Subcutaneous Implantable Cardioverter-Defibrillator Lead Extraction: First Multicenter French Experience.

OBJECTIVES: The aim of this multicenter study was to characterize the efficacy and safety of subcutaneous implantable cardioverter-defibrillators (S-ICDs) lead extraction procedures. BACKGROUND: S-ICDs have been developed to limit lead-related complications inherent to transvenous ICD devices. To date, no study has specifically investigated the safety and feasibility of S-ICD lead extraction procedures. METHODS: Patients requiring S-ICD lead extraction between February 1, 2014, and February 28, 2019, were retrospectively included in 10 centers. The primary endpoint of the study was procedural success, defined as the removal of all the lead and lead material from the subcutaneous space. Secondary endpoints included procedural complications and the need for specific extraction tools. RESULTS: S-ICD lead extraction procedures were performed in 32 patients (mean age 45.7 ± 13.8 years, 75.0% men, 65.6% in primary prevention). The median time from S-ICD lead implantation was 9.3 months (5.4 to 17.5 months). The primary endpoint, that is, complete removal of the material, was achieved in 96.9% of the patients, and only 1 procedural failure occurred (3.1%). Simple traction of the S-ICD lead was successful in 19 patients (59.4%), whereas 3 patients (9.4%) needed an additional incision and 9 patients (28.1%) required mechanical sheath to remove lead adhesions around the coil. No procedure-related complications occurred. Patients with successful simple traction extraction were implanted more recently (7.1 months [2.8 to 12.2 months] vs. 16.5 months [7.5 to 20.8 months]; p = 0.04) and had less prior history of sternotomy (2 [10.5%] vs. 5 [38.5%] patients; p = 0.09). CONCLUSIONS: S-ICD lead extraction is an efficient and safe procedure, but may require some specific tools like mechanical sheath, specifically when fibrotic adhesions developed around the parasternal coil.

Maximal Pre-Excitation Based Algorithm for Localization of Manifest Accessory Pathways in Adults.

OBJECTIVES: This study evaluated a new algorithm relying on maximal pre-excitation. BACKGROUND: Prior knowledge of accessory pathway (AP) location facilitates an individual ablation strategy. Delta-wave analysis on a 12-lead electrocardiogram is recognized as crucial for predicting ablation site, but can be ambiguous at basal state. METHODS: An algorithm based on maximal pre-excitation, as induced by atrial pacing during an electrophysiological study, was initially developed in 132 patients with a single manifest AP. The maximally pre-excited QRS features included the global polarity in lead V1 (step 1), inferior leads (step 2), and leads V3 or I (step 3), as well as the morphology in lead II (step 4). Three investigators prospectively tested the new algorithm in 207 consecutive patients by comparing its efficacy to a control algorithm relying on basal pre-excitation. RESULTS: The accuracy, defined as the percent of patients with an exact prediction of AP location, was significantly greater with the new algorithm (90% vs. 63%; p < 0.001). The reproducibility, defined as the level of agreement between investigators in determining AP location, was excellent (κ > 0.75; p < 0.05) with the new algorithm and fair (0.40 < κ < 0.75; p < 0.05) with the control algorithm. CONCLUSIONS: An algorithm based on maximal pre-excitation allows accurate and reproducible localization of manifest APs. When ablation is indicated, the analysis of maximal pre-excitation is a sensible approach for giving a head start in endocardial mapping.

Contact-force guided single-catheter approach for pulmonary vein isolation: Feasibility, outcomes, and cost-effectiveness.

BACKGROUND: For conventional ablation of paroxysmal atrial fibrillation (AF), an ablation catheter in conjunction with a circular mapping catheter (CMC) is typically used for pulmonary vein isolation (PVI). OBJECTIVE: The purpose of this study was to evaluate an approach for PVI with a single contact-force (CF) ablation catheter in terms of procedural reliability, outcomes, and cost-effectiveness. METHODS: One hundred consecutive patients with paroxysmal AF were included in the study. Fifty patients (study group) underwent a CF-guided single-catheter approach, whereby PVI was demonstrated when sequential pacing at 9 equidistant points within the lesion set (carina included) failed to capture the left atrium. For confirmation, PVI was verified with a CMC. In comparison, 50 patients (control group) underwent a conventional PVI ablation guided by a CMC. RESULTS: Procedure time (101 ± 17 minutes vs 107 ± 15 minutes, P = .11), ablation time (24.2 ± 7.1 minutes vs 22.6 ± 8.8 minutes, P = .37), fluoroscopy time (5.6 ± 2.2 minutes vs 8.3 ± 3.4 minutes, P = .09), and applied CF (17.8 ± 2.6 g vs 18 ± 2.8 g, P = .72) did not reach statistical difference between the study and control groups. CF-guided single-catheter ablation achieved successful PVI in 98% of the study group and a 31% reduction in cost. At 1-year follow-up, sinus rhythm maintenance rate was similar in both groups (86% vs 84%, P = .78). CONCLUSION: In paroxysmal AF, a CF-guided single-catheter technique is an effective method for PVI, yielding substantial cost savings and clinical results similar to a conventional approach.