Successful transvenous lead extraction of abandoned lead implanted through persistent left superior vena cava

Persistent left superior vena cava, the most common thoracic venous anomaly, may complicate transvenous lead extraction (TLE). We report a successful case of TLE in a patient with persistent left superior vena cava, despite a long dwelling time and several pocket revisions due to pocket infection. The lead was removed via a hand-powered mechanical extraction sheath, and postoperative complications did not occur. Complicated TLE cases may have a better outcome if performed in a high-volume center with experienced specialists.

Lead Dependent Tricuspid Valve Dysfunction-Risk Factors, Improvement after Transvenous Lead Extraction and Long-Term Prognosis

Background: Lead-related tricuspid valve dysfunction (LDTVD) has not been studied in a large population and its management remains controversial. Methods: An analysis of the clinical data of 2678 patients undergoing transvenous lead extraction (TLE) in years 2008–2021 was conducted, with a separate group of 119 patients with LDTVD. Potential risk factors for LDTVD, improvement in valve function, and long-term prognosis after TLE were assessed. Results: LDTVD was diagnosed in 4.44% of patients referred for lead extraction due to different reasons. The most common mechanism of LDTVD was propping upward or clamping down the leaflet by the lead (85.71%). The probability of LDTVD was higher in female sex, patients with valvular heart disease, atrial fibrillation, heart failure, large right ventricle and high pulmonary artery systolic pressure, the presence of only pacing lead, and in case of collision of the lead with tricuspid valve and adhesion of the lead to the heart structures. The prognosis of patients with LDTVD was worse, however, patients with improved valve function after TLE showed a significantly better long-term survival. Conclusions: Lead dependent tricuspid valve dysfunction is a potentially serious condition that requires thorough diagnostics and thoughtful management. The risk factors for LDTVD are primarily related to the course of the lead and its adhesion to the heart structures. Improvement of tricuspid valve function after TLE is observed in 35.29% of patients Patients with LDTVD have a worse long-term survival, but the improvement in valve function following TLE contributes to a significant reduction in mortality.

Comparison between laser sheaths, femoral approach and rotating mechanical sheaths for lead extraction

Introduction Efficiency and safety are important features in the selection of lead extraction tools. We report our experience with different endovascular techniques to extract individual pacing and defibrillator leads. Methods This is a single-centre study of consecutive lead extraction procedures from 1997 until 2019. A total of 1725 leads were extracted in 775 patients. Direct traction sufficed for 588 leads, and 22 leads were primarily removed by surgery. The endovascular techniques used in the remainder were a laser sheath (190 leads), the femoral approach (717 leads) and rotating mechanical sheaths (208 leads). Results The three approaches were comparably effective in completely removing the leads (p = 0.088). However, there were more major complications with the laser sheath than with the femoral approach or rotating mechanical sheaths (8.4%, 0.5% and 1.2%, respectively). Therefore, the procedural result—extraction without major complications—was significantly better with both the femoral approach and rotating mechanical sheaths than with the laser sheath (p < 0.001). This result was confirmed after propensity score matching to compensate for differences between lead cohorts (p = 0.007). Cross-over to another endovascular tool was necessary in 7.9%, 7.1% and 8.2% of laser, femoral and rotating mechanical attempts, respectively. Conclusion All three endovascular lead extraction techniques showed comparable efficacy. However, there were significantly more major complications using the laser sheath compared to the femoral approach or rotating mechanical sheaths, leading us to abandon the laser technique. Importantly, no single endovascular technique sufficed to successfully extract all leads.

689 Hybrid transvenous and surgical approach for the extraction of coronary sinus leads: a case series

Aims The rates of cardiac device-related infection have increased substantially over the past years. Transvenous lead extraction is the standard therapy for such cases. In some patients, however, the procedure cannot be completed through the transvenous route alone. A hybrid surgical and transvenous approach may provide the solution in such cases. Methods and results We present three cases who underwent hybird transvenous and surgical extraction for coronary sinus leads due to infection of CRT-D systems. One patient had an Attain Starfix lead implanted in the coronary sinus. The procedures were performed under local anaesthesia with continuous haemodynamic and transthoracic echocardiographic monitoring. We highlight the characteristics of the patients, the features of the devices, the technical difficulties, and the outcomes of the procedures. In all cases, the right atrial and right ventricular leads were extracted through the transvenous route. In one patient, they were extracted using regular stylets and manual traction, while in the other two patients, telescoping dilator sheaths (Cook), Tightrail hand-powered mechanical sheaths (Spectranetics), and/or Glidelight Excimer Laser sheaths (Spectranetics) were used. The coronary sinus lead could not be retrieved due to extensive fibrosis after utilizing locking stylets and mechanical dilator sheaths in all three cases, in addition to rotational mechanical sheaths and laser sheaths in one case, so the patients were referred to surgery. Two patients underwent left mini-thoracotomy and one patient underwent midline sternotomy to extract the remaining CS lead. The target vein was identified and ligated, then the fibrosis around the lead was dissected, this was followed by lead retrieval through the surgical incision. The patient who underwent sternotomy suffered from mediastinitis, which required reoperation and mediastinal lavage. There were no complications in the other two patients. All three patients were reimplanted with a new CRT-D device on the contralateral side after the resolution of infection. Conclusions A hybrid surgical and transvenous approach can be complementary in case the transvenous route alone fails to completely extract the coronary sinus lead. The transvenous approach can be used to free the proximal part of the lead, while the distal adhesions can be removed surgically, preferably though a limited thoracic incision.

598 Are risk scores sufficient to stratify patients undergoing lead extraction? A single-centre analysis

Aims Device implantation is growing exponentially, as well as associated infections, ranging from isolated pocket erosion to endocarditis and bacteraemia, all worsening the prognosis of patients with frailty and comorbidity. Transvenous lead extraction (TLE) can resolve the complications, although a 1-year mortality risk of up to 25% is reported; despite higher health costs, prolonged hospitalization, and poor quality of life, strategies for predicting increased infection risk and reduced infection incidence are yet missing. Currently applied clinical scores do not consider etiologic microbial agents. We aimed to assess whether PADIT and UPCM scores could be implemented when bacteria or fungi are known to be causative of infection, and how these agents affected the outcome. Methods and results A retrospective analysis of patients undergone cardiac implantable electronic device (CIED) pocket revision, and/or TLE between 2016 and 2021 was performed. For each procedure, microbiological samples of both generator pocket tissue and intracardiac portions of the leads were analysed. In addition, blood cultures were performed in three sets. Transesophageal echocardiography was performed in all cases for ruling out suspected endocarditis. Spearman ad Pearson coefficients were tested for correlation among microorganism, prior infection and/or procedure, PADIT and UPCM scores; a P-value less than 0.05 was considered significant. We analysed 14 patients (10 males, 4 females, mean age ± SD: 72 ± 13): one case (4%) affected by pocket erosion, seven cases (50%) affected by both pocket site and lead infection (with associated bacteraemia in one subject), and one case (4%) due to lead-related infective endocarditis. Of these, five (36%) underwent device replacement, while nine (64%) to extraction or pocket/lead revision. Nine (64%) patients had positive culture examinations (Figure 1). The correlation method gave a statistically significant association between Gram- infection and prior sepsis (r 0.63; P-value 0.02). We considered the number of procedures on the same pocket and/or CIED previous infections as markers of frailty and increased infectious risk. As expected, the PADIT score, but not UPCM, significantly correlated with the number of previous procedures (r 0.70; P-value 0.006). Indeed, both scores had a similar infectious risk prediction. Conclusions In our analysis, predictive PADIT score of infectious risk performed better than UPCM, while both proved their reliability in identifying high-risk patients. The absence of correlation between UPCM score and infective agents is not conclusive, but probably due to the small sample size. Interestingly, growing rate of device reinfection correlates with the risk of Gram- bacterial infection. Thus, the integration of the microbiological data in the current prediction models could significantly increase their performance.

283 His bundle pacing: safety, performance, and clinical outcomes in a single-centre experience

Aims Permanent His bundle pacing (HBP) is a more physiological technique for cardiac stimulation and has recently emerged as an alternative for anti-bradycardia pacing and cardiac resynchronization therapy (CRT). Its main advantages over ‘classical’ pacing are both its protective role over pacing-induced cardiomyopathy and the possibility of resynchronization by normalization of His-Purkinje activation. To evaluate the intermediate-term outcomes of HBP in terms of safety, performance, and clinical outcomes. Methods and results Between December 2018 and July 2020, we enrolled a series of consecutive patients with indication for pacing in whom HBP was attempted. A specific lead (3830 Select Secure MRI SureScan) and sheath (C315His) was used. At follow-up clinical, safety and performance outcomes were evaluated. A significant rise in HBP pacing threshold was defined as an increase of at least 1 V@1ms in the minimum voltage that could produce an effective myocardial depolarization. Remote or in-hospital device interrogation was performed by an experienced electrophysiologist. HBP was attempted in 99 patients and all implantations were performed by the same two operators. Eighty-two procedures were successful (83%). The main reasons for HBP failure were high pacing-thresholds (n = 8, 47%), infra-Hisian block (n = 5, 29,4%), difficult HB location (n = 3, 17,6%), unsatisfactory sensing (n = 1, 5,9%), or lead instability (n = 1, 5,9%). During a mean follow-up of 9.5 ± 5.9 months, the overall technical and clinical complication rates were 39% and 13.3%, respectively. Three (3.6%) patients underwent His lead extraction and subsequent conventional right ventricular septum (RV) lead implantation because of lead dislodgement (n = 2) or rise in pacing threshold (n = 1), while two (2.4%) patients required His lead repositioning because of lead dislodgement (n = 1) and phrenic nerve stimulation (n = 1). Nineteen patients (23.2%) experienced a significant rise in Hisian pacing threshold and 1 of these patients also had poor sensing parameters. Oversensing was noted in 8 (9.7%) patients and in 7 of them (87.5%) it was due to both atrioventricular and ventriculoatrial crosstalk events. As regards clinical outcomes, seven patients (8.5%) were diagnosed with new onset atrial fibrillation (AF), one of them complicated by stroke. Three patients (3.6%) were hospitalized for acute heart failure, one of them after His lead dislodgement. Finally, five patients (6.1%) died during follow-up, but no death was related to cardiovascular events. Conclusions HBP is an effective technique to obtain a more physiological cardiac pacing, but it is limited by a moderate rate of procedural failure and follow-up complications, mainly rising in pacing threshold and oversensing events. This is probably due to suboptimal implantation tools and lack of specific programming algorithms. New dedicated tools, increased experience, knowledge of device limitations, and optimal programming are needed to improve future outcomes.