Giovanni Coluccia

Major predictors of fibrous adherences in transvenous implantable cardioverter-defibrillator lead extraction

BACKGROUND Percutaneous removal of implantable cardioverter-defibrillator (ICD) leads is a difficult procedure because of the consequence of massive fibrous tissue growth along the lead. OBJECTIVE The purpose of this study was to describe the occurrence and location of fibrous adherences in ICD lead extraction and to identify potential predictors among patient and lead characteristics. METHODS We studied 637 consecutive patients who underwent transvenous extraction of 678 ICD leads from 1997 to 2013. RESULTS Procedural success rate was 99%, without major complications. Areas of adherence were found in the subclavian vein (78%), innominate vein (65%), superior vena cava (66%), and heart (73%). Dwell-time, passive fixation, and dual-coil lead design were independently associated with adherences. Dual-coil lead design was associated with adherences in the innominate vein and superior vena cava, whereas coil treatment (eg, expandable polytetrafluoroethylene-coated or medical adhesive back-filled strategies) prevented adherences. Passive fixation mechanism was associated with adherences in the heart. CONCLUSION ICD leads, after long dwell-time, are affected by fibrous adherences uniformly distributed along the lead course. Lead features represent major predictors of the phenomenon. Careful lead selection is recommended at the time of implantation to prevent adherences. In addition, lead-related risk stratification is mandatory before a transvenous extraction procedure.

Cardiovascular implantable electronic device endocarditis treated with daptomycin with or without transvenous removal

BACKGROUND AND METHODS Nine patients with cardiovascular implantable electronic device (CIED) endocarditis were treated with daptomycin after the failure of previous treatment. The blood and CIED lead cultures of 1 patient were negative. In the other 8 patients, we observed 6 monomicrobic infections and 2 polymicrobic infections. Overall, 10 strains were isolated in these patients: 4 methicillin-sensitive Staphylococcus aureus, 2 methicillin-sensitive Staphylococcus epidermidis, 1 methicillin-resistant Staphylococcus aureus, 1 methicillin-resistant Staphylococcus epidermidis, 1 methicillin-sensitive Staphylococcus hominis, and 1 Propionibacterium acnes. The CIED was removed transvenously in 7 patients. Two patients were too sick for the removal of their CIED, and were cured with 6 mg/kg of daptomycin for 60 and 110 days, respectively, without adverse events. RESULTS One patient died 4 days after the removal of his CIED because of a complicated abdominal aortic aneurysm. The other 8 patients were cured, with a mean follow-up of 17 ± 8 months. The removed leads were negative, after daptomycin therapy, in 4 cases out of 7. The mean ratio between peak daptomycin concentration and minimal inhibitory concentration (MIC) of the causative strains was 38.3 ± 18.5. For patients whose data were available, the ratio between peak daptomycin concentration and minimal bactericidal concentration (MBC) was 13.2 ± 3.2. CONCLUSION Daptomycin monotherapy may be a useful therapeutic tool in difficult-to-treat CIED endocarditis, resulting in a high rate of cures and sterilized leads removed. The ratio between peak daptomycin concentration and MIC or MBC may be useful as predictive tool for treatment success.

Short-term extraction profile of cardiac pacing leads with hybrid silicone–polyurethane insulator: A pilot study

[8]. There are no other studies which were designed to compare vernakalant versus EC. Our study is the first clinical investigation which compared these two protocols and showed that the conversion rate and hospital stay length were similar in both groups without statistical differences with the same safety. With these results with a protocol for EC which needs sedation and fasting for a minimum of 3 to 6 h depending on the different recommendations, we think that vernakalant is a safe and effective drug for conversion recent-onset atrial fibrillation instead of EC in this population, althoughwe believe thatwe need clinical randomized trials withmore patients to be able to reach the certainty that these results are able to extrapolate to the daily practice. Study limitations: Not to be a randomized trial is the most important limitation of this study. The sample size may underestimate the differences between the groups. A larger sample size could produce statistically significant differences in conversion rate and hospital stay length between both groups. Conclusions: The conversion rate of recent-onset AF and hospital stay length was similar in vernakalant and EC group without statistical differences. No adverse events were reported in both groups. References

Cardiac resynchronization therapy after coronary sinus lead extraction: feasibility and mid-term outcome of transvenous reimplantation in a tertiary referral centre

AIMS Few data are available on cardiac resynchronization therapy (CRT) after coronary sinus (CS) lead extraction. We aimed to evaluate the feasibility and mid-term outcome of transvenous CS lead reimplantation in a tertiary referral centre. METHODS AND RESULTS We enrolled all patients who were referred to our hospital for CS lead removal from December 2000 through to May 2009 and were transvenously reimplanted with a CRT system before June 2009. One-year follow-up was performed to evaluate the incidence of infections, malfunctions, and mortality. We studied 113 consecutive patients undergoing successful CS lead extraction; 90 patients (75 male, mean age 69.2, range 35-84) underwent CS lead reimplantation (success rate: 95.6%; right-sided approach: 64.4%). In these patients, cardiac device infection was the usual indication for extraction (74.4%) and the subsequent reimplantation was performed after a median time of 3 days. The coronary sinus lead was usually positioned in the left ventricular (LV) postero-lateral region (62.2%); two procedures were required in two cases (2.2%). Balloon angioplasty was necessary for two patients (failure in one), whereas for the others we used a conventional implant technique. During follow-up, we observed four cases (4.4%) of local infection and six cases (6.7%) of system malfunction, requiring reintervention (two cases during the same hospitalization). One-year mortality was 5.5%. CONCLUSION Left ventricular lead reimplantation is in our experience an effective and safe procedure, also in the case of right-sided approach. During follow-up, 1-year mortality was particularly low, whereas overall infection rate was higher than first implant procedures.

Where is the future of cardiac lead extraction heading

ABSTRACT Introduction: Transvenous lead extraction (TLE) is the gold standard for lead removal. The increasing rate of cardiac implantable electronic device (CIED) implantations and of CIED related complications highlight the importance of transvenous lead extraction . Areas covered: The TLE scenario is constantly changing. Optimizing lead related technology and improving TLE practice across the world are the cornerstones to improving safety and efficacy. We review the state of the art in TLE, focusing on potential future implications and improvements in terms of skills and technologies. Expert commentary: The increased number of extractions will increase the necessity of safe and effective TLE. New technologies, techniques and appropriate training is warranted across the world.

Silence Is Golden: An Uncommon Case of Vocalization-Triggered Atrial Tachycardia

Vocalization-related atrial tachyarrhythmias are extremely rare. We describe the case of a young woman in whom speaking was proven to be the trigger of a nearly incessant right atrial tachycardia, poorly controlled with medical therapy and successfully treated with catheter ablation. The identification of the trigger was pivotal for mapping and ablation, providing a reliable means to assess the success of the procedure.

Effective Percutaneous Repositioning of an Active Fixation ICD Lead

We report a case of effective trans catheter repositioning of an ICD lead that was displaced during a trans venous extraction procedure of another malfunctioning ICD lead. This original technique was effective also in screwing-in the active fixation tip of the lead. Skilled operators could take into account this technique to avoid the re-opening of the device pocket, when dealing with specific situations at high risk of infection.

How to temporarily pace a pacemaker-dependent patient after lead extraction for device infection?

We read with interest the work by Pecha et al .1 recently published in the Journal . The authors aimed to evaluate a new option of temporary pacing (TP) in pacemaker-(PM)-dependent patients undergoing lead extraction (LE) for a cardiac implantable electronic device (CIED) infection, that was used to delay re-implantation and improve safety and freedom from re-infection in follow-up. An active-fixation lead (AFL) was ipsilaterally implanted and connected to an externalized PM, in this way keeping the infected extraction side for TP and preserving the site of definitive device re-implantation. They did not observe infection recurrences, nor lead dislocation after a mean follow-up time of 21.1 months in spite of the long duration of TP (median 12.7 days, …

Importance of Knowing Lead and Patient Interaction

The implantable cardiac pacemaker (PM)/defibrillator is a technically sophisticated system composed of a generator connected to one or more leads. Pacemaker/defibrillator leads play a pivotal role for system function, delivering the output pulse or the endocardial shock from the generator to the myocardium and acquiring spontaneous intracardiac electrogram from the heart to the device. Leads are also the most frequently involved component in case of system malfunction, and when a generator-pocket infection is present, their extraction — always necessary to guarantee complete resolution — is a challenge. The success of lead extraction is highly influenced by lead characteristics; for that reason, this chapter is dedicated to lead technology, i.e., polarity, electrodes, fixation mechanisms, electrode-tissue interaction, conductors, insulators, and connectors, with particular attention to aspects that may interfere with the extraction procedure. We discuss separately cardiac PM and defibrillator leads to emphasize their different technology.