Julia Vogler

Pulmonary Vein Isolation Versus Defragmentation: The CHASE-AF Clinical Trial.

BACKGROUND Long-term success rates using ablation for persistent atrial fibrillation (AF) are disappointing and usually do not exceed 60%. OBJECTIVES This study sought to compare arrhythmia-free survival between pulmonary vein isolation (PVI) and a stepwise approach (full defrag) consisting of PVI, ablation of complex fractionated electrograms, and additional linear ablation lines in the setting of atrial tachycardias (AT) in patients with persistent AF after PVI. METHODS From November 2010 to February 2013, 205 patients (151 men; 61.7 ± 10.2 years of age) underwent de novo ablation for persistent AF. Subsequently, patients were prospectively randomized to either PVI alone (n = 78) or full defrag (n = 75), with 52 patients not randomized due to AF termination with the original PVI. The primary endpoint was recurrence of any AT after a blanking period of 3 months. RESULTS During the entire study, 241 ablations were performed (mean: 1.59 in the PVI-alone group, 1.55 in the full-defrag group). With the stepwise approach, termination of AF occurred in 45 (60%) patients. However, arrhythmia-free survival did not differ whether patients underwent single or multiple procedures (p = 0.468). Procedure duration, fluoroscopy time, and radiofrequency duration were significantly longer in the full-defrag group (all p < 0.001). CONCLUSIONS A stepwise approach aimed at AF termination does not seem to provide additional benefit over PVI alone in patients with persistent AF, but it is associated with significantly longer procedural and fluoroscopic duration as well as radiofrequency application time. (The Randomized Catheter Ablation of Persist End Atrial Fibrillation Study [CHASE-AF]; NCT01580124).

Evaluation of tricuspid valve regurgitation following laser lead extraction

OBJECTIVES The objective of this study was to examine the effect of laser lead extraction (LLE) on the development of post-procedural tricuspid regurgitation (TR). Some reports have suggested an increase in TR associated with LLE. We present a series of patients who underwent both, LLE and complete echocardiographic evaluation for TR. METHODS A single centre analysis of consecutive patients referred for LLE between January 2012 and August 2015. One hundred and three patients had tricuspid valve function evaluated before the procedure with a transthoracic echocardiography (TTE), during the procedure using transoesophageal echocardiography and postoperatively using a TTE. TR was graded from 0 (none) to 4 (severe). RESULTS We treated 235 leads in 103 patients, including 118 ventricular leads. Seventy-seven were male (74.8%) and 26 female (25.2%), with a mean age of 65.6 ± 15.4 years. Mean time from initial lead implantation was 98.0 ± 67.3 months. Twenty-one patients (20.4%) had ejection fraction below 30%. No intra-procedural worsening of tricuspid valve function was seen with TEE in any of the patients. Ten patients (9.7%) were found to have TR before LLE that returned to normal valve function after the procedure. Two patients (1.9%) experienced mild TR after the procedure (both with tricuspid valve endocarditis). Ninety-one patients (88.3%) did not experience any significant change of the tricuspid valve function after LLE. CONCLUSION Transthoracic and transoesophageal echocardiography findings showed that laser lead extraction was not associated with a significant increase in the incidence of tricuspid valve regurgitation.

Lead extraction with high frequency laser sheaths: a single-centre experience

OBJECTIVES Extraction of chronically implanted cardiac implantable electrophysiological devices leads can be difficult. Excimer laser-assisted extraction with 40 Hz sheaths has shown good results in challenging cases. In 2012, a new 80 Hz high-frequency laser sheath became available that delivers twice as many pulses per second. Here, we report our clinical experience with the new GlideLight 80 Hz laser sheath. METHODS Between January 2012 and August 2016, 292 leads were treated in 151 patients using 80 Hz GlideLight laser sheath. Lead extraction indications included systemic infection or lead endocarditis n =  35 (23.2%), local infection n =  73 (48.3%), lead dysfunction n =  32 (21.2%), system upgrade n =  5 (3.3%), tricuspid regurgitation n =  3 (2.0%) and other indications n =  3 (2.0). All patient-related and procedural data were collected into a database and analysed. RESULTS Mean patients age was 66.2 ± 14.4 years, 73.5% were male. Ninety-one (31.2%) atrial, 159 (54.4%) ventricular and 42 (14.4%) coronary sinus leads had to be extracted. The mean time from initial lead implantation was 98.0 ± 65.2 months. Mean laser treatment time was 67.5 ± 71.3 s, mean laser pulses delivered were 5130 ± 6592. Clinical success was achieved in 99.3% of the cases, while complete procedural success was observed in 96.7%. A failure of extraction was seen in 2 (1.3%) patients. An overall complication rate of 2.0%, including two major (1.3%) and one minor (0.7%) complications, was observed. No periprocedural mortality was seen. CONCLUSIONS The new GlideLight high-frequency laser sheath allows for a high safety and efficacy in extraction of chronically implanted pacemaker- and implantable cardioverter-defibrillator leads.

The Bridge Occlusion Balloon as a safety net in a high-risk transvenous lead extraction procedure

Injuries to the superior vena cava (SVC) during transvenous lead extraction (TLE) procedures are a rare but life-threatening complication. The Bridge Occlusion Balloon (BOB) is specifically designed for temporary SVC occlusion in TLE procedures. We report the first case of a 27-year-old man using the BOB as a safety net in a high-risk TLE procedure. This patient, with a congenitally corrected transposition of the great arteries and a third-degree atrioventricular block, presented with 4 dysfunctional pacemaker leads, venous stenosis and the necessity for a new pacemaker system. The leads were implanted for 10 and 19 years. The BOB was placed with a radiopaque marker at the cavoatrial junction and was inflated with 46 ml of an 80/20 saline/contrast agent mixture. An angiography was performed to confirm SVC occlusion. With the deflated balloon in place, the TLE procedure with laser and mechanical sheaths was performed. Successful extraction of 2 dysfunctional leads, as well as venous recanalization, for the new right atrial and right ventricular lead implantation was achieved. We have shown the feasibility of using powered extraction sheaths with a deflated BOB in place. This allows for immediate balloon inflation, in case of an SVC perforation.

Navigation of lead extraction—is it possible? Impact of preprocedural electrocardiogram-triggered computed tomography on navigation of lead extraction

OBJECTIVES As the number of transvenous lead extractions continues to increase, preprocedural protocols for this procedure must be assessed. The objective of this study was to determine whether an electrocardiogram (ECG)-triggered computed tomography (Et-CT) with three-dimensional (3D) reconstructions could aid lead extractors in choosing the optimal tools to improve procedural success and avoid complications. METHODS In this study, 31 patients scheduled for transvenous lead extraction underwent a preprocedural Et-CT between January 2016 and May 2017. Both 3D-reconstructions and the two-dimensional files were reviewed for possible lead adhesions, calcifications, migrations or perforations. RESULTS Mean age was 46.7 ± 14.0 years. Seventy-one percent of patients were men, and 29.0% had undergone prior cardiac surgery. Indications for extraction included infection (n = 18, 58.1%), lead dysfunction (n = 8, 25.8%), upgrade (n = 3, 9.7%), severe tricuspid regurgitation (n = 1, 3.2%) and superior vena cava occlusion (n = 1, 3.2%). Eighteen patients had an implantable cardioverter defibrillator (58.1%). Sixty-eight of 70 targeted leads were extracted with a mean of 2.2 leads per patient and an average lead age of 109.3 ± 58.7 months. Et-CT files supported transvenous lead extraction by revealing possible adhesions in 16 patients, 5 perforations and 2 venous occlusions. Lead extraction was performed using the excimer laser, mechanical tools and femoral snares. Complete procedural success was achieved in 93.5% (n = 29) of cases. Clinical success was 100%, and intraoperative mortality was 0%. CONCLUSIONS A preprocedural Et-CT with 3D reconstructions can help to visualize lead alignment and identify abnormalities that may foreshadow procedural difficulties. A preprocedural Et-CT may therefore aid lead extractors in choosing the optimal extraction tool and strategy.

Aktuelle Strategien zur Vermeidung von ICD-Therapien

ZusammenfassungDie Einführung des implantierbaren Kardioverter-Defibrillators (ICD) in die klinische Routine der Primär- und Sekundärprävention ventrikulärer Arrhythmien hat zu einer deutlichen Reduktion der Mortalität von Patienten mit hochgradig eingeschränkter linksventrikulärer Funktion geführt. Trotz des immensen Benefits dieser Therapie stellt im klinischen Alltag neben den adäquaten ICD-Therapien vor allem der hohe Anteil inadäquater Therapien ein großes Problem dar. Tachykard übergeleitetes Vorhofflimmern ist dabei neben supraventrikulären Tachykardien, Artefaktsensing und elektromagnetischen Interferenzen die häufigste Ursache für inadäquate ICD-Schocks. Da sowohl adäquate als auch inadäquate ICD-Schocks paradoxerweise die Mortalität erhöhen, kommt der Vermeidung von ICD-Therapien eine entscheidende Bedeutung zu. Neben den klassischen erweiterten Detektionskritieren (Stabilität, Onset und Morphologie des Kammerkomplexes) sowie den firmenspezifischen Zweikammer-ICD-Algorithmen gelingt eine Therapiereduktion vor allem durch Erhöhung der Detektionsfrequenz für ventrikuläre Tachykardien und Programmierung einer langen Detektionsdauer. Dies konnte eindrucksvoll in den neueren Studien wie MADIT-RIT, ADVANCE-III und PROVIDE gezeigt werden. Ein erhöhtes Risiko für Synkopen ist durch die Therapiereduktion nicht zur befürchten. Zusätzlich zur optimierten Programmierung kann der Anteil von adäquaten ICD-Therapien durch Antiarrhythmika und durch eine Katheterablation beeinflusst werden.AbstractImplantation of an internal cardioverter defibrillator (ICD) has become the routine therapy for primary and secondary prevention of ventricular arrhythmia due to its proven reduction of mortality. Despite the significant benefits for patients with highly reduced left ventricular function, ICD therapy, especially inappropriate ICD therapy, is a major concern in the daily routine. Causes of inappropriate ICD therapy can be divided into supraventricular arrhythmia, sensing problems and electromagnetic interference, with atrial fibrillation being the most common cause of inappropriate ICD shocks. As appropriate and inappropriate ICD therapies both seem to be associated with an increased mortality, physicians should focus on avoiding ICD therapy. Apart from enhanced detection criteria, such as stability, onset and QRS morphology as well as dual-chamber ICD algorithms, reduction of ICD therapy can safely be achieved by programming higher detection rates and prolonged detection as recent studies such as MADIT-RIT, ADVANCE III and PROVIDE were able to show. Antiarrhythmic drug therapy and catheter ablation of ventricular arrhythmia are further possibilities to reduce ICD therapy, especially in patients with repetitive ICD shocks due to recurrent ventricular arrhythmia.