Anna Polewczyk

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.

Lead-Dependent Infective Endocarditis: The Role of Factors Predisposing to Its Development in an Analysis of 414 Clinical Cases

Lead‐dependent infective endocarditis (LDIE) is a serious and insidious infective disease spreading along the leads to valve leaflets and endocardial surface. LDIE is still a lesser known disease with unclear risk factors, most often evaluated jointly for all infectious complications.

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.

Complications of permanent cardiac pacing in patients with persistent left superior vena cava

BACKGROUND Persistent left superior vena cava (PLSVC) is present in about 0.3-0.5% of the general population and in about 12% of patients with other abnormalities. This congenital anomaly is usually asymptomatic and does not cause any physiological problems. However, it may become a significant problem in multiple clinical situations. Various complications related to PLVSC are encountered in anesthesiological, nephrological, oncological and cardiological procedures. The presence of PLSVC is usually incidentally detected during placement of pacemaker (PM), implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) leads. Technical difficulties during lead positioning (especially ventricular leads) are commonly known and often described in the literature. The purpose of the present study was to evaluate the specific methods used for implantation of increasingly complicated pacing systems, finding an optimal strategy in patients with PLSVC, especially with electrotherapy complications. METHODS We performed a single-center retrospective analysis of 11 patients (7 women and 4 men, mean age 60.4 ± 13 years) with PLSVC hospitalized in single Cardiology Department between 2000 and 2012. The clinical characteristic, indications for PM/ICD/CRT implantation, technique of implantation and complications were evaluated. RESULTS In PLSVC patients, different indications for pacing or resynchronization therapy were represented: sick sinus syndrome (SSS) in 4 patients, 3rd degree atrio-ventricular (AV) block in 4 patients, dilated cardiomyopathy with left bundle branch block in 2 patients, dilated cardiomyopathy and non-sustained ventricular tachycardia episodes in 1 patient. In patients no. 1, 3, 4 and 10 the complications necessitated the change of leads or type of pacing. Transvenous lead extraction was successfully performed in patient no. 1 and 10 with re-implantation of new leads via PLSVC in patient no. 1 and via right superior vena cava in patient no. 10. Patient no. 3 received an additional ventricular lead via PLSVC because of 2nd degree AV block (formerly atrial lead implanted due to SSS). In patient no. 4 with left atrial pacing (lead in coronary sinus), prosthetic mitral valve replacement was combined with epicardial ventricular lead placement. Patients no. 2 and 7 received a CRT device, without technical problems in patient no. 7, whereas in patient no. 2 due to difficulties with left ventricular lead positioning a hybrid approach to epicardial lead pacing was used. In patient no. 8 an ICD was implanted with difficulty in placing defibrillator lead. Patient no. 5 received 2 atrial leads via PLSVC with successful biatrial pacing; patient no. 6 with the necessity of DDD pacing had a (ventricular) lead for left atrial pacing and a typical right ventricular lead. In patients no. 9 and 11 typical DDD pacing was used with contralateral placement of the leads due to anatomical and technical differences. After 12 years of follow-up the survival is 90.9%. Late electrotherapy complications have developed only in patient no. 8 (problems with the defibrillator lead). CONCLUSIONS Patients with PLSVC are a very heterogeneous group with different indications for pacing, therefore individualization of therapy is required. Technical complications connected with pacing of the right heart chambers are commonly known, hence transvenous left atrial or left ventricular lead implantation should be attempted. In case of difficulties in transvenous positioning of the lead, a hybrid or isolated cardiac surgery technique should be considered. Because of the increasing number of electrotherapy complications, these problems are also present in PLSVC patients. Transvenous lead extraction with re-implantation of a pacing system has not been reported yet. For this reason a thorough evaluation of the venous system is required in PLSVC patients before intervention.

Progress in the management of ST-segment elevation myocardial infarction during economic transition in Poland between 1992 and 2006

Implementation of new therapeutic strategies is intended to decrease morbidity and mortality in patients with acute coronary syndromes (ACS). The aim of this study is to evaluate progress in the treatment of ST-segment elevation myocardial infarction (STEMI) in 1992-2006 based on data from Polish National ACS Registry. A total of 881 STEMI patients in 1992-1996 and 889 in 2005-2006 were enrolled. The use of reperfusion therapy resulted in marked reduction in in-hospital and post-discharge mortality with the best results achieved in the invasive arm. Low invasive approach rate in high-risk patients resulted in no reduction in global mortality.

Lead-related infective endocarditis: Factors influencing early and long-term survival in patients undergoing transvenous lead extraction

BACKGROUND Lead-related infective endocarditis (LRIE) is a serious infectious disease with uncertain prognosis. OBJECTIVE The purpose of this study was to evaluate the factors that influence survival in patients with LRIE undergoing transvenous lead extraction (TLE). METHODS Clinical data obtained from 500 consecutive patients with LRIE undergoing TLE in the reference center in the years 2006 to 2015 were retrospectively analyzed. We evaluated the effect of demographic, clinical, and procedure-related factors on 30-day and long-term survival (mean 3-year follow-up). RESULTS Analysis of 30-day survival after TLE revealed 19 deaths (3.8%), with long-term mortality (mean 3-year follow-up) of 29.3% (146 deaths). Multivariate analysis showed unfavorable effects of age (hazard ratio [HR] 1.056, 95% confidence interval [CI] 1.030-1.082); decreased left ventricular ejection fraction (HR 0.687, 95% CI 0.545-0.866); renal failure (HR 3.099, 95% CI 1.865-5.150); and presence of vegetation fragments remaining after TLE (HR 1.384, 95% CI 1.089-1.760). Log-rank test and Kaplan-Meier survival curves demonstrated statistically worse prognosis in patients with large vegetations (>2 cm) and with vegetation remnants. Better prognosis was associated with LRIE coexisting with generator pocket infection. CONCLUSION Long-term mortality in LRIE patients is still high. Factors that influence negatively on prognosis include large cardiac vegetations and their remnants after TLE. Such vegetations develop most frequently in patients with decreased left ventricular ejection fraction and renal failure. Probably, early detection of LRIE would tend to limit the formation of large vegetations that invade the adjacent cardiac structures.

Late complications of electrotherapy — a clinical analysis of indications for transvenous removal of endocardial leads: a single centre experience

BACKGROUND Despite advances in electrotherapy, late complications constitute an increasing clinical and therapeutic problem. Transvenous lead extraction (TLE) is becoming a safe and effective approach to the treatment of such complications. AIM To assess indications for TLE and to evaluate safety and efficacy of TLE procedures. METHODS A retrospective clinical analysis of 100 patients with complications of electrotherapy admitted to a tertiary care centre in 2008-2011. RESULTS In 2008-2011, the number of electrotherapy complications increased markedly. The most frequent reason for TLE was lead dysfunction (62% of patients, including 31% with an implanted cardioverter-defibrillator [ICD] and 31% with a pacemaker [PM]). The most common type of lead dysfunction was conductor damage (38% of patients, including 23% with ICD, 15% with PM), followed by late myocardial perforation (14% of patients, including 7% with ICD, 7% with PM), abnormal course of the lead (7% of patients, including 1% with ICD, 6% with PM), and lead insulation failure (3% of patients). Other reasons for TLE were infectious complications (24% of patients, including 15% with PM pocket infection), venous insufficiency (17% of patients, including 10% in whom an indwelling lead was a direct obstacle to switching the pacing mode), and the need to switch the pacing mode (4% of patients). Procedural efficacy was 96% (lead fragments were left in place in 4% of patients). No significant clinical complications were observed in any of the patients in the periprocedural period. CONCLUSIONS Clinical manifestations of electrotherapy complications in the study group varied and included a relatively small number of infectious complications (24%) and a relatively large number of late myocardial perforations (14%). Efficacy and safety of the procedures were very high.

Does reperfusion in the treatment of acute myocardial infarction improve the prognosis of acute myocardial infarction in diabetic patients

Diabetic patients have a 6‐fold increased mortality in acute coronary syndromes.

Leads dislodged into the pulmonary vascular bed in patients with cardiac implantable electronic devices

Introduction Spontaneous lead dislodgement into the pulmonary circulation is a rare complication of permanent pacing with unproven harmfulness and an indication of controversial class for transvenous lead extraction (TLE). Aim To assess TLE safety in patients with leads dislodged into the pulmonary artery. Material and methods A retrospective analysis of a 9-year-old database of transvenous lead extraction procedures comprising 1767 TLEs was carried out, including a group of 19 (1.1%) patients with leads dislodged into the pulmonary artery (LDPA). Results Under univariate analysis the factors that increased the likelihood of the presence of an electrode in the pulmonary artery were mean lead dwelling time (increase of risk by 9% per year), total number of leads in the heart before TLE (increase of risk by 66% for one lead) and the number of abandoned leads (increase of risk by 119%). The presence of LDPA was associated with frequent occurrence of intracardiac lead abrasion (increase by 316%) and isolated lead-related infective endocarditis (LRIE) (increase by 500%). There were no statistically significant differences in clinical (p = 0.3), procedural (p = 0.94) or radiological (p = 0.31) success rates in compared (LDPA and non-LDPA) groups. Long-term mortality after TLE was comparable in both groups. Conclusions As the effectiveness and safety of TLE in patients with LDPA are comparable to those in standard TLE procedures, in our opinion, such patients should be considered TLE candidates.

Pregnancy after myocardial infarction and coronary artery bypass grafting - is it safe?

Pregnancy after myocardial infarction (MI) and coronary artery bypass grafting (CABG), although still rare, is slowly becoming a challenge in everyday clinical practice. In recent decades MI has been observed to occur more frequently in young women. Concurrently an increasing number of women decide to become pregnant at more advanced age. Although pregnancy after MI and CABG may be possible and safe, a multidisciplinary approach involving careful evaluation by the cardiac and obstetric team in each individual is mandatory. Two cases of pregnant women with a history of MI treated with CABG are presented and their management is discussed.