Maciej Polewczyk

Lead dependent tricuspid dysfunction: Analysis of the mechanism and management in patients referred for transvenous lead extraction

BACKGROUND Lead-dependent tricuspid dysfunction (LDTD) is one of important complications in patients with cardiac implantable electronic devices. However, this phenomenon is probably underestimated because of an improper interpretation of its clinical symptoms. The aim of this study was to identify LDTD mechanisms and management in patients referred for transvenous lead extraction (TLE) due to lead-dependent complications. METHODS Data of 940 patients undergoing TLE in a single center from 2009 to 2011 were assessed and 24 patients with LDTD were identifi ed. The general indications for TLE, pacing system types and lead dwell time in both study groups were comparatively analyzed. The radiological and clinical effi cacy of TLE procedure was also assessed in both groups with precision estimation of clinical status patients with LDTD (before and after TLE). Additionally, mechanisms, concomitant lead-dependent complications and degree (severity) of LDTD before and after the procedure were evaluated. Telephone follow-up of LDTD patients was performed at the mean time 1.5 years after TLE/replacement procedure. RESULTS The main indications for TLE in both groups were similar (apart from isolated LDTD in 45.83% patients from group I). Patients with LDTD had more complex pacing systems with more leads (2.04 in the LDTD group vs. 1.69 in the control group; p = 0.04). There were more unnecessary loops of lead in LDTD patients than in the control group (41.7% vs. 5.24%; p = 0.001). There were no signifi cant differences in average time from implantation to extraction and the number of preceding procedures. Signifi cant tricuspid regurgitation (TR-grade III-IV) was found in 96% of LDTD patients, whereas stenosis with regurgitation in 4%. The 10% frequency of severe TR (not lead dependent) in the control group patients was observed. The main mechanism of LDTD was abnormal leafl et coaptation caused by: loop of the lead (42%), septal leafl et pulled toward the interventricular septum (37%) or too intensive lead impingement of the leafl ets (21%). LDTD patients were treated with TLE and reimplantation of the lead to the right ventricle (87.5%) or to the cardiac vein (4.2%), or surgery procedure with epicardial lead placement following ineffective TLE (8.3%). The radiological and clinical effi cacy of TLE procedure was very high and comparable between the groups I and II (91.7% vs. 94.2%; p = 0.6 and 100% vs. 98.4%; p = 0.46, respectively). Repeated echocardiography showed reduced severity of tricuspid valve dysfunction in 62.5% of LDTD patients. The follow- -up interview confi rmed clinical improvement in 75% of patients (further improvement after cardiosurgery in 2 patients was observed). CONCLUSIONS LDTD is a diagnostic and therapeutic challenge. The main reason for LDTD was abnormal leafl et coaptation caused by lead loop presence, or propping, or impingement the leafl ets by the lead. Probably, TLE with lead reimplantation is a safe and effective option in LDTD management. An alternative option is TLE with omitted tricuspid valve reimplantation. Cardiac surgery with epicardial lead placement should be reserved for patients with ineffective previous procedures.

Safety and effectiveness of transvenous lead extraction in elderly patients

BACKGROUND There is a considerable controversy regarding safety of transvenous lead extraction (TLE) in elderly patients due to their potentially worse general condition, more concomitant diseases, more difficult sedation or analgesia. Moreover, the present experience is not relevant. The aim of the study was the comparison of safety and feasibility of TLE in elderly and middle-aged patients. METHODS We have extracted an ingrown pacemaker (PM)/implantable cardioverter-defibrillator (ICD) leads from 1,060 adult patients (21-70 years) and 192 octogenarians (mean age 83.4 ± 3.1 years) using standard mechanical systems within the last 7 years. We compared effectiveness and complications of the TLE procedures in the two mentioned groups of patients. RESULTS There were more women in octogenarians referred for TLE (45.3% vs. 36.9%). In addition, more pocket infections (37.0% vs. 24.5%), less non-infective indications for PM (46.9% vs. 57.7%) and ICD systems (7.3% vs. 28.8%) TLE were observed in this group. Leads body dwelling time was similar (76.4 ± 56.8 vs. 83.5 ± 63.0) in both groups. Procedure efficacy (full radiological success 97.4% vs. 94.6%, partial radiological success 2.6% vs. 4.34%), safety measures (major complications 1.6% vs. 1.51%, minor complications 1.0% vs. 1.9%) were similar in both compared groups. CONCLUSIONS Old age does not influence TLE effectiveness. Therefore, TLE can be safely and successfully performed in octogenarians.

Complications of permanent cardiac pacing in patients with persistent left superior vena cava

BACKGROUND Persistent left superior vena cava (PLSVC) is present in about 0.3-0.5% of the general population and in about 12% of patients with other abnormalities. This congenital anomaly is usually asymptomatic and does not cause any physiological problems. However, it may become a significant problem in multiple clinical situations. Various complications related to PLVSC are encountered in anesthesiological, nephrological, oncological and cardiological procedures. The presence of PLSVC is usually incidentally detected during placement of pacemaker (PM), implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) leads. Technical difficulties during lead positioning (especially ventricular leads) are commonly known and often described in the literature. The purpose of the present study was to evaluate the specific methods used for implantation of increasingly complicated pacing systems, finding an optimal strategy in patients with PLSVC, especially with electrotherapy complications. METHODS We performed a single-center retrospective analysis of 11 patients (7 women and 4 men, mean age 60.4 ± 13 years) with PLSVC hospitalized in single Cardiology Department between 2000 and 2012. The clinical characteristic, indications for PM/ICD/CRT implantation, technique of implantation and complications were evaluated. RESULTS In PLSVC patients, different indications for pacing or resynchronization therapy were represented: sick sinus syndrome (SSS) in 4 patients, 3rd degree atrio-ventricular (AV) block in 4 patients, dilated cardiomyopathy with left bundle branch block in 2 patients, dilated cardiomyopathy and non-sustained ventricular tachycardia episodes in 1 patient. In patients no. 1, 3, 4 and 10 the complications necessitated the change of leads or type of pacing. Transvenous lead extraction was successfully performed in patient no. 1 and 10 with re-implantation of new leads via PLSVC in patient no. 1 and via right superior vena cava in patient no. 10. Patient no. 3 received an additional ventricular lead via PLSVC because of 2nd degree AV block (formerly atrial lead implanted due to SSS). In patient no. 4 with left atrial pacing (lead in coronary sinus), prosthetic mitral valve replacement was combined with epicardial ventricular lead placement. Patients no. 2 and 7 received a CRT device, without technical problems in patient no. 7, whereas in patient no. 2 due to difficulties with left ventricular lead positioning a hybrid approach to epicardial lead pacing was used. In patient no. 8 an ICD was implanted with difficulty in placing defibrillator lead. Patient no. 5 received 2 atrial leads via PLSVC with successful biatrial pacing; patient no. 6 with the necessity of DDD pacing had a (ventricular) lead for left atrial pacing and a typical right ventricular lead. In patients no. 9 and 11 typical DDD pacing was used with contralateral placement of the leads due to anatomical and technical differences. After 12 years of follow-up the survival is 90.9%. Late electrotherapy complications have developed only in patient no. 8 (problems with the defibrillator lead). CONCLUSIONS Patients with PLSVC are a very heterogeneous group with different indications for pacing, therefore individualization of therapy is required. Technical complications connected with pacing of the right heart chambers are commonly known, hence transvenous left atrial or left ventricular lead implantation should be attempted. In case of difficulties in transvenous positioning of the lead, a hybrid or isolated cardiac surgery technique should be considered. Because of the increasing number of electrotherapy complications, these problems are also present in PLSVC patients. Transvenous lead extraction with re-implantation of a pacing system has not been reported yet. For this reason a thorough evaluation of the venous system is required in PLSVC patients before intervention.

Late complications of electrotherapy — a clinical analysis of indications for transvenous removal of endocardial leads: a single centre experience

BACKGROUND Despite advances in electrotherapy, late complications constitute an increasing clinical and therapeutic problem. Transvenous lead extraction (TLE) is becoming a safe and effective approach to the treatment of such complications. AIM To assess indications for TLE and to evaluate safety and efficacy of TLE procedures. METHODS A retrospective clinical analysis of 100 patients with complications of electrotherapy admitted to a tertiary care centre in 2008-2011. RESULTS In 2008-2011, the number of electrotherapy complications increased markedly. The most frequent reason for TLE was lead dysfunction (62% of patients, including 31% with an implanted cardioverter-defibrillator [ICD] and 31% with a pacemaker [PM]). The most common type of lead dysfunction was conductor damage (38% of patients, including 23% with ICD, 15% with PM), followed by late myocardial perforation (14% of patients, including 7% with ICD, 7% with PM), abnormal course of the lead (7% of patients, including 1% with ICD, 6% with PM), and lead insulation failure (3% of patients). Other reasons for TLE were infectious complications (24% of patients, including 15% with PM pocket infection), venous insufficiency (17% of patients, including 10% in whom an indwelling lead was a direct obstacle to switching the pacing mode), and the need to switch the pacing mode (4% of patients). Procedural efficacy was 96% (lead fragments were left in place in 4% of patients). No significant clinical complications were observed in any of the patients in the periprocedural period. CONCLUSIONS Clinical manifestations of electrotherapy complications in the study group varied and included a relatively small number of infectious complications (24%) and a relatively large number of late myocardial perforations (14%). Efficacy and safety of the procedures were very high.

Leads dislodged into the pulmonary vascular bed in patients with cardiac implantable electronic devices

Introduction Spontaneous lead dislodgement into the pulmonary circulation is a rare complication of permanent pacing with unproven harmfulness and an indication of controversial class for transvenous lead extraction (TLE). Aim To assess TLE safety in patients with leads dislodged into the pulmonary artery. Material and methods A retrospective analysis of a 9-year-old database of transvenous lead extraction procedures comprising 1767 TLEs was carried out, including a group of 19 (1.1%) patients with leads dislodged into the pulmonary artery (LDPA). Results Under univariate analysis the factors that increased the likelihood of the presence of an electrode in the pulmonary artery were mean lead dwelling time (increase of risk by 9% per year), total number of leads in the heart before TLE (increase of risk by 66% for one lead) and the number of abandoned leads (increase of risk by 119%). The presence of LDPA was associated with frequent occurrence of intracardiac lead abrasion (increase by 316%) and isolated lead-related infective endocarditis (LRIE) (increase by 500%). There were no statistically significant differences in clinical (p = 0.3), procedural (p = 0.94) or radiological (p = 0.31) success rates in compared (LDPA and non-LDPA) groups. Long-term mortality after TLE was comparable in both groups. Conclusions As the effectiveness and safety of TLE in patients with LDPA are comparable to those in standard TLE procedures, in our opinion, such patients should be considered TLE candidates.

Effectiveness, safety, and long-term outcomes of non-powered mechanical sheaths for transvenous lead extraction

Aims To analyse the effectiveness, safety and long-term outcomes of conventional non-powered mechanical systems for transvenous lead extraction (TLE) performed by experienced first operators. Outcomes were assessed according to lead location and type of operating room in which the procedure was performed. Methods and results Data from 2049 patients (mean age: 65 years), with infectious (40%) or non-infectious (60%) indications, were analysed over a mean of 3.37 (±2.29) years. A total of 3426 leads were extracted; and, overall, 95% full procedural, 4% partial procedural, and 98% clinical success were demonstrated. Within the patient cohort, 1.8% (37/2049) experienced major complications, with cardiac tamponade being predominant (30/37). Cardiac tamponade was identified as the main cause of mortality, as well as the cause of all procedure-related deaths (6/2049; 0.3%). Cardiac tamponade occurred in 1.8% of atrial and 0.3% of right ventricular lead extractions, with fatal tamponade reported in 9% of atrial, 40% of ventricular, and 67% of coronary sinus lead extractions. No association between lead location and cardiac tamponade-related mortality was observed; however, lead location did affect the success of pericardiocentesis. The cardiac tamponade-related mortality rate was 37% when TLE was performed in an electrophysiology laboratory. No deaths were reported when the procedure was performed in a cardiac surgery or hybrid operating room. Long-term survival was improved when TLE was performed due to non-infectious indications, rather than pocket infection or lead-related endocarditis (P < 0.001). Conclusion Using conventional non-powered mechanical sheaths, TLE was effective even in patients at high risk of complications.

Proximal end of 15-year-old ventricular electrode penetrating pulmonary tissue – a source of infection and a challenge for transvenous lead extraction

We report a case of a 56-year-old man with a DDD pacemaker implanted in 1998 followed by additional ventricular lead implantation in 2000 due to lead dysfunction and battery replacement in 2006 (proximal end of the abandoned lead already observed in the pulmonary artery), with currently present clinical signs of lead-dependent infective endocarditis (LDIE). In March 2013 he was diagnosed with recurrent episodes of shortness of breath, cough and fever. Initially the patient was hospitalized in the pneumology ward and underwent a series of diagnostic examinations, including computed tomography (CT) and bronchoscopy. Chest CT revealed localized signs of inflammation (which could be differentiated from neoplastic lesions) in the mid-right pulmonary lobe. Given the vicinity of the migrated lead to the lung inflammatory process, penetration of the lead in the lung tissue was confirmed. Blood cultures were positive for Staphylococcus epidermidis (MSS). After cardiologist consultation the patient was transferred to the Cardiology Clinic with LDIE diagnosed. The patient was qualified for a transvenous lead extraction (TLE) procedure. Pre-operative transthoracic echocardiography (TTE) revealed dilatation of the right atrium and ventricle with very high pulmonary artery systolic pressure (PASP = 80 mm Hg) calculated from tricuspid regurgitation. There were no signs of vegetations in transesophageal echocardiography (TEE) examination. The TLE procedure was performed in the cardiovascular operating room with on-site surgical standby. General anesthesia was used; invasive blood pressure, ECG, and ventilation parameters were monitored. At the beginning both functional leads were removed (using a Byrd dilator mechanical sheath). After unsuccessful grasping of the non-functional lead at the level of the right ventricle (due to adherences to the wall), it was successfully captured in the pulmonary artery using a pig-tail catheter; afterwards the proximal end was grasped in the right atrium lumen with a lasso catheter and the lead was finally extracted using the left subclavian approach and dilator sheaths (Figure 1). There were no procedural or post-procedural complications. Full radiological and clinical success was achieved. Postoperative TTE/TEE showed no signs of lead fragments or vegetations and reduction of PASP (60 mm Hg). As the patient was not pace-dependent, system reimplantation was delayed. Figure 1 A – Proximal end of the abandoned non-functional lead penetrating pulmonary tissue. B – Removed leads covered with fibrotic tissue. C, D – The lead recaptured with a lasso via the left subclavian approach According to the current guidelines, indications for TLE of a non-functional lead present in the pulmonary bed should be considered as class IIb (extraction during procedure on cardiac implantable electronic device if contraindications are absent, the lead position might become dangerous) or even class IIa (potentially dangerous lead, which does not immediately threaten the patient) but not class III (despite anomalous lead displacement) [1]. Although the TLE complication rate remains low (about 2%) [2], longer dwelling time of the lead is a known risk factor of TLE, lead adherence to the vessel wall is much stronger after years, which often necessitates the use of extra tools [3]. Moreover, the proximal end of the broken lead in pulmonary tissue might have an impact on development of infection. Having in mind the fact that in spite of technical difficulties, the clinical success rate of TLE in patients with broken, migrating leads is comparable to the “standard” procedure [4], earlier extraction could prevent lead-related infections and reduce the potential procedural risk.

Acute Coronary Syndromes in Women - Gender Specific Changes in Coronarography

Cardiovascular diseases (CVD) are one of the leading cause of mortality in both men and women in the world. According to a WHO report, about 55% of deaths in European women are related to CVD, including 23% caused by coronary artery disease (CAD) and 18% due to stroke. Conversely, in men, CVD is the cause of 43% of deaths, including CAD (21%) and stroke (11%). These statistics are alarming — in Europe, one woman dies of CVD every 6 minutes. In respect of above data is very important to perform randomized clinical trials with women treated for acute coronary syndromes (ACS). This operation was initiated relatively not long ago. In the past 40 years, the attention of cardiologists regarding the treatment of coronary artery disease (CAD) has been focused mainly on the group of male patients, markedly less on the female population. In the meantime, to the best of our knowledge, despite of apparent similarity of ACS clinical course in men and women, differences in the pathophysiological mechanisms, prevalence and profile of risk factors, angiographic changes, kind of treatment and prognosis are found. These observations are particularly important up against constantly rising cardiovascular morbidity and mortality among women.