Removal of Electrophysiological Devices in the Context of Heart Transplantation: Comparison of Combined and Staged Extraction Procedures

Background During heart transplantation (HTx), tip of the leads of cardiac implantable electrophysiological devices (CIEPD) has to be cut when resecting the heart. Timing of the removal of the remaining device and leads is still discussed controversially. Methods Between 2010 and 2021, n = 201 patients underwent HTx, of those n = 124 (61.7%) carried a present CIEPD. These patients were divided on the basis of the time of complete device removal (combined procedure with HTx, n = 40 or staged procedure, n = 84). Results CIEPD was removed 11.4 ± 6.7 days after the initial HTx in staged patients. Dwelling time, number of leads as well as incidence of retained components (combined: 8.1%, staged: 7.7%, p = 1.00) were comparable between both groups. While postoperative incidence of infections (p = 0.52), neurological events (p = 0.47), and acute kidney injury (p = 0.44) did not differ, staged patients suffered more often from primary graft dysfunction with temporary mechanical assistance (combined: 20.0%, staged: 40.5%, p = 0.03). Consecutively, stay on intensive care unit (p = 0.02) was prolonged and transfusions of red blood cells (p = 0.15) and plasma (p = 0.06) as well as re-thoracotomy for thoracic bleeding complications (p = 0.10) were numerically increased in this group. However, we did not observe any differences in postoperative survival. Conclusion Presence of CIEPD is common in HTx patients. However, the extraction strategy of CIEPD most likely did not affect postoperative morbidity and mortality except primary graft dysfunction. Especially, retained components, blood transfusions, and infective complications are not correlated to the timing of CIEPD removal.

Local device infection successfully treated without pacemaker removal in a neonate: a case report

Aims: Local device infection is a serious complication, especially in neonates. Complete device removal is the gold standard treatment for cardiac device infection; however, in selected cases alternative strategies could be adopted. We describe a case of a 14-day-old neonate, weighing 2.5kg, who had undergone epicardial double chamber pacemaker implantation for a congenital complete atrioventricular block. The generator pocket was created in the epigastric area below the rectus abdominis. At six days after implantation, pocket infection was found; blood cultures and the transoesophageal echocardiogram were normal. Due to the low weight of the neonate, and the limited possibility of finding a new comfortable site for housing the generator far from the infected area, we opted for a conservative strategy. We successfully applied a combination of antibiotic therapy, a vacuum-assisted wound closure system (KCI, Germany) for 40 days, and then skin transfer flap from the right flank without device removal. At one-year follow-up there were no local or systemic signs of infection.

Four-corner arthrodesis using the 4Fusion® quadripodal shape memory staple: a long-term review

We investigated the reliability of the 4Fusion® quadripodal memory staple in a consecutive series of 59 four-corner arthrodeses in a single centre. Forty-one patients (46 wrists) had a radiological and clinical assessment at a mean follow-up of 7.4 years. Thirteen patients (13 wrists) were lost to follow-up. Bone union was achieved in all but one patient. Seven patients were reoperated, six for device removal and one for nonunion. Most patients were satisfied, had a functional range of wrist mobility, good strength and were free of pain, comparable with the best previously reported series. Level of evidence: IV

Comparison of Electrocautery Platforms for Pulse Generator Replacement Procedures

Introduction: Lead damage can occur during cardiovascular implantable electronic device (CIED) generator replacement procedures, resulting in additional procedures and added costs. PlasmaBlade (PL) and PhotonBlade (PH) are two commercially available insulated electrocautery devices designed to reduce this risk. Objective: This study compared complication rates of PL and PH in CIED generator replacement procedures. Methods: This retrospective study analyzed transvenous CIED generator replacements using PL or PH from 2017-2020. The primary endpoint was lead damage. Secondary endpoints included rate of pocket hematoma, superficial infection, and infections requiring device removal. Results: A total of 209 patients were included for analysis, including 86 procedures (188 leads) using PL and 123 procedures (266 leads) using PH. Lead insulation material consisted of 237 (52.2%) silicone, 66 (14.5%) polyurethane, and 151 (33.3%) copolymer leads, with no significant difference in frequency of insulation materials (p=0.91). The rate of lead damage was low for both PL and PH (0 vs. 0.4%, p=0.59). There was no significant difference in pocket hematoma (1.2% vs. 1.6%, p=0.43), superficial infection (1.2% vs. 0.8%, p=0.49), or infection requiring device removal (1.2% vs. 0%, p=0.41). The mean absolute change in lead impedance from pre- to post-procedure was similar between PL and PH (72.3 ± 126.1 ohms vs. 60.6 ± 72.3 ohms, p=0.10). Conclusions: There was a low rate of complications after CIED replacement procedures, with no significant difference between the PL and PH groups. A majority of leads with silicone insulation material may have contributed to the low rate of lead damage.