Is Venoplasty an Alternative to Lead Extraction for Patients With Venous Obstruction?

BACKGROUND: Indications for cardiovascular implantable electronic devices (CIEDs) have increased over time. Patients may require lead replacement or implantation due to lead failure or need for device upgrade. Venous obstruction is a common finding in these patients and often poses difficulties for operators. Venoplasty as an alternative to lead extraction emerges as an important intervention in the treatment of selected patients, particularly with a view to minimising procedural risk. METHODS: Nine (9) patients with CIED related venous occlusion were treated with venoplasty at our institution between April 2006 and October 2019. Six (6) of nine patients were initially referred to our institution for consideration of transvenous lead extraction in the setting of venous occlusion. These patients are the subjects of the case series. Patient demographics, indication for venoplasty and procedural outcomes were examined. RESULTS: We present a series of six patients in whom venoplasty has been performed at our centre as an alternative to lead extraction. Device and patient characteristics have been examined as well as radiation exposure and fluoroscopy time. The median age of our cohort was 64.5 years (range: 37-81 years) and 67% were female. Luminal calibre was improved in all patients allowing lead replacement, device upgrade or relief of symptoms. Procedural complications were not observed, and all patients remained free of symptoms related to venous occlusion at 3-month follow-up. CONCLUSIONS: We present venoplasty as a viable alternative to lead extraction in high risk patients or in those who favour a less invasive approach.

Pulmonary Vein Re-Isolation as a Routine Strategy Regardless of Symptoms: The PRESSURE Randomized Controlled Trial.

OBJECTIVES: The goal of this study was to determine whether a strategy of early re-isolation of pulmonary vein (PV) reconnection in all patients, regardless of symptoms, would reduce the recurrence of atrial fibrillation (AF) and improve quality of life. BACKGROUND: Lasting pulmonary vein isolation (PVI) remains elusive. PV reconnection is strongly linked to the recurrence of arrhythmia. METHODS: A total of 80 patients with paroxysmal AF were randomized 1:1 after contact force-guided PVI to receive either standard care or undergo a repeat electrophysiology study after 2 months regardless of symptoms (repeat study). At the initial procedure, PVI was demonstrated by entrance/exit block and adenosine administration after a minimum 20-min wait. At the repeat study, all sites of PV reconnection were re-ablated. Patients recorded electrocardiograms daily and whenever symptomatic for 12 months using a handheld monitor. Recurrence was defined as ≥30 s of atrial tachyarrhythmia (AT) after a 3-month blanking period. The Atrial Fibrillation Effect on Quality-of-Life Questionnaire was completed at baseline and at 6 and 12 months. RESULTS: All 40 patients randomized to repeat study attended for this after 62 ± 6 days, of whom 25 (62.5%) had reconnection of 41 (26%) PVs. There were no complications related to these procedures. Subjects recorded a total of 32,203 electrocardiograms (380 [335 to 447] per patient) during 12.6 (12.2 to 13.2) months of follow-up. AT recurrence was significantly lower for the repeat study group (17.5% vs. 42.5%; p = 0.03), as was AT burden (p = 0.03). Scores on the Atrial Fibrillation Effect on Quality-of-Life Questionnaire were higher in the repeat study group at 6 months (p < 0.001) and 12 months (p = 0.02). CONCLUSIONS: A strategy of routine repeat assessment with re-isolation of PV reconnection improved freedom from AT recurrence, AT burden, and quality of life compared with current standard care. (The Effect of Early Repeat Atrial Fibrillation [AF] on AF Recurrence [PRESSURE]; NCT01942408).

Lead Extraction for Treatment of Cardiac Device Infection: A 20-Year Single Centre Experience.

BACKGROUND: Infection is one of the most feared complications of cardiac implantable electronic devices. We report microbiology, antimicrobial therapy and infection recurrence in patients with cardiac device infection (CDI) treated with transvenous lead extraction (TLE) at a single centre over a 20-year period. METHODS: We identified a cohort of consecutive patients undergoing TLE for CDI by a single operator at a single high volume centre. Retrospective analysis of patient characteristics, microbiology, outcomes and infection recurrence was performed. RESULTS: Between May 1992 to March 2012, 348 patients underwent extraction due to localised or systemic infection. Seven hundred and twenty leads were extracted from these patients. The mean follow-up was 5.5+/-4.9 years. Staphylococcal species accounted for 81% of CDI. A difference is seen in infection onset for device revision compared with initial implants [median 10 months vs 24 months, P=0.0001]. Duration of antibiotics therapy depended on the nature of the CDI (21 days post TLE for systemic vs. 10 days for localised infection, P < 0.0001). There was comparable mortality in the 37 (11.2%) patients who did not have a replacement device compared with a replacement (30% vs 29%, P=0.9). Retained lead fragments are a risk factor for CDI recurrence (20.8% recurrence in retained fragments vs 4.3% in complete removal, P=0.006). CONCLUSION: Cardiac device infection can be successfully treated with a combination of TLE and antibiotic therapy. Device therapy can be safely withdrawn in some patients. Retained lead fragments are a risk factor for recurrent CDI following extraction.

Ablation index, a novel marker of ablation lesion quality: prediction of pulmonary vein reconnection at repeat electrophysiology study and regional differences in target values.

AIMS: Force-Time Integral (FTI) is commonly used as a marker of ablation lesion quality during pulmonary vein isolation (PVI), but does not incorporate power. Ablation Index (AI) is a novel lesion quality marker that utilizes contact force, time, and power in a weighted formula. Furthermore, only a single FTI target value has been suggested despite regional variation in left atrial wall thickness. We aimed to study AI's and FTI's relationships with PV reconnection at repeat electrophysiology study, and regional threshold values that predicted no reconnection. METHODS AND RESULTS: Forty paroxysmal atrial fibrillation patients underwent contact force-guided PVI, and the minimum and mean AI and FTI values for each segment were identified according to a 12-segment model. All patients underwent repeat electrophysiology study at 2 months, regardless of symptoms, to identify sites of PV reconnection. Late PV reconnection was seen in 53 (11%) segments in 25 (62%) patients. Reconnected segments had significantly lower minimum AI [308 (252-336) vs. 373 (323-423), P < 0.0001] and FTI [137 (92-182) vs. 228 (157-334), P < 0.0001] compared with non-reconnected segments. Minimum AI and FTI were both independently predictive, but AI had a smaller P value. Higher minimum AI and FTI values were required to avoid reconnection in anterior/roof segments than for posterior/inferior segments (P < 0.0001). No reconnection was seen where the minimum AI value was ≥370 for posterior/inferior segments and ≥480 for anterior/roof segments. CONCLUSION: The minimum AI value in a PVI segment is independently predictive of reconnection of that segment at repeat electrophysiology study. Higher AI and FTI values are required for anterior/roof segments than for posterior/inferior segments to prevent reconnection.

Long-Term Outcomes Following Transvenous Lead Extraction.

BACKGROUND: Complications related to a cardiac implantable electronic device sometimes require transvenous lead extraction (TLE). We report long-term follow-up of patients undergoing TLE, particularly mortality, recurrent device infection, and need for repeat procedures. METHODS AND RESULTS: Consecutive patients undergoing TLE at a high-volume center were assessed for characteristics, indications, and outcomes. One thousand and six leads were extracted from 510 patients. Clinical success rate was 98.2% and complete procedural success was 92.2%, with one intraprocedural death. The mean follow-up was 5.5 +/- 4.9 years (range 0.2-18 years). Cumulative mortality was 3.3% at 30 days, 7.7% at 6 months, 10.0% at 1 year, and 33.0% at 10 years. Factors associated with increased long-term mortality included cardiac device infection (CDI; 33% vs 17% for non-CDI; χ² 13.8, P = 0.0003), procedural complications (43% vs 27% for no complications; χ² 4.2, P = 0.04), age (75.0 +/- 10.9 years in patients who died vs 62.7 +/- 17.2 years; P < 0.0001), and impaired renal function (creatinine 142.5 +/- 106.4 µmol/L in patients who died vs 106.3 +/- 90.7 µmol/L; P = 0.001). The rate of CDI after TLE was 3.9% (mean 11.6 months post extraction, range 0.3-84 months) and is higher in patients with retained lead fragments (13.5% vs 3.0% with complete removal; χ² 10.7, P = 0.001). CONCLUSION: Long-term mortality following TLE is high, particularly in those with systemic infection, procedural complications, advanced age, and renal impairment. Retained fragments are a risk factor for CDI post extraction.

Twenty-year experience of transvenous lead extraction at a single centre.

AIMS: Indications for cardiovascular implantable electronic devices continue to evolve, which has led to an increasing requirement for transvenous lead extraction. We explore the indications, complications, and success rates involved in the removal of pacemaker and implantable cardioverter-defibrillator (ICD) leads in a high-volume centre, over 20 years. METHODS AND RESULTS: We performed a retrospective analysis of all consecutive patients undergoing transvenous lead extraction by a single operator at a single centre between 1993 and 2012. Patient characteristics, indications, and outcomes were analysed. A total of 1006 leads were removed from 510 patients. Seventy-two per cent of patients were males. The mean age was 64 years (range 14-96). Indications included systemic infection (25%), pocket infection (40%), lead failure (26%), chronic pain (3%), and other (6%). Ninety-six per cent of leads were completely removed. There was one procedure-related death, and the major complication rate was 0.3%. Infection was the only identified predictor of increased complication (χ² for difference between groups 20, P< 0.0001). CONCLUSION: Pacing and ICD leads can be safely extracted with mechanical techniques. The presence of device infection appears to be the major predictor of procedural complications.

Balloon warming time is the strongest predictor of late pulmonary vein electrical reconnection following cryoballoon ablation for atrial fibrillation.

BACKGROUND: Pulmonary vein isolation by cryoballoon ablation is an accepted method of treating atrial fibrillation. Little data exist regarding factors affecting late electrical reconnection of pulmonary veins following cryoballoon ablation. OBJECTIVE: To investigate factors determining pulmonary vein reconnection in patients undergoing repeat catheter ablation for recurrent atrial fibrillation following cryoballoon ablation. METHODS: Fifty-one consecutive patients undergoing repeat catheter ablation for recurrent atrial fibrillation following initial cryoballoon ablation underwent retrospective assessment of initial cryoablation characteristics, including balloon and vein sizes, venogram occlusion score, balloon freezing time from 0 to -30 °C, nadir temperature, and balloon warming time from -30 to +15 °C, recorded during the initial cryoballoon procedure. RESULTS: Of 199 veins assessed, 91 had reconnected (1.8 per patient). Balloon warming time (odds ratio [OR] 3.21; 95% confidence interval [CI] 2.00-5.13; P < .0001), nadir temperature (OR 1.94; 95% CI 1.42-2.66; P < .0001), vein occlusion score (OR 1.74; 95% CI 1.29-2.34; P = .0003), and balloon freezing time (OR 1.58; 95% CI 1.03-2.42; P = .037) predicted pulmonary vein reconnection. On multivariate analysis, balloon warming time (OR 3.71; 95% CI 2.2-6.24; P ≤ .0001), pulmonary vein size (OR 1.63; 95% CI 1.08-2.43; P = .020), and vein occlusion score (OR 1.48; 95% CI 1.06-2.08; P = .021) remained statistically significant independent predictors of pulmonary vein reconnection. The receiver operating characteristic for the multivariate model yielded an area under the curve of 0.82. CONCLUSIONS: Balloon warming time, vein occlusion score, and pulmonary vein size predict pulmonary vein reconnection. Balloon warming time was the most important predictive factor, and the manipulation of balloon warming may be a novel therapeutic strategy for improving outcomes of cryoballoon ablation for atrial fibrillation.

Giant right atrium in an adult: case report of a rare condition.

We report one of the largest descriptions of the right atrium (RA) in an adult, in absence of Ebstein's anomaly, tricuspid stenosis and other common adult associations of RA enlargement, such as pulmonary hypertension secondary to chronic pulmonary disease or severe mitral valvular pathology and pulmonary embolism. The RA volume was estimated to be over 1400 ml and was notably disproportionate to that of the left atrium and either ventricle.