Transvenous lead extraction after heart transplantation: How to avoid abandoned lead fragments.

BACKGROUND: Many patients awaiting heart transplantation (HTX) have a cardiac implantable electronic device (CIED). Lead removal is often still a part of the HTX procedure. Abandoned lead fragments carry a risk for infections and prohibit magnetic resonance imaging (MRI) imaging. This study evaluated the concept of an elective lead management algorithm after HTX. METHODS AND RESULTS: Between 2009 and 2018, 102 consecutive patients with previously implanted CIED underwent HTX. Lead removal by manual traction during HTX was performed in 74 patients until December 2014. Afterward, treatment strategy was changed and 28 patients received elective lead extraction procedures in a hybrid operating room (OR) using specialized extraction tools. Total of 74 patients with 157 leads underwent lead extraction by manual traction during HTX. The mean lead age was 32.3 ± 38.7 months. Postoperative X-ray revealed abandoned intravascular lead fragments in 31(41.9%) patients, resulting in a complete lead extraction rate of only 58.1%. The high rate of unsuccessful lead extractions led to the change in the extraction strategy in 2015. Since then, HTX was performed in 28 CIED patients. In those patients, 64 leads with a mean lead age of 53.8 ± 42.8 months were treated in an elective lead extraction procedure. No major or minor complications occurred during lead extraction. All leads could be removed completely, resulting in a procedural success rate of 100%. CONCLUSION: Our results demonstrate that chronically implanted leads should be removed in an elective procedure, using appropriate extraction tools. This enables complete lead extraction, which reduces the infection risk in this patient population with the necessity for permanent immunosuppressive therapy and allows further MRI surveillance.

Distinction of non-ischemia inducing versus ischemia inducing coronary stenosis by fluorescent cardiac imaging.

Intraoperative fluorescent cardiac imaging (FCI) can quantitatively assess myocardial perfusion abnormalities produced by graded flow-limiting coronary stenosis (FLS), but there are no data to distinguish FLS from non flow-limiting stenosis (NFLS) to determine their functional significance. The aim of the study was to evaluate whether non-ischemia inducing NFLS can be quantified and differentiated from FLS by FCI technology. Data are compared to gold standard fluorescent microspheres (FM). 11 domestic pigs of either sex underwent sternotomy. Left anterior descending coronary artery blood-flow was recorded by transit-time flow measurements. After baseline and Adenosine-induced hyperemia, two stenosis of low severity (50 and 90 % NFLS) were produced, followed by FLS (50 %) and total vessel occlusion. Time-dependent fluorescence intensity curves were recorded by FCI. Slope of fluorescence intensity (SFI) and background-subtracted peak fluorescence (BSFI) intensity were calculated and data compared to myocardial blood flow measurements using FM. All NFLS and FLS reduced myocardial perfusion as quantified by FCI showing decreased normalized BSFI and SFI (P < 0.001). Box-plot analysis showed significant difference between NFLS (50 and 90 %) and FLS (50 %) assessed by BSFI (P < 0.001) and SFI (P < 0.001). In each animal, a linear correlation between FM-derived myocardial blood flow and FCI-derived BSFI (r = 0.936, P < 0.001) or SFI (r = 0.942, P < 0.001) was observed during baseline, hyperemia, graded NFLS, and FLS. Both, BSFI (r = 0.789, P < 0.001) and SFI (r = 0.802, P < 0.001) significantly correlated with transit-time flow measurements. FCI quantitative technology is capable of distinguishing between non-ischemia inducing NFLS and ischemia inducing FLS showing a good correlation compared to fluorescent microspheres.

Implantation of a right ventricular implantable cardioverter-defibrillator lead in the right ventricular outflow tract in a patient with Ebstein anomaly and right ventricular lead dislocation.

An 80-year-old patient with Ebstein anomaly and prior implantable cardioverter-defibrillator (ICD) implantation was sent to our heart center because of right ventricular (RV)-ICD lead dislocation. Positioning of the new RV lead was difficult, no stable position could be found, and sensing and threshold measurements showed weak results in the RV basis, apex, and septum. So, we conducted positioning of the lead in the RV outflow tract where a stable position with good sensing and threshold parameters was found.