Mechanical extraction of implantable cardioverter-defibrillator leads with a dwell time of more than 10 years: insights from a single high-volume centre.

AIMS: To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) of implantable cardioverter-defibrillator (ICD) leads with a dwell time of >10 years (Group A) vs. younger leads (Group B) using mechanical extraction systems. METHODS AND RESULTS: Between October 2011 and July 2022, we performed TLE in 318 patients. Forty-six (14.4%) extracted ICD leads in 46 (14.5%) patients that had been implanted for >10 years. The median dwell time of all extracted ICD leads was 5.9 years. Cardiovascular implantable electronic device-related infection was an indication for TLE in 31.8% of patients. Complete ICD leads removal and complete procedural success in both groups were similar (95.7% in Group A vs. 99.6% in Group B, P = 0.056% and 95.6% in Group A vs. 99.6% in Group B, P = 0.056, respectively). We did not find a significant difference between major and minor complication rates in both groups (6.5% in Group A vs. 1.5% in Group B and 2.2% in Group A vs. 1.8% in Group B, P = 0.082, respectively). One death associated with the TLE procedure was recorded in Group B. CONCLUSION: The TLE procedures involving the extraction of old ICD leads were effective and safe. The outcomes of ICD lead removal with a dwell time of >10 years did not differ significantly compared with younger ICD leads. However, extraction of older ICD leads required more frequent necessity for utilizing multiple extraction tools, more experience and versatility of the operator, and increased surgery costs.

Indications for transvenous lead extraction and its procedural and early outcomes in elderly patients: a single-center experience.

INTRODUCTION: Due to the prolonged survival of patients with cardiovascular implantable electronic devices, leads often need to be removed in elderly individuals. OBJECTIVES: We aimed to analyze indications for transvenous lead extraction (TLE), procedure effectiveness and safety, as well as 30­day follow­up in younger patients (≤80 years) and octogenarians (>80 years). PATIENTS AND METHODS: This prospective study included 667 patients who underwent TLE: 90 octogenarians (13.5%) at a mean age of 83.8 (range, 80.4-93) years and 577 younger patients (86.5%) at a mean age of 64.2 (range, 18.9-79.9) years. RESULTS: Octogenarians had a greater number of comorbidities, fewer implantable cardioverter­defibrillators implanted, and more frequently had infection as an indication for TLE, as compared with younger patients (33.3% vs 17.1%; P <0.001). In octogenarians, 138 leads were extracted, as compared with 894 leads in younger patients. Octogenarians and younger patients had similar rates of complete lead removal (98.6% and 97.1%, respectively; P = 0.48), total procedural success (97.8% and 96%, respectively; P = 0.7), major complications (0% and 1.6%, respectively; P = 0.45), and minor complications (2.2% and 1.6%, respectively; P = 0.45). There was 1 death associated with TLE in younger patients. Non-procedure­related deaths within 30 days after TLE were more frequent in octogenarians than in younger patients (5.6% vs 1.9%; P = 0.04). CONCLUSION: We showed that TLE in patients older than 80 years seems to be as effective as in younger patients; however, it is associated with significantly higher non-procedure­related 30­day mortality.

Effectiveness and safety of transvenous extraction of single- versus dual-coil implantable cardioverter-defibrillator leads at single-center experience.

The available literature lacks data concerning direct comparison of the effectiveness and safety of single- versus dual-coil implantable cardioverter-defibrillator (ICD) leads transvenous extraction. Certainly, additional shocking coil in superior vena cava adds to the amount of metal in the vascular system. Adhesions developing around the superior vena cava coil add to the difficulty of extraction of ICD lead if lead removal is required. The aim of the study was to assess the effectiveness and safety of single- and dual-coil ICD leads transvenous extraction using mechanical systems. We performed transvenous lead extraction (TLE) of 197 ICD leads in 196 patients. There were 46 (23.3%) dual-coil leads removed from 46 (23.5%) patients. Cardiovascular implantable electronic device-related infection was an indication for TLE in 25.0% of patients. The following extracting techniques were used: manual direct traction, mechanical telescopic sheaths, controlled-rotation mechanical sheaths, and femoral approach. Complete ICD lead removal and complete procedural success in both groups were similar (99.3% in single-coil vs 97.8% in dual-coil, P = .41 and 99.3% in single-coil vs 97.8% in dual-coil, P = 0.41, respectively). We did not find significant difference between major and minor complication rates in both groups (2.0% in single-coil vs 4.3% in dual-coil, and 0.7% in single-coil vs 0.0% in dual-coil, P = .58, respectively). There was 1 death associated with the TLE procedure of single-coil lead.This study shows that extraction of dual-coil leads seems to be comparably safe and effective to extraction of single-coil leads. On the other hand, it requires longer fluoroscopy time and frequent utilization of advanced tools.

Transvenous extraction of very old (over 20-year-old) pacemaker leads using mechanical systems: Effectiveness and safety.

OBJECTIVE: To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) with mechanical systems of pacing leads older than 20 years (group A) versus younger leads (group B). METHODS: We performed TLE of 591 pacing leads in 377 patients. Fifty (8.5%) leads in 43 (11.4%) patients were implanted for equal to or more than 20 years. The mean dwell time of all extracted leads was 8.9 years (range, 0.1-36.0). Infection related to cardiovascular implantable electronic device was an indication for TLE in 18.3% of patients. RESULTS: Complete lead removal and complete procedural success rates were similar between both groups (94.7% in group A vs 97.1% in group B, P = 0.445, and 90.7% in group A vs 95.8% in group B, P = 0.329, respectively). Incomplete lead removal in group A was observed only in leads older than 20 years. Removal of leads in group A was associated with significantly longer fluoroscopy time compared with group B (4.6 vs 1.9 minutes, P < 0.001). We did not find a significant difference in major and minor complication rates between groups (2.3% in group A vs 0.9% in group B and 2.3% in group A vs 2.2% in group B, P = 0.687, respectively). There were no deaths associated with the TLE procedure within 30 days after the procedure in either group. CONCLUSION: This study shows that TLE of leads older than 20 years conducted at an experienced center seems to be comparably safe and effective as extraction of younger leads but requires longer fluoroscopy time.

The analysis of indications and early results of transvenous lead extraction in patients with a pacemaker, ICD and CRT - single-center experience.

INTRODUCTION: Transvenous lead extraction (TLE) is a recognized method of treatment in the case of permanent stimulation complication. OBJECTIVES: The objective of this study was to analyse the indications and presentation of the early experience of TLE procedures in a group of patients with old pacing systems. PATIENTS AND METHODS: Patients with a relevant history of stimulation (at least 12 months in case of a pacemaker) qualified for the research. Indications, effectiveness and complications of TLE procedures were analysed. RESULTS: Two hundred patients at the age of 66.4 (19.1-86.2 years) were enrolled and 278 leads with dwell time 76.2 months (2.1-327.4) were removed. The indications for TLE were: lead-dependent infective endocarditis in 13 cases (6.5%), pocket infection in 29 cases (14.5%), lead damage in 120 cases (60.0%), and upgrade of device system in 38 cases (19.0%). Manual traction was used to remove 66 active fixation leads (23.7%). A femoral approach was required to extract 4 leads (1.4%). Two hundred and eight leads (74.8%) were extracted using the mechanical (Cook) system and subclavian approach. Laser technique, and an electrosurgical sheath were not used. Complete procedural success was achieved in 96% of cases and overall clinical success was 98.5%. Complication rate was 5.5% (11 patients): minor and major complication rate was 3.0% (6 patients) and 2.5% (5 cases), respectively. Low body mass index (BMI) was associated with a higher rate of complications. CONCLUSIONS: The dominant indication to TLE procedures was lead dysfunction. Transvenous lead extraction has a high success rate and a low complication rate. Low BMI increased the complication rate.

Clinical outcomes in patients after surgical and transcatheter aortic valve replacement.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (minithoracotomy and ministernotomy) have become a valuable alternative to conventional surgical treatment of severe aortic stenosis (AS) in high-risk patients. OBJECTIVES: The aim of the study was to evaluate long-term results and complications in patients with symptomatic AS treated with TAVI, surgical aortic valve replacement (SAVR), minithoracotomy, or ministernotomy. PATIENTS AND METHODS: A total of 173 patients with symptomatic AS were enrolled to the study between the years 2011 and 2013. Propensity scores were calculated for TAVI and each surgical method separately. Differences in clinical outcomes between patients treated with TAVI and those treated with surgical methods were adjusted for propensity scores using a logistic regression analysis and presented as adjusted odds ratios with 95% confidence intrervals. RESULTS: A median follow-up was 583.5 days (interquartile range, 298-736 days). Before aortic valve replacement (AVR), no significant differences in ejection fraction (EF) were observed between the groups. At 1 week after AVR, mean EF values were significantly higher in patients after TAVI in comparison with the other groups (TAVI, 50.2% ±13.1%; minithoracotomy, 44.1% ±13.4%; ministernotomy, 37.8% ±12.8%; SAVR, 40.3% ±12.5%; P = 0.001). There were no differences in the longest available follow-up mortality between the analyzed groups (P = 0.8). To our best knowledge, this is the first study comparing minithoracotomy, ministernotomy, and SAVR with TAVI in terms of long-term outcomes such as the longest available follow-up mortality, left ventricular (LV) function, complications after the procedure, and conduction disturbances and arrhythmias after the procedure. CONCULSIONS: Patients undergoing TAVI show more beneficial long-term outcomes in comparison with patients undergoing minithoracotomy, ministernotomy, and SAVR and do not differ in terms of the longest available follow-up mortality. TAVI seems to have a more favorable effect on LV function and an increase in EF in comparison with the surgical methods.

Atrial septal defect surgery in adults--populational and epidemiological analysis.

UNLABELLED: Atrial septal defect (ASD) is one of the most common congenital heart diseases found in adolescents and adults. Shunt may lead to serious further complications, such as pulmonary hypertension and right heart chambers overload. The aim of this study was the analysis of the population of adult patients with ASD together with the frequency of the annuloplasty tricuspid ring implantation in ASD II and the necessity of anterior mitral valve cusp suturing due to the cleft accompanying ASD I. MATERIALS AND METHODS: The study group consisted of 58 males and 122 females aged 17 to 77. Individuals were divided into three age brackets: 17-30 years old--22%; 31-50--38,5% and 51-77--39,5%. RESULTS: In 92,8% of cases median sternotomy was performed. Other approaches were: right mini- thoracotomy 5%, 2,2% underwent lower hemisternotomy. There were 16 annuloplasties accompanying ASD closure: 13 in ASD II patients, 1 in PFO patient, 2 in ASD I patients. Average size of the pericardiac patch used to ASD type II correction was bigger in patients, who also underwent annuloplasty tricuspid ring implantation (Mann- Whitney U test: -2,25, p=0,024). CONCLUSION: Repair of ostium secundum and sinus venosus ASD can be performed safely via minithoracotomy endoscopic approach with similar outcomes as sternotomy. Beside the mitral cleft suturing in ASD I patients, annuloplasty tricuspid ring implantation is the most common additional procedure. ASD II patients, who had undergone such annuloplasties needed the bigger pericardial patches.

The risk of cholelithiasis in patients after heart transplantation.

INTRODUCTION: Extended immunosuppressive treatment in patients after heart transplantation modifies etiopathogenesis and occurrence of many diseases in this population. The aim of the present study was to evaluate the frequency and to define risk factors for cholelithiasis after heart transplantation (HTX). MATERIAL AND METHODS: The study population consisted of 176 subjects. Of them, 24 patients (group A) presented with symptomatic cholelithiasis. Another group of 24 patients without cholelithiasis (group B) served as controls. Both groups were similar with respect to age, gender and follow-up after the transplant. Clinical interview, surgical and hospitalization data were collected from medical records. RESULTS: The groups did not differ in demographic features. There were statistical differences (p < 0.05) between group A and B in rejection reaction, doses of immunosuppressive drugs, type 2 diabetes, serum lipid disorders and acute rejection episodes. These events were caused by modification of treatment, especially the immunosuppressive regimen. Group A consisted of 75% men and 25% women. The frequency of symptomatic cholelithiasis was 11.7% in men and 27.3% in women, on average 19.5%. Mean time to cholelithiasis following HTX was 37.9 ±4.9 (Me = 41.5) months, 27.7 ±8.2 (Me = 30.0) months in women and 41.3 ±5.9 (Me = 41.5) months in men. The female to male ratio was 2.3: 1. CONCLUSIONS: Cholelithiasis following HTX was significantly more frequent as compared with the non-transplant population. Patients with cholelithiasis required more aggressive immunosuppression because of more frequent episodes of acute transplant rejection. Patients with cholelithiasis significantly more frequently showed increased glycemia and blood lipids, which could be the side effect of intensive immunosuppressive therapy.

[Body mass index influence on aortic valve stenosis]. / Wskaznik masy ciala, a naturalny przebieg zwezenia lewego ujscia tetniczego.

AIM: The 12 months' observation of body mass index (BMI) influence on natural course of aortic valve stenosis (AVS). PATIENTS: 60 AVS patients who did not agree for operational treatment were divided into group A (n = 15) with BMI 20-25, group B (n = 27) with BMI 25,01-30 and group C BMI > 30. METHODS: Plasma Lp(a), total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor (TNF-alpha) as well as titers of immunoglobulin (Ig) class G, A, M against chlamydia pneumoniae were measured every 12 months. Echo-cardiographic evaluation of aortic valve was also done every 12 months. RESULTS: Means serum CRP at 12 month was the highest in group C. No differences in mean serum TNF-alpha and IL-6 levels as well as in Ig titers between groups A, B, C were found. At 12 month of observation HDL/total cholesterol ratio as well as HDL/LDL-cholesterol ratio were the lowest in group B. Left atrium diameter and right ventricle diameter were bigger in groups B and C compared to group A at the visit I and after 12 months of observation. Systolic intraventricular septum (IVS syst) thickness was the highest in group C at visit I. Diastolic left ventricle posterior wall thickness (LVPW) was the highest in group C during 12 months of observation. CONCLUSION: The increase in fat tissue mass may lead to increase in inflammatory process and cardiac muscle remodeling in AVS patients.

[One year observation of natural course of aortic valve stenosis in patients with normal and abnormal lipoprotein (a) plasma level]. / Roczna obserwacja naturalnego przebiegu zwezenia lewego ujscia tetniczego u chorych z prawidlowym i podwyzszonym stezeniem lipoproteiny (a) w osoczu.

AIM: The observation of natural course of aortic valvae stenosis (AVS) in patients with high lipoprotein (a) [Lp(a)]. PATIENTS: 60 AVS patients who did not agree for operational treatment were divided into group A (n = 19) with high serum Lp(a) level and into group B (n = 41) with normal plasma Lp(a) level. METHODS: Plasma Lp(a), total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor (TNF-alpha) as well as titers of immunoglobulin (Ig) class G, A, M against chlamydia pneumoniae were measured every 12 months. Echocardiographic evaluation of aortic valve was also done every 12 months. RESULTS: Means serum CRP at 12 month was higher in group A. Mean serum TNF-alpha level was also higher at visit I and at 12 month (visit II) in group A. Mean serum IL-6 level did not differ between groups. IgG titer was higher in group A at visit I and visit II. At 12 month of observation HDL-cholesterol plasma level was lower in group A. HDL/total cholesterol ratio as well as HDL/LDL-cholesterol ratio was laso lower in group A at 12 month of observation. No statistically significant differences in echocardiographic parameters were founf between groups. CONCLUSION: The results may suggest risk factors similarity of AVS and atherosclerosis.

[Natural course of aortic valve stenosis in patients with normal and abnormal lipid profile]. / Porównanie rocznej obserwacji naturalnego przebiegu zwezenia lewego ujscia tetniczego u pacjentów z prawidlowym i podwyizszonym stezeniem lipidów.

AIM: Comparison of echocardiographic findings in AVS patients with and without hypercholesterolemia during 12 months' observation of AVS natural course. PATIENTS: 60 AVS patients who did not agree for operational treatment were divided into group A (n = 47) with high serum total cholesterol and into group B (n = 13) with normal plasma cholesterol. METHODS: plasma total cholesterol, HDL-cholesterol, LDL-cholesterol, tri-glycerides and lipoprotein (a) were measured every 12 months and echocardiographic evaluation of aortic valve was also done every 12 months. RESULTS: Means total cholesterol did not change in group A, while increased in group B. HDL-cholesterol decreased in group A and LDL-cholesterol increased in group B. Mean TG and Lp(a) levels did not change in both groups. Increase in AOG max and AOG mean as well as V max were found only group A. LVPW syst increase was found in group A. LA diameter increased and AVA decreased only in group A. CONCLUSION: The results may suggest risk factors similarity of AVS progression and atherosclerosis.

Architecture of intraluminal thrombus removed from abdominal aortic aneurysm.

Little is known about architecture of intraluminal thrombus (ILT) in abdominal aortic aneurysm (AAA). We present a 74-year-old woman with AAA and high cardiovascular risk. Scanning electron microscopy of ILT removed during surgery showed that its luminal layer is relatively rich in fibrin fibers forming irregular compact structure with low amounts of erythrocytes and platelets, while abluminal portion is composed of densely packed fibrin with caniculi. The structure of ILT may differ largely among AAA patients contrary to previous findings and may reveal large dense fibrin-rich areas deprived of cells, which impair fibrinolysis and stabilize the thrombus size.

Stenotrophomonas maltophilia pacemaker endocarditis in a patient with d-transposition of the great arteries after atrial switch procedure.

We report a case of pacemaker endocarditis due to Stenotrophomonas maltophilia in a 22-year-old Caucasian man with d-transposition of the great arteries after atrial switch procedure. S.maltophilia isolated from blood cultures was susceptible to trimethoprim-sulfamethoxazole and amikacin, and resistant to ciprofloxacin and all tested ß-lactam antibiotics. The infected pacemaker system was completely removed by thoracotomy. Simultaneously, a new DDD pacemaker and epicardial electrodes were successfully implanted and selective antibiotic therapy consisting of trimethoprim-sulfamethoxazole (480 mg i.v. q 6 h) and amikacin (250 mg i.v. twice daily) was continued. However, the post-operative course was complicated by septic shock and the patient died on 9th day after surgery. Importantly, S.maltophilia isolated from extracted pacemaker leads was multidrug-resistant including to trimethoprim-sulfamethoxazole, ciprofloxacin, all tested aminoglycosides, and ß-lactams, with the exception of ticarcillin-clavulanate. In conclusion, pacemaker endocarditis due to Stenotrophomonas maltophilia is an extremely rare but serious complication of permanent pacing therapy. The susceptibility of S.maltophilia isolates to antimicrobial agents can change during the course of infection. Despite the inherent resistance of S.maltophilia to most ß-lactam antibiotics, multidrug-resistant strains may be susceptible in vitro to ticarcillin-clavulanate. Further studies are needed to determine the optimal management of patients with pacemaker endocarditis caused by Stenotrophomonas maltophilia.

Sutureless aortic valve bioprothesis '3F/ATS Enable'--4.5 years of a single-centre experience.

BACKGROUND: Management of patients with acquired heart malformations, including aortic valve disease, is still challenging. Due to ageing of population, patients undergoing valve surgery are older than in the past. The 3F Therapeutics, conducting a programme of construction of heart valves for transarterial or transapical implatation, prepared the 'Enable' bioprosthetic valve for sutureless insertion in the aortic position. The first world implantation was performed in our Department on 13 January 2005. AIM: To present our experience, qualification criteria and methods of implantation of sutureless bioprosthesis of aortic valve 'Enable'. METHODS: The 'Enable' valve is a tubular structure, tailored and sutured of equine pericardium, treated with glutaraldehyde, and mounted on an openwork Nitinol" alloy stent. It consists of two distal rings connected with three vertical sticks. The characteristic property of nitinol is thermoplaticity: due to refrigeration it becomes elastic and easy to bend, after rewarming returns to the initial dimensions and shape, remaining stable at the body temperature. Distension of the nitinol ring make possible strong mounting of the valve in aortic annulus. The examined group consised of 27 patients (16 males, 11 females), aged 60-78 years (average 69.5), with advanced aortic valve disease, left ventricular hypertrophy, and aortic gradient up to 102 mmHg. Exclusion criteria were: severe annular deformations or bicuspid aortic valve, other valves' malformations, coronary disease, severe other comorbidities or no agreement for 'Enable' valve implantation. The patients were operated using extracorporeal circulation, general moderate hypothermia and cold crystalloid cardioplegia. Care was taken to remove calcifications, estimate of aortic annulus geometry, valve size selection, and orientation of the valve toward coronary ostia The mounting time was approximately one min, and the aorta cross-clamp time was reduced to 26-56 min, mean 30 min. RESULTS: There was no mortality in the perioperative period, and during 3 months to 4.5 years of follow-up. No severe complications were present after surgery. One patient needed reoperation on post operative day 4 due to severe perivalvular leak. One other patient presented discrete leak with no need for intervention. The clinical improvement of one to three NYHA classes was observed. Echocardiographic and MSCT examinations confirmed adequate position of the valves, no structural deteriorations, normal movement and coaptation of the leaflets. The average maximal transvalvular gradient was 11.6 mmHg and the mean gradient--6.8 mmHg, which remained stable during the follow-up period. No thromboembolic or infective complications were present. CONCLUSIONS: (1) The 'Enable' aortic bioprosthetic valve has very good hemodynamic properties. (2) Self-expanding thermoplastic nitinol-made ring allows permanent stable mounting. (3) The quick fixation (about 1 min) significantly shortens the operation time. (4) The 'Enable' valve seems to be suitable for patients with increased periopertive risk.

Age effect on human aortic valvular glycoproteins.

BACKGROUND: The aortic valve has been the subject of many hemodynamic studies but, to our knowledge, posttranslational modification of human valve proteins has not yet been studied. Thus, the aim of this study was to determine whether any age-related changes in the protein composition of normal human aortic valves and their glycosylation pattern could be observed. METHODS: Aortic valves harvested from male cadaveric donors free of cardiovascular diseases were divided into four age groups: I, mean age 21 years; II, 30 years; III, 41 years; IV, 51 years. Proteins were separated by SDS-PAGE and transferred to PVDF membranes. Identification of monosaccharide moieties or oligosaccharide units was performed with the use of eight lectins of narrow specificity: Galantus nivalis agglutinin, Sambucus nigra agglutinin, Maackia amurensis agglutinin, Datura stramonium agglutinin, Aleuria aurantia agglutinin, Arachis hypogeae agglutinin, Phaseolus vulgaris agglutinin, and Lycopersicon esculentum agglutinin. RESULTS: Isolated proteins showed no age-related changes in SDS-PAGE protein profile, contrary to their glycosylation. Protein sialylation, number of tri/tetraantennary complex glycans, proteins having terminal galactose and polylactosaminyl units increased with age, whereas protein fucosylation showed the opposite relationship. Moreover, groups III and IV possessed a larger number of proteins bearing high-mannose and/or hybrid-type glycans, and the quantity of these structures seemed to change, in particular proteins, with the age of donors. CONCLUSIONS: Our results clearly demonstrate that glycosylation profile in human aortic proteins is associated with the age of the donor.