Surgical Management of Cardiac Implantable Electronic Device Complications in Patients Unsuitable for Transvenous Lead Extraction.

BACKGROUND: Although surgical approaches for infected or failing cardiac implantable electronic device (CIED) leads are more invasive than transvenous approaches, they are still required for patients considered unsuitable for transvenous procedures. In this study, surgical management with transvenous equipment for CIED complications was examined in patients unsuitable for transvenous lead extraction.Methods and Results: We retrospectively examined 152 consecutive patients who underwent CIED extraction between April 2009 and December 2021 at the Department of Cardiovascular Surgery, Nippon Medical School. Nine patients (5.9%; mean [±SD] age 61.7±16.7 years) who underwent open heart surgery were identified as unsuitable for the isolated transvenous approach. CIED types included 5 pacemakers and 4 implantable cardioverter-defibrillators; the mean [±SD] lead age was 19.5±7.0 years. Indications for surgical management according to Heart Rhythm Society guidelines included failed prior to transvenous CIED extraction (n=6), intracardiac vegetation (n=2), and severe lead adhesion (n=1). Transvenous CIED extraction tools were used in all patients during or before surgery. Additional surgical procedures with CIED extraction included epicardial lead implantation (n=4) and tricuspid valve repair (n=3). All patients were discharged; during the follow-up period (mean 5.7±3.7 years), only 1 patient died (non-cardiac cause). CONCLUSIONS: Surgical procedures and transvenous extraction tools were combined in the removal strategy for efficacious surgical management of CIED leads. Intensive surgical procedures were safely performed in patients unsuitable for transvenous extraction.

Temporal and Microbiological Analysis of Cardiac Implantable Electrical Device Infections　- A Retrospective Study.

Background: Although the causative pathogens in cardiac implantable electronic device (CIED) infections are well known, the relationship between time after implantation and infection patterns has not been sufficiently investigated. This study investigated the microbiology and onset of CIED infections according to infection patterns. Methods and Results: This retrospective study included 97 patients who underwent CIED removal due to device-related infections between April 2009 and December 2018. After device implantation, infections peaked in the first year and declined gradually over 10 years. Most infections (>60%) occurred within 5 years. Staphylococcal infections, the predominant form of CIED infections, occurred throughout the study period. CIED infections were categorized as systemic (SI; n=26) or local (LI; n=71) infections according to clinical presentation, and as CIED pocket-related (PR; n=85) and non-pocket-related (non-PR; n=12) infections according to the pathogenic pathway. The main causative pathogen in SI was Staphylococcus aureus, whereas coagulase-negative staphylococci were mainly related to LI. Both SI and LI peaked in the first year after implantation and then decreased gradually. There was no significant microbiological difference between PR and non-PR infections. PR infections showed the same temporal distribution as the overall cohort. However, non-PR infections exhibited a uniform temporal distribution after the first year. Conclusions: The severity of CIED infections depends on the causative pathogen, whereas their temporal distribution is affected by the microbiological intrusion pathway.

Histological properties of oscillating intracardiac masses associated with cardiac implantable electric devices.

BACKGROUND: There have been a few cases of echogenic cardiac implantable electric device (CIED) lead-associated oscillating intracardiac masses (ICMs) in leads imaged by echocardiography. The histological properties of ICMs could help clarify the etiological diagnosis. Although there is extensive literature on mass size, the histological properties of such masses have not been characterized. The aim of this research was to clarify the histological features of oscillating ICMs in CIED patients. METHODS: Preoperative echocardiography was performed in all candidates for CIED removal. In the patients with ICMs, specimens were obtained by 3 methods: direct tissue collection during open-heart surgery; tissue collection together with the CIED lead during transvenous extraction; and tissue collection by catheter vacuum during transvenous CIED removal. A standard histopathological examination of ICM tissue was performed. RESULTS: A total of 106 patients underwent lead removal in our institute (April 2009-March 2018); 14 patients had an ICM (13.2%), and 7 specimens were obtained in patients with CIED lead-related ICM. Following histological examination, 2 types of ICM were identified: one mainly composed of thickened endocardium (EN type; 3 patients), and the other mainly an aggregate of inflammatory cells as a neutrophil cell (NC type; 4 patients). CONCLUSIONS: Two histological types of intracardiac masses, including a thickened endocardium type and a neutrophil cell type, were identified. These classifications might help make an accurate histological diagnosis of lead-associated intracardiac masses.