Andrzej Ząbek

Safety and effectiveness of transvenous lead extraction in elderly patients

BACKGROUND There is a considerable controversy regarding safety of transvenous lead extraction (TLE) in elderly patients due to their potentially worse general condition, more concomitant diseases, more difficult sedation or analgesia. Moreover, the present experience is not relevant. The aim of the study was the comparison of safety and feasibility of TLE in elderly and middle-aged patients. METHODS We have extracted an ingrown pacemaker (PM)/implantable cardioverter-defibrillator (ICD) leads from 1,060 adult patients (21-70 years) and 192 octogenarians (mean age 83.4 ± 3.1 years) using standard mechanical systems within the last 7 years. We compared effectiveness and complications of the TLE procedures in the two mentioned groups of patients. RESULTS There were more women in octogenarians referred for TLE (45.3% vs. 36.9%). In addition, more pocket infections (37.0% vs. 24.5%), less non-infective indications for PM (46.9% vs. 57.7%) and ICD systems (7.3% vs. 28.8%) TLE were observed in this group. Leads body dwelling time was similar (76.4 ± 56.8 vs. 83.5 ± 63.0) in both groups. Procedure efficacy (full radiological success 97.4% vs. 94.6%, partial radiological success 2.6% vs. 4.34%), safety measures (major complications 1.6% vs. 1.51%, minor complications 1.0% vs. 1.9%) were similar in both compared groups. CONCLUSIONS Old age does not influence TLE effectiveness. Therefore, TLE can be safely and successfully performed in octogenarians.

Venous Stenosis and Occlusion in the Presence of Endocardial Leads.

BACKGROUND Venous stenosis and occlusion in the presence of endocardial leads constitute one of the complications of permanent cardiac pacing either by pacemaker, implantable cardioverter-defibrillator or cardiac resynchronization therapy. OBJECTIVES The aim of this study was to assess the incidence of stenosis and occlusions and determine the risk factors in patients with endocardial leads in a prospective single-center study. MATERIAL AND METHODS Two hundred eighty consecutive patients aged 25-95 years (male 68.8%) were included. A contrast venography examination of the ipsilateral access vein was performed. The whole study population was divided into 2 groups, based on the presence (group I) or absence (group II) of endocardial leads. RESULTS Venous stenosis/occlusion was identified in 51 patients (37.5%) in group I and in 3 patients (3.6%) in group II; p < 0.0001. The lead presence most highly correlated with venous complications (OR = 4.172; p < 0.001). In patients with endocardial leads divided into I A and I B according to venous patency diabetes mellitus was proved in multivariate analysis to be the only protective factor against the development of venous stenosis/occlusion (OR = 0.473; p = 0.010). CONCLUSIONS The presence of endocardial leads is a predisposing factor for venous stenosis/occlusion and increases the risk 4-fold. The venous lesions in the presence of endocardial leads are less frequent among patients with diabetes mellitus.

Broken leads with proximal endings in the cardiovascular system: Serious consequences and extraction diffi culties

BACKGROUND Retrospective analysis of effectiveness, technical problems, and complications of transvenous extraction of leads with the free endings migrated to the cardiovascular system (CVS). METHODS A 5-year-old database of transvenous lead extraction (TLE) procedures comprising 906 patients with 1563 leads being removed was analyzed. TLE procedures of leads migrated in the CVS were compared with TLE procedures of leads with their proximal ends accessible in the pacemaker/implantable cardioverter-defibrillator (PM/ICD) pocket. RESULTS In our material, the phenomenon of leads migration occurred in 5% of patients referred for TLE and affected most frequently unipolar and atrial leads. The presence of migrating leads was associated with local venous occlusion in 64% of patients. Removal of migrating leads required other techniques than extraction of leads with their proximal ends accessible in the PM/ICD pocket. More than 95% of migrating leads were extracted transvenously, but procedures were significantly longer. The presence of other leads made extraction of migrated leads even more complicated. Effectiveness and complication rates for removal of migrated leads and leads accessible in the PM/ICD pocket were similar. CONCLUSIONS We postulate that every lead migrating in the CVS should be considered for TLE. However, this extraction is technically more difficult and challenging than extraction of leads accessible in the PM/ICD pocket.

Elevated NT-proBNP is associated with unfavorably altered plasma fibrin clot properties in atrial fibrillation

BACKGROUND Dense fibrin clot formation and hypofibrinolysis have been reported in atrial fibrillation (AF). It is unclear which factors affect fibrin clot properties in AF. METHODS AND RESULTS We investigated plasma fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP) as well as other coagulation and fibrinolysis parameters along with N-terminal pro-B-type natriuretic peptide (NT-proBNP) in 160 AF patients (median age, 70.5years). Previous stroke (n=15; 9.4%) was associated with decreased Ks (P=0.04) and longer CLT (P=0.005), together with higher antiplasmin (P=0.03) and lower tissue-type plasminogen activator (P=0.01). Lower Ks (P=0.04) and tendency towards longer CLT (P=0.10) were observed in patients with a left atrium diameter>40mm. Patients with a CHA2DS2-VASc score of 3 or more (82.5%) were characterized by higher thrombin-activatable fibrinolysis inhibitor antigen (P=0.009). Ks was inversely correlated with log NT-proBNP (r=-0.34, P<0.0001), plasminogen activator inhibitor-1 (PAI-1) antigen (r=-0.24, P=0.002) and C-reactive protein (r=-0.18, P=0.02), while CLT was positively correlated with log NT-proBNP (R=0.61, P<0.0001) and ETP (r=0.37, P<0.0001), which were interrelated (r=0.59, P<0.0001). After adjustment for potential confounders, PAI-1 (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.02-1.26) was the only independent predictor of low Ks (the lowest quartile,≤6×10-9cm2), while NT-proBNP (OR: 1.21; 95% CI: 1.12-1.31) and PAI-1 (OR: 1.30; 95% CI: 1.12-1.51) both predicted prolonged CLT (the top quartile,≥109min). CONCLUSION In AF patients prothrombotic fibrin clot properties assessed ex vivo are determined by PAI-1 and NT-proBNP and this phenotype is associated with prior ischemic stroke.

Transvenous removal of endocardial leads with coexisting great vegetation (3.5 cm)--case report.

We discuss a case of transvenous removal of endocardial leads in a patient with initial contraindication for such a procedure due to the size of the vegetation in his right atrium. Simultaneously, the patients progressive general poor condition during the course of infective endocarditis prognosed that cardiosurgical intervention with the use of cardiopulmonary bypass would be unsuccessful. Using an innovative solution, that is placing the Dotters basket in the right ventricular outlet as a protection against massive pulmonary embolism, the leads were removed. An asymptomatic pulmonary embolism caused by defragmented vegetation was revealed after the procedure.

Inhibition of left ventricular stimulation due to left ventricular lead failure and the left ventricular T-wave protection algorithm in patient with cardiac resynchronization therapy and pacemaker dependency

The electrocardiogram (ECG) interpretation in patients with cardiac resynchronization therapy (CRT) is often a perplexing problem. The difficulty in the device evaluation increases in the presence of unfamiliar timing cycles and a lead dysfunction. Authors describe a special function of a Biotronik CRT devices called the left ventricle T‐wave protection (LVTP), and demonstrate its behavior in a patient with left ventricular (LV) lead failure. This report shows that sometimes it might be difficult to understand the loss of resynchronization in 12‐lead ECG when LVTP feature is on, and a malfunction of left ventricular lead sensing occurs.

Atrioventricular synchrony in the background of ventricular noise and undersensing

The 24‐hr electrocardiogram (ECG) interpretation in patients with double‐chamber pacemakers may be challenging. The difficulty increases if not well‐known pacemaker algorithm and device malfunction coexist. We show atrial synchronization pace (ASP) in a patient with ventricular lead damage. We provide detailed description of electrocardiogram and intracardiac electrogram. ASP may confuse 24‐hr ECG monitoring interpretation, especially in patients with ventricular lead dysfunction.

The utility of a CHA2DS2-VASc score in predicting the presence of significant stenosis and occlusion of veins with indwelling endocardial leads.

BACKGROUND Currently, there are no studies in which a CHA2DS2-VASc score has been used to predict the risk of venous stenosis and occlusion (VSO) in patients after the implantation of a cardiac implantable electronic device (CIED). METHODS The material consists of the records of 223 consecutive patients qualified for transvenous lead extraction, generator change and system revisions or upgrades in whom we assessed the utility of a CHA2DS2-VASc score in the prediction of VSO. The CHA2DS2-VASc score was calculated retrospectively based on the clinical data. The whole study population was divided into two groups, based on the presence (group I) or absence (group II) of VSO. Using the receiver operating characteristic (ROC) curve, we identified the optimal cut-off point for the CHA2DS2-VASc score that allowed the prediction of the absence of VSO. RESULTS The venography was performed in 223 consecutive patients aged on average 68.2years (25.7-95.3), 77 females (34.5%). The presence of VSO was detected in 79 (35.4%) patients aged 68.3±14.1years, 30 female (40%) patients-group I. The level of the cut-off point for the CHA2DS2-VASc score that allowed the prediction of the absence of VSO was 3.0. CONCLUSION In the whole population the incidence of VSO amounted to 35.4%. The result of the CHA2DS2-VASc score was a destimulant of VSO occurrence and was characterized by moderate sensitivity (73.4%) and specificity (42.4%) in predicting the absence of VSO. The most significant factor, which prevented VSO development was diabetes.

Atrio-ventricular block in the presence of double-chamber ICD — how is that possible?

We present description of ECG by Holter monitoring in a 26-year-old patient with double-chamber implantable cardioverter-defibrillator (ICD). Fragments of record show atrio-ventricular block, which may suggests ICD dysfunction. However, this is working mode of ICD having minimal ventricular pacing algorhythm.

Relationship between changes in selected thrombotic and inflammatory factors, echocardiographic parameters and the incidence of venous thrombosis after pacemaker implantation based on our own observations.

Introduction Thrombosis (VTh) is a rare dangerous complication of pacemaker implantation (PM). The aim of the study was to determine the dynamics of change in selected thrombotic and inflammatory factors after PM. Material and methods The study involved 81 patients (30 female, mean age: 71.1 years) with PM, divided into two groups. Group A (71 patients) consisted of patients without VTh, whereas group B (10 patients) comprised the patients with VTh. A transthoracic echocardiogram (TTE) and a venous ultrasound (VU) examination were performed. The levels of D-dimers, fibrinogen, tissue factor (TF), factor VII, plasminogen activator inhibitor-1 (PAI-1), interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) were determined in the venous blood. After PM, the TTE and VU examinations were repeated at 6 and 12 months, and blood analyses were performed within 7 days after PM, and subsequently at 6 and 12 months. Results In 10 patients of group B, symptomatic VTh occurred at a mean time of 13.06 months after PM. Initially, the levels of IL-6, hsCRP, D-dimers, fibrinogen, TF, VII factor and PAI-1 were considerably higher in group B than in group A. In all patients the levels of these factors kept on increasing for up to 7 days after the procedure. In group A they subsequently decreased, whereas in group B they continued to rise. Conclusions Increased levels of inflammatory and thrombotic factors were observed in patients with VTh before and after PM. The factors of highest risk of VTh occurrence were D-dimers, fibrinogen and TF.