Novel Hematological Parameters in the Assessment of the Extent of Cardiac Implantable Electronic Device-Related Infections.

BACKGROUND: Patients with infectious complications related to the presence of cardiac implantable electronic devices (CIED) constitute a heterogeneous group, ranging from local pocket infection (PI) to lead-related infectious endocarditis (LRIE) infection spreading along the leads to the endocardium. The detection of isolated LRIE and the assessment of the spread of infection in a patient with PI is often difficult and requires complex imaging and microbiological tests. The aim of the current study is to evaluate the usefulness of new simple hematological parameters in detecting infectious complications in patients with CIED, differentiating vegetation and vegetation-like masses, and assessing the extent of infections in patients with PI. METHODS: A retrospective analysis of clinical data of 2909 patients (36.37% with CIED-related infections), undergoing transvenous lead extraction (TLE) procedures in three high-volume centres in the years 2006-2020, was conducted. Receiver operating characteristic (ROC) curve analysis was used to assess the sensitivity and specificity of neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-platelet ratio (NPR), and lymphocyte-to-platelet ratio (LPR) in the diagnosis of CIED infections, evaluate the spread of the infectious process in patients with PI and differentiate additional structures related to the presence of lead. RESULTS: The values of NLR and NPR were significantly higher in infectious patients than non-infectious controls (3.07 vs. 2.59; p < 0.001, and 0.02 vs. 0.01; p = 0.008) and the area under the ROC curve (AUC) was 0.59; p < 0.001 and 0.56; p < 0.001, respectively. The high specificity of the new markers in detecting the infectious process was demonstrated: 72.82% for NLR (optimal cut-off value: 3.06) and 79.47% for NPR (optimal cut off value: 0.02). The values of NLR and NPR were significantly higher in patients with vegetations than in non-infectious patients with the presence of additional lead-related masses (3.37 vs. 2.61; p < 0.001 and 0.03 vs. 0.02; p = 0.008). The AUC of NLR and NPR for the prediction of vegetations was 0.65; p < 0.001 and 0.60; p < 0.001 with the highest specificity of NPR (82.78%) and an optimal cut-off value of 0.03. NLR and NPR were higher in patients with LRIE compared to isolated PI (4.11 vs. 2.56; p < 0.001 and 0.03 vs. 0.02; p < 0.001) and the ROC curve analysis for coexistence LRIE with PI showed the AUC for NLR: 0.57; p < 0.001 and AUC for NPR: 0.55; p = 0.001. High specificity in the detection of coexistence between PI and LRIE was demonstrated for NLR (87.33%), with an optimal cut-off value of 3.13. CONCLUSIONS: Novel hematological markers (NLR and NPR) are characterized by high specificity in the initial diagnosis of CIED infections, with optimal cut-off values of 3.06 and 0.02. NLR is also useful in the assessment of the spread of infection in patients with PI, with a calculated optimal cut-off value of 3.13. NPR may be helpful in the differentiation of vegetation and vegetation-like masses with an optimal cut-off value of 0.03.

Tricuspid Valve Damage Related to Transvenous Lead Extraction.

BACKGROUND: Damage to the tricuspid valve (TVD) is now considered either a major or minor complication of the transvenous lead extraction procedure (TLE). As yet, the risk factors and long-term survival after TLE in patients with TVD have not been analyzed in detail. METHODS: This post hoc analysis used clinical data of 2631 patients (mean age 66.86 years, 39.64% females) who underwent TLE procedures performed in three high-volume centers. The risk factors and long-term survival of patients with worsening tricuspid valve (TV) function after TLE were analyzed. RESULTS: In most procedures (90.31%), TLE had no negative influence on TV function, but in 9.69% of patients, a worsening of tricuspid regurgitation (TR) to varying degrees was noted, including significant dysfunction in 2.54% of patients. Risk factors of TLE relating to severe TVD were: TLE of pacing leads (5.264; p = 0.029), dwell time of the oldest extracted lead (OR = 1.076; p = 0.032), strong connective scar tissue connecting a lead with tricuspid apparatus (OR = 5.720; p < 0.001), and strong connective scar tissue connecting a lead with the right ventricle wall (OR = 8.312; p < 0.001). Long-term survival (1650 ± 1201 [1-5519] days) of patients with severe TR was comparable to patients without tricuspid damage related to TLE. CONCLUSIONS: Severe tricuspid valve damage related to TLE is relatively rare (2.5%). The main risk factors for the worsening of TV function are associated with a longer lead dwell time (more often the pacing lead), causing stronger connective tissue scars connecting the lead to the tricuspid apparatus and right ventricle. TVD is unlikely to affect long-term survival after TLE.

Safety and Effectiveness of Transvenous Lead Extraction in Patients with Infected Cardiac Resynchronization Therapy Devices; Is It More Risky than Extraction of Other Systems?

Background: Transvenous lead extraction (TLE) in patients with implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) devices is considered as more risky. The aim of this study was to assess the safety and effectiveness of TLE in patients with infected CRT systems. Methods: Data of 3468 patients undergoing TLE in a single high-volume center in years 2006−2021 were analyzed. The clinical and procedural parameters as well as the efficacy and safety of TLE were compared between patients with infected CRT and pacemakers (PM) and ICD systems. Results: Infectious indications for TLE occurred in 1138 patients, including 150 infected CRT (112 CRT-D and 38 CRT-P). The general health condition of CRT patients was worse with higher Charlson's comorbidity index. The number of extracted leads was higher in the CRT group, but implant duration was significantly longer in the PM than in the ICD and CRT groups (98.93 vs. 55.26 vs. 55.43 months p < 0.01). The procedure was longer in duration, more difficult, and more complex in patients with pacemakers than in those in the CRT group. The occurrence of major complications and clinical and procedural success as well as procedure-related death did not show any relationship to the type of CIED device. Mortality at more than one-year follow-up after TLE was significantly higher among patients with CRT devices (22.7% vs. 8.7%) than among those in the PM group. Conclusion: Despite the greater burden of lead and comorbidities, the complexity and efficiency of removing infected CRT systems is no more dangerous than removing other infected systems. The duration of the implant seems to play a dominant role.

Echocardiography in Pulmonary Arterial Hypertension: Comprehensive Evaluation and Technical Considerations.

Pulmonary arterial hypertension (PAH) is a rare, progressive disease in which there is a persistent, abnormal increase in pulmonary artery pressure. Symptoms of pulmonary hypertension are nonspecific and mainly associated with progressive right ventricular failure. The diagnosis of PAH is a multistep process and often requires the skillful use of several tests. The gold standard for the diagnosis of PAH is hemodynamic testing. Echocardiography currently plays an important role in the diagnostic algorithm of PAH as it is minimally invasive and readily available. Moreover, many echocardiographic parameters are closely related to pulmonary hemodynamics. It allows assessment of the right heart's structure and function, estimation of the pressure in the right ventricle, right atrium, and pulmonary trunk, and exclusion of other causes of elevated pulmonary bed pressure. Echocardiographic techniques are constantly evolving, and recently, measurements made using new techniques, especially 3D visualization, have become increasingly important. In echocardiographic assessment, it is crucial to know current guidelines and new reports that organize the methodology and allow standardization of the examination. This review aims to discuss the different echocardiographic techniques used to evaluate patients with PAH.

Atypical Cardiac Location of Melanoma of Unknown Origin.

The subject was a 66-year-old woman, suffering from the chest pain evoked by physical activity. Transthoracic echocardiography (TTE) revealed an abnormal structure, 41 × 29 mm. In MSCT, a hypodensic mobile tissue lesion that was infiltrating the whole thickness of left ventricle was confirmed. PET excluded the existence of other remote lesions. After surgical tumor removal, histopathological differential diagnosis revealed melanoma, myoepithelial cancer, and MPNST "high-grade" sarcoma. A control TTE detected a tumor that was 14 × 10 mm. After immunohistochemical results, immunotherapy with pembrolizumab was used, which resulted in complete tumor resolution. Presently, surgical resection and neoadjuvant targeted immunochemotherapy remain the treatment of choice for clinical stage III/IV melanoma.

Lead Dependent Tricuspid Valve Dysfunction-Risk Factors, Improvement after Transvenous Lead Extraction and Long-Term Prognosis.

BACKGROUND: Lead-related tricuspid valve dysfunction (LDTVD) has not been studied in a large population and its management remains controversial. METHODS: An analysis of the clinical data of 2678 patients undergoing transvenous lead extraction (TLE) in years 2008-2021 was conducted, with a separate group of 119 patients with LDTVD. Potential risk factors for LDTVD, improvement in valve function, and long-term prognosis after TLE were assessed. RESULTS: LDTVD was diagnosed in 4.44% of patients referred for lead extraction due to different reasons. The most common mechanism of LDTVD was propping upward or clamping down the leaflet by the lead (85.71%). The probability of LDTVD was higher in female sex, patients with valvular heart disease, atrial fibrillation, heart failure, large right ventricle and high pulmonary artery systolic pressure, the presence of only pacing lead, and in case of collision of the lead with tricuspid valve and adhesion of the lead to the heart structures. The prognosis of patients with LDTVD was worse, however, patients with improved valve function after TLE showed a significantly better long-term survival. CONCLUSIONS: Lead dependent tricuspid valve dysfunction is a potentially serious condition that requires thorough diagnostics and thoughtful management. The risk factors for LDTVD are primarily related to the course of the lead and its adhesion to the heart structures. Improvement of tricuspid valve function after TLE is observed in 35.29% of patients Patients with LDTVD have a worse long-term survival, but the improvement in valve function following TLE contributes to a significant reduction in mortality.

Overexpression of PD-1 on Peripheral Blood Lymphocytes in Patients with Idiopathic Pulmonary Arterial Hypertension and Its Association with High Viral Loads of Epstein-Barr Virus and Poor Clinical Parameters.

Idiopathic pulmonary arterial hypertension (IPAH) is a rare but severe disease with the elevated blood pressure in the pulmonary arteries without a known trigger of vascular remodelling. It leads to the right heart failure with reduced survival. Changes in the immunological landscape of the lungs and the periphery are common in IPAH patients, suggesting an immune system dysfunction. A cohort of 25 IPAH patients was enrolled in our study to investigate a link between the patient's clinical status, immune parameters of the blood, and the Epstein-Barr virus (EBV) infection. We found significant alterations of the patients' peripheral blood parameters. Therein, T lymphocytes and NK cell counts were decreased in the IPAH patients' blood, while the proportion of regulatory T cells was increased. Additionally, levels of proinflammatory cytokines interleukin-6 (IL-6), IL-2, and interferon-gamma (IFN-γ) were elevated. We identified a weak correlation between EBV loads and IPAH patients' clinical state (r = 0.54) and between EBV loads and overexpression of PD-1 on helper T cells (r = 0.56). We speculate that a significant dysregulation of the immune system homeostasis observed in IPAH patients may contribute to increased susceptibility of those patients to EBV infection, yet further longitudinal studies are required to characterize this relation in detail.

Transesophageal Echocardiography As a Monitoring Tool During Transvenous Lead Extraction-Does It Improve Procedure Effectiveness?

BACKGROUND: Transesophageal echocardiography (TEE) is a valuable tool for monitoring the patient during transvenous lead extraction (TLE), but the direct impact of TEE on the effectiveness and safety of TLE has not yet been documented. METHODS: The effectiveness of TLE and short-term survival were compared between two groups of patients: 2106 patients in whom TEE was performed before and after TLE and 1079 individuals in whom continuous TEE monitoring was used. The procedure-related risk of major complications was assessed using a predictive SAFeTY TLE score. RESULTS: The patients monitored by TEE were characterized by older age, more comorbidities and higher SAFeTY TLE scores (6.143 ± 4.395 vs. 5.593 ± 4.127; p = 0.004). Complete procedural success was significantly higher in the TEE-guided group (97.683% vs. 95.442%, p < 0.01). The rate of serious complications in the TEE-guided group was lower than the predictive SAFeTY TLE score-a reduction of 28.75% (p < 0.05). Periprocedural mortality in the TEE-guided and non-TEE-guided groups was zero vs. six deaths (p = 0.186). Short-term survival was comparable between the groups. CONCLUSIONS: Transesophageal echocardiography as a monitoring tool during transvenous lead extraction provides valuable results-higher rates of complete procedural success and a reduced risk of the most severe complications, thus preventing periprocedural deaths.

Echocardiographic assessment of residuals after transvenous intracardiac lead extraction.

Detection of residual fibrotic tissue, called ghosts, after lead extraction is a new phenomenon in cardiology. This paper aims at describing the phenomenon of ghosts and determining their characteristic features. The study group consisted of 580 consecutive patients who underwent transvenous lead extraction (TLE) due to local infection, endocarditis and a superfluous lead. Each patient was clinically examined with the application of transthoracic echocardiography and transesophageal echocardiography directly before and after TLE. In the study population ghosts were detected in 110 patients (19%), and in 470 cases (81%) fibrotic tissue residuals were not found. Ghosts were most often located along the originally implanted lead's route. Longer ghosts were found after the removal of cardiac resynchronization therapy (CRT) and dual chamber pacing (DDD) devices. The local infection and infective endocarditis are associated with a larger number of ghosts revealed after the removal procedure (p = 0.006). The type of the implanted device: CRT/ICD/double chamber pacemaker/single chamber pacemaker, similar to the number of leads, did not impact on the number of the detected ghosts. The relationship between abrasions of the leads and the presence of ghosts proved significant, however (p = 0.043). TLE is associated with the presence of fibrotic tissue residuals in approx. 19% of patients. Indications for lead extraction due to local infection and endocarditis yielded significantly more cases of ghosts than in the entire patient population. The presence of abrasions is a good predictor for the presence of ghosts on the leads.

Total anomalous pulmonary vein drainage in a 60-year-old woman diagnosed in an ECG-gated multidetector computed tomography - a case report and review of literature.

PURPOSE: Total anomalous pulmonary vein drainage (TAPVD) is a congenital cardiac defect in which there is no connection between pulmonary veins and the left atrium. Pulmonary veins form a confluence independent of the left atrium and drain to a systemic vein. TAPVD types are: supracardiac, cardiac, infracardiac, and mixed. TAPVD accounts for approximately 1.5-2.2% of all congenital heart diseases. This anomaly is usually diagnosed in the neonatal period, and it coexists with atrial septal defect. Adult cases of TAPVD are rarely reported. CASE REPORT: We report a rare case of a 60-year-old woman with incidentally found, uncorrected TAPVD in ECG-gated multidetector computed tomography. In previous echocardiographic examinations partial anomalous pulmonary venous return and atrial septal defect were diagnosed. CONCLUSIONS: ECG-gated multidetector computed tomography is a valuable diagnostic method for adults with congenital heart disease. It enables evaluation of coronary arteries and simultaneously provides detailed anatomy of great vessels.