Venous stenosis and occlusion in the presence of endocardial leads in patients referred for transvenous lead extraction.

Objective The aim of this study was to evaluate the incidence of venous stenosis and occlusion (VSO) in patients referred for transvenous lead extraction (TLE) with regard to the indications for this treatment and to analyse the influence of VSO on efficacy, complications and technical challenges of TLE procedures. Methods The material consists of 133 consecutive TLE procedure records. The contrast venography examination of the ipsilateral access vein was performed prior to the operation. The whole study population was divided into two subgroups, based on the presence (subgroup I) or absence (subgroup II) of VSO. Results Phlebography was performed in 133 patients with age ranging from 25.7 to 86.1 years, 44 female (33.1%). The VSO was confirmed in 48 (36.1%) patients - subgroup I. Most of the patients were referred to TLE due to non-infectious reasons (100 pts-75.2%). The absence of VSO was observed substantially more frequently in patients with diabetes (P = 0.02). Procedural success rate reached 93.3% in subgroup I and 98.8% in subgroup II (P = 0.1). There was no significant difference in the use of advanced tools and alternative access sites. Conclusion The presence of VSO can be expected in one third of patients referred for lead extraction. There is no association between indication for TLE (infected or noninfected lead extraction) and the incidence of VSO. Diabetes proved to have a protective effect on venous patency in the previously mentioned group. VSO does not influence the effectiveness, safety, and the use of additional tools during TLE procedures.

Sex differences in venous stenosis and occlusion in patients with endocardial leads.

Venous stenosis and occlusion (VSO) in the presence of endocardial leads constitute one of the complications of permanent cardiac pacing. At present there are no scientific reports on the influence of sex on the incidence of VSO. AIM: The aim of the study was to examine the influence of sex on the incidence of VSO in patients with earlier implanted endocardial leads in a single-center retrospective analysis. MATERIALS AND METHODS: The material consists of 284 records of consecutive patients admitted to hospital to undergo electrotherapy procedures. In all patients a contrast venography for ipsilateral venous confluence was performed before the procedure. Patients were divided into two groups according to sex criterion. Groups were compared concerning following parameters: demographic characteristics, cardiac implantable electronic device (CIED) characteristics, comorbidities, CHA2DS2-VASc score, selected risk factors for VSO. RESULTS: Group I consist of 101 females, whereas group II consist of 183 males. Both groups did not differ significantly for age, number of implanted endocardial leads and lead dwell time. In the cohort males were with significantly greater burden of morbidity, reflected by the mean result of CHA2DS2-VASc (P=0.0098). In males there was significantly more often chronic heart failure (P<0.0001), chronic obstructive pulmonary disease (P=0.0450) and tobacco use (P=0.0159). Males had more ICD implanted than females (P=0.0270). In the examine cohort 88 patients (31%) had VSO. There was no statistically significant difference in terms of presence of VSO between females and males (P=0.4685). The detailed analysis of the patients with VSO divided according to sex revealed higher morbidity in males. CONCLUSIONS: The equality of VSO incidence in groups of males and females along with the predominance of factors protecting against VSO in group of males support the assumption that female gender is a protective factor against the development of VSO, equally as known protective factors in males.

Gender differences in dual-chamber pacemaker implantation indications and long-term outcomes.

OBJECTIVE: Dual-chamber (DDD) pacing is the most commonly used mode of heart stimulation. The data on gender-related differences in the long-term follow-up of DDD pacing mode are still limited. We performed a retrospective single-centre study to determine the effect of gender on the implantation indications and the incidence of adverse events resulting in DDD mode loss. METHODS AND RESULTS: A group of 1,049 consecutive patients with DDD pacemaker implanted between 1984 and 2002 were followed up until 2014. The study group consisted of 995 patients who performed at least one follow-up visit. Follow-up period was 124.2 ± 68.3 months, mean age was 63.5 ± 12.4 years, 56% were male. Adverse events were defined as loss of primary DDD stimulation--lead malfunction, progression to permanent AF, and infective complications. Women were older than men (64.7 vs 62.6 years) at the time of implantation and they remained, on average, 1.5 year longer in follow-up compared with men. Female patients had significantly more SSS, history of paroxysmal AF, and a similar percentage of AVB compared with male patients. The incidence of lead malfunction, device-related infections, and progression to permanent AF did not show significant differences. However, in the group without prior paroxysmal AF, women developed permanent AF more frequently. CONCLUSIONS: This patients cohort showed that there is an association between gender and indications to DDD pacing therapy. The rate of adverse events was similar in both genders. Women had a significantly longer duration of follow-up, despite markedly higher age at implantation.

The analysis of indications and early results of transvenous lead extraction in patients with a pacemaker, ICD and CRT - single-center experience.

INTRODUCTION: Transvenous lead extraction (TLE) is a recognized method of treatment in the case of permanent stimulation complication. OBJECTIVES: The objective of this study was to analyse the indications and presentation of the early experience of TLE procedures in a group of patients with old pacing systems. PATIENTS AND METHODS: Patients with a relevant history of stimulation (at least 12 months in case of a pacemaker) qualified for the research. Indications, effectiveness and complications of TLE procedures were analysed. RESULTS: Two hundred patients at the age of 66.4 (19.1-86.2 years) were enrolled and 278 leads with dwell time 76.2 months (2.1-327.4) were removed. The indications for TLE were: lead-dependent infective endocarditis in 13 cases (6.5%), pocket infection in 29 cases (14.5%), lead damage in 120 cases (60.0%), and upgrade of device system in 38 cases (19.0%). Manual traction was used to remove 66 active fixation leads (23.7%). A femoral approach was required to extract 4 leads (1.4%). Two hundred and eight leads (74.8%) were extracted using the mechanical (Cook) system and subclavian approach. Laser technique, and an electrosurgical sheath were not used. Complete procedural success was achieved in 96% of cases and overall clinical success was 98.5%. Complication rate was 5.5% (11 patients): minor and major complication rate was 3.0% (6 patients) and 2.5% (5 cases), respectively. Low body mass index (BMI) was associated with a higher rate of complications. CONCLUSIONS: The dominant indication to TLE procedures was lead dysfunction. Transvenous lead extraction has a high success rate and a low complication rate. Low BMI increased the complication rate.

Permanent atrial fibrillation in patients with a dual­chamber pacemaker.

BACKGROUND: Atrial fibrillation (AF) is thought to be a progressive arrhythmia. The impact of sex and position of right ventricular lead is not well recognized. Whilst nonparoxysmal AF compared with paroxysmal AF has been associated with increased mortality in the general population, its prognostic significance nin patients with a dual­chamber (DDD) pacemaker is less clear. AIMS: The aim of the study was to determine the incidence of permanent AF in patients with a DDD pacemaker, analyze the effect of selected baseline characteristics on permanent AF development, and examine the impact of permanent AF on patient survival. METHODS: A retrospective cohort study included 3932 consecutive patients who underwent DDD pacing system implantation between 1984 and 2014. Follow­up was completed in August 2016. We included 3771 patients (96%) with post­operative follow­up and known vital status. Occurrence of permanent AF and all­cause mortality were the study endpoints. RESULTS: During mean follow­up of 6.5 years, permanent AF occurred in 717 patients (19%). Sex (hazard ratio [HR], 1.316; 95% CI, 1.134-1.528, for men), age at implant (HR, 1.041; 95% CI, 1.033-1.049, 1-year increase), history of AF (HR, 3.521; 95% CI, 3.002-4.128) were independently associated with permanent AF development, whereas position of right ventricular lead (apical versus nonapical) and primary pacing indication (atrioventricular block versus sick sinus syndrome) were not related to permanent AF. Permanent AF was a significant risk factor for increased mortality (age- and sex­adjusted HR, 1.475; 95% CI, 1.294-1.682). CONCLUSIONS: Permanent AF occurrence was independently predicted by advanced age at implant, male sex, and preexisting AF and associated with worse survival.

Association of selected factors with long-term prognosis and mortality after dual-chamber pacemaker implant.

BACKGROUND: Dual-chamber (DDD) pacing is the most widely utilised pacing modality in many parts of the world. The present study aimed to evaluate life expectancy of DDD pacemaker patients in comparison to the age- and sex-matched general population, assess changes in baseline characteristics over three decades of the inclusion period and determine the association between selected variables and patient survival. METHODS: This longitudinal study of consecutive de novo DDD pacemaker implantations performed between 1984 and 2014, with all-cause mortality until 2016 as the endpoint, was conducted at a singlecenter university hospital. RESULTS: Under assessment were 3928 patients with a total of 30,087 patient-years of survival time. Compared to the general population, the observed survival was significantly inferior until 12 years post DDD pacemaker implant (HR = 1.499, p < 0.001), whereas after 12 years of follow-up the observed survival was significantly superior (HR = 0.555, p < 0.001). A comparison of patient baseline characteristics over three decades revealed the following significant changes: more elderly patients, more female patients, less patients with atrioventricular block, more patients with atrial fibrillation/atrial flutter (AF/AFL) and fewer patients with an apical right ventricular (RV) lead position in the later decades. In multivariate analysis male sex and higher age were the only variables significantly associated with shorter survival time. Indication for pacing, history of pre-implant AF/AFL, RV lead position and device infection were not associated with survival. CONCLUSIONS: In the very-long-term follow-up of DDD pacemaker patients, the parameters associated with survival were sex and baseline age at first implantation.

Years of life lost as a measure of premature death among dual­chamber pacemaker recipients from Malopolska Province.

BACKGROUND: Pacemakers have become the standard of care in patients with severe bradycardia and conduction abnormalities. The survival and premature mortality can be assessed using the years of life lost (YLLs). AIMS: The aim of the study was to analyze mortality trends over the period from 1999 to 2015 among patients implanted with a dual­chamber (DDD) pacemaker who were inhabitants of Malopolska Province. METHODS: This was a retrospective study of records collected from consecutive patients who underwent de novo DDD pacemaker implantation at a single center between 1984 and 2014. Inclusion criteria were residence status in Malopolska Province at the latest follow­up visit and death between 1999 and 2015. The standard expected years of life lost per death was used to calculate YLLs. Time trends were evaluated with joinpoint models and presented as an average annual percentage change (AAPC). RESULTS: Among a total of 3932 consecutive patients implanted with a DDD pacemaker, 1211 patients met the inclusion criteria. We noted an increase in the mean age at implant from 70 years in 1999 to 75.5 years in 2015 (AAPC, 0.6%; P <0.05), the number of years lived after DDD pacemaker implantation from 2.6 years to 8.2 years (AAPC, 7.4%; P <0.05), and the mean age at death from 72.6 years to 83.8 years (AAPC, 0.89%; P <0.05). Finally, we observed a reduction of the YLLs per death from 17.4 years in 1999 to 9 years in 2015 (AAPC, -4%; P <0.05). All trends were significant for both men and women. CONCLUSIONS: In the 17­year follow­up, we showed significant changes in analyzed trends, in particular a reduction in the YLLs per death.

Lead-related complications after DDD pacemaker implantation.

BACKGROUND: Pacing leads remain the weakest link in pacemaker systems despite advances in manufacturing technology. AIM: The aim of the study was to assess the long-term pacing lead performance in an unselected real-life cohort following primary DDD pacing system implantation. METHODS: A single-centre retrospective analysis of patients who underwent DDD pacing system implantation between October 1984 and December 2014 and were followed-up until August 2016 was conducted. The inclusion criterion was at least one follow-up visit after post-implant discharge. The performance of each atrial and ventricular lead implanted was evaluated during the follow-up period, and the incidence of, and predictive factors for, lead dislodgement and failure were analysed. RESULTS: The data of 3771 patients and 24,431.8 patient-years of follow-up were analysed. The mean follow-up of patients was 77.7 ± 61.8 months. During the study period, 7887 transvenous atrial and right ventricular pacing leads were implanted. Lead dislodgement occurred in 94 (1.2%) leads (92 [2.4%] patients), perforation in 11 (0.1%) leads (10 [0.3%] patients), and lead failure in 329 (4.2%) leads (275 [7.3%] patients). Atrial lead position was a predictive factor for lead dislodgement, while age at implantation, polyurethane 80A insulation, subclavian vein access, unipolar lead construction, and lead manufacturer were multivariate predictors of lead failure. CONCLUSIONS: Leads with polyurethane 80A insulation, unipolar construction, and those implanted via subclavian vein puncture exhibited the worst long-term performance.

The utility of a CHA2DS2-VASc score in predicting the presence of significant stenosis and occlusion of veins with indwelling endocardial leads.

BACKGROUND: Currently, there are no studies in which a CHA2DS2-VASc score has been used to predict the risk of venous stenosis and occlusion (VSO) in patients after the implantation of a cardiac implantable electronic device (CIED). METHODS: The material consists of the records of 223 consecutive patients qualified for transvenous lead extraction, generator change and system revisions or upgrades in whom we assessed the utility of a CHA2DS2-VASc score in the prediction of VSO. The CHA2DS2-VASc score was calculated retrospectively based on the clinical data. The whole study population was divided into two groups, based on the presence (group I) or absence (group II) of VSO. Using the receiver operating characteristic (ROC) curve, we identified the optimal cut-off point for the CHA2DS2-VASc score that allowed the prediction of the absence of VSO. RESULTS: The venography was performed in 223 consecutive patients aged on average 68.2years (25.7-95.3), 77 females (34.5%). The presence of VSO was detected in 79 (35.4%) patients aged 68.3±14.1years, 30 female (40%) patients-group I. The level of the cut-off point for the CHA2DS2-VASc score that allowed the prediction of the absence of VSO was 3.0. CONCLUSION: In the whole population the incidence of VSO amounted to 35.4%. The result of the CHA2DS2-VASc score was a destimulant of VSO occurrence and was characterized by moderate sensitivity (73.4%) and specificity (42.4%) in predicting the absence of VSO. The most significant factor, which prevented VSO development was diabetes.

Venous Stenosis and Occlusion in the Presence of Endocardial Leads.

BACKGROUND: Venous stenosis and occlusion in the presence of endocardial leads constitute one of the complications of permanent cardiac pacing either by pacemaker, implantable cardioverter-defibrillator or cardiac resynchronization therapy. OBJECTIVES: The aim of this study was to assess the incidence of stenosis and occlusions and determine the risk factors in patients with endocardial leads in a prospective single-center study. MATERIAL AND METHODS: Two hundred eighty consecutive patients aged 25-95 years (male 68.8%) were included. A contrast venography examination of the ipsilateral access vein was performed. The whole study population was divided into 2 groups, based on the presence (group I) or absence (group II) of endocardial leads. RESULTS: Venous stenosis/occlusion was identified in 51 patients (37.5%) in group I and in 3 patients (3.6%) in group II; p < 0.0001. The lead presence most highly correlated with venous complications (OR = 4.172; p < 0.001). In patients with endocardial leads divided into I A and I B according to venous patency diabetes mellitus was proved in multivariate analysis to be the only protective factor against the development of venous stenosis/occlusion (OR = 0.473; p = 0.010). CONCLUSIONS: The presence of endocardial leads is a predisposing factor for venous stenosis/occlusion and increases the risk 4-fold. The venous lesions in the presence of endocardial leads are less frequent among patients with diabetes mellitus.

[DDD pacemaker implantation during atrial fibrillation in a patient with persistent left superior vena cava]. / Implantacja rozrusznika przedsionkowo-komorowego DDD w trakcie napadu migotania przedsionków u chorego z przetrwala lewa zyla glówna górna.

The case of 65-year-old male patient who underwent DDD pacemaker implantation due to symptomatic tachy-brady syndrome with first degree AV block is presented. During the procedure a paroxysmal atrial fibrillation occured and the presence of persistent left superior vena cava (PLSVC) was diagnosed. The "straight" passive fixation leads were introduced through the PLSVC and placed in the right atrium and ventricle, using curved stylets. Atrial lead implantation during atrial fibrillation is discussed. At three month, a follow-up revealed normal DDD pacemaker function.

[Long-term results of radiofrequency (RF) catheter ablation of cardiac arrhythmias]. / Odlegla skutecznosc zabiegów przezskórnej ablacji RF w leczeniu zaburzen rytmu serca--doswiadczenia wlasne.

BACKGROUND: Although the short-term results after radiofrequency (RF) catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT), accessorry pathway (AP), atrioventricular junction (AVJ) and common atrial flutter (Aflu) have been widely reported, there is insufficient data on long-term outcome. AIM: To evaluate the long-term efficacy of RF ablation of cardiac arrhythmias in a single center. METHODS: The study population consisted of 349 consecutive patients (mean age 49.5 years) who underwent RF ablation of AP (136 patients), AVNRT (105 patients), AVJ (86 patients) or Aflu (15 patients). In 4 patients two AP and in 3 patients AP and AVNRT were ablated during the same session. The patients were subsequently followed-up for an average of 44.3 months (12-76 months). RESULTS: Ablation was successful in 341 patients (97.7%). Major complications occurred in 8 patients (2.3%) and included av block (6 patients), ventricular fibrillation (1 patient) and cardiac tamponade (1 patient). Tachycardia recurrences were observed in 21 patients (6.2%) after successful ablation. All the recurrences occurred within 10 months (mean 2.3 months) after ablation. The recurrence rate was 5.8% (6 patients) in the AVNRT group, 9.2% (12 patients) in the AP group, 1.2% in the AVJ group (1 patient) and 13% (2 patients) in the Aflu group. The differences between groups were insignifficant. CONCLUSIONS: (1) The immediate success rate of RF ablation of AVNRT, AP, AVJ or Aflu was high and there was a low incidence of complications. (2) The recurrence rate during long-term observation is low. (3). All the recurrences occurred within 10 months after successful ablation.

[Atrial fibrillation in a long-term follow-up after mitral valve replacement]. / Migotanie przedsionków w czasie dlugotrwalej obserwacji po implantacji sztucznej zastawki mitralnej.

UNLABELLED: The aim of the study was to analyse cardiac rhythm after mitral valve replacement and to define pre-operative predictive factors for persistence of atrial fibrillation. MATERIAL AND METHODS: The study group consisted of 76 consecutive pts (54 F, 22 M), mean age 54.8 +/- 8.2 (38-71) years in whom mitral valve replacement was performed due to mitral stenosis (15 pts), regurgitation (18 pts) or mixed lesion (43 pts). The prevalence of AF after the procedure was analysed with relation to age, gender and the following preoperative echocardiographic parameters: left atrial size, mitral valve area, mitral regurgitation, tricuspid regurgitation and left ventricular ejection fraction. RESULTS: Chronic AF was present in 51 pts (67.1%) before the procedure and in 34 pts (44.7%) after 17.3 +/- 11.9 months (6-46) follow-up, p<0.005. Patients with AF after operation had larger left atrium size (58.6 +/- 10.9 vs 51.3 +/- 10.1 mm, p<0.005) and lower ejection fraction (53.8 +/- 7.9 vs. 59.9 +/-8.4%, p<0.01) as compared with pts in sinus rhythm. Among 51 pts with preoperative chronic AF, 21 pts recovered to sinus rhythm (subgroup I) and 30 pts remained in AF (subgroup II) after operation. The only significant differences between subgroup I and II were: higher prevalence of mitral regurgitation (85.7 vs 60%, p<0.05), larger mitral valve area (1.4 +/- 0.3 vs 1.1 +/- 0.6 cm2, p<0.025) and higher ejection fraction (58.9 +/- 7.3 vs. 53.4 +/- 8.4%, p<0.025) in subgroup I. CONCLUSIONS: 1. The prevalence of AF diminishes significantly after mitral valve replacement. 2. Patients with pure mitral stenosis are at higher risk of remaining in AF after operation. 3. Preoperative left atrial dimension and LV ejection fraction are the most important predictive parameters for persistence of AF.

Long-term follow-up of DDD pacing mode.

BACKGROUND AND AIM: The aim of this study was to determine the long-term survival of DDD pacing and identify the main reasons for its loss. METHODS: The study group consisted of 496 patients in whom a DDD pacing system was implanted between October 1984 and March 2002 and who were followed up until July 2010. The follow-up period was 152.1 ± 35.5 months. The patients' mean age at the time of implantation was 59.5 ± 12.5 years, and 53.5% were male; 58% had sick sinus syndrome (SSS), 26% had atrioventricular block (AVB), 15% had both of these indications simultaneously, and 1% had other indications. The incidence of lead malfunction, progression to chronic atrial fibrillation (AF), and the rate of infective complications was analysed. RESULTS: During the follow-up, 369 patients remained in DDD mode stimulation. DDD mode survival rate at one, five, ten and 15 years was, respectively, 96%, 86%, 77% and 72%. The most common reason for reprogramming out of DDD mode was the development of permanent AF in 65 (13.1%) patients. The occurrence of chronic AF was associated with a prior history of paroxysmal AF (p = 0.0001), SSS (p = 0.0215), and older age at time of implantation (p = 0.0068) compared to patients who remained in sinus rhythm. Lead malfunction caused loss of DDD mode pacing in 56 (11.3%) patients. Atrial leads were damaged in 37 patients, ventricular in 12 patients, and both leads in seven patients. The subclavian vein puncture was correlated with the mechanical damage of the atrial lead (p = 0.02935) compared to cephalic vein access. At the moment of complication, the patients with a dysfunctional lead were significantly younger than those who progressed to chronic AF(p = 0.0019). Infective complications which caused temporary loss of DDD pacing were observed in six patients: five had pocket infection and one had lead-dependent infective endocarditis. CONCLUSIONS: 1. Effective DDD pacing from the originally implanted system was noted in a high percentage (72%) of patients in long-term observation (15 years). 2. Progression to permanent AF is the most common reason for loss of DDD pacing;a history of paroxysmal AF and old age are the risk factors. 3. Subclavian vein puncture is associated with a higher rate of atrial lead damage.