Octogenarian patients and laser-assisted lead extraction: Should we put a limit?

BACKGROUND: Transvenous laser lead extraction (TLE) for cardiac implantable electric devices (CIED) is a challenging procedure especially if performed in octogenarians. In this study we evaluated the safety and efficacy of transvenous laser lead extraction in elderly patients. METHODS: This is a retrospective study of octogenarian patients who underwent laser-assisted lead extraction (LLE) (GlideLight laser sheath, Philips, San Diego, USA). 270 Consecutive patients were included. Patients were divided into two groups. Octogenarian group and non-octogenarian group. The Data was gathered from patients treated between September 2013 and January 2020 and is retrospectively analyzed. RESULTS: Of 270 consecutive patients, 38 (14.0%) were 80 years old or more. The total number of the extracted leads was 556 among which 84(15.0%) from the Octogenarian group. From these leads were 155 single coil leads, 82 dual coil leads, 129 right ventricular pacing leads, 155 right atrial leads, and 35 left ventricular leads. In the Octogenarian group the number of removed leads was as follows: 13 single coil leads, 10 dual coil leads, 28 right ventricular pacing leads, 28 right atrial leads and 5 left ventricular leads. No mortality was recorded in the Octogenarian group. One patient in the YG suffered from a superior vena cava tear and one patient suffered from pulmonary embolism. CONCLUSION: In octogenarian laser assisted lead extraction patients is a safe and effective procedure. No increase in morbidity, mortality or perioperative complication could be recorded in this group. Age should not be a limiting factor to perform this procedure.

Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery.

Objectives: Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) surgery may develop postcardiotomy cardiogenic shock. In these cases, implantation of an Impella 5.0 or 5.5 microaxial pump offers full hemodynamic support while simultaneously unloading of the left ventricle. Methods: Preoperative, perioperative, and postoperative data of all patients receiving postoperative support with an Impella 5.0 or 5.5 after CABG surgery between September 2017 and October 2022 were retrospectively collected. Cohort built-up was performed according to the timing of Impella implantation, either simultaneous during CABG surgery or delayed. Results: A total of n = 42 patients received postoperative Impella support, of whom 27 patients underwent simultaneous Impella implantation during CABG surgery and 15 patients underwent delayed Impella therapy. Preoperative left ventricular ejection fraction was similarly low in both groups (26.7 ± 0.7% vs 24.8 ± 11.3%; P = .32). In the delayed cohort, Impella implantation was performed after a median of 1 (1; 2) days after CABG surgery. Survival after 30 days (75.6% vs 47.6%, P = .04) and 1 year (69.4% vs 29.8%, P = .03) was better in the cohort receiving simultaneous Impella implantation. Conclusions: The combined advantages of hemodynamic support and LV unloading with microaxial pumps may lead to a favorable survival in patients with left ventricular failure following CABG surgery. Early implantation during the initial surgery shows a trend toward a more favorable survival as compared with patients receiving delayed support.

Symptomatic Upper Extremity Deep Venous Thrombosis After Laser Lead Extraction.

INTRODUCTION: Laser lead extraction is a well-established method for removing unwanted leads with low morbidity and mortality. In this small series of cases, we documented our experience with venous thrombosis after laser lead extraction. METHODS: Retrospective data of patients who underwent laser lead extraction with postoperative axillo-subclavian vein thrombosis between May 2010 and January 2020 were analyzed. Demographic, operative, clinical, and follow-up characteristics of those patients were collected from our medical database. RESULTS: Six patients underwent percutaneous laser lead extraction. Mean age of the patients was 64±7 years. And four of them were male. A total of 11 leads with a mean age of 92±43.8 months were extracted. Patients presented with painful arm swelling postoperatively. CONCLUSION: Laser lead extraction may lead to symptomatic upper extremity deep venous occlusion.

Endocardial versus epicardial pacing in pacemaker-dependent patients after device extraction: a meta-analysis.

INTRODUCTION: Pacemaker-dependent (PM) patients with cardiac implantable electronic device (CIED) infection require implantation of a temporary-pacemaker (TP) and delayed endocardial reimplantation or implantation of an epicardial-pacing-system (EPI) before device extraction. Our aim was to compare the TP and EPI-strategy after CIED extraction through a meta-analysis. METHODS: We searched electronic databases up to 25 March 2022, for observational studies that reported clinical outcomes of PM-dependent patients implanted with TP or EPI-strategy after device extraction. RESULTS: 3 studies were included enrolling 339 patients (TP: 156 patients; EPI: 183 patients). TP compared to EPI showed reduction in the composite outcome of relevant complications (all-cause death, infections, need for revision or upgrading of the reimplanted CIED) (12.1% vs 28.9%; RR: 0.45; 95%CI: 0.25-0.81; p = 0.008) and a trend in reduction of all-cause death (8.9% vs 14.2%; RR: 0.58; 95%CI: 0.33-1.05; p = 0.07). Furthermore, TP-strategy proved to reduce need of upgrading (0% vs 12%; RR: 0.07; 95%CI: 0.01-0.52; p = 0.009), reintervention on reimplanted CIED (1.9% vs 14.7%; RR: 0.15; 95%CI: 0.05-0.48; p = 0.001) and significant increase in pacing threshold (0% vs 5.4%; RR: 0.17; 95%CI: 0.03-0.92; p = 0.04), with a longer discharge time (MD: 9.60 days; 95%CI: 1.98-17.22; p = 0.01). CONCLUSION: TP-strategy led to a reduction of the composite outcome of all-cause death and complications, upgrading, reintervention on reimplanted CIED, and risk of increase in pacing threshold compared to EPI-strategy, with longer discharge time.

Anterior Access to the Cervicothoracic Junction via Partial Sternotomy: A Clinical Series Reporting on Technical Feasibility, Postoperative Morbidity, and Early Surgical Outcome.

Surgical access to the cervicothoracic junction (CTJ) is challenging. The aim of this study was to assess technical feasibility, early morbidity, and outcome in patients undergoing anterior access to the CTJ via partial sternotomy. Consecutive cases with CTJ pathology treated via anterior access and partial sternotomy at a single academic center from 2017 to 2022 were retrospectively reviewed. Clinical data, perioperative imaging, and outcome were assessed with regards to the aims of the study. A total of eight cases were analyzed: four (50%) bone metastases, one (12.5%) traumatic instable fracture (B3-AO-Fracture), one (12.5%) thoracic disc herniation with spinal cord compression, and two (25%) infectious pathologic fractures from tuberculosis and spondylodiscitis. The median age was 49.9 years (range: 22-74 y), with a 75% male preponderance. The median Spinal Instability Neoplastic Score (SINS) was 14.5 (IQR: 5; range: 9-16), indicating a high degree of instability in treated cases. Four cases (50%) underwent additional posterior instrumentation. All surgical procedures were performed uneventfully, with no intraoperative complications. The median length of hospital stay was 11.5 days (IQR: 9; range: 6-20), including a median of 1 day in an intensive care unit (ICU). Two cases developed postoperative dysphagia related to stretching and temporary dysfunction of the recurrent laryngeal nerve. Both cases completely recovered at 3 months follow-up. No in-hospital mortality was observed. The radiological outcome was unremarkable in all cases, with no case of implant failure. One case died due to the underlying disease during follow-up. The median follow-up was 2.6 months (IQR: 23.8; range: 1-45.7 months). Our series indicates that the anterior approach to the cervicothoracic junction and upper thoracic spine via partial sternotomy can be considered an effective option for treatment of anterior spinal pathologies, exhibiting a reasonable safety profile. Careful case selection is essential to adequately balance clinical benefits and surgical invasiveness for these procedures.

Symptomatic Upper Extremity Deep Venous Thrombosis After Laser Lead Extraction

ABSTRACT Introduction: Laser lead extraction is a well-established method for removing unwanted leads with low morbidity and mortality. In this small series of cases, we documented our experience with venous thrombosis after laser lead extraction. Methods: Retrospective data of patients who underwent laser lead extraction with postoperative axillo-subclavian vein thrombosis between May 2010 and January 2020 were analyzed. Demographic, operative, clinical, and follow-up characteristics of those patients were collected from our medical database. Results: Six patients underwent percutaneous laser lead extraction. Mean age of the patients was 64±7 years. And four of them were male. A total of 11 leads with a mean age of 92±43.8 months were extracted. Patients presented with painful arm swelling postoperatively. Conclusion: Laser lead extraction may lead to symptomatic upper extremity deep venous occlusion.

Risk of venous occlusion after lead laser extraction preventing future lead implantation.

BACKGROUND: Lead laser extraction is a well-established method for removing unwanted leads with low morbidity and mortality. OBJECTIVE: In this observational study, we documented our experience with venous occlusion after lead laser extraction. METHODS: Retrospective data of patients who underwent lead laser extraction between May 2010 and August 2018 was analyzed. Two subgroups of patients were identified. First group represented patients after lead laser extraction who suffered postoperative venous occlusion. Second group represents patients after lead laser extraction, who has documented patent venous access after lead laser extraction. RESULTS: 219 patients underwent percutaneous laser lead extraction. The mean age of patients was 65 ± 14 years. Of these patients, 74% were male. The Most common indication for extraction was Nonfunctional lead (45.2%, n = 99) followed by pocket infection with 33.8% and endocarditis (17.3%). A total number of 447 leads underwent laser extraction. In 7.8% of the patients, lead extraction was partially successful and lead extraction was not successful in only 2.3% of the patients. Only 13 patients developed a documented venous occlusion postoperatively and 26 patients has documented absence of venous occlusion, of whom 17 were under oral anticoagulation. CONCLUSION: Lead laser extraction may lead to venous occlusion, which is mostly asymptomatic but it prevents future lead implantation. The use of oral anticoagulant may prevent postoperative venous occlusion.

Are Sutureless and Rapid-Deployment Aortic Valves a Serious Alternative to TA-TAVI? A Matched-Pairs Analysis.

BACKGROUND: Transcatheter aortic valve implantation is a feasible alternative to conventional aortic valve replacement with expanding indication extending to low-risk patients. Sutureless and rapid-deployment aortic valves were developed to decrease procedural risks in conventional treatment. This paired-match analysis aims to compare patients undergoing surgical transcatheter aortic valve implantation to sutureless and rapid-deployment aortic valve implantation. METHODS: Retrospective database analysis between 2010 and 2016 revealed 214 patients undergoing transcatheter aortic valve implantation procedures through surgical access (predominantly transapical) and 62 sutureless and rapid-deployment aortic valve procedures including 26 patients in need of concomitant coronary artery bypass surgery. After matching, 52 pairs of patients were included and analyzed. RESULTS: In-hospital death (5.8% vs. 3.8%; p = 0.308) was comparable between transcatheter aortic valve implantation (mean age 77 ± 4.3 years) and sutureless and rapid-deployment aortic valve implantation groups (mean age 75 ± 4.0 years), including 32 females in each group. The logistic EuroSCORE was similar (19 ± 12 vs. 17 ± 10; p = 0.257). Postoperative renal failure (p = 0.087) and cerebrovascular accidents (p = 0.315) were without significant difference. The incidence of complete heart block requiring permanent pacemaker treatment was relatively low for both groups (1.9% vs. 7.7%; p = 0.169) for TAVI and sutureless and rapid-deployment valves respectively. Intraoperative use of blood transfusion was higher in the sutureless and rapid-deployment aortic valve implantation group (0.72 U vs. 1.46 U, p = 0.014). Estimated survival calculated no significant difference between both groups after 6 months (transcatheter aortic valve implantation: 74 ± 8% vs. sutureless and rapid-deployment aortic valve implantation: 92 ± 5%; log rank p = 0.097). CONCLUSION: Since sutureless and rapid-deployment aortic valve implantation is as safe and effective as transapical transcatheter aortic valve implantation, combining the advantage of standard diseased-valve removal with shorter procedural times, sutureless and rapid-deployment aortic valve replacement may be considered as an alternative for patients with elevated operative risk considered to be in the "gray zone" between transcatheter aortic valve implantation and conventional surgery, especially if concomitant myocardial revascularization is required.

The use of laser lead extraction sheath in the presence of supra-cardiac occlusion of the central veins for cardiac implantable electronic device lead upgrade or revision.

BACKGROUND: The implantation of cardiac implantable electronic devices (CIED) has increased in the last decades with improvement in the quality of life of patients with cardiac rhythm disorders. The presence of bilateral subclavian, innominate or superior vena cava obstruction is a major limitation to device revision and/or upgrade. METHODS AND MATERIAL: This is retrospective study of patients who underwent laser-assisted lead extraction (LLE) (GlideLight laser sheath, Spectranetics Corporation, Colorado Springs, USA) with lead revision or upgrade using the laser sheath as a guide rail. Patients with known occlusion, severe stenosis or functional obstruction of the venous access vessels with indwelling leads were included in this study. RESULTS: 106 patients underwent percutaneous LLE with lead revision and/or upgrade. Preoperative known complete occlusion or severe stenosis of access veins was present in 23 patients (21.5%). More patients with implantable cardioverter-defibrillator (ICD) underwent LLE (64.1%) than patients with CRT-Ds (24.5%) and pacemaker patients (11.3%). In total 172 leads were extracted: 79 (45.9%) single-coil defibrillator leads, 35 (20.3%) dual-coil defibrillator leads, 31 (18.0%) right atrial leads, 24 (13.9%) right ventricular leads and three (1.7%) malfunctional coronary sinus left ventricular pacing leads. The mean age of leads was 99.2±65.6 months. The implantation of new leads after crossing the venous stenosis/obstruction was successful in 98 (92.4%) cases. Postoperative complications were pocket hematoma in two cases and wound infection in one case. No peri-operative and no immediate postoperative death was recorded. One intraoperative superior vena cava tear was treated by immediate thoracotomy and surgical repair. CONCLUSION: In a single-center study on LLE in the presence of supra-cardiac occlusion of the central veins for CIED lead upgrade and revision we could demonstrate a low procedural complication rate with no procedural deaths. Most of the leads could be completely extracted to revise or upgrade the system. Our study showed a low complication rate, with acceptable mortality rates.

A Clean Cut: Minimally Invasive Mitral Valve Replacement after Heart Transplantation.

A 50-year-old female presented with progressive heart failure due to obstruction of the mitral valve after heart transplantation in 2008. Through the occlusion catheter (IntraClude Intra-Aortic Occlusion Device), aortic cross-clamping, antegrade cardioplegia, and aortic root venting were performed. Our case reports the first published study on minimally invasive mitral valve replacement for valve stenosis through intraluminal aortic clamping. The hazard of traumatic injuries can be reduced by avoiding resternotomy and circumventing adhesions between the aorta and the pulmonary artery after heart transplantation. Minimally invasive valve surgery is a safe and effective method with regard to short- and long-term results, especially in redo operations.

Epicardial pacemaker as a bridge for pacemaker-dependent patients undergoing explantation of infected cardiac implantable electronic devices.

BACKGROUND AND AIM OF THE STUDY: Cardiac implantable electronic device (CIED) implantation is associated with an increase in CIED infection. For pacemaker-dependent patients, temporary pacemaker leads are implanted until infection remission, which allows new CIED implantation. We compared the outcome of pacemaker-dependent patients with infected CIED based on whether a combined single procedure of epicardial pacemaker implantation with system extraction or a temporary transjugular pacemaker implantation with interval system implantation was performed. METHODS: This retrospective study included pacemaker-dependent patients with CIED infection who were divided into two groups: the Tempo and Epi groups. The Tempo group received temporary transvenous pacemaker connected to an external pulse generator. After infection remission, a new permanent pacemaker was implanted, and the temporary pacemaker leads were removed. The Epi group received implantable epicardial right-ventricular pacemaker through infrasternal inferior pericardiotomy, and a permanent pulse generator was implanted through the same incision between the subcutaneous tissue and abdominal fascia. RESULTS: Sixty-six patients were included. Forty-two patients with epicardial pacemakers were discharged after 9.5 ± 8.8 days without infection of the newly implanted epicardial pacemaker. Patients with temporary transjugular pacemaker lead were discharged 23 ± 15 days after receiving permanent pacemakers. No serious complications were recorded in the Epi group. CONCLUSIONS: CIED infections in pacemaker-dependent patients can be treated through epicardial pacemaker implantation that allows early patient mobility and reduces hospital stay with no risk of epicardial pacemaker infection. Epicardial pacemakers can be used as a bridge until permanent intravenous CIED is implanted or as a replacement for permeant intravenous CIED.

Computer-based comparison of different methods for selecting mitral annuloplasty ring size.

BACKGROUND: Ring sizing for mitral valve annuloplasty is conventionally done intraoperatively using specific 'sizer' instruments, which are placed onto the valve tissue. This approach is barely reproducible since different sizing strategies have been established among surgeons. The goal of this study is to virtually apply different sizing methods on the basis of pre-repair echocardiography to find out basic differences between sizing strategies. METHODS: In three-dimensional echocardiographs of 43 patients, the mitral annulus and the contour of the anterior mitral leaflet were segmented using MITK Mitralyzer software. Similarly, three-dimensional virtual models of Carpentier-Edwards Physio II annuloplasty rings and their corresponding sizers were interactively generated from computer tomography images. For each patient, the matching annuloplasty ring was selected repeatedly according to popular sizing strategies, such as the height of anterior mitral leaflet, the intercommissural distance and the surface area of anterior mitral leaflet. The areas of the selected rings were considered as the neo-surface area of the mitral annulus after implantation. RESULTS: The sizing of the mitral valve according to the height of anterior mitral leaflet (mean ring size = 29.9 ± 3.90), intercommissural distance (mean ring size = 37.5 ± 1.92) or surface area of anterior mitral leaflet (mean ring size = 32.7 ± 3.3) led to significantly different measurements (p ≤ 0.01). In contrary to intercommissural distance, height and surface area of the anterior mitral leaflet exhibited significant variations between the patients (p ≤ 0.01). The sizing according to the height of anterior mitral leaflet led to the maximal reduction of the mitral annulus surface area followed by the sizing according to the surface area of anterior mitral leaflet and finally by the intercommissural distance. CONCLUSIONS: This novel comprehensive computer-based analysis reveals that the surveyed sizing methods led to the selection of significantly different annuloplasty rings and therefore underscore the ambiguity of routinely applied annuloplasty sizing strategies.

The geometrical effect of different annuloplasty rings on mitral valve annulus.

BACKGROUND: Different types of mitral annuloplasty rings are commercially available. The aim of this study was to investigate the effect of implantation of six types of annuloplasty rings on the geometry and dynamics of the mitral valve. METHODS: Three-dimensional echocardiography images of 42 patients were acquired to visualize the mitral valve annulus. Virtual representations of six commercially available annuloplasty rings were matched to anatomical mitral annuli of each patient according to anterolateral-posteromedial diameter. The virtual displacement of each annuloplasty ring after the implantation was measured and compared with the other rings. RESULTS: Patients with severe mitral regurgitation had significantly dilated annuli according to anterolateral-posteromedial diameter, anterior-posterior diameter and to annulus circumference. Anterior and posterior heights of the mitral annuli and non-planarity angle showed no significant differences among different patients with different degree of mitral regurgitation. The ratio of anterior-posterior to anterolateral-posteromedial diameter was almost identical in all groups with identical annular shapes. The implantation of the Carpentier-Edwards Classic Annuloplasty Ring™ led to maximal displacement of mitral annulus, followed by the IM-Ring™, without a statistical significance. In contrary, the implantation of a MyxoETlogix Ring™ was associated with minimal displacement of mitral annulus throughout the groups, but without statistical significance. CONCLUSIONS: The implantation of different ring types in patients with different annuli shapes and dimensions did not lead to any significant change in the configuration of mitral annuli after the virtual implantation of the tested annuloplasty rings.

Intraoperative Quantitative Mitral Valve Analysis Using Optical Tracking Technology.

PURPOSE: Analysis of mitral valve morphology during reconstruction is routinely based on visual assessment and subjective, poorly reproducible measurements. We prove the feasibility of a new intraoperative system for quantitative mitral valve analysis. DESCRIPTION: The proposed computer-based assistance system enables accurate intraoperative localization of anatomic landmarks on the mitral valve apparatus using optical tracking technology. Measurement and visualization strategies were specifically developed and tailored for mitral valve operations. EVALUATION: The feasibility of intraoperative quantitative measurements was successfully shown for 9 patients. Precise geometric descriptions of the valve were obtained and adequately visualized, providing valuable decision support during the intervention. The mean annular area obtained from the intraoperative measurements was 736 ± 266 mm(2), in good agreement with the mean area of the implanted prosthetic rings of 617 ± 124 mm(2), which are slightly smaller due to annular downsizing. Comparison with preoperative three-dimensional echocardiography revealed differences between the beating heart, with transverse and septolateral annular diameters of 40.6 ± 15.4 mm and 41.2 ± 8.2 mm, and the intraoperative cardioplegic condition, with corresponding diameters of 34.3 ± 6.9 mm and 27.4 ± 5.6 mm. CONCLUSIONS: Mitral valve analysis by optical tracking represents a unique technologic advance in intraoperative assessment, providing the surgeon with an extended quantitative perception of surgical target. This technology promotes a major philosophical change from an empirical procedure toward a quantitatively predictable modern reconstructive operation.

Accuracy evaluation of a mitral valve surgery assistance system based on optical tracking.

PURPOSE: Mitral valve reconstruction is a widespread surgical method to repair incompetent mitral valves, which usually includes implantation of a ring prosthesis. To date, intraoperative analysis of the mitral valve is merely based on visual assessment using simple surgical tools, which might not allow for accurate assessment of the complex anatomy. METHODS: We propose a novel intraoperative computer-based assistance system, which combines passive optical tracking technology with tailored measurement strategies applicable during different phases of the intraoperative workflow. Based on the assessment of the valvular apparatus by customized tracked instruments, the system (1) generates an enhanced three-dimensional visualization, which (2) incorporates accurate quantifications and (3) provides assistance, e.g., in terms of virtual prosthesis selection. RESULTS: Phantom experiments in a realistic environment revealed a high system accuracy (mean precision [Formula: see text] mm and mean trueness [Formula: see text] mm) and a low user error (mean precision [Formula: see text] mm and mean trueness [Formula: see text] mm). The assistance system was successfully applied five times during open and minimally invasive reconstructive surgery in patients having mitral valve insufficiency. The measurement steps integrate well into the traditional workflow, enhancing the surgeon's three-dimensional perception and generating a suggestion for an appropriate prosthesis. CONCLUSION: The proposed assistance system provides a novel, accurate, and reproducible method for assessing the valvular geometry intraoperatively.

The number of wires for sternal closure has a significant influence on sternal complications in high-risk patients.

OBJECTIVES: Sternal dehiscence and mediastinitis are rare but serious complications following cardiac surgery. The aim of this study was to investigate the influence of the number of sternal wires used for chest closure on sternal complications. METHODS: From May 2003 to April 2007, 4714 adult patients received cardiac surgery in our institute. X-ray images of all patients were reviewed and the used wires were counted. Patients who received another material or longitudinal wiring technique according to Robicsek for chest closure were excluded from this analysis; thus 4466 patients were included into the final analysis. Figure-of-eight wiring was counted as two wires. RESULTS: Sternal complications occurred in 2.4%, and hospital mortality with or without sternal complications were 2.8 and 2.7%, respectively (P = 0.60). Mean numbers of sternal wires were 7.8 in both patient groups with or without sternal complications (P = 0.79). Multivariate analysis revealed diabetes mellitus [odds ratio (OR) 1.54, 95% CI 1.01-2.34, P = 0.04], chronic obstructive pulmonary disease (OR 1.85, 95% CI 1.12-2.79, P = 0.01) and renal insufficiency (OR 1.70, 95% CI 1.11-2.59, P = 0.001) as significant risk factors for sternal complications. In high-risk patients, the use of less than eight wires was significantly associated with postoperative sternal complications. CONCLUSIONS: Particularly in high-risk patients, careful haemostasis should be done and eight or more wires should be used to avoid sternal complications.