Sex differences in long-term outcomes following transvenous lead extraction.

INTRODUCTION: Transvenous lead extraction (TLE) is generally considered a safe procedure, albeit not without risks. While gender-based disparities have been noted in short-term outcomes following TLE, a notable gap exists in understanding the long-term consequences of this procedure. The objective of this analysis was to investigate sex differences in both acute and long-term outcomes among patients who underwent TLE at a tertiary referral center. METHODS: In this retrospective cohort study, consecutive patients who underwent TLE between January 2014 and January 2016 were enrolled. The primary outcome comprised a composite of all-cause mortality and need for repeated TLE procedures. Secondary outcomes included fluoroscopy time, lead extraction techniques, success rates, and major and minor complications. Results were compared between female and male cohorts. RESULTS: The study population comprised 191 patients (median age, 70 years), 29 (15.2%) being women and 162 men (84.8%). Study groups had similar baseline characteristics. Complete procedural success was achieved in 189 out of 191 patients (99.0%), with no significant difference observed between the two groups (p = .17). No major complications were reported in the total cohort. However, there was a significantly higher incidence of minor complications in women compared to men (17.2% vs. 2.5%, p < .01). Following a median follow-up of 6.5 years, the incidence of the primary composite outcome occurred similarly between the study groups (log-rank p = .68). CONCLUSION: Women who underwent TLE exhibited a significantly higher incidence of minor acute intra- and peri-procedural complications than men. However, no differences in long-term outcomes between genders were observed.

Implantable loop recorder in Brugada syndrome: Insights from a single-center experience.

Background: This study aimed to investigate the characteristics and outcomes of patients diagnosed with Brugada syndrome (BrS) who underwent implantable loop recorder (ILR) insertion during routine clinical activity. Methods: We conducted a comprehensive screening of all consecutive patients diagnosed with BrS at our institution. We analyzed baseline clinical characteristics, arrhythmic findings, and outcomes. Results: Out of 147 BrS patients, 42 (29 %) received an ILR, 13 (9 %) underwent implantable cardioverter-defibrillator (ICD) placement, and 92 patients (63 %) continued regular cardiological follow-up. Patients who received an ILR had a higher prevalence of suspected arrhythmic syncope (43 % vs. 22 %, p = 0.012) and tended to be younger (median age 38 years, interquartile range 30-52, vs. 43 years, 35-55, p = 0.044) with a higher presence of SCN5A gene mutations (17 % vs. 6 %, p = 0.066) compared to those who continued regular follow-up. Additionally, compared to patients with an ICD, those with an ILR had a significantly lower frequency of positive programmed ventricular stimulation (0 % vs. 91 %, p < 0.001). During a median follow-up period of 14.7 months (4.7-44.8), no deaths occurred among the patients with ILR. Eight individuals (19 %) were diagnosed with arrhythmic findings through continuous ILR monitoring, primarily atrial fibrillation, and asystolic pauses. The median time from insertion to the occurrence of these events was 8.7 months (3.6-46.4). No adverse events related to ILR were reported. Conclusion: Continuous monitoring with ILR may facilitate the timely detection of non-malignant rhythm disorders in BrS patients with risk factors but without an indication for primary prevention ICD implantation.

Ion channel dysfunction and fibrosis in atrial fibrillation: Two sides of the same coin.

BACKGROUND: Atrial fibrillation (AF) is a common heart rhythm disorder that is associated with an increased risk of stroke and heart failure (HF). Initially, an association between AF and ion channel dysfunction was identified, classifying the pathology as a predominantly electrical disease. More recently it has been recognized that fibrosis and structural atrial remodeling play a driving role in the development of this arrhythmia also in these cases. PURPOSE: Understanding the role of fibrosis in genetic determined AF could be important to better comprise the pathophysiology of this arrhythmia and to refine its management also in nongenetic forms. In this review we analyze genetic and epigenetic mechanisms responsible for AF and their link with atrial fibrosis, then we will consider analogies with the pathophysiological mechanism in nongenetic AF, and discuss consequent therapeutic options.

Transvenous lead extraction, factors affecting procedural difficulty.

BACKGROUND: A complex transvenous lead extraction (TLE) procedure could be associated with lower success and higher complication rates in inexperienced hands. In this study, we aim to assess the factors that determine procedural difficulty in TLE. METHODS: We retrospectively studied 200 consecutive patients undergoing TLE in a single referral centre from June 2020 to December 2021. Lead extraction difficulty was assessed by the success of simple manual traction with or without a locking stylet, the need for advanced extraction tools and the number of tools required to extract the lead. Logistic and linear regression analyses were used to determine the factors independently affecting these 3 parameters. RESULTS: 363 leads were extracted from 200 patients (79% males, mean age 66.85 years). The indication for TLE was device-related infection in 51.5%. Multivariate analysis revealed the lead indwelling time to be the only factor affecting the 3 parameters of difficulty. Passive fixation leads and dual coil leads increased procedural difficulty by affecting 2 parameters each. Factors that affected one parameter included infected leads, coronary sinus leads, older age of the patient and a history of valvular heart disease, all associated with a simpler procedure. Right ventricular leads were associated with a more complex one. CONCLUSION: The most important factor that increased TLE procedural difficulty was a longer lead indwelling time, followed by passive fixation and dual-coil leads. Other contributing factors were the presence of infection, coronary sinus leads, older patients, a history of valvular heart disease and right ventricular leads.

The role of preoperative venography in predicting the difficulty of a transvenous lead extraction procedure.

INTRODUCTION: We hypothesized that an accurate assessment of preoperative venography could be useful in predicting transvenous lead extraction (TLE) difficulty. METHODS AND RESULTS: A dedicated preoperative venogram was performed in consecutive patients with cardiac implantable electronic device who underwent TLE. The level of stenosis was classified as without significant stenosis, moderate, severe, and occlusion. The presence of extensive lead-venous wall adherence (≥50 mm) was also assessed. A total of 105 patients (median age: 71 years; 72% male) with a median of 2 (1-2) leads to extract were enrolled. Preoperative venography showed moderate to severe stenosis in 31 (30%), complete occlusion in 15 (14%), and extensive lead-venous wall adherence in 50 (48%) patients. Complete TLE success was achieved in 103 (98%) patients. A total of 55 (52%) were advanced extractions as they required a powered mechanical and/or laser sheath. They were more prevalent in the group with extensive lead-venous wall adherence (72% vs. 34%, p < .001), while no differences were found between patients with and without venous occlusion. In multivariate analysis, the presence of adherence was a predictor of advanced extraction (odds ratio: 2.89 [1.14-7.32], p = .025). The fluoroscopy time was also significantly longer (14.0 [8.2-18.7] vs. 5.1 [2.1-10.0] min, p < .001). The rate of complications did not differ based on the presence of venous lesions. CONCLUSION: Although procedural success and complication rates were similar, patients with extensive lead-venous wall adherence required a longer fluoroscopy time and were three times more likely to need advanced extraction tools. Conversely, the presence of total venous occlusion had no impact on the procedure complexity.

Transvenous lead extraction in patients with persistent left superior vena cava.

PURPOSE: Predictors of difficulty and complications of transvenous lead extraction (TLE) have been investigated in several studies; however, little is known about the venous anatomical characteristics that can have an impact on procedural outcomes. Among them, the persistent left superior vena cava (PLSVC) is a common anomaly often discovered incidentally during cardiac device implantation and could raise concerns if TLE is indicated. We report technical considerations and outcomes of TLE for two patients with leads implanted via PLSVC. METHODS AND RESULTS: Two cardiac implantable electronic device recipients with isolated PLSVC required TLE due to infective endocarditis in one case and lead failure in the other. In the first case, TLE procedure was performed in a hybrid operating room with minimally invasive video-assisted thoracoscopic monitoring due to the high procedural risk. Two active fixation 20-year-old pacing leads were removed with a relatively short fluoroscopy time. In the second case, we successfully extracted a single-coil active fixation lead without the need of a locking stylet or advanced extraction tools. There were no procedural complications or adverse events at 1-year follow-up. CONCLUSION: TLE procedures for two patients with isolated PLSVC were successfully completed with less difficulty and tools than expected based on the characteristics of the targeted leads. If indicated, TLE in the presence of a PLSVC should be considered in experienced centers.

Technical considerations for CRT-D implantation in different varieties of persistent left superior vena cava.

PURPOSE: The persistent left superior vena cava (PLSVC) is usually asymptomatic and creates a challenge when detected incidentally during cardiac resynchronization therapy defibrillator (CRT-D) implantation. The purpose of our cases is to show different anatomical variables of PLSVC and different strategies used for CRT-D implantation. METHODS: Four cases of PLSVC were presented. Pre-procedural bilateral venography was done to define anatomical variant of PLSVC. The side of approach and vein of approach were chosen according to the anatomical variant. Major challenges, electrical parameters, procedural times, long-term follow up, and complications were addressed. RESULTS: Two cases were de novo CRT-D implantation. One case was an extraction/re-implantation of the coil lead, and one case was an upgrading. In one case, CRT-D implantation was followed by AVN ablation. All cases had successful devices implantation. Two cases had isolated PLSVC: one of them had right approach and the other had left approach. One case had double SVC with no connecting brachiocephalic veins and underwent a left-sided approach. One case had double SVC with a small connecting brachiocephalic vein and had a left approach for implantation with using the small brachiocephalic vein for the RV lead. Electrical parameters were acceptable for all leads implanted. Long-term follow-up was done for 6 months to 5 years. One complication occurred (acute atrial lead dislodgement). CONCLUSIONS: In our case series, the presence of PLSVC did not preclude successful placement of pacemaker/defibrillator leads using standard tools. Bilateral venography helped to decide the side and vein of lead insertion.

Leadless pacemaker: State of the art and incoming developments to broaden indications.

Theleadless pacemaker (LLPM) therapy has been developed in recent years to overcome the transvenous lead and device pocket-related complications. The LLPMs now available are self-contained right ventricular pacemakers and are limited to single-chamber ventricular pacing modality. This literature review deals with the current status of LLPM technology and current areas of clinical applicability. The safety and efficacy outcomes published from randomized clinical trials and real world registries are analyzed and compared with historical conventional transvenous pacemaker data. Furthermore, new pacing modalities and future perspectives to broaden the clinical use and cover most of pacing indications are discussed. Due to the overall safe and effective profile in the short term and intermediate term, also in fragile patients, the LLPM use is constantly growing in daily clinical practice. Actually, it can be considered a landmark innovation, through which a new era of cardiac pacing has begun.

A novel generation of hybrid photochromic vinylidene-naphthofuran silica nanoparticles through fine-tuning of surface chemistry.

Novel photochromic 1-vinylidene-naphtho[2,1-b]furan derivatives (VNF-1 and VNF-2) were successfully anchored onto silica nanoparticles (SiO2 NPs) through direct adsorption (SiO2@VNF-1) and covalent post-grafting (SiO2@VNF-2). SiO2 NPs with different sizes (15 ± 3 and 123 ± 7 nm) and surface chemistry (pHpzc in the range of 5-9) were used, offering a wide range of possibilities to fabricate tailor-made photochromic materials. The characterization of VNF-based SiO2 NPs confirmed the efficient VNF immobilization and the integrity of both organic and inorganic components. The photochromic behavior of these new nanoparticles indicates that silica surface acidity and the type of VNF immobilization strategy (adsorption vs. covalent grafting) were crucial factors for the occurrence of photochromism in the VNF-based SiO2 NPs. Upon UV (λ = 365 nm) or sunlight exposure for 1 min, only the SiO2@VNF-1 nanomaterials prepared by direct VNF adsorption onto SiO2 NPs with pHpzc ≈ 6.0 showed direct and reversible photochromic properties, developing fast (in seconds) and intense salmon and violet coloration, with high values of total color difference () and optical densities (ΔOD = 0.14-0.25). In contrast, all nanomaterials prepared by covalent grafting of VNF-2 onto SiO2 NPs (SiO2@VNF-2) did not exhibit photochromism. In the case of the photochromic SiO2@VNF-1 NPs, the decoloration process followed a bi-exponential decay with fast rate constants (k1 = 1.6 × 10-1-1.6 min-1 and k2 = 9.1 × 10-3-1.3 × 10-1 min-1), which were responsible for the loss of coloration in less than 10 min. Furthermore, they presented very good resistance to fatigue, showing reversibility between the colored/uncolored states without significant loss of their performance for at least 8 successive UV/dark cycles.