significance. Radiological and clinical successes were more frequent in HiV vs. LoV centres. Conclusion The ELECTRa study is the largest prospective registry on TLE and confirmed the safety and efficacy of the current practice of TLE. Lead extraction was associated with a higher success rate with lower all cause complication and mortality rates in high volume compared with low volume centres.

Abrasions of the outer silicone insulation of endocardial leads in their intracardiac part: a new mechanism of lead-dependent endocarditis.

AIMS The aim of the study was to identify and characterize the morphology of abrasions and to establish the frequency of the phenomena and their association with infective endocarditis (IE). METHODS AND RESULTS A total of 212 endocardial leads removed from 141 consecutive patients-due to IE (32), pocket infection (37), and non-infective indications (72)-were analysed with a stereomicroscope and a scanning electron microscope. The presence of abrasions in the intracardiac part (IP) of the atrial (P < 0.01) and ventricular (P < 0.00002) leads, regardless of its advancement, was strongly associated with IE. There were associations between abrasions in the IP of the ventricular (P < 0.00002) and atrial (P < 0.005) leads and two or more implanted endocardial leads. In atrial leads, there was an association between the presence of any abrasion and passive fixation (P < 0.05), dwell time (P < 0.05), and number of procedures until removal (P < 0.006). The abrasions were classified into three levels of degradation under two subtypes according to the morphology observed with a stereomicroscope. The third level of degradation was the most frequently observed in the IP of the leads. CONCLUSIONS The abrasion of the outer insulation in the IP of silicone leads was significant regardless of the level of degradation and is associated with IE. The abrasions observed in the IP of the leads were similar to those observed in the intravenous and pocket parts, with predomination of the third level of degradation. There was an association between the presence of any abrasion in the IP of the leads and the number of leads, and in the case of atrial leads between abrasions and fixation type, dwell time, and number of procedures until explantation.

Lead dependent tricuspid dysfunction: Analysis of the mechanism and management in patients referred for transvenous lead extraction

BACKGROUND Lead-dependent tricuspid dysfunction (LDTD) is one of important complications in patients with cardiac implantable electronic devices. However, this phenomenon is probably underestimated because of an improper interpretation of its clinical symptoms. The aim of this study was to identify LDTD mechanisms and management in patients referred for transvenous lead extraction (TLE) due to lead-dependent complications. METHODS Data of 940 patients undergoing TLE in a single center from 2009 to 2011 were assessed and 24 patients with LDTD were identifi ed. The general indications for TLE, pacing system types and lead dwell time in both study groups were comparatively analyzed. The radiological and clinical effi cacy of TLE procedure was also assessed in both groups with precision estimation of clinical status patients with LDTD (before and after TLE). Additionally, mechanisms, concomitant lead-dependent complications and degree (severity) of LDTD before and after the procedure were evaluated. Telephone follow-up of LDTD patients was performed at the mean time 1.5 years after TLE/replacement procedure. RESULTS The main indications for TLE in both groups were similar (apart from isolated LDTD in 45.83% patients from group I). Patients with LDTD had more complex pacing systems with more leads (2.04 in the LDTD group vs. 1.69 in the control group; p = 0.04). There were more unnecessary loops of lead in LDTD patients than in the control group (41.7% vs. 5.24%; p = 0.001). There were no signifi cant differences in average time from implantation to extraction and the number of preceding procedures. Signifi cant tricuspid regurgitation (TR-grade III-IV) was found in 96% of LDTD patients, whereas stenosis with regurgitation in 4%. The 10% frequency of severe TR (not lead dependent) in the control group patients was observed. The main mechanism of LDTD was abnormal leafl et coaptation caused by: loop of the lead (42%), septal leafl et pulled toward the interventricular septum (37%) or too intensive lead impingement of the leafl ets (21%). LDTD patients were treated with TLE and reimplantation of the lead to the right ventricle (87.5%) or to the cardiac vein (4.2%), or surgery procedure with epicardial lead placement following ineffective TLE (8.3%). The radiological and clinical effi cacy of TLE procedure was very high and comparable between the groups I and II (91.7% vs. 94.2%; p = 0.6 and 100% vs. 98.4%; p = 0.46, respectively). Repeated echocardiography showed reduced severity of tricuspid valve dysfunction in 62.5% of LDTD patients. The follow- -up interview confi rmed clinical improvement in 75% of patients (further improvement after cardiosurgery in 2 patients was observed). CONCLUSIONS LDTD is a diagnostic and therapeutic challenge. The main reason for LDTD was abnormal leafl et coaptation caused by lead loop presence, or propping, or impingement the leafl ets by the lead. Probably, TLE with lead reimplantation is a safe and effective option in LDTD management. An alternative option is TLE with omitted tricuspid valve reimplantation. Cardiac surgery with epicardial lead placement should be reserved for patients with ineffective previous procedures.

Atrial Electromechanical Sequence and Contraction Synchrony during Single‐ and Multisite Atrial Pacing in Patients with Brady‐Tachycardia Syndrome

Objectives: Investigation of which atrial pacing modality provides atrial synchrony and the most physiological atrial contraction pattern in patients with brady‐tachycardia syndrome.

Hemodynamic effects of alternative atrial pacing sites in patients with paroxysmal atrial fibrillation.

DABROWSKA‐KUGACKA, A., et al.: Hemodynamic Effects of Alternative Atrial Pacing Sites in Patients with Paroxysmal Atrial Fibrillation. Recently, multisite atrial pacing has been suggested as an alternative therapy to prevent recurrences of paroxysmal atrial fibrillation (PAF). A study was conducted to compare the acute effects of biatrial (BiA), left atrial (LA), and right atrial appendage (RAA) pacing on cardiac hemodynamics. In 14 patients with PAF and a BiA pacemaker (with leads in the RAA and coronary sinus), cardiac output (CO), right (RV) and left ventricular (LV) filling, RA‐LA contraction delay [PA(m‐t)] and the difference in A wave duration [Adif(m‐p)] at the level of the mitral valve (Adurm) and pulmonary veins (Adurp) during RAA, BiA, and LA pacing were examined by echo‐Doppler measurements. The atrial pacing site did not affect the CO. LA, but not BiA, pacing resulted in delayed RA contraction in comparison with RAA pacing with significant diminution of the RA contribution to RV filling. With LA pacing, the usual right‐to‐left atrial contraction sequence was reversed (PA(m‐t): 8 ± 7 ms control; 5 ± 30 ms RAA; −10 ± 21 ms BiA; −72 ± 36 ms LA; LA versus control versus RAA and versus BiA, P < 0.001. LA and BiA pacing prolonged Adurp (LA 186 ± 52 ms, BiA 180 ± 45 ms, RAA 153 ± 49 ms; LA and BiA vs RAA, P < 0.01) . Thus Adurp exceeded Adurm[Adif (m‐p): control 38 ± 40 ms, RAA 7 ± 42 ms, BiA −12 ± 43 ms, LA −20 ± 44 ms; control vs RAA, BiA, and LA; and RAA vs LA, P < 0.05]. The study showed that (1) the atrial pacing site has no influence on global cardiac performance; (2) the hemodynamic effect of BiA pacing is not superior to that of RAA pacing, and LA pacing can even be deleterious; (3) LA pacing reverses the usual right‐to‐left atrial contraction sequence and reduces the RA contribution to RV filling; (4) BiA and LA pacing prolong Adurp due to an altered activation pattern, decreased pulmonary venous return, or increased LA pressure. (PACE 2003; 26[Pt. II]:278–283)

Inflammatory activation following interruption of long-term cardiac resynchronization therapy

Previous observations suggest that cardiac resynchronization therapy (CRT) may exert an anti-inflammatory effect. The objective of this study was to evaluate the effect of temporary interruption of long-term CRT on plasma concentrations of proinflammatory cytokines and brain natriuretic peptide (BNP). The study group consisted of 54 patients (32 male and 22 female, mean age 64 years) with chronic heart failure (HF) treated with CRT. BNP, high-sensitivity C-reactive protein (hs-CRP), interleukin 6 (IL-6), and neopterin were measured three times: after 26–28 weeks of continuous CRT (CRT-on), 48 h after its cessation (CRT-off), and 48 h after switching the CRT-on again. CRT interruption resulted in a significant worsening of left ventricular systolic function: reduction of cardiac output (CO), dP/dt, and left ventricular ejection fraction (LVEF), as well as deterioration of mitral regurgitation in the CRT responder group. A significant increase in serum concentrations of hs-CRP, neopterin, IL-6, and BNP was noted in this subpopulation. In CRT nonresponders, no significant changes were observed. In responders the changes in serum concentrations of hs-CRP, IL-6, neopterin, and BNP, following CRT interruption, significantly correlated with the respective changes in thoracic fluid content (TFC) and inversely correlated with LVEF changes. Even short (48 h) interruption of long-term CRT led to a significant increase of proinflammatory cytokines and BNP concentrations in responders. The changes in hs-CRP, IL-6, neopterin, and BNP concentrations correlated with the change in TFC-marker of pulmonary congestion and inversely correlated with the change in LVEF.

Relationship between P-wave duration and atrial electromechanical delay assessed by tissue Doppler echocardiography.

Background: The aim of the study was to assess the relationship between P‐wave duration on the surface electrocardiogram (ECG) and echocardiographic parameters of atrial electromechanical delay (EMD), as well as contraction synchrony during different atrial pacing modalities.

Analysis of ventricular late potentials in signal-averaged ECG of people with epilepsy.

Purpose:  There has been growing interest in cardiac disturbances in epilepsy patients and their etiologic role in the context of sudden death. Ventricular late potentials (VLPs) recorded on signal‐averaged electrocardiography (SAECG) reflects delayed ventricular depolarization and identifies the structural or functional substrate for the ventricular tachycardia in the reentry mechanism. Therefore, abnormal SAECG poses the potential of identifying patients at increased risk of malignant ventricular arrhythmias and sudden cardiac death. The aim of this exploratory study was to screen epilepsy patients who were treated with established doses of antiepileptic drugs (AEDs) on the presence of VLPs.

Atrial lead location at the Bachmann's bundle region results in a low incidence of far field R-wave sensing

AIMS The aim of the study was to investigate far field R-wave sensing (FFRS) rate and characteristics at different right atrial (RA) positions in patients treated with multisite atrial pacing, with the RA lead implanted at the Bachmanns bundle (BB) area in 69 patients, in comparison to RA appendage (RAA) in 70 patients. METHODS AND RESULTS All measurements were done during sinus rhythm in supine patients, with unipolar (UP) and bipolar (BP) sensing configuration. The presence, amplitude threshold (FFRS trsh) and FFRS timing were determined. Sensing safety margin was defined as the ratio of sensed P-wave vs. FFRS trsh, for both the minimal (Pmin) and the mean (Pmean) P-wave amplitude. At both atrial locations BP sensing was superior to UP in FFRS rejection (P < 0.0001). At 0.5 mV sensitivity level (BP) FFRS occurred in 1% of patients at the BB site vs. 11% at the RAA (P = 0.01). FFRS trsh (BP) was 0.2 +/- 0.1 mV at the BB vs. 0.4 +/- 0.3 mV in the RAA position (P < 0.0001). Sensing safety margin, when determined for the Pmin amplitude was > or =5 in 99% of patients from the BB group, in comparison to 66% of RAA patients (P < 0.0001), in whom it was <2 in 13%. Even with the use of BP leads equipped with a 10 mm tip-to-ring spacing FFRS incidence was lower at the BB site (P < 0.01), FFRS trsh was lower (P < 0.001), and sensing safety margin was higher vs. RAA (P = 0.002). CONCLUSION Bachmanns bundle area features optimal conditions for signal sensing, and such atrial lead positioning may offer advantages to prevent oversensing of R-wave, thus improving functioning of standard dual chamber pacemakers, ICDs and CRT-Ds.

Biventricular versus right ventricular pacing decreases immune activation and augments nitric oxide production in patients with chronic heart failure

Immune system activation and oxidative stress are involved in the pathogenesis of heart failure (HF). We aimed to test the hypothesis that upgrading from right ventricular pacing (RVp) to biventricular pacing (BiVp) can counteract these phenomena.