Clinical utility of intraprocedural transesophageal echocardiography during transvenous lead extraction.

BACKGROUND: Transvenous lead extraction carries a risk of significant complications. Although intraoperative transesophageal echocardiography (TEE) is widely used to monitor cardiac performance and structures, its utility during transvenous lead extraction has not been well described. OBJECTIVE: This study evaluates the utility of TEE during transvenous lead extraction. METHODS: The records of 108 consecutive patients who underwent transvenous lead extraction with TEE guidance were reviewed. RESULTS: Transvenous extraction of 202 leads was attempted; complete extraction was achieved for 174 leads (86%) and partial extraction for 13 leads with clinically acceptable outcomes in 187 leads (93%). Mean age of the patients was 63 +/- 21 (14-99) years and 37% were female. The average number of leads per patient was 1.9 (1-6). Mean implant duration was 71 +/- 57 (1-360) months. Indications for extraction were pocket infection (53 patients), bacteremia (33), atrial J-lead fracture or recall (13), lead malfunction (8), and venous thrombosis (1). TEE identified critical findings that prompted emergency surgical intervention or converted transvenous lead extraction to surgical explantation in 6 patients (two cases with cardiac laceration, 3 cases of cardiac tamponade, and one case with a large vegetation and a patent foramen ovale). TEE eliminated the need for the premature termination of the procedure in 11 patients by excluding significant structural cardiac damage. Overall, TEE provided clinically useful information during transvenous lead extraction in 17 cases (16%). CONCLUSIONS: TEE during transvenous lead extraction provides valuable real-time information that improves efficacy and safety.

Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Studies suggest that the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System, which makes public the operator-specific mortality for patients undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI), may deter operators from providing revascularization to high-risk cardiac patients in New York compared to other states. METHODS: We performed a retrospective analysis of 545 US patients with acute myocardial infarction and cardiogenic shock due to predominant left ventricular failure enrolled in the SHOCK Registry. Adjusting for case mix using a propensity score method, we compared the use of coronary angiography, PCI, CABG, and outcomes between 220 patients in New York and 325 in other states. RESULTS: New York patients were older with similar or less severe baseline characteristics. After propensity score adjustment, New York patients were less likely than non-New York patients to undergo coronary angiography (odds ratio 0.46, 95% CI 0.31-0.68, P < .001) and PCI (odds ratio 0.51, 95% CI 0.33-0.77, P = .002). Coronary artery bypass graft rates were similarly low (14.1% vs 15.1%, P = not significant), but New York patients waited significantly longer after shock onset for surgery (101.2 vs 10.3 hours, P < .001) with only 32.3% of New York patients vs 75.5% of non-New York patients (P < .001) taken for CABG within 3 days of shock onset. CONCLUSIONS: In our propensity-adjusted retrospective analysis, New York patients with acute myocardial infarction and cardiogenic shock were less likely to undergo coronary angiography and PCI and waited significantly longer to receive CABG than their non-New York counterparts. These findings suggest that state-required reporting to the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System may result in the reluctance to revascularize the highest-risk cardiac patients.