Artur Oręziak

Post heart transplant extraction of the abandoned fragments of pacing and defibrillation leads: proposed management algorithm.

BACKGROUND An increasing number of patients is referred for orthotopic heart transplantation (OHT) after previous implantable cardioverter-defibrillator (ICD) or cardiac resynchronisation therapy (CRT) device implantation. AIM To assess the rate of unsuccessful lead extractions during OHT and propose an appropriate management algorithm. METHODS The study population included 73 consecutive patients who underwent OHT in our hospital between January 2009 and December 2011. RESULTS In the study group, 36 (49.3%) patients previously underwent ICD (21 patients, 28.8%) or CRT (15 patients, 20.5%) implantation. In 29 patients, all previously implanted leads were completely removed during transplantation. In 7 (19.5%) patients, fragments of the leads could not be removed and were abandoned due to their adherence to the venous system, including a proximal defibrillation coil in 6 cases and a fragment of a left ventricular lead in 1 case. All abandoned lead fragments were extracted after the transplantation (10-70 days, mean 27 days) either with manual traction techniques (1 case, left ventricular lead), or with the assistance of lead extraction sheaths (6 cases, dual-coil defibrillation leads). Due to lead fracture, it was necessary to use femoral approach in 1 case. No complications of lead extraction were noted. CONCLUSIONS In a significant number of patients, previously implanted leads cannot be removed during OHT. Therefore, abandoned lead fragments should be removed after the transplantation using transvenous lead extraction techniques.

Regaining venous access for implantation of a new lead

Introduction Venous occlusion is a relatively common complication of endocardial lead implantation. It may cause a critical problem when implantation of a new lead is needed. Traditional methods result in leaving abandoned leads. The optimal approach seems to be the extraction of the damaged or abandoned lead, regaining venous access and implantation of a new lead. Aim To assess the efficacy and safety of new lead implantation by the method of lead extraction. Material and methods All transvenous lead extraction procedures (203 patients) between 1 August 2008 and 15 October 2012 were assessed. The analysis included cases with leads implanted for at least 6 months prior to extraction. Results Regaining venous access was the main indication for lead extraction in 5 patients (4.9%). The reason for new lead implantation was lead damage (n = 7) and system up-grade to cardiac resynchronization therapy (CRT) (n = 3). In total, 23 leads were extracted (9 defibrillation leads, 12 pacing leads and 2 left ventricular leads). The mean time from the implantation was 92.2 ±43.2 (48-152) months. In all cases Cook mechanical sheaths were applied. The use of the Evolution system was necessary to extract 3 leads. In all cases the new leads were successfully implanted as planned. No serious complications occurred. Conclusions Diagnosis of venous occlusion should not be a contraindication for ipsilateral implantation of the new lead, because the techniques of transvenous lead extraction enable successful regaining of venous access.

SVM detection of premature ectopic excitations based on modified PCA

The paper presents a modified version of principal component analysis of 3-channel Holter recordings that enables to construct one SVM linear classifier for the selected group of patients with arrhythmias. Our classifier has perfect generalization properties. We studied the discrimination of premature ventricular excitation from normal ones. The high score of correct classification (95%) is due to the orientation of the system of coordinates along the largest eigenvector of the normal heart action of every patient under study.

PCA Representation of ECG Signal as a Useful Tool for Detection of Premature Ventricular Beats in 3-Channel Holter Recording by Neural Network and Support Vector Machine Classifier

In the paper classification method of compressed ECG signal was presented. Classification of single heartbeats was performed by neural networks and support vector machine. Parameterization of ECG signal was realized by principal component analysis (PCA). For every heartbeat only two descriptors have been used. The results of real Holter signal were presented in tables and as plots in planespherical coordinates. The efficiency of classification is near to 99%.

Long-term temporary pacing with an active fixation lead

BACKGROUND Ensuring a haemodynamically effective cardiac rhythm is a challenge in patients waiting for pacemaker reimplantation after transcutaneous lead extraction due to an infection of the implanted system. AIM The authors report a retrospective analysis of temporary pacing with an active fixation lead (AFTP) connected to an externalised pacemaker in patients after transvenous lead extraction (TLE) due to an infection. METHODS AFTP was used in 34 patients (12 women) aged from 38 to 88 years (mean 67.5 years). This represented 24.5% of the population of patients undergoing TLE due to infective indications. In 32 cases, the indication for temporary pacing was atrioventricular block, and in 2 patients sick sinus syndrome. The lead was implanted via the internal jugular vein puncture into the right ventricle in 33 cases and into the right atrium in 1 case. Leads were secured to the skin and attached to externalized pacemakers. RESULTS AFTP was used for 4 to 26 days (average 14.5 days). Re-implantation was performed in 29 patients (85.3% of the study group). There was no early infection recurrence. Three patients died during AFTP (8.8% of the study group), including two due to septic shock, and a cardiac arrest due to pulseless electrical activity in another patient. CONCLUSIONS Temporary pacing with an active fixation lead is an effective and safe method to ensure a hemodynamically stable heart rhythm for a period ranging from a few to several days after the surgery in patients after transcutaneous lead extraction due to infective indications.

Lead extraction: The road to successful cardiac resynchronization therapy

BACKGROUND Still increasing life expectancy in patients with implanted devices and large number of leads more and more often induce the need to cure the treatment complications or to change especially to cardiac resynchronization therapy (CRT). In order to prevent further complications, the possibility of damaged or redundant leads extraction should be taken into consideration. The aim of the paper was to assess the effectiveness and safety of transvenous lead extraction (TLE) with co-implantation of resynchronization systems. METHODS AND RESULTS Between 2008 and March 2013, the system removal with TLE was conducted in 246 patients. In 38 patients (11 women, 28.9%), aged 43-79 (mean 65 years), it was combined with co-implantation of CRT-pacemaker or defibrillator (CRT-P/D). Indications for TLE covered: lead failure in 21 (55.3%) patients, redundant leads in 6 (15.8%), and the occluded venous system in 7 (18.4%). The up-grade of the pacemaker or defibrillator system to CRT-D was performed in 19 cases, CRT-P/D revision in next 19. Together 32 defibrillation leads and 42 pacing leads (27 left ventricular leads, and 1 epicardial lead) were implanted. The intended clinical target--an effective resynchronization therapy--was obtained in all patients. There was no case of death or severe complications. In 2 cases of venous occlusion, the implantation on the contralateral side was required. CONCLUSIONS TLE enables effective resynchronization therapy also in the case of the presence of too many leads, occlusion of the venous system or lead failure. Significant technical problems can occur especially in patients with venous system occlusion.

Clinical and echocardiographic parameters as risk factors for atrial fibrillation in patients with hypertrophic cardiomyopathy

Atrial fibrillation (AF) is a common complication in patients with hypertrophic cardiomyopathy (HCM) and may contribute to high cardiovascular morbidity and mortality. Therefore, it is important to assess parameters associated with AF in HCM patients.

Left ventricular tumour masquerading as hypertrophic cardiomyopathy: how one can be misled by transthoracic echocardiography

Cardiac fibromas are common benign primary cardiac tumours in children. The incidence of these tumours is rare in the adult population but increases in patients suffering from Gorlin’s syndrome. These patients present with multiple basal cell carcinomas, ovarian fibromas, medulloblastomas, as well as skeletal abnormalities and congenital malformations. We present a case of a 41-year-old male with a longstanding history of heart failure in the course of hypertrophic cardiomyopathy (HCM) treated with implantable cardioverter-defibrillator (ICD), as primary prevention of sudden cardiac death, for seven years. At this point he was admitted to our clinic because of atrial and ventricular lead failure. The Heart Team decided on the transvenous lead removal strategy. During transoesophageal echocardiography performed intraoperatively a pathological mass in the right atrium was first encountered. Previous multiple transthoracic echocardiography (TTE) performed with poor echocardiographic window using only standard views as well as electrocardiogram (Fig. 1) did not drown suspicion of any pathology other than HCM. After ICD-VR re-implantation (intentional downgrading of CIED) a chest computed tomography (CT) was performed, which revealed the presence of a heart tumour with

Risk factors of atrial fibrillation recurrence despite successful radiofrequency ablation of accessory pathway: At 11 years of follow-up

BACKGROUND Previous reports on patients with radiofrequency catheter ablation (RFCA) of accessory pathway (AP) and atrial fibrillation (AF) include only short follow-up periods. The aim of this study was to analyze predictors of recurrence of AF in patients after successful RFCA of APs over long term follow-up periods. METHODS Of the 1,007 patients who underwent non-pharmacological treatment of APs (between the years 1993-2008), data of 100 consecutive patients were retrospectively analyzed (75 men, mean age 43.6 ± 14.7), with the longest period of follow-up (mean 11.3 ± 3.5 years) after successful RFCA of AP. In Group 1, there were 72 patients (54 men, mean age 40.66 ± 13.85 years) without documented episodes of AF after RFCA of AP. Group 2 consisted of 28 patients (21 men, mean age 50.79 ± 14.49 years) with AF episodes despite successful elimination of AP. RESULTS In univariate analysis, patients from Group 1 were significantly younger at the time of abla-tion than patients from Group 2 (40.66 ± 13.85 vs. 50.79 ± 14.49 years; p = 0.002), had shorter his¬tory of AF episodes (4.11 ± 4.07 vs. 8.25 ± 7.50 years; p = 0.024) and had less frequently documented atrial tachycardia (AT) prior to ablation (3.39 vs. 20.00% years; p = 0.022). In multivariate analysis, the history of AF in years (p = 0.043), was an independent risk factor for AF recurrences. CONCLUSIONS Older patient age, longer history of AF and AT prior to RFCA of APs identified a sub-group of patients who required additional treatment. In the multivariate analysis, the history of AF in years (p = 0.043) was a risk factor for AF recurrence.

Early stage of left atrium remodelling predicts better outcome in long-term follow-up of atrial fibrillation ablation.

BACKGROUND Radiofrequency catheter ablation (RFCA) has been increasingly used for the treatment of patients with symptomatic atrial fibrillation (AF). AIM To identify simple pre-procedural success predictors of RFCA in patients with AF. METHODS AND RESULTS It comprised 294 consecutive patients (mean age 54 ± 11 years, 71% male) with symptomatic AF (28% - paroxysmal with short episodes (< 12 h); 50% - paroxysmal with episodes ≥ 12 h and < 7 days; 11.5% - persistent; 10.5% - long standing persistent), having undergone the first RFCA. Before RFCA, all patients underwent pulmonary vein (PV) anatomy imaging and echocardiographic left atrium diameter (LAD) evaluation. PV periostial or antral isolation guided by electroanatomical mapping was performed with additional lines or complex fractionated electrograms ablation (if required). Outcomes were defined as clinical success (complete or improvement) or failure. After a mean follow-up of 36.9 ± 13 months, clinical success was observed in 90.5% of patients, made up of 47.3% complete success, and 43.2% improvement. Patients with short AF episodes underwent fewer procedures (1.6 vs. 2, p = 0.026) and had the highest clinical (97.6%) and complete (63.9%) success rates. AF episodes < 12 h (p < 0.001), LAD < 4 cm (p = 0.01) and male gender (p = 0.002) independently predicted RFCA long-term clinical success. PV anatomy did not correlate with RFCA outcome. A trend was observed towards a larger number of procedures in patients with atypical PV anatomy (p = 0.059). CONCLUSIONS AF ablation should be performed in the early stage of AF, before structural remodelling development.