Large Lead Vegetations Research Articles

PO-02-057 CHARACTERISTICS, INDICATIONS, AND OUTCOMES OF ELECTIVE OPEN CHEST LEAD EXTRACTIONS

While transvenous lead extraction (TLE) has become a pillar of modern lead management, it still carries significant risk of morbidity and mortality – including need for emergent sternotomy for management of complications. There is little data available on patients who undergo elective open-chest lead extraction (OLE) rather than TLE. We describe the characteristics, indications, and outcomes of patients undergoing elective OLE. We collected all data from Jan 2010 to Oct 2022 on patients referred to our center for TLE who subsequently underwent elective OLE. Patient characteristics, procedural outcomes, complications, and survival at follow-up were evaluated. Out of 985 patients referred for TLE, 12 patients (1.2%) underwent elective OLE. Indications for elective OLE included need for valve repair or replacement (5/12, 42%), failed previous TLE with amputated leads (3/12, 25%), RV lead perforation requiring repair (2/12, 17%) and large lead vegetations > 2.5 cm (2/12, 17%). Mean indwelling time for the oldest lead was 17.8 ± 12.6 years. A mean of 3.4 ± 1 leads were removed at time of procedure with 100% success rate. Five patients (42%) had indwelling leads > 20 years and 4 (33%) patients had prior TLE. Six patients (50%) had epicardial pacemakers implanted at time of OLE, two patients (17%) had leadless pacemakers implanted in the post-op period, and two did not require device re-implant. All patients survived at 30-day follow-up and 7/8 (87%) patients survived at 1 year follow-up with 1 patient passing after 30 days due to mediastinitis from an infected epicardial defibrillator patch. In our series, elective OLE has a high success rate and excellent short-term survival. For patients with need for concomitant cardiothoracic surgery, prior failed TLE, or at high risk of complications from TLE, elective OLE should be considered as an alternative.

CLEANING UP THE MESS: ANGIOVAC DEBULKING IN ENDOCARDITIS PATIENT WITH LARGE, DEVICE-RELATED VEGETATIONS

Despite improvements in cardiovascular implantable electronic device (CIED) design and functionality, the risk of device infection is on the rise. Complete removal of the device is recommended following CIED infection. However, the optimal management of large lead vegetations (> 2 cm) remains

Transcatheter aspiration of large pacemaker and implantable cardioverter-defibrillator lead vegetations facilitating safe transvenous lead extraction.

Treatment of patients with systemic cardiac implantable electronic device (CIED) infection with large lead vegetations is challenging and associated with relevant morbidity and mortality. To avoid complications from open surgical extraction, a novel approach with percutaneous aspiration of large vegetations prior to transvenous lead extraction was instituted. The results of this treatment concept were retrospectively analysed in this multicentre study. One hundred and one patients [mean age 68.2 ± 13.1 (30-92) years] were treated in four centres for endovascular CIED infection with large lead vegetations. Mean lead vegetation size was 30.7 ± 13.5 mm. Two hundred and forty-seven leads were targeted for extraction (170 pacemaker leads, 77 implantable cardioverter-defibrillator leads). Mean lead implant duration was 81.7 (1-254) months. The transcatheter aspiration system with a specialized long venous drainage cannula and a funnel-shaped tip was based on a veno-venous extracorporeal circuit with an in-line filter. The aspiration of vegetations showed complete procedural success in 94.0% (n = 95), partial success in 5.0% (n = 5). Three major complications (3.0%) were encountered. Complete procedural success (per lead) of the subsequently performed transvenous lead extraction procedure was 99.2% (n = 245). Thirty-day mortality was 3.0% (n = 3). Five patients (5.0%) died in the further course on Days 51, 54, 68, 134, and 182 post-procedure (septic complications: n = 4; heart failure: n = 1). The percutaneous aspiration procedure is highly effective and is associated with a low complication profile. The aspiration of vegetations immediately prior and during the lead extraction procedure may avoid septic embolization into the pulmonary circulation. This may potentially lead to a long-term survival benefit.

P3136Percutaneous aspiration procedure as an adjunct to transvenous lead extraction procedures in patients with large lead vegetations

Abstract Background Patients with systemic CIED (Cardiac implantable electronic device) infection with large lead vegetations are a clinical challenge and carry a high operative risk. In three lead extraction centers a treatment strategy with minimal-invasive percutaneous aspiration of vegetations and subsequent transvenous lead extraction was established. The results of this concept were evaluated with regard to safety and efficacy in this retrospective multi-center study. Methods Between June 2015 and December 2018 we performed combined percutaneous aspiration procedures and transvenous lead extractions in 107 patients with 262 targeted leads (179 pacemaker leads, 83 ICD leads) for extraction. Mean lead vegetation size in preoperative echocardiography was 30.6±13.3 mm. Mean lead implant duration were 82.8 (1–254) months. The aspiration system is based on a veno-venous extracorporeal circuit with an in-line filter and a specialized venous drainage cannula. Results Complete procedural success of the percutaneous aspiration procedure was 94.4% (n=101), partial success was achieved in 4.7% (n=5). Three complications (2.8%) related to the aspiration procedure were encountered. In the concomitantly performed transvenous lead extraction procedures complete procedural success per targeted lead was 99.2% (n=260). 30 day mortality was 2.8% (n=3). Conclusion The minimal-invasive percutaneous aspiration procedure proved to be safe and effective. It facilitated the subsequent transvenous lead extraction procedure, avoids septic embolization into the pulmonary circulation and abolished the need for open surgical extraction in this high-risk patient group.

Managing large lead vegetations in transvenous lead extractions using a percutaneous aspiration technique

ABSTRACTBackground: Treatment of patients with systemic infections of cardiac implantable electronic devices and large lead vegetations are a clinical challenge. In such situations patients potentially had to undergo open surgical extraction in the past. The objective of this study was to evaluate the results of a concomitant percutaneous, minimal-invasive aspiration procedure with the use of an extracorporeal circulation in transvenous lead extraction procedures in patients with large lead vegetations.Research design and methods: Prior and during transvenous lead extraction procedures lead vegetations were targeted for removal with a percutaneous aspiration technique based on a veno-venous extracorporeal circulation with an in-line filter. Clinical outcomes of the procedures were retrospectively analyzed.Results: This innovative and minimal-invasive treatment concept was used in 35 patients with systemic CIED infections (mean echocardiographic lead vegetation size 22.6 (12–40) mm). Complete procedural success of the aspiration procedure was seen in 88.6% of the patients. No major complication related to the aspiration procedure occurred. Clinical success of the concomitant transvenous lead extraction procedures (35 patients, 83 leads) was 97.1%.Conclusion: The presented data show that the aspiration procedure is safe and efficient as an adjunct in transvenous lead extraction procedures avoiding the need for open surgical extraction in such cases.

64Percutaneous aspiration of large lead vegetations and subsequent transvenous lead extraction in a single step procedure

64Percutaneous aspiration of large lead vegetations and subsequent transvenous lead extraction in a single step procedure

Laser Extraction of Pacemaker and Implantable Cardioverter-Defibrillator Leads in Patients with Large Intracardiac Lead Vegetations ≥ 20 mm

Objectives: In recent years, pacemaker (PM) and implantable cardioverter-defibrillator (ICD) insertion has increased. Lead infection or vegetation formation is one of the major complications of these devices. Complete device and lead removal is recommended for all patients with local or systemic infection (Class I). Management of patients with large lead vegetations ≥ 20 mm is still in debate. Historically, they were treated with open surgical lead removal. We here present our 10-years' experience in laser lead extraction of PM and ICD leads as a routine approach in patients with large intracardiac vegetations.

A Serendipitous Identification of a Lead Extraction Complication

A 57-year-old male with a dual chamber pacemaker and symptomatic, persistent atrial fibrillation (AF) accompanying a febrile illness presented for elective transesophageal echocardiography (TEE)-guided cardioversion. The patient was found to have a large 2.5cm×2.3cm, mobile mass attached to the right atrial lead. Following device and lead extraction, he developed progressive shortness of breath which was attributed to his underlying arrhythmia. One month later, AF ablation was pursued and preablation TEE revealed a dilated main pulmonary artery with a 1.8cm×1.6cm mass in the distal left pulmonary artery, which was corroborated by a 1.4cm×2.5cm filling defect in the descending left pulmonary artery on magnetic resonance angiography (MRA). To our knowledge, this is the first case report to document the distal migration of vegetation material into the pulmonary artery with serial TEE and highlights the risk of pulmonary embolism (PE) in patients with large endocardial lead vegetations undergoing transvenous lead extraction.

Vacuum Assisted Vegetation Extraction for the Management of Large Lead Vegetations

Complete device and lead removal is recommended for management of infected implantable cardiac device. Management of large lead vegetation (2 cm) is still in debate. We report a series of patients involving percutaneous extraction of large vegetations (>2 cm) from ICD/pacing leads using the AngioVac Cannula in patients with infective endocarditis. This approach was used to debulk the ICD/pacing lead vegetations in order to minimize the risk of septic pulmonary embolism during lead explantation. AngioVac Cannula can be used safely and effectively as an adjunctive method for patients with large lead vegetation.

New surgical minimally invasive lead explantation due to infective endocarditis with large lead vegetations is superior to conventional approach via median sternotomy

Objectives: Infective rhythm device-related, and particularly lead endocarditis is becoming a significant source of morbidity and mortality with incidence from 1–7% and mortality approaching 33%. The therapy of choice is transcutaneous removal of infected leads using extraction sheaths or excimer laser. However, in the presence of very large and fragile lead vegetations the potential hazard of pulmonary embolism increases substantially. Moreover, due to concomitant tricuspid valve endocarditis an open-heart surgery is often necessary. Since the complication rates of standard approach via median sternotomy (MS) are relatively high we evaluated the impact of new minimally invasive lead explantation technique (MI) on outcome of these patients.

High-Dose Daptomycin for Cardiac Implantable Electronic Device-Related Infective Endocarditis

Cardiac implantable electronic device (CIED)-related endocarditis is a growing challenge because of increasing incidence and significant mortality. Current treatment is based on complete hardware removal coupled with long-term administration of effective and safe antimicrobials. Daptomycin at the dose of 6 mg/kg/day has been found to be effective in staphylococcal endocarditis, but limited data exist on CIED endocarditis. Moreover, whether higher doses could be more effective but equally safe in this setting is currently unknown. We report here our experience with high-dose daptomycin in the treatment of 25 cases of CIED endocarditis due to staphylococci. Patients were mostly elderly and male, with large lead vegetations and severe comorbidities. Pathogens were Staphylococcus epidermidis (56%), Staphylococcus aureus (28%), and other coagulase-negative staphylococci (16%). Only 4 patients (16%) had a normal pretreatment renal function. The median daptomycin daily dose was 8.3 mg/kg (range, 6.4-10.7). Daptomycin was administered for a median of 20 days (range, 8-52). Percutaneous lead extraction was performed in 88% of patients. Two patients (8%) failed to clear bacteremia. The overall clinical success of treatment was 80%, whereas a complete microbiological success was observed in 92% of patients. Creatine phosphokinase values were monitored and increased above normal in 5 cases (20%). No serious adverse event related to high-dose daptomycin was observed and no patient required discontinuation because of muscle toxicity. Our experience suggests that high-dose daptomycin may be a safe therapeutic option in staphylococcal CIED endocarditis and may be associated with high microbiological responses and clinical success.

Pacemaker endocarditis: approach for lead extraction in endocarditis with large vegetations

The presence of large lead vegetations poses additional difficulties for explantation because many methods cannot be used due to the potential hazard of embolism. We report two patients with large vegetation on the ventricular lead due to endocarditis and one of them with an atrial septal defect associated. It was applied a combined technique of transvenous lead removal and sternotomy with cardiopulmonary bypass for the complete removal of pacemaker wires. This procedure resolved the pacemakers endocarditis safely and subsequently a new transvenous device was placed on the opposite site.