Jacek Lelakowski

Early Abrasion of Outer Silicone Insulation after Intracardiac Lead Friction in a Patient with Cardiac Device‐Related Infective Endocarditis

We present a case of a 76‐year‐old woman on a permanent pacing device, with early abrasion of silicone endocardial lead insulations complicated by lead‐dependent infective endocarditis 13 months after placement of an implantable pulse generator. The leads were removed using transvenous technique with direct traction, and with no additional tools. In the previous report, a set of additional tools was used, and therefore intraoperative endocardial lead abrasions or mechanical damage of leads could have not been excluded. The present case undoubtedly proves that the friction of leads against each other may result in abrasions of insulation of the intracardiac section of the lead. (PACE 2012; 35:e156–e158)

Left atrial accessory appendages, diverticula, and left-sided septal pouch in multi-slice computed tomography. Association with atrial fibrillation and cerebrovascular accidents

BACKGROUND The aim of this study is to provide a morphometric description of the left-sided septal pouch (LSSP), left atrial accessory appendages, and diverticula using cardiac multi-slice computed tomography (MSCT) and to compare results between patient subgroups. METHODS Two hundred and ninety four patients (42.9% females) with a mean of 69.4±13.1years of age were investigated using MSCT. The presence of the LSSP, left atrial accessory appendages, and diverticula was evaluated. Multiple logistic regression analysis was performed to check whether the presence of additional left atrial structures is associated with increased risk of atrial fibrillation and cerebrovascular accidents. RESULTS At least one additional left atrial structure was present in 51.7% of patients. A single LSSP, left atrial diverticulum, and accessory appendage were present in 35.7%, 16.0%, and 4.1% of patients, respectively. After adjusting for other risk factors via multiple logistic regression, patients with LSSP are more likely to have atrial fibrillation (OR=2.00, 95% CI=1.14-3.48, p=0.01). The presence of a LSSP was found to be associated with an increased risk of transient ischemic attack using multiple logistic regression analysis after adjustment for other risk factors (OR=3.88, 95% CI=1.10-13.69, p=0.03). CONCLUSIONS In conclusion LSSPs, accessory appendages, and diverticula are highly prevalent anatomic structures within the left atrium, which could be easily identified by MSCT. The presence of LSSP is associated with increased risk for atrial fibrillation and transient ischemic attack.

Gender differences in dual-chamber pacemaker implantation indications and long-term outcomes.

Objective Dual-chamber (DDD) pacing is the most commonly used mode of heart stimulation. The data on gender-related differences in the long-term follow-up of DDD pacing mode are still limited. We performed a retrospective single-centre study to determine the effect of gender on the implantation indications and the incidence of adverse events resulting in DDD mode loss. Methods and results A group of 1,049 consecutive patients with DDD pacemaker implanted between 1984 and 2002 were followed up until 2014. The study group consisted of 995 patients who performed at least one follow-up visit. Follow-up period was 124.2 ± 68.3 months, mean age was 63.5 ± 12.4 years, 56% were male. Adverse events were defined as loss of primary DDD stimulation – lead malfunction, progression to permanent AF, and infective complications. Women were older than men (64.7 vs 62.6 years) at the time of implantation and they remained, on average, 1.5 year longer in follow-up compared with men. Female patients had significantly more SSS, history of paroxysmal AF, and a similar percentage of AVB compared with male patients. The incidence of lead malfunction, device-related infections, and progression to permanent AF did not show significant differences. However, in the group without prior paroxysmal AF, women developed permanent AF more frequently. Conclusions This patients cohort showed that there is an association between gender and indications to DDD pacing therapy. The rate of adverse events was similar in both genders. Women had a significantly longer duration of follow-up, despite markedly higher age at implantation.

The analysis of indications and early results of transvenous lead extraction in patients with a pacemaker, ICD and CRT - single-center experience.

INTRODUCTION Transvenous lead extraction (TLE) is a recognized method of treatment in the case of permanent stimulation complication. OBJECTIVES The objective of this study was to analyse the indications and presentation of the early experience of TLE procedures in a group of patients with old pacing systems. PATIENTS AND METHODS Patients with a relevant history of stimulation (at least 12 months in case of a pacemaker) qualified for the research. Indications, effectiveness and complications of TLE procedures were analysed. RESULTS Two hundred patients at the age of 66.4 (19.1-86.2 years) were enrolled and 278 leads with dwell time 76.2 months (2.1-327.4) were removed. The indications for TLE were: lead-dependent infective endocarditis in 13 cases (6.5%), pocket infection in 29 cases (14.5%), lead damage in 120 cases (60.0%), and upgrade of device system in 38 cases (19.0%). Manual traction was used to remove 66 active fixation leads (23.7%). A femoral approach was required to extract 4 leads (1.4%). Two hundred and eight leads (74.8%) were extracted using the mechanical (Cook) system and subclavian approach. Laser technique, and an electrosurgical sheath were not used. Complete procedural success was achieved in 96% of cases and overall clinical success was 98.5%. Complication rate was 5.5% (11 patients): minor and major complication rate was 3.0% (6 patients) and 2.5% (5 cases), respectively. Low body mass index (BMI) was associated with a higher rate of complications. CONCLUSIONS The dominant indication to TLE procedures was lead dysfunction. Transvenous lead extraction has a high success rate and a low complication rate. Low BMI increased the complication rate.

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.

Analysis of electrical lead failures in patients referred for transvenous lead extraction procedures

We evaluated the influences of selected factors on electrical lead failure (ELF) occurrence in patients referred for transvenous lead extraction (TLE) procedures.

Association of cardiac troponin I with prothrombotic alterations in atrial fibrillation

INTRODUCTION Atrial fibrillation (AF) increases the risk of stroke and systemic thromboembolism. A hypercoagulable state in AF is reflected by elevated von Willebrand factor (vWF), D-dimer, and thrombin generation (TG), as well as increased platelet activation [1]. The usefulness of several biomarkers in stroke and bleeding risk prediction among AF patients, in particular N-terminal pro–B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin I (cTnI-hs), has been demonstrated, although practical implications of this strategy are uncertain [2]. We sought to assess the relations of four such markers: cTnI-hs, cystatin C, vWF, and NT-proBNP, with prothrombotic alterations in AF patients.

Lead-related complications after DDD pacemaker implantation

BACKGROUND Pacing leads remain the weakest link in pacemaker systems despite advances in manufacturing technology. AIM The aim of the study was to assess the long-term pacing lead performance in an unselected real-life cohort following primary DDD pacing system implantation. METHODS A single-centre retrospective analysis of patients who underwent DDD pacing system implantation between October 1984 and December 2014 and were followed-up until August 2016 was conducted. The inclusion criterion was at least one follow-up visit after post-implant discharge. The performance of each atrial and ventricular lead implanted was evaluated during the follow-up period, and the incidence of, and predictive factors for, lead dislodgement and failure were analysed. RESULTS The data of 3771 patients and 24,431.8 patient-years of follow-up were analysed. The mean follow-up of patients was 77.7 ± 61.8 months. During the study period, 7887 transvenous atrial and right ventricular pacing leads were implanted. Lead dislodgement occurred in 94 (1.2%) leads (92 [2.4%] patients), perforation in 11 (0.1%) leads (10 [0.3%] patients), and lead failure in 329 (4.2%) leads (275 [7.3%] patients). Atrial lead position was a predictive factor for lead dislodgement, while age at implantation, polyurethane 80A insulation, subclavian vein access, unipolar lead construction, and lead manufacturer were multivariate predictors of lead failure. CONCLUSIONS Leads with polyurethane 80A insulation, unipolar construction, and those implanted via subclavian vein puncture exhibited the worst long-term performance.