Implantable Cardioverter-defibrillator Lead Research Articles

Trends and Implications of DF-4 Implantable Cardioverter-Defibrillator Lead Adoption in the United States of America

Trends and Implications of DF-4 Implantable Cardioverter-Defibrillator Lead Adoption in the United States of America

Failure-free survival of the Riata implantable cardioverter-defibrillator lead after a very long-term follow-up

AimsRiata® implantable cardioverter-defibrillator (ICD) leads from St. Jude Medical are prone to malfunction. This study aimed to describe the rate of this lead's malfunction in a very long-term follow-up. MethodsThis single-centre observational study included 50 patients who received a Riata 7Fr dual-coil lead between 2003 and 2008. Follow-up was conducted both in person and remotely, and analysed at 8-month intervals. We evaluated the rates of cable externalization (CE), electrical failure (EF), and the interaction of these two complications. Structural lead failure was defined as radiographic CE. Oversensing of non-cardiac signal or sudden changes in impedance, sensing, or pacing thresholds constituted EF. ResultsDuring a mean follow-up of 10.2 ± 2.9 years, 16 patients (32%) died. We observed lead malfunction in 13 patients (26%): three (23%) due to CE, six (46%) to EF and four (31%) to both complications. Of the malfunctioning leads, 77% failed after seven years of follow-up. The incidence rate (IR) of overall malfunction per 100 patients per year was 0.9 during the first seven years post-implantation, increased to 7.0 after the 7th year and more than doubled (to 16.7) after 10 years. Beyond seven years post-implantation, IR per 100 patient-years increased in both EF and CE (from 0.6 to 5.6 vs. 0.3 to 4.2, respectively). Presence of CE was associated with a 4-fold increase in the proportion of EF. ConclusionThe incidence of Riata ICD lead malfunction, both for EF and CE, increased dramatically after seven years and then more than doubled after 10 years post-implantation.

The Bionic Man: Surgical and Percutaneous Advances in Heart Failure and D-transposition of the Great Arteries

BackgroundModern advances in surgery and percutaneous interventions have resulted in new therapeutic possibilities for end-stage heart failure in congenital heart disease. We present a case of a patient with D-transposition of the great arteries undergoing multiple surgeries and percutaneous interventions for advanced heart failure.DescriptionA 44-year-old man with D-transposition of the great arteries underwent a Blalock-Hanlon septectomy at age 9 days and a Mustard atrial switch procedure at age 3 years. He received an epicardial ventricular pacemaker at age 12 years for high grade atrioventricular (AV) block. He developed supraventricular tachycardia ten years ago, received electrophysiology ablation, and was found to have an inferior vena cava (IVC) baffle leak for which he underwent Amplatzer occluder device placement. Four years ago, he developed superior vena cava (SVC) and IVC baffle stenosis and underwent dilation and covered stent placements in the SVC and IVC baffles. His pacemaker was upgraded to a biventricular implantable cardioverter defibrillator (ICD) utilizing the epicardial ventricular lead and an endocardial lead through the covered stent in the SVC baffle for primary prevention of sudden cardiac death. Due to worsening heart failure despite inotropic support, the patient underwent systemic HeartWare ventricular assist device (VAD) implantation as a bridge to transplantation.DiscussionThe chest X-ray shows a HeartWare ventricular assist device attached to the systemic right ventricle. The biventricular ICD includes endocardial right-atrial lead, ICD lead in the non-systemic left-ventricle, and two epicardial ventricular leads. Multiple sternotomy wires, endotracheal tube and right internal jugular catheter are seen. The stented superior and inferior vena cava baffles and Amplatzer closure device for baffle leak project over the mediastinum.ConclusionSignificant advances in surgery and percutaneous interventions allow for complex therapeutic options for patients with congenital heart disease and advanced heart failure. Modern advances in surgery and percutaneous interventions have resulted in new therapeutic possibilities for end-stage heart failure in congenital heart disease. We present a case of a patient with D-transposition of the great arteries undergoing multiple surgeries and percutaneous interventions for advanced heart failure. A 44-year-old man with D-transposition of the great arteries underwent a Blalock-Hanlon septectomy at age 9 days and a Mustard atrial switch procedure at age 3 years. He received an epicardial ventricular pacemaker at age 12 years for high grade atrioventricular (AV) block. He developed supraventricular tachycardia ten years ago, received electrophysiology ablation, and was found to have an inferior vena cava (IVC) baffle leak for which he underwent Amplatzer occluder device placement. Four years ago, he developed superior vena cava (SVC) and IVC baffle stenosis and underwent dilation and covered stent placements in the SVC and IVC baffles. His pacemaker was upgraded to a biventricular implantable cardioverter defibrillator (ICD) utilizing the epicardial ventricular lead and an endocardial lead through the covered stent in the SVC baffle for primary prevention of sudden cardiac death. Due to worsening heart failure despite inotropic support, the patient underwent systemic HeartWare ventricular assist device (VAD) implantation as a bridge to transplantation. The chest X-ray shows a HeartWare ventricular assist device attached to the systemic right ventricle. The biventricular ICD includes endocardial right-atrial lead, ICD lead in the non-systemic left-ventricle, and two epicardial ventricular leads. Multiple sternotomy wires, endotracheal tube and right internal jugular catheter are seen. The stented superior and inferior vena cava baffles and Amplatzer closure device for baffle leak project over the mediastinum. Significant advances in surgery and percutaneous interventions allow for complex therapeutic options for patients with congenital heart disease and advanced heart failure.

Implantable Cardioverter Defibrillators in Patients with Continuous Flow Left Ventricular Assist Devices: Utilization Patterns, Shock Therapies and Complications.

Background The use of implantable cardioverter defibrillators (ICDs) in patients with continuous flow left ventricular assist devices (LVADs) has not been evaluated in randomized clinical trials and the observational data published so far is controversial. To our knowledge, the burden of ICD related procedures after LVAD has not been previously described. Methods This is a retrospective single center study that included patients who underwent continuous flow LVAD implantation at the Cleveland Clinic between October 2004 and March 2017. Patients were grouped according to the presence or absence of ICD at the time of LVAD insertion. Outcomes after LVAD insertion were assessed including revisions of existing and subsequent implantation of ICDs. Results There were 486 patients in the study cohort; of those, 387 (79.6%) had an ICD prior to LVAD insertion. Patients with ICD prior to LVAD were older and had lower use of inotropes, extracorporeal membrane oxygenation, and mechanical ventilation before LVAD. There were 4 patients with leads cut or removed during LVAD, and 12 that had post-operative lead dysfunction due to dislodgment. There were 80 patients (21% of patients with ICD) who required 96 procedures after LVAD: 74 generator exchanges because of end of life or technical failure, 15 lead revisions, and 7 complete system removals because of infection. Of the 99 patients without ICD, 52 underwent ICD implantation: 38 for primary prevention and 14 for secondary prevention. Of those 4, had additional procedures: 2 generator changes due to end of life, 1 lead revision, and 1 system extraction due to pseudomonas endocarditis. The median follow ICD data follow up was 227 days in the pre-LVAD ICD group and 390 days in the post LVAD ICD group. There were 115(30%) and 13 (25%) patients that experimented ICD shocks in the pre-LVAD and post-LVAD ICD groups respectively. In both groups approximately 80% were categorized as appropriate.The unadjusted 30-day mortality was 5.2% and 10.1% in patients with and without ICD respectively (p=0.097). Conclusion In this cohort, ICD related procedures are common in patients with continuous flow LVADs and occur in about 1/5th of patients. During LVAD implantation displacement or cut of the ICD lead because of tricuspid valve intervention is not infrequent. More than half of patients without an ICD at baseline had an ICD implanted after LVAD. A substantial proportion of patients experience ICD shocks. The impact of shocks in outcomes remains to be determined.

Towards eradication of inappropriate therapies for ICD lead failure by combining comprehensive remote monitoring and lead noise alerts.

Recognition of implantable cardioverter defibrillator (ICD) lead malfunction before occurrence of life threatening complications is crucial. We aimed to assess the effectiveness of remote monitoring associated or not with a lead noise alert for early detection of ICD lead failure. From October 2013 to April 2017, a median of 1,224 (578-1,958) ICD patients were remotely monitored with comprehensive analysis of all transmitted materials. ICD lead failure and subsequent device interventions were prospectively collected in patients with (RMLN) and without (RM) a lead noise alert (Abbott Secure Sense™ or Medtronic Lead Integrity Alert™) in their remote monitoring system. During a follow-up of 4,457 patient years, 64 lead failures were diagnosed. Sixty-one (95%) of the diagnoses were made before any clinical complication occurred. Inappropriate shocks were delivered in only one patient of each group (3%), with an annual rate of 0.04%. All high voltage conductor failures were identified remotely by a dedicated impedance alert in 10 patients. Pace-sense component failures were correctly identified by a dedicated alert in 77% (17 of 22) of the RMLN group versus 25% (8 of 32) of the RM group (P=0.002). The absence of a lead noise alert was associated with a 16-fold increase in the likelihood of initiating either a shock or ATP (OR: 16.0, 95% CI 1.8-143.3; P=0.01). ICD remote monitoring with systematic review of all transmitted data is associated with a very low rate of inappropriate shocks related to lead failure. Dedicated noise alerts further reduce inappropriate detection of ventricular arrhythmias.

A simple technique for relocating chronic CIED leads to a subpectoral position for relief of erosion and pain.

Methodology specific for moving superficial chronically implanted transvenous pacing leads to a subpectoral pocket is not described in the literature. Relocation of prepectoral leads and generator to a submuscular pocket for relief of erosion and pain with minimal pectoral trauma is possible by applying a variant of a previously described submammary tunneling technique. All patients presenting for device follow-up, elective battery replacement, or system upgrade over an 8-month period were considered for relocation if experiencing significant thinning or pain over their prepectoral implant. Those selected for relocation then had their system moved subpectorally via the tunneling technique. Patients were followed for 6months postoperatively for procedurally related complications and resolution of preprocedure symptoms. Thirty-two leads in 14 patients were all successfully relocated. Of the relocated leads, five (16%) were a three-pin connector implantable cardioverter defibrillator lead. Three patients (21%) in the group required short-term prescription analgesia in the immediate postdischarge period. Pain and erosion concerns abated in the study group by the 3-month follow-up. Relocation of superficial pacing leads with CIED generator to a subpectoral pocket facilitated by this tunneling method is successful, safe, and can accommodate single and multipin leads with minimal pectoral trauma and no nerve damage.

Simultaneous lead traction from above and below: A novel technique to reduce the risk of superior vena cava injury during transvenous lead extraction

Superior vena cava (SVC) injury is a rare but dreaded complication during percutaneous transvenous lead extraction (TLE) that carries high morbidity and mortality. Despite technological advances and improved efficacy, complication rates remain unchanged. We sought to develop and test a novel technique that could reduce the risk of SVC injury during TLE. Fifteen patients referred for TLE of an implantable cardioverter-defibrillator lead were included. Patients underwent fluoroscopic and intracardiac echocardiographic (ICE) imaging of the lead-SVC interface with traction from above, below, and simultaneously. Clinical characteristics, fluoroscopic and ICE findings, and procedural outcomes were collected and analyzed. Fourteen of 15 patients were men (93%) with a mean ageof 58 years. The mean lead dwell time was 8.09 ± 3.97 years (range 1.08-16.25 years), and 12 of 15 leads (80%) were dual-coil. Acceptable ICE imaging was not possible in 3 of 15 patients (20%). Simultaneous traction showed greater leftward fluoroscopic shift compared with traction from above (24.96 ± 8.82 mm vs 13.68± 6.86 mm; P < .01), created greater separation between the lead and the SVC wall upon ICE imaging (2.0 ± 0.52 mm vs 1.24 ± 0.38 mm; P < .01), and maintained a more parallel relationship of the lead with the SVC wall (24.41° ± 4.14° vs 27.91° ± 4.92°; P< .05). In patients presenting for TLE, simultaneous traction results in increased separation and a more parallel alignment of the lead and SVC wall, allowing the sheath to be better oriented in the desired cleavage plane. This improved sheath alignment is particularly critical when powered sheaths are to be used.

Prospective Assessment of Linox Implantable Cardioverter Defibrillator Leads for Structural or Electrical Abnormalities.

Insulation failure leading to conductor externalization (CE) of a Linox (Biotronik, Berlin, Germany) implantable cardioverter defibrillator (ICD) lead has recently been reported. The aim of this study was to assess prospectively all Linox family ICD leads implanted at our center for evidence of CE or an electrical abnormality. All patients with a Linox family ICD lead implanted at our center, between November 2007 and March 2015, were identified and all living patients were invited to attend for fluoroscopic screening and electrical assessment of the lead. A total of 183 patients had a Linox family ICD lead implanted at our center. Of these, 5 patients (2.7%) had the lead extracted because of electrical failure and 2 of these leads had evidence of CE. Out of 158 living patients with a Linox family ICD lead, 111 patients attended for screening (mean age 63.1years, 22.5% female). In this group of patients, no cases of CE or electrical abnormalities of the lead were identified. In this study evaluating 183 patients with a Linox family ICD lead implanted at a single center, 5 leads (2.7%) were explanted because of electrical failure and 2 of these leads had evidence of CE. Prospective fluoroscopic assessment of 111 Linox family ICD leads, with a mean dwell time of 31.5months, revealed no further cases of CE.

Transvenous extraction of advisory implantable cardioverter defibrillator leads with a relatively long implant duration

BackgroundOptimal management of advisory implantable cardioverter defibrillator (ICD) leads has not been established. Several studies were reported concerning the lead extraction of advisory ICD leads, but the implant duration of those studies was short. We estimated the efficacy of lead extractions of advisory ICD leads with a relatively longer duration in Japanese patients. MethodsWe retrospectively analyzed 28 patients who underwent a lead extraction at Kokura Memorial Hospital and Tokyo Medical and Dental University Hospital [Fidelis (Medtronic, Minneapolis, MN, USA): n=19, Riata (St. Jude Medical, Sylmar, CA, USA): n=8, Isoline (SORIN CRM SAS, Clamart, France): n=1]. The mean implant duration was 63.3±19.3 months. The indications were device related infections in 3, electrical lead failures in 18, electrical lead failures and venous obstructions in 3, and prophylactic reasons in 4 patients. Inappropriate shocks because of electrical lead failures were observed in 9 patients. ResultsComplete removals were achieved of all 28 advisory leads. In 23 out of 28 patients, new ICD leads were implanted during the same procedure. In one patient, open chest surgery was performed for a hemothorax that occurred during a new ICD lead implantation just after successfully removing the advisory ICD lead. There were no other major or minor complications. ConclusionTransvenous extractions of advisory ICD leads with relatively long implant duration were performed with a high success rate and low complication and mortality rate in Japanese patients.

Comparison of single-coil lead versus dual-coil lead of implantable cardioverter defibrillator on lead-related venous complications in a canine model.

Dual- coil lead (DCL) of implantable cardioverter defibrillator (ICD) is preferred clinically in patients. However, it is related to higher risk of venous stenosis and thrombosis. The present study was done to compare the fibrosis and extraction of the leads between the single-coil lead (SCL) and DCL in animal models. This was a chronic animal study with a follow-up duration of 6 months. Twenty mongrel dogs were randomly divided into DCL group or SCL group. Venography was performed before the sacrifice to evaluate the venous stenosis in vivo. The maximum pulling-out tension of the ICD lead was measured by a tensometer. Hematoxylin-eosin stain and toluidine blue O stain were applied to show the pathological changes of the superior vena cava (SVC) to evaluate the fibrosis and the thickness of the SVC adjacent to the leads. The DCL group showed higher incidence of venous stenosis (OR = 31.5; 95% CI, 2.35-422.3; p = 0.005). It revealed increased tension to extract the leads in the DCL group (5.96 ± 1.86 vs. 3.68 ± 1.46 N, p = 0.027). The difference of venous wall thickness of SVC was 4.3 ± 0.3 fold-changes between two groups (p = 0.007). Moreover, the degree of venous wall fibrosis in DCL group was more serious than that it in SCL group (3.61 ± 1.26 vs. 1.08 ± 1.35 mm2, p = 0.015). The DCL was proved to increase thrombosis, fibrosis, and stenosis in the SVC. Likewise, the DCL was mechanically harder to be extracted than the SCL. Our study showed that lead-related complications of the DCLs were higher than those of the SCLs regardless of the equal defibrillation thresholds between them. Results of the present study would help to choose the proper lead which could be removed.

545Failure-free survival of the Riata implantable cardioverter-defibrillator lead after a very long-term follow-up

545Failure-free survival of the Riata implantable cardioverter-defibrillator lead after a very long-term follow-up

Magic Angle in Cardiac CT: Eliminating Clinically Relevant Metal Artifacts in Pacemaker Leads with a Lead-Tip/Gantry Angle of ≤70°

To identify the influence of various parameters for reducing artifacts in computed tomography (CT) of commonly used pacemakers or implantable cardioverter-defibrillator (ICD) lead tips. This ex vivo phantom study compared two CT techniques (Dual-Energy CT [DECT] vs. Dual-Source CT [DSCT]), as well as the influence of incremental alterations of current-time product and pacemaker lead-tip angle with respect to the gantry plane. Four pacemaker leads and one ICD lead were evaluated. The images were assessed visually on a five-point Likert scale (1 = artifact free to 5 = massive artifacts). Likert values 1-3 represent clinically relevant, diagnostic image quality. 344 of 400 total images were rated with diagnostic image quality. The DECT and dual-source DSCT technique each scored 86% diagnostic image quality. Statistically, DECT images showed significantly improved image quality (P < .05). Concerning the current-time product, no statistically significant change was found. Regarding lead-tip positioning, an angle of ≤70° yielded 100% diagnostic image quality. Pacemaker and ICD leads were assessed to have statistically significant differences. Surprisingly, the lead-tip angle of 70° has been established as the key angle under which diagnostic image quality is always ensured, regardless of the imaging technique. Thus, we call 70° the "Magic angle" in CT pacemaker imaging.

Transvenous Lead Extraction in Adults With Congenital Heart Disease: Insights From a 20-Year Single-Center Experience.

Safety and feasibility data on transvenous lead extraction (TLE) in the challenging population of adults with congenital heart disease (A-CHD) are limited. Herein, we report the results of TLE in A-CHD during a 20-year period. All consecutive TLE procedures in A-CHD were included in a monocentric prospective registry from 1996. A total of 121 leads were extracted in 49 A-CHD (median age, 38 years; 51% men) during 71 TLE procedures. Twenty-four (49%) patients had transposition of the great arteries. Main indications for extraction were infection in 34 (48%) and lead failure in 22 (31%). A laser sheath was required for 56 (46%) leads and a femoral approach for 10 (8%). Complete TLE was achieved for 111 leads (92%). In multivariable analysis, lead duration (odds ratio, 1.02; 95% confidence interval, 1.00-1.04; P<0.01) and number of previous cardiac surgeries (odds ratio, 2.65; 95% confidence interval, 1.52-4.67; P<0.01) were predictive of TLE failure. No perioperative death or pericardial effusion was observed. Subpulmonary atrioventricular valve regurgitation increased in 8 patients (5 with transposition of the great arteries) and was independently associated with an implantable cardioverter defibrillator lead (odds ratio, 9.69; 95% confidence interval, 1.31-71.64; P=0.03) and valvular vegetation (odds ratio, 7.29; 95% confidence interval, 1.32-40.51; P=0.02). After a median of 54 (19-134) months of follow-up after the first TLE, 3 deaths occurred independently from lead management. Despite complex anatomic issues, TLE can be achieved successfully in most A-CHD using advanced extraction techniques. Subpulmonary atrioventricular valve regurgitation is a prevalent complication, particularly in patients with transposition of the great arteries.

Surgical treatment for late-onset pericardial effusion after implantation of an implantable cardioverter defibrillator lead：a case report

Surgical treatment for late-onset pericardial effusion after implantation of an implantable cardioverter defibrillator lead：a case report

Unrecognized venous injuries after cardiac implantable electronic device transvenous lead extraction

The major complication rate of transvenous lead extraction (TLE) is estimated to be 1%-2%. Laceration of the central veins can be fatal. To define the incidence and extent of venous injuries on a microscopic level after TLE and compare these data with those of clinically documented events of venous laceration. We studied all patients who underwent TLE at our tertiary center within 30 months via a variety of techniques. Extracted leads and tissue around them were fixed in formalin. Pathologic examination was standardized to examine the leads identifying the areas covered by tissue cuffs along the length of the lead. The cuffs were removed and sectioned transversely to their longitudinal axis. Microscopic examination was performed using hematoxylin and eosin stains and Movat stains to identify the presence of vein tissue. In all, 861 leads (585 pacemaker and 272 defibrillator leads) were extracted from 461 patients (median age 63 years, standard deviation 15 years), with an average of 1.9 leads per patient and a median lead age of 2546 days. On microscopic review, 80 leads (9.3%) in 72 of 461 patients (15.6%) showed segments of vein, most of which were transmural (venous tissue including adventitia). Despite this finding, only 5 catastrophic complications (1.1%) occurred that required emergent surgical intervention. Risk factors for venous injury included implantable cardioverter defibrillator lead, age of lead, and the use of laser sheath. Microscopic venous injuries during lead extraction are common but often not recognized clinically.

Retained pacemaker and implantable cardioverter-defibrillator components after heart transplantation are common and may lead to adverse events

Many patients have a cardiac implantable electronic device (CIED) extracted at the time of heart transplantation. CIED components may be retained after heart transplantation, but their frequency, nature, and clinical significance is uncertain. Consecutive patients that underwent heart transplantation over 10 years from 1 January 2007 until 1 January 2017 were identified from the unit database. Pre- and post-operative chest radiographs were reviewed by two independent observers for the presence of CIED components. Adverse events relating to any retained CIED component were recorded. Two hundred and six patients had a CIED removed at the time of transplantation. Retained CIED components were present in 86 (42%) patients. The most common retained CIED components were suture sleeves and superior vena cava (SVC) coils of dual coil implantable cardioverter-defibrillator (ICD) leads. An SVC coil was retained in 25% of patients that had a dual coil ICD lead. Seven adverse events were associated with CIED removal or retained CIED components, including one fatal event. However, retained CIED components were not associated with reduced long-term survival after heart transplantation. Retained CIED components were seen in 42% of patients that had a CIED prior to transplantation, may be associated with serious adverse events but are not associated with reduced long-term survival. Cardiac surgeons should be aware of all CIED system components and be familiar with techniques for their complete removal at the time of transplantation.

Frequency and clinical impact of retained implantable cardioverter defibrillator lead materials in heart transplant recipients.

End-stage heart failure patients with implantable cardioverter-defibrillator (ICD) with/without cardiac resynchronization therapy (CRT-D) often require heart transplantation (HTPL) as a last-resort treatment. We aimed to assess the frequency and clinical impact of retained ICD lead materials in HTPL patients. In this retrospective single center study, we examined the clinical records and chest radiographs of patients with ICD and CRT-D who underwent HTPL between January 1992 and July 2014. Of 40 patients with ICD and CRT-D at HTPL, 19 (47.5%) patients had retained ICD lead materials within the central venous system. Retained ICD lead materials following HTPL were more frequently noted in patients with longer implantation durations until HTPL. None of the patients underwent extraction procedures after HTPL. All patients were asymptomatic and did not exhibit significant complications or death related to the retained ICD lead materials. Seven (7/40, 17.5%) patients without any retained ICD lead materials underwent magnetic resonance imaging (MRI) during the follow-up period (median, 29.5 months); none of the patients with retained lead materials were given MRI. Considering the common use of MRI in HTPL patients, further studies on the prophylactic extraction of retained ICD lead materials and safety of MRI in these patients are needed.

Temporal Trends in and FactorsAssociated With Use of Single-VersusDual-Coil Implantable Cardioverter-Defibrillator Leads: Data From the NCDR ICD Registry.

This analysis evaluated temporal trends and factors associated with the use of dual-coil implantable cardioverter-defibrillator (ICD) leads. Data suggest that dual-coil ICD leads are not associated with lower mortality and can be more difficult to extract than single-coil leads. A total of 435,772 patients at 1,690 hospitals underwent ICD lead insertion in the National Cardiovascular Data Registry's ICD Registry between April 2010 and December 2015. Hospitals were classified into 3 pre-specified groups (low, decreasing, or high use) based on the frequency of dual-coil lead use. Nationally, the use of dual-coil leads has decreased over time, from 87% of ICD leads in early 2010 to 55% at the end of 2015. Hospitals in the low-use (n= 292) or decreasing-use (n= 561) group had more ICDs inserted by electrophysiologists compared to the high-use (n= 837) group (90% or 80% vs 46%; p< 0.001 for both) and more extractions performed (median 7 or 11 vs 2; p< 0.001 for both). Despite statistical differences, there were no clinically significant differences in patient characteristics across all 3 groups. Although the use of dual-coil ICD leads has decreased over time, it continues to represent the majority of insertions in the United States. Hospital-level factors, but not patient factors, were associated with use of dual-coil ICD leads. Whether decreasing dual-coil ICD lead use has improved patient outcomes remains unknown and should be examined in large, multicenter, contemporaneous patient groups.

Cable externalization at the proximal portion of the superior vena cava coil in Riata implantable cardioverter defibrillator leads

Many Riata (St. Jude Medical, St. Paul, MN, USA) implantable cardioverter defibrillator (ICD) leads have reportedly developed cable externalization. The most likely cause of cable externalization is insulation abrasion, which often occurs at the can or between the right ventricular coil and superior vena cava (SVC) coil. We report a rare case of an adult male whose ICD lead cable was externalized at the proximal portion of the SVC coil. This lead became fixed to the wall at the subclavian vein and SVC and became bent between these adhesions. Furthermore, the motion of this lead was affected by pulsation of the aortic arch. The ICD lead might develop inside-out abrasion due to mechanical stress evoked by pulsation of the aortic arch at this site.<Learning objective: Cable externalization of the implantable cardioverter defibrillator lead at the proximal portion of the superior vena cava (SVC) coil has rarely been reported. Externalization might be the result of deformation of the left brachiocephalic vein and the anatomical relationship with the aortic arch. The anatomical pathway of the lead should be carefully considered during the procedure, especially when a dual-coil lead is selected. Moreover, possible cable externalization at both the proximal and distal portions of the SVC coil should be kept in mind during follow-up.>

The Utilization of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Cardiovascular Implantable Electronic Device Infections in Case of a Negative Transesophageal Echocardiogram

Introduction: In the last decade, there has been an accelerated increase in the number of cardiovascular implantable electronic device (CIED) implantations. Similarly, CIED infections have risen significantly with a three-fold augmentation for pacemaker infections and a six-fold augmentation for implantable cardioverter defibrillator (ICD) infections. The complications of CIED infections may be critical, and related infections are associated with heightened risk of mortality. Most patients, who experience symptoms related to CIED infections present either a generator-pocket site inflammation or unspecific symptoms in relation to positive blood cultures or fever of unknown origin. The diagnosis is mainly supported by evidence of cardiac or CIED involvement by transesophageal echocardiography (TEE). Case Presentation: In this report, we describe a case of a CIED infection in a 49-year-old female, admitted in 2013 to a hospital in Copenhagen, Denmark, with persistent Staphylococcus epidermidis bacteremia without any clinical signs of generator-pocket infection and several negative TEE studies. Conclusions: The diagnosis of CIED infection was established with Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) scan revealing clear evidence of infection localized to the vascular ICD lead and generator-pocket.