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.

The Hemodynamic Effects of Different Pacing Modalities After Cardiopulmonary Bypass in Patients With Reduced Left Ventricular Function.

OBJECTIVES: Patients with decreased left ventricular function undergoing cardiac surgery have a greater chance of difficult weaning from cardiopulmonary bypass and a poorer clinical outcome. Directly after weaning, interventricular dyssynchrony, paradoxical septal motion, and even temporary bundle-branch block might be observed. In this study, the authors measured arterial dP/dtmax, mean arterial pressure (MAP), and cardiac index using transpulmonary thermodilution, pulse contour analysis, and femoral artery catheter and compared the effects between right ventricular (A-RV) and biventricular (A-BiV) pacing on these parameters. DESIGN: Prospective study. SETTING: Single-center study. PARTICIPANTS: The study comprised 17 patients with a normal or prolonged QRS duration and a left ventricular ejection fraction ≤35% who underwent coronary artery bypass grafting with or without valve replacement. INTERVENTIONS: Temporary pacing wires were placed on the right atrium and both ventricles. Different pacing modalities were used in a standardized order. MEASUREMENTS AND MAIN RESULTS: A-BiV pacing compared with A-RV pacing demonstrated higher arterial dP/dtmax values (846 ± 646 mmHg/s v 800 ± 587 mmHg/s, p = 0.023) and higher MAP values (77 ± 19 mmHg v 71 ± 18 mmHg, p = 0.036). CONCLUSION: In patients with preoperative decreased left ventricular function undergoing coronary artery bypass grafting, A-BiV pacing improve the arterial dP/dtmax and MAP in patients with both normal and prolonged QRS duration compared with standard A-RV pacing. In addition, arterial dP/dtmax and MAP can be used to evaluate the effect of intraoperative pacing. In contrast to previous studies using more invasive techniques, transpulmonary thermodilution is easy to apply in the perioperative clinical setting.

Haemodynamic evaluation of alternative left ventricular endocardial pacing sites in clinical non-responders to cardiac resynchronisation therapy.

INTRODUCTION: Non response to cardiac resynchronisation therapy (CRT) may be related to the position of the coronary sinus lead. METHODS: We studied the acute haemodynamic response (AHR) from alternative left ventricular (LV) endocardial pacing sites in clinical non-responders to CRT. AHR and the interval from QRS onset to LV sensing (Q-LV interval) from four different endocardial pacing sites were evaluated in 24 clinical non-responders. A rise in LVdP/dtmax ≥ 15 % from baseline was considered a positive AHR. We also compared the AHR from endocardial with the corresponding epicardial lead position. RESULTS: The implanted system showed an AHR ≥ 15 % in 5 patients. In 9 of the 19 remaining patients, AHR could be elevated to ≥ 15 % by endocardial LV pacing. The optimal endocardial pacing site was posterolateral. There was no significant difference in AHR between the epicardial and the corresponding endocardial position. The longest Q-LV interval corresponded with the best AHR in 12 out of the 14 patients with a positive AHR, with an average Q-LV/QRS width ratio of 90 %. CONCLUSIONS: Acute haemodynamic testing may indicate an alternative endocardial pacing site with a positive AHR in clinical non-responders. The Q-LV interval is a strongly correlated with the optimal endocardial pacing site. Endocardial pacing opposite epicardial sites does not result in a better AHR.

Managing patients with advisory defibrillator leads: what can we learn from published data?

Defibrillator lead advisories stir a lot of emotions, both with patients and physicians, and this may influence lead management. We reviewed the literature for a more evidence-based approach to this issue.From the complications of two of the current advisory leads, the Medtronic Sprint Fidelis and St. Jude Riata leads, and the consequences of possible interventions, we can conclude that a restrained approach to premature replacement is appropriate. It may be opportune to replace the leads during a scheduled generator replacement in case of a higher electrical failure rate, in order to prevent future premature interventions.We found no support to extract non-functional advisory leads. In contrast, extraction is often more demanding than anticipated, and the risk substantially exceeds that of simply abandoning the leads.

Potential reach of effective smoking prevention programmes in vocational schools: determinants of school directors' intention to adopt these programmes.

OBJECTIVES: Investigating the current, intended and potential reach of two effective smoking prevention programs in Dutch vocational schools and identifying determinants of school directors' intention to adopt these programs. STUDY DESIGN: Cross-sectional survey. METHODS: Two questionnaires were developed based on the Diffusion of Innovation theory and the I-Change model, focussing on either the 'Healthy School and Stimulants program' (HSS program) or the 'Out-of-school Computer Tailoring program' (CT program). The questionnaires were distributed amongst all Dutch vocational school directors (n = 452) of which 34% completed the questionnaire. RESULTS: The potential reach of the HSS program was 29% whereas the potential reach of the CT program was 5%. Regression analyses revealed that being female, perceiving a higher percentage of smoking students in school, having a personality more open towards change, perceiving a low need for a smoking prevention program, fewer disadvantages of the program, a higher level of self-efficacy towards adopting the program and a more positive social norm towards adopting a smoking prevention program from other school directors resulted in a positive intention towards adopting either program. CONCLUSIONS: The present study showed that the reach of effective smoking prevention programs is fairly low. School-based smoking prevention efforts are likely to improve if schools choose to use programs that are proven to be effective, which can be encouraged by adapting existing and newly designed programs to school directors' characteristics and providing easy access to reliable information regarding available programs.

Visual LV motion and invasive LVdP/dtmax for selection and optimisation of cardiac resynchronisation therapy.

Echocardiography shows that multiphasic septal movement and a septal to lateral apical systolic left ventricular (LV) motion have a high predictive value for dyssynchrony and the response to cardiac resynchronisation therapy (CRT). Presence of dyssynchrony is also the major marker for CRT response in the presence of scar tissue, provided the interventricular (V-V) pacing interval is optimalised. For atrioventricular (AV) interval optimisation, the velocity-time integral of the transmitral flow has an excellent correlation with invasive LVdP/dt(max). In acute haemodynamic measurements, LVdP/dt(max) shows strongly the effect of AV and V-V optimisation. It also illustrates that the haemodynamic effect of LV pacing when associated with intrinsic conduction over the right bundle is equal to or better than biventricular pacing. We found that once AV and V-V interval were optimised, QRS morphology could be used as a template for optimal therapy. Automated continuous optimisation of the pacing intervals will be the big challenge for the future. (Neth Heart J 2008;16(Suppl1):S32-S35.).

Coffee consumption is inversely associated with cognitive decline in elderly European men: the FINE Study.

OBJECTIVE: To investigate whether coffee consumption is associated with 10-year cognitive decline in elderly men, as results of previous studies obtained hitherto have been controversial and prospective information on this association has been lacking. DESIGN, SUBJECTS AND SETTING: Six hundred and seventy six healthy men born between 1900 and 1920 from Finland, Italy and the Netherlands participated in a 10-year prospective cohort study. Cognitive functioning was assessed using the Mini-Mental State Examination (0-30 points, with a higher score indicating better cognitive performance). Coffee consumption was estimated in cups per day. A mixed longitudinal model was used to investigate the association between baseline coffee consumption and 10-year cognitive decline. Multiple adjustments were made. RESULTS: Men who consumed coffee had a 10-year cognitive decline of 1.2 points (4%). Non-consumers had an additional decline of 1.4 points (P<0.001). An inverse and J-shaped association was observed between the number of cups of coffee consumed and cognitive decline, with the least cognitive decline for three cups of coffee per day (0.6 points). This decline was 4.3 times smaller than the decline of non-consumers (P<0.001). CONCLUSIONS: Findings suggest that consuming coffee reduces cognitive decline in elderly men. An inverse and J-shaped association may exist between the number of cups of coffee consumed and cognitive decline, with the least cognitive decline for men consuming three cups of coffee per day.

A giant pseudoaneurysm becoming apparent after cardiac resynchronisation therapy.

A 57-year-old male patient with coronary artery disease developed a pseudoaneurysm after an inferior infarct in 1997. He underwent coronary bypass surgery and resection of the pseudoaneurysm located at the inferior wall. Unfortunately, the pseudoaneurysm recurred due to dehiscence of the patch, necessitating a second surgical intervention. After six years he developed progressive heart failure due to severe left ventricular dysfunction. He was referred to our institution for cardiac resynchronisation therapy (CRT) because of drug refractory heart failure which was associated with a left bundle branch block, ejection fraction of 12%, and a NYHA class IV status. After successful implantation of a biventricular pacemaker, a remarkable clinical recovery was observed. Left ventricular function improved and echocardiography now demonstrated that the pseudoaneurysm at the inferior wall had recurred for the third time. This diagnosis could not be established by preoperative echocardiography.

Incidence of atrioventricular block and chronic atrial flutter/fibrillation after implantation of atrial pacemakers; follow-up of more than ten years.

The incidence of atrioventricular (AV) block and chronic atrial flutter/fibrillation was determined in 41 patients, mean age 62.2 years (22 to 88 years) who received atrial pacemakers before October 1980. The mean follow-up period was 12.3 years, range 11-14.4 years. Twenty-five patients suffered from bradycardia-tachycardia syndrome, 13 symptomatic bradycardia, and 3 bradycardia related ventricular tachycardia. At follow-up: 18 patients (44%) had permanent I-AV block; 11 patients had II-AV block, 9 patients (22%) transient Wenckebach block and 2 patients (5%) transient Mobitz block, all asymptomatic. The cumulative incidence of III-AV block was 1 (2.5%). Chronic atrial flutter/fibrillation occurred in 6 patients (15%), 5 were not pacemaker-dependent; 1 received a ventricular pacemaker. Seventeen patients died after a mean of 7 years (0.6-12.2 years). Cumulative survival rate of 58% for 14.4 years, did not differ from a matched cohort of the normal population. There were no pacemaker related deaths. We conclude that long-term atrial pacing was safe and effective. The incidence of III-AV block and chronic atrial flutter/fibrillation was low.

Left ventricular endocardial pacing in cardiac resynchronisation therapy: Moving from bench to bedside.

In cardiac resynchronisation therapy, failure to implant a left ventricular lead in a coronary sinus branch has been reported in up to 10% of cases. Although surgical insertion of epicardial leads is considered the standard alternative, this is not without morbidity and technical limitations. Endocardial left ventricular pacing can be an alternative as it has been associated with a favourable acute haemodynamic response compared with epicardial pacing in both animal and human studies. In this paper, we discuss left ventricular endocardial pacing and compare it with epicardial surgical implantation. Ease of application and procedural complications and morbidity compare favourably with epicardial surgical techniques. However, with limited experience, the most important concern is the still unknown long-term risk of thromboembolic complications. Therefore, for now endovascular implants should remain reserved for severely symptomatic heart failure patients and patients at high surgical risk of failed coronary sinus implantation.

Peak longitudinal strain delay is superior to TDI in the selection of patients for resynchronisation therapy.

BACKGROUND: Mechanical dyssynchrony has proven to be superior to QRS duration in predicting response to cardiac resynchronisation therapy (CRT). Whether time to peak longitudinal strain delay between the mid-septum and mid-lateral left ventricular wall better predicts CRT response than tissue Doppler imaging (TDI) is unclear. This study compares the value of the two methods for the assessment of mechanical dyssynchrony and prediction of CRT responders. METHODS: 66 clinical responders and 17 nonresponders to CRT with severe systolic heart failure (LVEF <35%), New York Heart Association classification III or IV and a wide QRS >130 ms with left bundle branch block were evaluated by peak longitudinal strain and TDI. Doppler echocardiograms and electromechanical time delay (EMD) intervals were acquired before and after pacemaker implantation. RESULTS: In all responders EMD measured by peak longitudinal strain was >60 ms before implantation, compared with 76% of the patients measured by TDI. Nonresponders had EMD <60 ms measured by both techniques. Only peak longitudinal strain delay showed shortened values in every responder postimplantation and demonstrated the most significant reduction and could predict responders to CRT. However, EMD measured by TDI did not diminish in 30% of the positive clinical responders. Nonresponders showed worsening of the EMD with peak longitudinal strain, but not with TDI. CONCLUSIONS: Responders to CRT can be excellently predicted if EMD before implantation determined by peak longitudinal strain delay is >60 ms. Peak longitudinal strain delay appears to be superior to TDI to predict the response to CRT. (Neth Heart J 2010;18:574-82.).

Decline in cognitive functioning is associated with a higher mortality risk.

OBJECTIVE: This study investigates the association between 5-year change in cognitive functioning and subsequent mortality. METHODS: Four hundred and ninety-three Dutch and Italian men from the Finland, Italy, and the Netherlands Elderly (FINE) Study, born between 1900 and 1920, participated in the present study between 1990 and 2000. Cognitive functioning was measured with the Mini-Mental State Examination in 1990 and 1995, and mortality data were obtained until the year 2000. A proportional hazard analysis was used to investigate the association between 5-year change in cognitive functioning and subsequent 5-year mortality. Adjustments were made for age, education, country, lifestyle factors, prevalence of chronic diseases and, additionally, for baseline cognitive functioning. RESULTS: Men whose cognition decreased (more than 1 standard deviation) between 1990 and 1995 had a 2-fold higher risk of dying in the following 5 years compared with men whose cognition was stable (adjusted hazard ratio=1.9; 95% confidence interval 1.3-2.7). Mortality risk of men whose cognition improved between 1995 and 2000 was not different from men whose cognition was stable (adjusted hazard ratio=1.1, 95% confidence interval 0.7-1.9). CONCLUSION: A decline in cognitive functioning is associated with a higher mortality risk.

Pacemaker-mediated tachycardia in a biventricular pacing system.

A 63-year-old man with chronic atrial fibrillation and heart failure had a biventricular pacing system implanted. The pulse generator was a standard DDDR pacemaker, using the atrial channel for the right ventricular lead and the ventricular channel for the left ventricular lead. During final adjustment of the pacing parameters, a pacemaker tachycardia triggered by T wave oversensing from the right ventricular lead was recorded.

Apparent P wave undersensing in a DDD pacemaker post exercise.

Wenckebach behavior of DDD pacemakers occurring when the P-P interval varies between the programmed upper rate interval and the total atrial refractory period is symmetrical in a sense that the pacemaker response during atrial rate acceleration is similar to the pacemaker response during atrial rate deceleration. This phenomenon can be observed in all patients with persistent AV block in whom a DDD pacemaker is implanted, during exercise testing when the spontaneous atrial rate exceeds the selected upper rate, i.e., the programmed upper rate interval. However, this phenomenon will not be observed in all patients with intermittent intact AV conduction during exercise. In this case report we describe a patient who showed an asymmetrical response during a bicycle exercise test. There was 1:1 atrial sensing ventricular pacing until the atrial rate exceeded the upper rate of 140 ppm, while atrial sensing was restored during recovery when the conducted sinus rhythm had decreased to 105 beats/min.