Samer Hakmi

Initial experience of pacemaker and implantable cardioverter defibrillator lead extraction with the new GlideLight 80 Hz laser sheaths

OBJECTIVES Laser lead extraction is a challenging procedure, especially in patients with old or multiple pacemaker (PM) or implantable cardioverter defibrillator (ICD) leads. The mechanical force is a leading cause of complications during the extraction procedure. Use of new laser sheaths, which deliver a rate of 80 pulses per second, may probably reduce intraoperative adverse events by reduction of extraction force. METHODS Between January 2012 and April 2013, 76 PM and ICD leads were treated in 38 patients using GlideLight 80 Hz laser sheaths. Indications for lead removals were pocket infection (42.1%), septicaemia or endocarditis (23.7%), lead dysfunction (31.6%) and upgrade from PM to ICD (2.6%). Data on procedural success rates, intra- and postoperative outcomes, as well as 30-day mortality were collected into a database and analysed retrospectively. RESULTS The mean patient age was 62.0 ± 17.7 years (range 18-83), and 73.7% were male. The mean time from initial lead implantation was 96.0 ± 58.3 months (range 24-288). Thirty-seven (48.7%) PM and 39 (51.3%) ICD leads had to be extracted. The mean procedural time was 68.3 ± 27.3 min (range 35-115). Seventy-two of 76 leads (94.8%) were completely removed, partial removal was achieved in 2 (2.6%) leads and a failure of extraction occurred in 2 (2.6%) leads. The overall complication rate was 5.2%, including one major (superior vena cava perforation) (2.6%) and one minor (pocket haematoma) (2.6%) complication. No death occurred during the 30-day follow-up. CONCLUSIONS The GlideLight 80 Hz laser sheath allows safe and effective removal of chronically implanted PM and ICD leads, combining high procedural success with low complication rates.

Efficacy of prophylactic intra-aortic balloon pump therapy in chronic heart failure patients undergoing cardiac surgery.

This study investigated the efficacy of prophylactic intraoperative intra-aortic balloon pump (IABP) usage in chronic heart failure patients with severely reduced left ventricular function undergoing elective cardiac surgery. Between January 2008 and December 2012, 107 patients with severely reduced left ventricular ejection fraction (LVEF <35%) received prophylactic intraoperative IABP implantation during open-heart surgery. Surgical procedures performed were isolated coronary artery bypass grafting (CABG) in 35 patients (32.7%), aortic valve replacement in 12 (11.2%), mitral valve repair or replacement in 15 (14.0%), combined valve and CABG procedures in 27 (25.2%), and other surgical procedures in 18 (16.8%). Results and outcomes were compared with those in a propensity score-matched cohort of 107 patients who underwent cardiac surgery without intraoperative IABP implantation. Matching criteria were age, gender, LVEF, and surgical procedure. Duration of intensive care unit (ICU) stay, duration of hospital stay, and 30-day mortality were markers of outcome. In the IABP group, mean patient age was 69.1 ± 13.7 years; 66.4% (70) were male. All IABPs were placed intraoperatively. Mean duration of IABP application time was 42.4 ± 8.7 h. IABP-related complications occurred in five patients (4.7%), including one case of inguinal bleeding, one case of mesenteric ischemia, and ischemia of the lower limb in three patients. No stroke or major bleeding occurred during IABP support. Mean durations of ICU and hospital stay were 3.38 ± 2.15 days and 7.69 ± 2.02 days, respectively, in the IABP group, and 4.20 ± 3.14 days and 8.57 ± 3.26 days in the control group, showing statistically significant reductions in duration of ICU and hospital stay in the IABP group (ICU stay, P = 0.036; hospital stay, P = 0.015). Thirty-day survival rates were 92.5 and 94.4% in the IABP and control group, respectively, showing no statistically significant difference (P = 0.75). IABP usage in chronic heart failure patients with severely reduced LVEF undergoing cardiac surgery was safe and resulted in shorter ICU and hospital stay but did not influence 7- and 30-day survival rates.

Laser lead extraction allows for safe and effective removal of single- and dual-coil implantable cardioverter defibrillator leads: A single-centre experience over 12 years

OBJECTIVES Lead extraction in patients with multiple or old leads of an implantable cardioverter defibrillator (ICD) is challenging. As adhesions are common at the side of the shock coils, we investigated success and procedural complication rates of laser lead extraction procedures in single- and dual-coil leads. METHODS Between January 2001 and June 2013, 41 single- and 145 dual-coil ICD leads were extracted from 171 patients using laser sheaths. Procedural data, success rates and complications were collected into a database and retrospectively analysed. RESULTS The mean patient age was 58.2 ± 16.1 years. The mean time from initial lead implantation to extraction was 50.3 ± 18.4 and 45.8 ± 14.5 months in the single- and dual-coil group, respectively (P = 0.1). In the single-coil group, complete procedural success was achieved in 36 of 37 (97.3%) cases, and clinical success in all cases (100.0%). In the dual-coil group, complete procedural success was seen in 131 out of 134 (97.8%) patients, and clinical success in 132 of 134 cases (98.5%). The transvenous extraction failed in 2 cases (1.5%). The overall complication rate was 2.7% in the single-coil group and 3.7% in the dual-coil group, respectively (P = 1.0). No deaths occurred during the 30-day follow-up. The mean laser treatment time was 1.8 ± 1.5 min for the single-coil group and 2.5 ± 1.2 min for dual-coil group (P = 0.002). CONCLUSIONS Laser lead extraction allows for safe and effective removal of ICD leads. Compared with single-coil leads, the extraction of dual-coil leads is associated with longer laser treatment times but without statistically significant differences in complications and procedural success rates.

Direct percutaneous transaxillary implantation of a novel self-expandable transcatheter heart valve for aortic stenosis

The aim of this study was to evaluate safety, feasibility, and efficacy of transaxillary TAVI using a novel self‐expandable transcatheter heart valve (THV) via a direct percutaneous technique.

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.

Predictors of Long-term Success After Concomitant Surgical Ablation for Atrial Fibrillation

According to guidelines, atrial fibrillation (AF) ablation success should be measured by 24-hour Holter electrocardiogram (ECG). However, information on long-term success, especially obtained by 24-hour Holter ECG, is rare. We therefore analyzed rhythm course and long-term outcomes of our patients undergoing concomitant surgical AF ablation. Between January 2003 and April 2011, 486 patients underwent concomitant surgical AF ablation in our institution. Patients with 24-hour Holter ECG rhythm status available between 5 and 10 years postoperatively were included in this retrospective data analysis (n = 155). Ablation lesions were limited to either a pulmonary vein isolation (n = 31, 20%), a more complex left atrial lesion set (n = 89, 57%), or biatrial lesions (n = 35, 23%). Primary end point of the study was freedom from AF during long-term follow-up. Mean patient age was 68.1 ± 8.4 years; 57.4% were male. Mean follow-up time was 5.9 years. Surgical AF ablation provided freedom from AF rate of 56.6% during long-term follow-up, with significantly better results in patients with paroxysmal than in those with persistent AF (67.2% vs 51.8% P = 0.03). A stable rhythm course was observed during follow-up, without statistically significant differences between 12 months and latest follow-up (63.2% vs 56.6%; P = 0.25). In multivariate analysis, preoperative paroxysmal AF, duration of AF, and left atrial diameter were predictors of long-term ablation success. Surgical AF ablation provided freedom from AF rate of 56.6% during long-term follow-up. Statistically significant predictors of ablation success at latest follow-up were preoperative paroxysmal AF, duration of AF, and a preoperative smaller left atrial diameter.

Long-term outcomes of prophylactic placement of an endovascular balloon in the vena cava for high-risk transvenous lead extractions

BACKGROUND Many clinicians use the strategy of prophylactically placing an endovascular balloon before transvenous lead extraction, yet there are no data regarding this practice. OBJECTIVE This study assesses long-term outcomes of prophylactic placement of an endovascular balloon in the venae cavae of patients during transvenous lead extraction. METHODS From April 1, 2016 to March 31, 2017 data were prospectively collected at 2 international cardiovascular centers on patients who had the balloon prophylactically placed in the venae cavae. Patients were monitored for a minimum of 3 months to capture any associated adverse events. RESULTS Twenty-one patients had the balloon prophylactically placed in the venae cavae during lead extraction. Sixteen patients were male (76%); the mean age was 57.6 ± 18.7 years; and the mean body mass index was 26.1 ± 4.4 kg/m2. The mean lead dwell time was 11.2 ± 8.3 years, with an average of 2.2 ± 1.1 leads per case, and most indications for extraction were noninfectious (62%). Two minor complications (10%, pocket hematomas) and 1 major complication (5%, cardiac tamponade) occurred during the procedure. All cases (100%) were procedural successes, and all patients (100%) were discharged alive. On follow-up (6.8 ± 3.7 months), all patients were alive and reported no adverse events related to prophylactic balloon placement, such as pulmonary emboli or deep venous thrombi. CONCLUSION During the study period, we observed no acute or long-term adverse outcomes associated with prophylactic placement of an endovascular balloon in the venae cavae of patients undergoing transvenous lead extraction.

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.

Coronary Sinus Lead Removal: A Comparison between Active and Passive Fixation Leads

Background Implantation of coronary sinus (CS) leads may be a difficult procedure due to different vein anatomies and a possible lead dislodgement. The mode of CS lead fixation has changed and developed in recent years. Objectives We compared the removal procedures of active and passive fixation leads. Methods Between January 2009 and January 2014, 22 patients at our centre underwent CS lead removal, 6 active and 16 passive fixation leads were attempted using simple traction or lead locking devices with or without laser extraction sheaths. Data on procedural variables and success rates were collected and retrospectively analyzed. Results The mean patient age was 67.2 ± 9.8 years, and 90.9% were male. The indication for lead removal was infection in all cases. All active fixation leads were Medtronic® Attain StarFix™ Model 4195 (Medtronic Inc., Minneapolis, MN, USA). The mean time from implantation for the active and passive fixation leads was 9.9 ± 11.7 months (range 1.0–30.1) and 48.7 ± 33.6 months (range 5.7–106.4), respectively (p = 0.012). Only 3 of 6 StarFix leads were successfully removed (50%) compared to 16 of 16 (100%) of the passive fixation CS leads (p = 0.013). No death or complications occurred during the 30-day follow-up. Conclusion According to our experience, removal of the Starfix active fixation CS leads had a higher procedural failure rate compared to passive.

Percutaneous left atrial unloading to prevent pulmonary oedema and to facilitate ventricular recovery under extracorporeal membrane oxygenation therapy

OBJECTIVES Left-sided unloading during extracorporeal membrane oxygenation (ECMO) therapy is crucial to prevent pulmonary oedema and facilitate ventricular recovery. We present the case of a 55-year-old man under ECMO therapy with pre-existing left ventricular (LV) thrombus formation and in need of ventricular unloading. METHODS We implanted a 21-Fr TandemHeart Protek Solo trans-septal cannula into the left atrium using a trans-septal approach via the femoral vein. The cannula was connected to the venous line of the ECMO circuit. A flow probe and a clamp to reduce flow, if necessary, were attached to the left atrium line. Left atrium flow was adjusted to 900 ml/min under transoesophageal echocardiography control to keep the atrial septum in the mid-line and to prevent suction of the inflow cannula. RESULTS After 9 days, the patient was weaned step-wise from ECMO and the TandemHeart cannula, which was then explanted. The patient is in New York health Association Class II without neurological sequelae (Cerebral Performance Scale 1). After 3 months, the patient has fully recovered and is working daily. The LV function is still moderately impaired, and the size of the LV thrombus remains the same. The atrial septum shows no residual defect. CONCLUSIONS Percutaneous trans-septal insertion of a TandemHeart cannula incorporated in an ECMO circuit for the prevention of pulmonary oedema and subsequent weaning from extracorporeal circulation was feasible and safe in a patient with cardiogenic shock and an LV thrombus.