Retained Lead Fragments Research Articles

2401. The Role of Quantitative Microbial Cell-free DNA (mcfDNA) Sequencing (Seq) from Plasma in the Diagnosis (Dx) of Staphylococcal Cardiac Implantable Electronic Device Infective Endocarditis (CIED IE)

Abstract Background Optimal treatment (rx) of staphylococcal CIED IE requires removing the entire CIED. Difficulty of dx plus cost and potential morbidity of rx make treatment challenging. Complicated staphylococcal bacteremia is associated with prolonged detection of plasma mcfDNA during antibiotic rx. To assess for IE, we studied plasma mcfDNA kinetics in CIED patients (pts) with staphylococcal bacteremia undergoing CIED removal. Methods With written consent, CIED pts (no persistent confounding infection) with bacteremia in the prior ≤ 7 days (d) and planned CIED removal had serial plasma specimens collected [Figure]. Quantitative mcfDNA-Seq was done using the Karius Test® at Karius CLIA certified Laboratory (Redwood City,CA) on batched pt specimens. Clinical data were obtained from the electronic medical record. CIEDs were removed through sterile pockets or surgically except in pt 012. Definite CIED IE was defined by multiple d of bacteremia plus a definite lead / tricuspid vegetation per echocardiogram, direct inspection or lead tip culture; multiple d bacteremia or a definite vegetation defined possible CIED IE. Results Nine pts with definite CIED IE had bacteremia 3-13 d (median 6 d) with Staphylococcus aureus (7 pts) or S. epidermidis (2 pts: 012 who due to retained lead fragment relapsed after rx 021) [Table 1]. At consent, after 2-11 d rx (median 6 d) mcfDNA was detected in 8 of 9 pts; in all 9, on CIED extraction mcfDNA increased significantly from consent and pre-extraction levels [Table3]. Five pts with possible S.aureus CIED IE had 1-3 d (median1 d) bacteremia [Table 2]. None had plasma mcfDNA after 5 d rx and 4 of 5 had no mcfDNA detectable on device extraction [Table3]. McfDNA patterns in definite CIED IE (8 of 9 pos on consent / pre-extraction and had an increase on extraction) differed from those in possible CIED IE (4 of 5 neg at 5 d of rx and none detected on extraction) [p=0.023 Fisher Exact]. Conclusion Quantitative mcfDNA patterns can help distinguish definite from possible CIED IE and absence of mcfDNA in plasma of possible CIED IE on device extraction suggests that the CIED may not be infected. After 5 days of rx, plasma mcfDNA-Seq in CIED pts with staphylococcal bacteremia coupled with clinical features may identify patients that can be effectively treated without device removal - a testable hypothesis. Disclosures Adolf W. Karchmer, MD, DeBiopharma: Advisor/Consultant|DeBiopharma: Honoraria|Karius: Grant to Institution for this study Jason D. Matos, MD, Merck: Wife is an employee Nicholas R. Degner, MD, MPH, MS, Karius: Employer

Abstract 14140: Management and Outcomes of Bacteremia After Transvenous Lead Extraction Complicated by Retained Lead Fragments

Introduction: Complete hardware removal is indicated for cardiovascular implanted electronic devices (CIED) infection. While transvenous lead extraction (TLE) is often successful in removing the entire device, some patients are left with residual hardware due to lead breakdown or unsuccessful attempts at removal. We sought to assess the outcomes and management in patients with retained CIED components that can be a nidus for ongoing infection. Methods: Single center retrospective case series among patients with lead extraction between 2010 and 2022. Results: There were 9 of 930 TLE patients (1%) who met study criteria (age 68 ± 23 yrs, 78% men, 67% ICD, 44% CRT, oldest lead 10.1 yrs IQR 6.1-22.2, combined lead age 21.2 yrs IQR 14.7-54.9). Two patients (22%) had epicardial leads as well. The majority of patients (n=8/9, 89%) had systemic infection, including lead vegetations in 22% (n=2). The most common infection organism was Staphylococcus aureus (n=5, 56%). Residual CIED components included lead tips (n=4, 44%), epicardial leads (n=2, 22%), entire intravascular lead portion (n=2, 22%), and a remnant ICD coil remaining in the SVC (n=1, 11%). TLE attempt was halted in 1 patient with a right atrial perforation during extraction (only removed 4/6 leads) and another patient with unsuccessful removal via laser, mechanical, and snaring attempts. Device reimplantation was performed in 4 patients (44%). The patient with the RA perforation underwent reimplantation of an epicardial system at the time of repair. Median follow-up was 0.9 years (IQR 0.4-7.2). Three patients (33%) were managed with indefinite antibiotic suppression, while the median antibiotic duration for the remainder was 35 days (IQR 14-43). Two patients (22%) had recurrent infections, both of which occurred despite the use of indefinite antibiotic suppression. None of the patients with residual lead tip alone had subsequent infections or were managed with suppressive antibiotics. Conclusion: Recurrent infection can be problematic when retained lead components are present after TLE and occurred despite the use of indefinite suppressive antibiotics in some patients. Further investigation is necessary to determine if the risk of recurrent infection varies by the type of residual CIED components.

Succimer chelation does not produce lasting reductions of blood lead levels in a rodent model of retained lead fragments

Retained lead fragments from nonfatal firearm injuries pose a risk of lead poisoning. While chelation is well-established as a lead poisoning treatment, it remains unclear whether chelation mobilizes lead from embedded lead fragments. Here, we tested whether 1) DMSA/succimer or CaNa2EDTA increases mobilization of lead from fragments in vitro, and 2) succimer is efficacious in chelating fragment lead in vivo, using stable lead isotope tracer methods in a rodent model of embedded fragments. DMSA was > 10-times more effective than CaNa2EDTA in mobilizing fragment lead in vitro. In the rodent model, succimer chelation on day 1 produced the greatest blood lead reductions, and fragment lead was not mobilized into blood. However, with continued chelation and over 3-weeks post-chelation, blood lead levels rebounded with mobilization of lead from the fragments. These findings suggest prolonged chelation will increase fragment lead mobilization post-chelation, supporting the need for long-term surveillance in patients with retained fragments.

Incidence of Temporary Peripheral Nerve Stimulator Lead Tip Retention: A Retrospective Review of 80 Lead Placements

ObjectivesThe primary objective of this study was to determine the current rate of lead fracture during temporary percutaneous peripheral nerve stimulator (PNS) lead removal at the Mayo Clinic Rochester Division of Pain Medicine. Materials and MethodsA retrospective review of electronic medical records was performed for patients implanted with a temporary percutaneous PNS device between January 1, 2018, and December 31, 2020. Patients were included if they underwent temporary percutaneous PNS system implant, with planned lead removal at 60 days. Data collection included date of implant, diagnosis, peripheral nerve target(s), number of leads, and lead tip status at the time of removal (intact vs fractured). ResultsFifty patients underwent a total of 80 temporary percutaneous PNS leads placed during the time frame analyzed. Of the 80 temporary percutaneous PNS leads implanted, there were five lead fractures at the time of intentional lead removal. ConclusionsThis retrospective review of 50 patients with 80 temporary percutaneous PNS leads implanted for chronic peripheral neuropathic pain resulted in a 6.25% rate of retained lead fragment at the time of lead removal by the provider at the end of 60-day treatment. This fracture and retention rate is consistent with previous published retrospective data on PNS, which has shown a 3% to 21% lead fracture rate during intentional lead removal.

682. Implantable Cardioverter-Defibrillator Lead Vegetation with Long-Standing Actinomyces neuii Bacteremia

BackgroundEndocarditis caused by Actinomyces species is uncommon with only 30 cases reported in contemporary literature. MethodsWe present a novel case of cardiovascular implantable electronic device (CIED) endocarditis secondary to infection by Actinomyces neuii – a unique non-branching member of the species that grows in both anaerobic and aerobic media.ResultsOur patient, a 51-year-old female, with a history of implantable cardioverter-defibrillator (ICD) placement 17 years prior for heart failure, presented with six weeks of fevers and rigors. She was referred to the infectious disease clinic for evaluation of pyrexia of unknown origin. Her examination was unremarkable, and the ICD pocket was uninflamed. Her initial labs revealed mildly elevated inflammatory markers and renal insufficiency. Blood cultures were positive for slow-growing non-branching gram-positive rods in both aerobic and anaerobic media. These were identified as Actinomyces neuii by mass spectrometry. Review of outside records showed positive blood cultures with Actinomyces neuii at another facility two weeks prior to our evaluation which were not acted upon and thought to be bacterial contamination. The patient was further evaluated with a transesophageal echocardiogram that demonstrated a 3.3 x 2.2cm mobile vegetation attached to the ICD lead. She subsequently underwent removal of her Saint Jude cardiac resynchronization therapy defibrillator and leads using laser and snaring techniques, but the tail end of the ventricular lead fractured and could not be retrieved. The ICD pocket was also found to be infected. A planned 6-week course of IV ampicillin was interrupted by 2 weeks of ceftriaxone for treatment of an intercurrent lower respiratory tract infection. The patient regained her baseline health and was discharged 2 weeks after ICD removal with a LifeVest. She is to complete 12 months of oral amoxicillin therapy after completion of IV antibiotics in view of retained lead fragment, and long standing Actinomyces bacteremia - consistent with published management strategies. Figure 1. Transesophageal echocardiogram demonstrating size of vegetation. Figure 2. Three-dimensional view demonstrating vegetation on the ICD lead.ConclusionHere we describe the first known case of Actinomyces neuii CIED endocarditis with a large lead vegetation and long-standing bacteremia, presenting as pyrexia of unknown origin.Disclosures All Authors: No reported disclosures

The prognostic value of transesophageal echocardiography after transvenous lead extraction: landscape after battle.

In patients undergoing transvenous lead extraction (TLE) transesophageal echocardiography (TEE) provide valuable information after procedure. We analyzed data from 936 TEE performed in patients undergoing TLE between 2015 and 2019 (mean follow-up 566.23±224.47 days) and assessed the role of echocardiographic phenomena after procedure. Increment in tricuspid regurgitation (TR) was observed in 9% of patients after TLE. Factors increasing the risk of TR were: binding sites between lead and right ventricle (RV) (OR: 5.429), tricuspid valve (TV) (OR: 3.42), superior vena cava (SVC) (OR: 3.30) and lead-to-lead adhesions (OR: 2.88). Predisposing factors of residual structures after TLE were: asymptomatic masses on the leads (AMEL) (OR: 1.68), binding sites between SVC and cardiac structures (OR: 1.72), and multiple leads (OR: 1.30). Probability of vegetation remnants increased in the presence of abandoned leads (OR: 7.91). The risk factors of tamponade were: dwell time of the oldest lead (OR: 1.17), lead-to-lead adhesion (OR: 22.47), binding sites between lead and TV (OR: 6.08), RA (OR: 11.50), SVC (OR: 4.47), higher LVEF (OR: 2.35; P=0.006), female gender (OR: 5.43), multiple leads (OR: 2.11), looped leads (OR: 4.90) and AMEL (OR: 6.42). The risk of lead fracture was increased by: lead-to-lead adhesion (OR: 5.69), fibrosis binding the lead to RV (OR: 5.16), RA (OR: 2.39) and dwell time of the oldest lead (OR: 1.068). The mortality rate was 11.97% during follow-up. The risk of death was increased by: severe TR and vegetation remnants. The most important phenomena evaluated after TLE are: tricuspid valve function, residual fibrosis and vegetation remnants, progression of pericardial effusion and retained lead fragments. Postoperative TEE provides information about the results of TLE and helps establish further management.

17-Year Single Center Retrospective Review of Rate, Risk Factors and Outcomes of Lead Breakage during Sacral Neuromodulation Lead Removal

One risk of removal of a tined sacral neuromodulation lead is breakage, resulting in a retained lead fragment. We report lead breakage rates, risk factors and outcomes of retained fragments. We report on 464 tined lead removals from 2002 to 2018. Clinical and surgical factors were reviewed and appropriate statistical analysis performed. Retained fragments were reviewed for fragment description and long-term complications. A total of 464 tined lead removals were included, with 35 lead breaks identified, for a rate of 7.5% (35). Factors associated with breakage included male gender (OR 6.58, 95% CI 2.54-17.01, p=0.001) and diabetes (OR 2.42, 95% CI 1.05-5.58, p=0.019). A shorter time since implantation was protective (OR 0.86, 95% CI 0.76-0.98, p=0.002). There was no difference in breakage rate based on age, weight, history of prior revision, bilateral leads, reason for lead removal, surgical technique or surgeon. Of the 35 breaks 27 had imaging available. Of these 66% (18) broke in the tined region and 81% (22) were ghost leads. Most patients (80%, 28 of 35) with retained lead fragments received another implant. Only 1 patient had a related complication of additional surgery for pain related to the fragment. There is a low rate of tined lead breakage during lead removal. However, it is higher than the manufacturer estimate. Protective factors include a shorter time between implant and lead revision. The most common location for lead breakage is in the region of the tines, most are ghost fragments and long-term complications are uncommon.

P3140Burden and the clinical significance of the retained cardiac implantable electronic device components after heart transplantation

Abstract Background Cardiovascular implantable electronic devices (CIEDs) are common in patients undergoing heart transplantation (HT), and complete removal is not always possible at the time of transplantation. Frequency and clinical significance of retained CIED components after HT is not well studied. Methods Adult heart failure patients whom had heart transplantation in our institution from date June 2000 to December 2018 were retrospectively evaluated. Pre-post operative chest x-rays and recorded fluoroscopy images of the previous coronary angiograms or endomyocardial biopsies were reviewed by a single observer for retained CIED components. All patients clinical records were also reviewed for adverse outcomes of retained components such as deep venous thrombosis of upper extremity, infection and mortality. Results A total of 226 patients had bicaval orthotopic heart transplantation during study time. 73 (32%) of the patients had CIED before transplantation and 24 (32.8%) of the patients had retained lead components after HT. (Table 1) All of the components were part of a superior vena cava coil of the right ventricular ICD lead. Mean follow up time was 46.6±49.8 months and only 1 (1.3%) adverse event (right subclavian DVT) occurred in a patient with retained lead. There were not any statistical significance for mortality and infection between patients with and without lead fragments. Patients were also compared for history of any cardiac surgery before HT, especially ventricular assist device procedures and no differences were observed between groups. For history of any cardiac surgery p=0.748, for assist device surgery, p=0.269). Patient's medical records reviewed for a history of magnetic resonance imaging (MRI). Two patients with retained lead fragments had non-thorocic (abdominal and cranial) MRI and any clinical pathology did not observed after MRI. Table 1 All Patients With Retained CIED comp. Without Retained CIED comp. p (n=226) (n=24) (n=49) Age ± sd 42.91±12.2 44.88±12.6 41.59±13 0.290 Ischemic etiology 65 (28.8%) 8 (33.3%) 13 (26.5%) 0.546 CIED type CRT-D 5 (20.8%) 5 (%10.2) 0.215 DR-ICD 5 (20.8%) 8 (16.3%) 0.636 VR-ICD 14 (58.3%) 35 (71.4%) 0.263 Dual coil ICD lead 24 (100%) 48 (97%) 1 Mortality (%) 96 (42.5) 7 (37%) 20 (40.8%) 0.463 Conclusion Retained CIED components were seen 32.8% of the HT patients with CIED prior to transplantation. According to our data retained leads are not associated with severe adverse clinical outcomes. Also non cardiac MRI could be safe in patients with retained lead fragments.

Femoral extraction of transvenous leads and leadless pacemakers-A review of the data, tools, and procedural steps.

Extraction of transvenous leads via the femoral route might be needed when extraction via the implant vein fails or when retained lead fragments exist. The skill set required for this procedure is unique as it relies on the ability to snare and the use of a variety of shelf tools. In this era of leadless pacing, this skill set might be called upon more frequently. In this article, we review the data, tools, and procedural steps of femoral lead extraction and retrieval/extraction of leadless pacemakers.

Minimally Invasive Techniques to Avoid Sternotomy in Complex Lead Extraction Cases.

Cardiac device lead extractions have increased in frequency over the past several years. Although most of these procedures are successfully performed through a percutaneous approach, certain cases may be unmanageable using conventional methods. The traditional approach for such complex cases has been median sternotomy. However, four surgical techniques offer a less-invasive alternative. These include the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy. In the present study, we reviewed data from patients who underwent minimally invasive, surgical lead extraction at our institution from January 2003 to October 2017 using an ongoing, prospective registry. Summary statistics were generated for age, sex, device extracted, lead dwell time (years), procedure indication, major/minor complications and procedural success as defined by the 2017 Heart Rhythm Society consensus statement, and survival at discharge. Between January 2003 and October 2017, 14 cases at our center were managed via a transatrial approach, whereas 11 involved the subxiphoid approach, 19 involved a left minithoracotomy or thoracoscopy, and one involved a ministernotomy. For the transatrial approach, all cases were classified as procedural successes and all patients were discharged alive. Additionally, for the subxiphoid approach, all cases were deemed procedural successes, whereas survival at discharge was 90.9%. For the left minithoracotomy/thoracoscopy, all cases were procedural successes and survival at discharge was 94.7%. Lastly, the ministernotomy was successfully used to remove an infected, retained lead fragment from the innominate vein. In conclusion, at our institution, the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy were used as minimally invasive, surgical approaches that represent fairly safe and effective alternatives to median sternotomy in complex cases unamenable to management via conventional, percutaneous approaches to lead extraction.

Novel extraction technique of retained pacemaker and defibrillator lead during heart transplantation

BackgroundRemoval of cardiac implantable electronic devices (CIEDs) by manual traction during orthotopic heart transplantation (OHT) sometimes results in retained lead fragments. Moreover, abandoned leads and retained lead fragments are a contraindication for magnetic resonance imaging (MRI) and may be a cause of CIED infection.ObjectiveTo eliminate complications of retained lead fragments, we completely removed residual leads using an excimer laser sheath technique during OHT. We report our clinical experience and high success rate of lead extraction using the excimer laser sheath compared with manual traction during OHT.Methods and resultsWe obtained data on 84 consecutive patients receiving OHT between August 2007 and August 2017. Thirty-nine of 84 patients had undergone CIED implantation before OHT and removal of all their leads was attempted during OHT. From 2007 to 2014, defibrillator and pacemaker leads were extracted by manual traction in all patients (N = 22). After 2015, all leads were extracted with the excimer laser sheath, and surgical assistance was prepared for the procedure (N = 17). Complete procedural success was achieved in 100% of patients in the excimer laser group and 77% of patients in the manual traction group.ConclusionExtraction of abandoned leads using the excimer laser sheath system during OHT is novel and safe technique, and has a higher success rate than extraction using manual traction during OHT.

Extra-Articular Retained Missiles; Is Surveillance of Lead Levels Needed?

Although gunshot wounds are relatively common, lead toxicity associated with extra-articular retained missiles (EARMs) is an uncommon, yet potentially devastating, complication. Although the risk of lead toxicity with intra-articular retained missiles is well known, EARMs are routinely left in situ or only removed in selected circumstances secondary to the relatively rare occurrence of complications. We first describe a patient with systemic lead poisoning associated with retained lead fragments after a gunshot-induced left femoral shaft fracture. We then performed a systematic review of the literature to answer the following questions: (1) In the setting of retained extra-articular bullets and/or bullet fragments, is regular monitoring and/or surveillance of lead levels in the blood routinely indicated? and, if so, (2) what are the selected factors that portend an increased risk for elevations in blood lead levels in the setting of retained extra-articular bullets and/or bullet fragments? The systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines, of the English language literature utilizing Medline (PubMed), EMBASE, Cochrane, and CINAHL on the topic of lead poisoning, retained bullet, and gunshot wound, and then searched for additional references by manually searching of bibliographies of the included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the accepted levels of evidence. Routine monitoring or surveillance of lead levels in blood is recommended in all cases of EARM at the time of hospital admission and again at discharge, followed by monthly intervals until 3 mo post-injury and then again at 1 yr post-injury. The studies identified demonstrated significant risk factors for elevated blood lead levels in the setting of EARM, which included the number of retained missiles and concomitant fracture. Recommendations for routine monitoring and surveillance of blood lead levels in all cases of EARM are conflicting, but such monitoring appears to be warranted given that the potential risks and morbidity associated with systemic lead poisoning are outweighed by any potential harm of short-term, blood lead level monitoring. Outside of concomitant fracture, the evidence for making further clinical recommendations regarding selected risk factors that portend an increased risk for elevated blood lead levels after gunshot injury is weak. Larger level II and III studies are needed to determine the indications for and frequency of lead toxicity screening after retained EARM.

Consequences of Retained Defibrillator and Pacemaker Leads After Heart Transplantation—An Underrecognized Problem

BackgroundCardiovascular implantable electronic devices (CIEDs) are common in patients undergoing heart transplantation (HT), and complete removal is not always possible at the time of transplantation. MethodsWe retrospectively assessed the frequency of retained CIED leads and clinical consequences in consecutive HT patients from 2013 to 2016. Clinical outcomes included bacteremia, upper-extremity deep venous thrombosis (UEDVT), lead migration, and inability to perform magnetic resonance imaging (MRI). ResultsA total of 138 patients (55 ± 11 years of age, 76% male) were identified; 37 (27%) had retained lead fragments (RLFs) at discharge. Patients with RLFs were older, had longer lead implantation time before HT, and a higher prevalence of dual-coil CIED leads compared with those without RLFs (P < .05 for all). Lead implantation time was identified as an independent predictor for RLFs (P < .05). Patients with RLFs had a higher frequency of DVT compared with the non-RLF group during the 1-year study period (42% vs 21%; P < .04). There was no difference in bacteremia. Fourteen patients (38%) could not undergo clinically indicated MRI. ConclusionRLFs after HT occur commonly and are associated with a higher rate of UEDVT and limit the use of MRI. Although no significant difference was found in the rates of bacteremia between the groups, this finding might be explained by the overall low incidence. Patients with risk factors for RLFs should be identified before transplantation, and complete lead removal should be considered with a multidisciplinary approach.

Lead Extraction for Treatment of Cardiac Device Infection: A 20-Year Single Centre Experience.

Infection is one of the most feared complications of cardiac implantable electronic devices. We report microbiology, antimicrobial therapy and infection recurrence in patients with cardiac device infection (CDI) treated with transvenous lead extraction (TLE) at a single centre over a 20-year period. We identified a cohort of consecutive patients undergoing TLE for CDI by a single operator at a single high volume centre. Retrospective analysis of patient characteristics, microbiology, outcomes and infection recurrence was performed. Between May 1992 to March 2012, 348 patients underwent extraction due to localised or systemic infection. Seven hundred and twenty leads were extracted from these patients. The mean follow-up was 5.5+/-4.9 years. Staphylococcal species accounted for 81% of CDI. A difference is seen in infection onset for device revision compared with initial implants [median 10 months vs 24 months, P=0.0001]. Duration of antibiotics therapy depended on the nature of the CDI (21 days post TLE for systemic vs. 10 days for localised infection, P < 0.0001). There was comparable mortality in the 37 (11.2%) patients who did not have a replacement device compared with a replacement (30% vs 29%, P=0.9). Retained lead fragments are a risk factor for CDI recurrence (20.8% recurrence in retained fragments vs 4.3% in complete removal, P=0.006). Cardiac device infection can be successfully treated with a combination of TLE and antibiotic therapy. Device therapy can be safely withdrawn in some patients. Retained lead fragments are a risk factor for recurrent CDI following extraction.

Long-Term Outcomes Following Transvenous Lead Extraction.

Complications related to a cardiac implantable electronic device sometimes require transvenous lead extraction (TLE). We report long-term follow-up of patients undergoing TLE, particularly mortality, recurrent device infection, and need for repeat procedures. Consecutive patients undergoing TLE at a high-volume center were assessed for characteristics, indications, and outcomes. One thousand and six leads were extracted from 510 patients. Clinical success rate was 98.2% and complete procedural success was 92.2%, with one intraprocedural death. The mean follow-up was 5.5 +/- 4.9 years (range 0.2-18 years). Cumulative mortality was 3.3% at 30 days, 7.7% at 6 months, 10.0% at 1 year, and 33.0% at 10 years. Factors associated with increased long-term mortality included cardiac device infection (CDI; 33% vs 17% for non-CDI; χ² 13.8, P = 0.0003), procedural complications (43% vs 27% for no complications; χ² 4.2, P = 0.04), age (75.0 +/- 10.9 years in patients who died vs 62.7 +/- 17.2 years; P < 0.0001), and impaired renal function (creatinine 142.5 +/- 106.4 μmol/L in patients who died vs 106.3 +/- 90.7 μmol/L; P = 0.001). The rate of CDI after TLE was 3.9% (mean 11.6 months post extraction, range 0.3-84 months) and is higher in patients with retained lead fragments (13.5% vs 3.0% with complete removal; χ² 10.7, P = 0.001). Long-term mortality following TLE is high, particularly in those with systemic infection, procedural complications, advanced age, and renal impairment. Retained fragments are a risk factor for CDI post extraction.

Transvenous retained lead fragment removal after incomplete extraction assisted by three-dimensional transoesophageal echocardiography

Transvenous retained lead fragment removal after incomplete extraction assisted by three-dimensional transoesophageal echocardiography

Frequency and Sequelae of Retained Implanted Cardiac Device Material Post Heart Transplantation

Cardiac implantable electronic devices (CIEDs) have now become common therapeutic adjuncts for patients prior to orthotopic heart transplantation (OHT). Removal of the generator and the intracardiac components occurs at time of transplantation but removal of the intravascular portion of leads may be unsuccessful without specialized extraction equipment. We performed a retrospective audit of chest radiographs and clinical records of patients undergoing OHT at Green Lane and Auckland City Hospitals between 2002 and 2012. At the time of transplant surgery, 56 of 100 patients had a CIED in situ. Hardware was retained postoperatively in 22 (39%), and the CIED had been in situ for 47 (interquartile range [IQR] 16-68) months for these cases, compared to 14 (IQR 3-24) months in those without. In two (9%) patients, the device generator was electively explanted during the week following OHT. There were no subsequent procedures undertaken to remove retained lead fragments. One (4%) had lead fragment embolization, one (4%) had endoluminal fragment migration, and one (4%) had lead fragment erosion into the mediastinum; all were asymptomatic and without adverse clinical sequelae. There was no infection associated with this hardware. The presence of retained lead fragments was not associated with additional mortality. Retained lead fragments following OHT occur commonly, without adverse clinical events for this cohort; however, the long-term clinical implications remain uncertain. Complete removal of all CIED hardware should be attempted at the time of OHT, and when this is not possible leads should be left in a state that facilitates their removal at a later date if required.

Pacemaker implantation through pericardial reflections under fluoroscopic guidance: a novel approach for patients with limited venous access

Methods Between June 2006 and November 2011, 15 adult patients underwent epimyocardial atrioventricular pacemaker implantation through a minimally invasive subxiphoid approach and pericardial window. Mean age was 46.4 ± 15.3 years and 9 (60.0%) patients were male. Patients selected for this new surgical approach were not amenable to transvenous lead placement due to: multiple abandoned leads (5), venous occlusion (3), presence of retained lead fragment in the intravascular after previous device extraction (3), tricuspid valve vegetation under treatment (2) and uncorrected intracardiac defects (2).

Transvenous extraction of pacing and defi brillator leads - a single-centre experience

Purpose Worldwide, the number of transvenous extractions of chronically implanted endocardial leads rapidly increases. Despite great technical progress, lead extraction remains a challenging procedure with possible life-threatening complications. We present the success and complication rate of lead extractions in the University Hospitals Leuven, and investigated a possible relationship between the use of powered sheaths and lead type, fi xation, location and implantation time.Methods We present an observational retrospective cohort study of 157 patients admitted to the University Hospitals Leuven between January 2005 and December 2010, for the transvenous removal of a total of 259 endocardial leads.Results Complete procedural success was achieved in 92% of patients (n = 144). Of all leads, 94% (n = 243) were completely extracted. Only in 5 patients (3%), lead extraction failed. Leads that could not be removed were signifi cantly older (134.1 ± 90.7 months vs. 73.1 ± 61.9 months; P= 0.02). In the other 8 patients the leads were partially removed with a remaining major retained lead fragment in 2 and a minor fragment in 6 patients. Major procedural complication rate was 2.5% (n = 4). There were no procedure-related deaths. Powered sheaths were used signifi cantly more for the extraction of defi brillator leads (51%) (vs. pacing leads (33%; P= 0.015)) and right ventricular located leads (43%) (vs. other location (28%; P= 0.011)). However, when comparing the need of powered sheaths for the extraction of right ventricular defi brillator leads vs. right ventricular pacing leads, only a trend to higher use was noticed (51 vs. 39%; P= 0.146). Powered sheath use was not related to fi xation type. Leads that required the use of a powered sheath were implanted signifi cantly longer (112 ± 69.5 months vs. 41.7 ± 33.7 months; P= 0.001).Conclusions Chronically implanted endocardial leads can be transvenously extracted in a high number of cases and with a low risk of procedural complications. Powered sheaths proved to be a helpful tool to extract leads that could not be removed by manual traction. Powered sheaths are necessary for leads with longer implantation duration and are more often used for the extraction of defi brillator leads.