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A 39‐years old ventricular lead of a right‐sided single‐chamber pacemaker required extraction for infection. Angulation at the right subclavian‐superior vena cava junction coupled with calcified fibrotic encapsulating tissue prevented advancement of a rotational dissecting sheath. To straighten the lead, it was pulled from the subclavian and out of the right internal jugular vein, whilst the Needle's‐Eye Snare via the femoral access provided counter‐traction. A 13‐french rotational dissecting sheath was successfully advanced over the lead via the jugular access to complete the lead extraction without any complication. [ABSTRACT FROM AUTHOR]

Background: With an increasing number of cardiac implantable electronic devices (CIEDs), there has been a paralleled increase in demand for transvenous lead extraction (TLE). Cardiac surgeons (CS) and cardiologists perform TLE; however, data comparing the two groups of operators is scarce. Objective: We compared the outcomes of TLE performed by cardiologists and CS from six European lead extraction units. Method: Data was collected retrospectively of 2205 patients who had 3849 leads extracted (PROMET) between 2005 and 2018. Patient demographics and procedural outcomes were compared between the CS and cardiologist groups, using propensity score matching. A multivariate regression analysis was also performed for variables associated with 30‐day mortality. Results: CS performed the majority of extractions (59.8%), of leads with longer dwell times (90 [57–129 interquartile range (IQR)] vs. 62 [31–102 IQR] months, CS vs. cardiologists, p <.001) and with pre‐dominantly non‐infectious indications (57.4% vs. 50.2%, CS vs. cardiologists, p <.001). CS achieved a higher complete success per lead than the cardiologists (98.1% vs. 95.7%, respectively, p <.01), with a higher number of minor complications (5.51% vs. 2.1%, p <.01) and similar number of major complications (0.47% vs. 1.3%, p =.12). Thirty‐day mortality was similarly low in the CS and cardiologist groups (1.76% vs. 0.94%, p =.21). Unmatched data multivariate analysis revealed infection indication (OR 6.12 [1.9–20.3], p <.01), procedure duration (OR 1.01 [1.01–1.02], p <.01) and CS operator (OR 2.67, [1.12–6.37], p =.027) were associated with 30‐day mortality. Conclusion: TLE by CS was performed with similar safety and higher efficacy compared to cardiologists in high and medium‐volume lead extraction centers. [ABSTRACT FROM AUTHOR]

Background: Cardiac implantable electronic device (CIED) therapy contributes to an improvement in morbidity and mortality across all patient demographics. Patient age is a recognized risk factor for unfavorable outcomes in invasive procedures. This is the largest series of non‐laser transvenous lead extraction (TLE) evaluating the association between patient age and procedure outcomes. Methods: Data of 2205 (3849 leads) patients was collected retrospectively from six European TLE centers between January 2005–December 2018 in the PROMET study. Of these, 153 patients with 319 leads were excluded for incomplete data. A comparison of outcomes was performed between the age groups young [< 50 years], young intermediate [50–69 years], older intermediate [70–79 years], and octogenarian [≥80 years]. Results: Infection was most common indication for TLE in the octogenarian cohort, less common in the younger population (60.1% vs. 33.2%, respectively, p <.01). High‐voltage leads were extracted most frequently from young patients, less frequently from octogenarians (31.6% vs. 10%, p <.001), while the opposite was evident for pacemaker leads (p <.001). Rotational sheath use was equally prevalent across all patient groups (p =.79). Minor and major complications across all the age groups were statistically similar, as was procedural success; the 30‐day mortality was most significant in the octogenarian and least in the young patients (4.9% vs. 0.4%, p =.005). Propensity matching multivariate analysis found systemic infection, lead dwell time, and patient age (p =.013, OR 1.064 [1.013–1.116]) increased risk of 30‐day mortality. Conclusion: TLE is safe and effective across all age groups. 30‐day mortality risk is significantly higher in the older patients. [ABSTRACT FROM AUTHOR]

Background: The Sars‐Cov‐2 infection is a multisystem illness that can affect the cardiovascular system. Tachyarrhythmias have been reported but the prevalence of bradyarrhythmia is unclear. Cases have been described of transient high‐degree atrioventricular (AV) block in COVID‐19 that were managed conservatively. Method: A database of all patients requiring temporary or permanent pacing in two linked cardiac centers was used to compare the number of procedures required during the first year of the pandemic compared to the corresponding period a year earlier. The database was cross‐referenced with a database of all patients testing positive for Sars‐Cov‐2 infection in both institutions to identify patients who required temporary or permanent pacing during COVID‐19. Results: The number of novel pacemaker implants was lower during the COVID‐19 pandemic than the same period the previous year (540 vs. 629, respectively), with a similar proportion of high‐degree AV block (38.3% vs. 33.2%, respectively, p =.069). Four patients with the Sars‐Cov‐2 infection had a pacemaker implanted for high‐degree AV block, two for sinus node dysfunction. Of this cohort of six patients, two succumbed to the COVID‐19 illness and one from non‐COVID sepsis. Device interrogation demonstrated a sustained pacing requirement in all cases. Conclusion: High‐degree AV block remained unaltered in prevalence during the COVID‐19 pandemic. There was no evidence of transient high‐degree AV block in patients with the Sars‐Cov‐2 infection. Our experience suggests that all clinically significant bradyarrhythmia should be treated by pacing according to usual protocols regardless of the COVID status. [ABSTRACT FROM AUTHOR]

Background: Cardiac implantable electronic device (CIED)‐related perforation is uncommon but potentially lethal. Management typically includes the use of computed tomography (CT) scanning and often involves cardiac surgery. Methods: Patients presenting to a single referral centre with CIED‐related cardiac perforation between 2013 and 2019 were identified. Demographics, diagnostic modalities, the method of lead revision, and 30‐day complications were examined. Results: A total of 46 cases were identified; median time from implantation to diagnosis was 14 days (interquartile range = 4–50). Most were females (29/46, 63%), 9/46 (20%) had cancer, 18 patients (39%) used oral anticoagulants, and no patients had prior cardiac surgery. Active fixation was involved in 98% of cases; 9% involved an implantable cardioverter defibrillator lead. Thirty‐seven leads perforated the right ventricle (apex: 24) and 9 punctured the right atrium (lateral wall: 5). Abnormal electrical parameters were noted in 95% of interrogated cases. Perforation was visualized in 41% and 6% of cases with chest X‐ray (CXR) and transthoracic echocardiography, respectively. CXR revealed a perforation, gross lead displacement, or left‐sided pleural effusion in 74% of cases. Pericardial effusion occurred in 26 patients (57%) of whom 11 (24%) developed tamponade, successfully drained percutaneously. Pre‐extraction CT scan was performed in 19 patients but was essential in four cases. Transvenous lead revision (TLR) was successfully performed in all cases with original leads repositioned in six patients, without recourse to surgery. Thirty‐day mortality and complications were low (0% and 26%, respectively). Conclusion: CT scanning provides incremental diagnostic value in a minority of CIED‐related perforations. TLR is a safe and effective strategy. [ABSTRACT FROM AUTHOR]

Background: Small series has shown that cardiac resynchronisation therapy (CRT) can be achieved in a majority of patients using exclusively cephalic venous access. We sought to determine whether this method is suitable for widespread use. Methods: A group of 19 operators including 11 trainees in three pacing centres attempted to use cephalic access alone for all CRT device implants over a period of 8 years. The access route for each lead, the procedure outcome, duration, and complications were collected prospectively. Data were also collected for 105 consecutive CRT device implants performed by experienced operators not using the exclusively cephalic method. Results: A new implantation of a CRT device using exclusively cephalic venous access was attempted in 1091 patients (73.6% male, aged 73 ± 12 years). Implantation was achieved using cephalic venous access alone in 801 cases (73.4%) and using a combination of cephalic and other access in a further 180 (16.5%). Cephalic access was used for 2468 of 3132 leads implanted (78.8%). Compared to a non‐cephalic reference group, complications occurred less frequently (69/1091 vs 12/105; P =.0468), and there were no pneumothoraces with cephalic implants. Procedure and fluoroscopy duration were shorter (procedure duration 118 ± 45 vs 144 ± 39 minutes, P <.0001; fluoroscopy duration 15.7 ± 12.9 vs 22.8 ± 12.2 minutes, P <.0001). Conclusions: CRT devices can be implanted using cephalic access alone in a substantial majority of cases. This approach is safe and efficient. [ABSTRACT FROM AUTHOR]

Background: The outcomes of pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) are suboptimal. The entire pulmonary venous component (PV‐Comp), consisting of the pulmonary veins, their antra, and the area between the antra, provides triggers and substrate for AF. PV‐Comp isolation is an alternative strategy for persistent AF ablation. Methods: Among 328 patients with persistent AF who underwent a first radiofrequency ablation procedure, 200 patients (PVI, n = 100; PV‐Comp isolation, n = 100) were selected by propensity score matching. Both groups were followed up for 1 year. Results: At 6‐ and 12‐month follow‐up, atrial tachyarrhythmia (AF/atrial tachycardia) recurred in 41 and 61 patients in PVI group and 22 (P =.006) and 33 patients (P <.001) in PV‐Comp isolation group, respectively. PV‐Comp isolation was associated with longer mean time to recurrence (PVI: 8 months, PV‐Comp isolation: 10 months, log‐rank P <.001) and a lower probability of recurrence (odds ratio [OR] = 0.32; 95% confidence of interval [CI] = 0.18‐0.56, P <.001), with no increase in procedural complications (PVI: 5 of 100, PV‐Comp isolation: 6 of 100, P =.76). Procedure duration was longer in PV‐Comp isolation group (PVI: 186 ± 42 min, PV‐Comp isolation: 238 ± 44 min, P <.001), as well as fluoroscopy time (PVI: 22 ± 16 min, PV‐Comp isolation: 31 ± 21 min, P =.001). Conclusion: PV‐Comp isolation for persistent AF reduced atrial tachyarrhythmia recurrence up to 1 year compared with PVI alone. While procedure and fluoroscopy time increased, there was no difference in procedural complications. [ABSTRACT FROM AUTHOR]

Abstract: Background: A proportion of patients who undergo an initial lead extraction procedure will require a second, repeat extraction. Data regarding this clinical entity are scarce and neither the predisposing risk factors for, nor outcomes from, these procedures have been described previously. We sought to determine the incidence, risk factors, and outcomes of repeat lead extraction. Methods: A database of extraction procedures from 2001 to 2015 was analyzed. Repeat extraction procedures were identified and the indication for extraction was dichotomized into infection and lead‐related problems. Univariate and multivariate analyses were performed to identify predictors of repeat extraction. Results: 807 extraction procedures were identified in 755 patients of whom 6% required a repeat extraction. At multivariate analysis, only suffering a major complication at the initial extraction procedure (odds ratio [OR] 21.5, 95% confidence interval [CI] 2.69–171.92; P < 0.01), complexity of device (cardiac resynchronization devices/implantable cardioverter defibrillators) (OR 2.58, 95% CI 1.2–5.2; P = 0.01), and age (OR 1.02 per year, 95% CI 1.0–1.4; P  =  0.03) were significant predictors of repeat extraction. When repeat extraction was required for infection there was a significant increase in mortality compared with those who did not require a second procedure (36% vs 23%; P  =  0.02). Conclusions: Repeat lead extraction is required in 6% of cases. Complexity of device, age at extraction, and a major complication at the first extraction were predictors of repeat extraction. Mortality is significantly increased where the repeat procedure is for infection. Clinicians should alert patients to the potential need for further extraction and the increased risks of repeat procedures when indicated for infection. [ABSTRACT FROM AUTHOR]

Background Cardiac resynchronization therapy (CRT) with biventricular epicardial (BV-CS) or endocardial left ventricular (LV) stimulation (BV-EN) improves LV hemodynamics. The effect of CRT on right ventricular function is less clear, particularly for BV-EN. Our objective was to compare the simultaneous acute hemodynamic response (AHR) of the right and left ventricles (RV and LV) with BV-CS and BV-EN in order to determine the optimal mode of CRT delivery. Methods Nine patients with previously implanted CRT devices successfully underwent a temporary pacing study. Pressure wires measured the simultaneous AHR in both ventricles during different pacing protocols. Conventional epicardial CRT was delivered in LV-only (LV-CS) and BV-CS configurations and compared with BV-EN pacing in multiple locations using a roving decapolar catheter. Results Best BV-EN (optimal AHR of all LV endocardial pacing sites) produced a significantly greater RV AHR compared with LV-CS and BV-CS pacing (P < 0.05). RV AHR had a significantly increased standard deviation compared to LV AHR (P < 0.05) with a weak correlation between RV and LV AHR (Spearman rs = −0.06). Compromised biventricular optimization, whereby RV AHR was increased at the expense of a smaller decrease in LV AHR, was achieved in 56% of cases, all with BV-EN pacing. Conclusions BV-EN pacing produces significant increases in both LV and RV AHR, above that achievable with conventional epicardial pacing. RV AHR cannot be used as a surrogate for optimizing LV AHR; however, compromised biventricular optimization is possible. The beneficial effect of endocardial LV pacing on RV function may have important clinical benefits beyond conventional CRT. [ABSTRACT FROM AUTHOR]

Background: As the population receiving cardiac device therapy ages, the number of extraction procedures performed in octogenarians is increasing. This group has more comorbidities and may be at higher risk of such procedures. Objectives: Document the safety and success of percutaneous lead extraction in octogenarians. Methods: All extraction cases performed between January 2001 and April 2011 entered into a computer database were analyzed for patient characteristics and indications, extraction technique, procedural success, and complications. Success and complications were classified according to the Heart Rhythm Society consensus statement. Outcomes in octogenarians were compared to younger patients undergoing extraction during the same period. Results: Four hundred and six cases were performed: 72 procedures in octogenarians (mean age 84, range 80-95) and 334 in younger adults (mean age 62, range 20-79). Octogenarians had a greater number of comorbidities per case. Infection was the commonest indication for extraction in both groups. One hundred forty-one leads were extracted in octogenarians and 657 in younger patients. Laser assistance was required in 51.4% of octogenarians versus 49.7% of younger patients. Procedural success was achieved in 71/72 (98.6%) octogenarians versus 329/334 (98.5%) younger patients. No procedural mortality occurred in either group. Overall, complications were more frequent in octogenarians with major and minor complications occurring in 2.8 and 8.3% of octogenarians versus 0.6 and 3.0% of younger patients (P = 0.014). Conclusions: Procedural success was equally high in octogenarians and younger patients. Percutaneous lead extraction can be performed effectively and safely in octogenarians and is associated with a higher complication rate but no increased mortality. (PACE 2012;00:1-9) [ABSTRACT FROM AUTHOR]