Kazimierz Haberka

Venous Stenosis and Occlusion in the Presence of Endocardial Leads.

BACKGROUND Venous stenosis and occlusion in the presence of endocardial leads constitute one of the complications of permanent cardiac pacing either by pacemaker, implantable cardioverter-defibrillator or cardiac resynchronization therapy. OBJECTIVES The aim of this study was to assess the incidence of stenosis and occlusions and determine the risk factors in patients with endocardial leads in a prospective single-center study. MATERIAL AND METHODS Two hundred eighty consecutive patients aged 25-95 years (male 68.8%) were included. A contrast venography examination of the ipsilateral access vein was performed. The whole study population was divided into 2 groups, based on the presence (group I) or absence (group II) of endocardial leads. RESULTS Venous stenosis/occlusion was identified in 51 patients (37.5%) in group I and in 3 patients (3.6%) in group II; p < 0.0001. The lead presence most highly correlated with venous complications (OR = 4.172; p < 0.001). In patients with endocardial leads divided into I A and I B according to venous patency diabetes mellitus was proved in multivariate analysis to be the only protective factor against the development of venous stenosis/occlusion (OR = 0.473; p = 0.010). CONCLUSIONS The presence of endocardial leads is a predisposing factor for venous stenosis/occlusion and increases the risk 4-fold. The venous lesions in the presence of endocardial leads are less frequent among patients with diabetes mellitus.

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.

Venous stenosis and occlusion in the presence of endocardial leads in patients referred for transvenous lead extraction

Objective The aim of this study was to evaluate the incidence of venous stenosis and occlusion (VSO) in patients referred for transvenous lead extraction (TLE) with regard to the indications for this treatment and to analyse the influence of VSO on efficacy, complications and technical challenges of TLE procedures. Methods The material consists of 133 consecutive TLE procedure records. The contrast venography examination of the ipsilateral access vein was performed prior to the operation. The whole study population was divided into two subgroups, based on the presence (subgroup I) or absence (subgroup II) of VSO. Results Phlebography was performed in 133 patients with age ranging from 25.7 to 86.1 years, 44 female (33.1%). The VSO was confirmed in 48 (36.1%) patients – subgroup I. Most of the patients were referred to TLE due to non-infectious reasons (100 pts—75.2%). The absence of VSO was observed substantially more frequently in patients with diabetes (P = 0.02). Procedural success rate reached 93.3% in subgroup I and 98.8% in subgroup II (P = 0.1). There was no significant difference in the use of advanced tools and alternative access sites. Conclusion The presence of VSO can be expected in one third of patients referred for lead extraction. There is no association between indication for TLE (infected or noninfected lead extraction) and the incidence of VSO. Diabetes proved to have a protective effect on venous patency in the previously mentioned group. VSO does not influence the effectiveness, safety, and the use of additional tools during TLE procedures.

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.

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.

Late complication of heart stimulation — lead abrasion in pacemaker pocket

An 81-year-old male patient was hospitalised due to recurrence of syncope 4 years after DDD pacemaker (PM) implantation. The DDD pacing system contained Vitatron C60DR PM and 2 Vitatron Crystalline BP leads: an atrial one implanted by left subclavian venipuncture, and a ventricular one implanted by left cephalic venesection. In this PM-dependent patient, periodic inhibition of pacing up to 2 s was recorded in Holter electrocardiogram. Pacing inhibition occurred although bipolar sensing was programmed. In the PM check-up, moving of the patient’s left upper limb induced in intracardiac electrogram records (IEGM), short-cycle abnormal signals, so called ‘crackles’, simultaneously in atrial and ventricular channels (Fig. 1). The remaining parameters i.e. pacing thresholds and lead impedance, were correct. Lead damage was diagnosed and a decision to perform transvenous lead extraction (TLE) was made. Because this patient had left ventricular ejection fraction lowered to 30% in the course of ischaemic cardiomyopathy, we decided to perform simultaneous implantation of a new implantable cardioverter-defibrillator (ICD) to prevent sudden cardiac death. Before the TLE procedure, venography of left-side venous inflow was performed and occlusion of left brachiocephalic vein with advanced collateral circulation was observed (Fig. 2). Nevertheless, a 150 cm-long guidewire Cordis 0.035 was successfully introduced into the heart. Firstly an ICD lead was implanted with the help of a set containing a long Peel-Away Curved Sheath made by Coock, designed for such a condition of blood vessels. The presence of the ICD lead in the right ventricle was used for temporary pacing during the removal of the damaged leads. Both leads were extracted using simple traction. Then we went along the narrowing of the inflow vein once again using a Medtronic Attain Command set designed for left ventricular lead implantation, and we implanted a new atrial lead. On examination of the extracted leads, we observed the presence of some abrasion in the external silicone lead insulation, with lead unsealing and metal wire exposure (Fig. 3). The damage distance from the distal end of the leads was compared to a chest X-ray conducted before TLE (Fig. 4). Measurements were performed using the DICOM system. This allowed the identification of sites of damage of the leads in the PM pocket where lead loops were located near the PM can, and where they remained in mutual contact (Fig. 4). Abrasion of endocardial silicone leads due to mutual friction is an important clinical problem. In this process, silicone insulation gradually becomes thinner until it completely breaks. This can have a negative influence on the functioning of the pacing system. It seems justified to take into account the abrasion of lead insulation in cases of pacing inhibition in the presence of bipolar sensing leads.