Jugular pacing lead extraction with laser sheath: a case report.

Over the past 20 years, the number of patients with pacemakers (PM) or implantable cardioverter defibrillators has risen markedly; consequently, an increasing number of lead-removal procedures have become necessary. A 64-year-old woman presenting with an infected device pocket and positive bacterial cultures (Staphylococcus aureus) was admitted to our department for lead removal; in 1991, she underwent VVI PM implantation for atrioventricular II degree Mobitz 1 block, and a unipolar lead was introduced via the left jugular vein. The procedure was performed in our Electrophysiology Lab with a cardiac surgeon on standby, using an excimer laser system emitting the energy at the tip of a flexible, fibre-optic 12 F sheath, developed by Spectranetics, Inc., Colorado Springs, CO, USA.

Lack of interference between small bowel capsule endoscopy and implantable cardiac defibrillators: an 'in vivo' electrophysiological study.

BACKGROUND: Capsule endoscopy is a widely performed procedure for small bowel investigation. Once swallowed by the patient, the capsule transmits images to an external recorder over a digital radiofrequency communication channel. Potential electromagnetic interferences with implantable cardiac devices have been postulated. Clinical studies on the safety of capsule endoscopy in patients with cardiac defibrillators are lacking. OBJECTIVE: The aim of this study was to assess potential mutual electromagnetic interferences between capsule and defibrillators. METHODS: This study used the Given M2A video capsule system. Ten different types of defibrillators were tested in a clinical setting. Before capsule ingestion, defibrillator electrical therapies were switched off. During capsule endoscopy patients were monitored with cardiac telemetry. At the end of capsule endoscopy the following defibrillator's parameters were analysed: change in device settings; inappropriate shocks; inappropriate anti-tachycardia therapy; inappropriate sensing or pacing; noise detection; device reset; programming changes; permanent electrical damages. Any technical problem related to capsule image transmission was recorded. RESULTS: Neither defibrillator malfunction nor interference in sensing or pacing was recorded; conversely, no capsule malfunction potentially caused by defibrillators was registered. CONCLUSION: Our results suggest that capsule endoscopy can be safely performed in patients with cardiac defibrillators.

Predicting the difficulty of a lead extraction procedure: the LED index.

BACKGROUND: According to recent surveys, many sites performing permanent lead extractions do not meet the minimum prerequisites concerning personnel training, procedures' volume, or facility requirements. The current Heart Rhythm Society consensus on lead extractions suggests that patients should be referred to more experienced sites when a better outcome could be achieved. The purpose of this study was to develop a score aimed at predicting the difficulty of a lead extraction procedure through the analysis of a high-volume center database. This score could help to discriminate patients who should be sent to a referral site. METHODS: A total of 889 permanent leads were extracted from 469 patients. All procedures were performed from January 2009 to May 2012 by two expert electrophysiologists, at the University Hospital of Brescia. Factors influencing the difficulty of a procedure were assessed using a univariate and a multivariate logistic regression model. The fluoroscopy time of the procedure was taken as an index of difficulty. A Lead Extraction Difficulty (LED) score was defined, considering the strongest predictors. RESULTS: Overall, 873 of 889 (98.2%) leads were completely removed. Major complications were reported in one patient (0.2%) who manifested cardiac tamponade. Minor complications occurred in six (1.3%) patients. No deaths occurred. Median fluoroscopic time was 8.7 min (3.3-17.3). A procedure was classified as difficult when fluoroscopy time was more than 31.2 min [90th percentile (PCTL)].At a univariate analysis, the number of extracted leads and years from implant were significantly associated with an increased risk of fluoroscopy time above 90th PCTL [odds ratio (OR) 1.51, 95% confidence interval (CI) 1.08-2.11, P = 0.01; and OR 1.19, 95% CI 1.12-1.25, P < 0.001, respectively). After adjusting for patient age and sex, and combining with other covariates potentially influencing the extraction procedure, a multivariate analysis confirmed a 71% increased risk of fluoroscopy time above 90th PCTL for each additional lead extracted (OR 1.71, 95% CI 1.06-2.77, P = 0.028) and a 23% increased risk for each year of lead age (OR 1.23, 95% CI 1.15-1.31, P < 0.001). Further nonindependent factors increasing the risk were the presence of active fixation leads and dual-coil implantable cardiac defibrillator leads. Conversely, vegetations significantly favored lead extraction.The LED score was defined as: number of extracted leads within a procedure + lead age (years from implant) + 1 if dual-coil - 1 if vegetation. The LED score independently predicted complex procedure (with fluoroscopic time >90th PCTL) both at univariate and multivariate analysis. A receiver-operating characteristic analysis showed an area under the curve of 0.81. A LED score greater than 10 could predict fluoroscopy time above 90th PCTL with a sensitivity of 78.3% and a specificity of 76.7%. CONCLUSION: The LED score is easy to compute and potentially predicts fluoroscopy time above 90th PCTL with a relatively high accuracy.

[Role of antiarrhythmic therapy for atrial fibrillation]. / Il ruolo dei farmaci antiaritmici nella fibrillazione atriale.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and is associated with a significantly increased risk of thromboembolic events and mortality. From the age of 50 years, prevalence of AF doubles every 10 years, being more common in males and reaching 5.9% in patients 65 years and older. The treatment of AF has as first objective the restoration and maintenance of sinus rhythm. The drugs used to date present several limitations in terms of side and pro-arrhythmic effects, associated with a limited antiarrhythmic effect. Recent European guidelines for the management of AF have pointed out that the pharmacological antiarrhythmic therapy to maintain sinus rhythm is helpful for symptoms related to the arrhythmia. Amiodarone is the drug with the greatest potential for maintenance of sinus rhythm in the older population as well. Other drugs currently in use are flecainide, propafenone, sotalol, and more recently introduced dronedarone and vernakalant. To date, there is no consensus among scientific societies on the management of AF: for elderly patients, who account for the majority of patients with AF, a strictly individualized evaluation is mandatory.

Hybrid Therapy for Atrial Fibrillation: where the Knife meets the Catheter.

During the past decades there has been a consistent evolution of both surgical and catheter-based techniques for the treatment of stand-alone atrial fibrillation, as alternatives or in combination with anti-arrhythmic drugs. Transcatheter ablation has significantly improved outcomes, despite often requiring multiple procedures and with limited success rates especially in presence of persistent atrial fibrillation. Surgical procedures have dramatically evolved from the original cut-and-sew Maze operation, allowing nowadays for closed-chest epicardial ablations on the beating heart. Recently, the concept of a close collaboration between the cardiac surgeon and the electrophysiologist has emerged as an intriguing option in order to overcome the drawbacks and suboptimal results of both techniques; therefore, the hybrid approach has been proposed as a potentially more successful strategy, allowing for a patient-tailored therapeutical approach. We reviewed the recent advancements either from the transcatheter and surgical standpoint, with a peculiar focus on the current option to merge both techniques along with an up-to-date review of the preliminary clinical experiences with the hybrid, surgical-transcatheter treatment of stand-alone atrial fibrillation.

Need for ongoing anti arrhythmic drugs after ablation of atrial fibrillation. Review.

Ablation of atrial fibrillation (AF) is increasingly common. Newer techniques have been developed and indications broadened to a greater number of patients with drug-resistant AF. The first end point of ablation is to cure AF without further need for Anti Arrhythmic Drugs (AADs), but the success rate at 1 year and over, after a single procedure, though higher than the success rate of AADs alone, is not 100% yet. The aim of the present work is to understand the added value of a persistent administration of previously ineffective AADs on the long-term success rate and to evaluate the timing of AADs suspension after ablation in different types of FA, when patients are in constant sinus rhythm after several months. The reduction of symptoms and the fear of asymptomatic recurrences of AF make physicians reluctant to discontinue AADs at the end of the blanking period, though the efficacy of AADs as a permanent solution late after procedure, to increase the sinus rhythm maintenance rate, is still a matter of ongoing debate. At the time, every patient undergoing ablation of AF should be assessed individually about the need to suspend AADs or not. To do this, good knowledge of AF recurrence predictors and long term success rates of AF ablation in specific clinical settings is essential. Loop Recorder as well is very useful in guiding the administration of AADs in a patient-tailored manner. Larger registries and controlled clinical trials in well-defined clinical settings are required to further elucidate the effects of a prolonged action of AADs after AF ablation. The article presented a short discussion of recent patents related to Anti Arrhythmic Drugs.

[Infective complications in patients with implantable cardiac devices: catheter extraction]. / Complicanze infettive nel paziente portatore di dispositivi: l'estrazione di elettrocateteri.

Complications related to device implantation, such as infections and malfunction, play a major role when considering the increasing rate of implant procedures. It is widely accepted in the scientific literature that the most effective way to eradicate device-related infections or complications resulting from malfunctioning involves the complete removal of the pacing system. The techniques of transvenous lead extraction include manual traction, mechanical dilation, powered sheaths (excimer laser system) using the femoral, jugular/subclavian or hybrid approach. The possibility of using different approaches, even in combination, has broadened the therapeutic armamentarium, allowing to revise the indications for removal of the system. Further clinical studies relating, specifically, to the different extraction techniques may contribute to develop common protocols by also evaluating the cost-effectiveness of the methods available.