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Glass waste dumps from crystal glass production is an health issue due to the occurrence of antimony, arsenic, cadmium and lead in crystal glass. Recovery of those elements could both decrease pollution and recycle metals in the circular economy. Pyrometallurgy is a potential recovery method, yet limited by high energy consumption. Here we tested a lower-energy alternative in which glass is mechanically activated in a ball mill and leached with nitric acid. Results show that mechanical activation destabilised the glass structure and resulted in 78% lead extraction during leaching at 95 °C. Temperature had the most significant effect on extraction, whereas acid concentration, from 0.5 to 3 M, and leaching time, from 0.5 to 12 h, had insignificant effects. In each experiment, 75% of the final extracted amount was achieved within 30 min. The study demonstrates potential for lead extraction from glass waste at lower acid concentration, shorter leaching time and lower temperature, of 95 °C, than traditional pyrometallurgical extraction, typically operating at 1100 °C. [ABSTRACT FROM AUTHOR]

Background: In the aging population equipped with cardiac implantable electronic devices, an increasing number of octogenarians require lead extractions. This patient population is often considered as a high‐risk group for surgical procedures. We, therefore, investigated the safety and efficacy of transvenous lead extraction in octogenarians using powered extraction sheaths. Methods: Between January 2013 and March 2017, 403 patients underwent lead extraction at two high‐volume lead extraction centers. A total of 71 octogenarians were treated with laser lead extraction and were included in this analysis. Primary extraction method was laser lead extraction, with additional use of mechanical rotational sheaths or femoral snares, if necessary. Patient‐based and procedural data were collected and analyzed retrospectively. Results: Mean age was 83.5 ± 3.3 years, 64.7% were males. A total of 152 leads were extracted. The mean lead dwell time of treated leads was 10.2 ± 5.2 years. Complete procedural success rate was 92.9%, while clinical success was achieved in 98.6%. Failure of extraction occurred in one patient (1.4%). In six (7.7%) patients, additional mechanical rotational sheaths or femoral snares were used. Overall complication rate was 4.2%, including one (1.4%) major (RA perforation) and two (2.8%) minor complications. No procedure‐related mortality was observed in any of the patients. Conclusion: Transvenous lead extraction in octogenarians with old leads is safe and effective when performed in experienced centers. Patient's age should therefore not be considered as contraindication for lead extraction using powered extraction sheaths. [ABSTRACT FROM AUTHOR]

Aims: FRench Attitude reGistry in case of ICD LEad replacement (FRAGILE) registry was set-up to describe the attitude in different French institutions in case of implantable cardioverter-defibrillator (ICD) lead replacement, extraction, or abandonment and to compare outcomes in both groups.Methods and Results: Prospective observational study comparing two attitudes in case of ICD lead replacement, extraction, or abandonment. Primary endpoint describes the attitude in different French centres, collect parameters that may influence the decision. Secondary endpoint compares early and mid-term (2 years) complications in both groups.Between April 2013 and April 2017, 552 patients were included in 32 centres. 434 (78.6%) were male, mean patient's age was 60.3 ± 14.4 years. In 56.9% of the cases, the decision was to explant the lead. Patients in the extraction group were younger than in the abandonment group (56.7 ± 14.5 vs. 65 ± 12.7 P < 0.0001) and less likely to have comorbidities (46.5% vs. 58.3% of the patients P = 0.022). The mean lead dwelling time was significantly longer in the abandonment group as compared with the extraction group (7.6 ± 3.9 vs. 5.2 ± 3.1 years, P < 0.0001). There was no statistical difference between both groups concerning early and 2 years complications.Conclusion: In this registry, the strategy in case of non-infected ICD lead replacement was mainly influenced by patient's age and comorbidities and lead dwelling time. No difference was observed in outcomes in both strategies. [ABSTRACT FROM AUTHOR]

Background Lead perforation is one of the major complications of pacemaker implantation, but cases of right ventricular (RV) lead perforation through the septum and left ventricle are rarely reported. We described a rare case of left ventricular (LV) free wall perforation by an RV lead and the management of this complication. Case summary An 84-year-old man was admitted with a dual-chamber pacemaker due to pacing failure caused by an RV lead fracture. New lead implantation was performed on the next day, but pacing failure occurred again on the second post-operative day (POD). We found the lead perforation on the fluoroscopy during temporary pacemaker insertion. Computed tomography scan and transthoracic echocardiogram showed that the added lead perforated through both the septum and LV free wall. A new lead was inserted on the fourth POD, and an off-pump open chest surgery for extraction of the penetrating lead was performed uneventfully on the 20th POD. Discussion We considered that some features of the lead (SelectSecure 3830-69, Medtronic) may be related to this complication, as the lead was very thin, had a non-retractable bare screw and was inserted with a dedicated delivery catheter. We have to be careful when performing implantation of this kind of lead to avoid such a rare complication. [ABSTRACT FROM AUTHOR]

An editorial is presented on PLEXES trial demonstrated improved outcomes of Transvenous lead extraction (TLE) with the use of an excimer laser sheath which uses a combination of photothermal and photochemolysis to disrupt fibrotic adhesions encountered. Topics include TLE is an important component of the care of patients with cardiovascular implantable electronic devices (CIEDs); and outcomes and complications were adjudicated by the investigators.

A 28-year-old woman with polysplenia was referred to our hospital for atrial lead failure. She had undergone an intracardiac repair (ICR) for incomplete atrioventricular septal defect and the implantation of epicardial pacing leads due to complete atrioventricular block at the age of 1 year. When she was 13 years old, an endocardial dual-chamber pacemaker was implanted via the right subclavian vein because of epicardial lead failure. The contrast-enhanced computed tomography scan revealed an inferior vena cava defect with an azygos vein connection to the superior vena cava, occlusion of the right brachiocephalic vein, a defect of the left brachiocephalic vein, and a persistent left superior vena cava ligated at the ICR. Therefore, lead exchange was indicated. During the operation, the temporary pacing lead and the guidewire for emergent deployment of the Bridge Occlusion Balloon® were advanced through the azygos vein and placed at the right ventricle and the hepatic vein, respectively. Both 11-Fr and 13-Fr mechanical rotational dilator sheaths were needed for the lead extraction owing to dense calcification and tight adhesions. The atrial lead was successfully extracted without any complications despite extremely restricted venous access. A new atrial lead was inserted through the space created by the 13-Fr sheath. < Learning objective: Transvenous lead extraction in patients with polysplenia is technically challenging. These patients often undergo pacemaker implantation in childhood, which results in tight adhesions and dense calcifications on the leads, and venous access is extremely restricted. It may be impossible to use a snare and deploy the endovascular balloon to prevent a catastrophic complication from the right femoral vein to the superior vena cava in cases of the inferior vena cava defect.> [ABSTRACT FROM AUTHOR]

Purpose: Current guidelines recommend complete extraction of cardiovascular implantable electronic devices (CIEDs) in the case of persistent or recurrent fungemia without other identifiable sources, though supporting evidence is lacking. We sought to evaluate the prognosis of patients with candidemia and CIEDs. Methods: Twelve consecutive patients (54 ± 12 years, 8 male) with CIED and concurrent candidemia were reviewed. Results: At the time of diagnosis with candidemia, seven patients were immunocompromised, six were on long-term antibacterial therapy, two were intravenous drug users, four were on chronic hemodialysis, and six had a central venous catheter. Four patients were confirmed as definite CIED infection as vegetation was visible on lead by echocardiogram. The other 8 patients were considered possible CIED infection with candidemia of unknown focus. All patients with visible vegetation underwent CIED removal without complications, and other patients were initially managed non-operatively. After 1 year of follow-up, 7 patients had died and at extended follow-up, all patients without lead removal died while 3 of 4 patients with lead extraction survived. Of note, 50% of deaths in the patients without lead removal were associated with fungal sepsis. Conclusions: Candida fungemia is associated with a high mortality. CIED removal should be an early consideration in these patients even if lead vegetations are not seen. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript.

Competing Interests: None.

Rates of cardiac pacemaker implantation rise with age, and, meanwhile, elderly patient may be at great risk of complications, as pneumothorax, lead perforation, or pocket dehiscence. The use of leadless pacemaker could overcome peri- and post-procedural complications related to the presence of transvenous leads and pocket. The study aims to investigate feasibility and outcomes of Micra Transcatheter Pacing System (M-TPS) implantation in elderly, which represents a challenge for conventional cardiac pacing. Between May 2014 and July 2019, 109 patients (88 males, mean age 77.71±9.68 years) underwent M-TPS implantation at our Center, targeting a non-apical site of delivery when feasible. Study population was divided into two groups according to age (group 1 <79 years vs group 2 group 2 80 years). The outcome evaluation included electrical performance at hospital discharge, and during follow-up. In 46/109 cases (34 males, 73.91%) M-TPS was implanted in patients older than 80 years. There were no statistically significant differences between groups for demographics characteristics, except for age. The procedure was performed via the right femoral access in 102/109 cases and was successful in all cases, with no device-related events. No differences were observed between groups in procedure duration, single device delivery, electrical performance at implant and at 12 month F-U. MTP-S implant is an effective and safe procedure in elderly patients, with similar electrical performance and outcome compared with younger patients at mid-term follow-up. [ABSTRACT FROM AUTHOR]

Rates of cardiac pacemaker implantation rise with age, and, meanwhile, elderly patient may be at great risk of complications, as pneumothorax, lead perforation, or pocket dehiscence. The use of leadless pacemaker could overcome peri- and post-procedural complications related to the presence of transvenous leads and pocket. The study aims to investigate feasibility and outcomes of Micra Transcatheter Pacing System (M-TPS) implantation in elderly, which represents a challenge for conventional cardiac pacing. Between May 2014 and July 2019, 109 patients (88 males, mean age 77.71±9.68 years) underwent M-TPS implantation at our Center, targeting a non-apical site of delivery when feasible. Study population was divided into two groups according to age (group 1

Background Patients undergoing lead extraction for infected devices have worse outcomes compared with those with noninfected devices. We assessed predictors of in‐hospital mortality and procedure‐related major adverse events (MAEs) in a large cohort undergoing lead extraction. Methods and Results Deidentified hospital records procedure from 7 states between 1994 and 2013 were aggregated and International Classification of Disease, Ninth Revision (ICD‐9) procedure codes were used to identify hospital records reporting lead extraction. MAEs included death, cardiac tamponade, hemothorax, and need for emergent cardiac surgery. Predictors of in‐hospital MAEs for infected compared with noninfected leads were identified using multivariate regression. Associations between outcomes and specific microbe were also assessed. In total, 57 220 discharges specified lead extraction. Infected leads accounted for the minority of total lead extractions compared with fractured leads (16.1 versus 59.8%, 25.7% not reported). There were 3298 MAEs (5.8%) including 980 deaths (1.7%). Multivariate predictors of MAE included black race, atrial fibrillation, anemia, heart failure, and admission via either hospital transfer or emergency department versus home (all P

The remedē system is a novel fully implantable transvenous phrenic nerve stimulation (TPNS) device developed to treat central sleep apnea. No information is published on how to explant or replace its leads. An eighty‐one year‐old had a fractured lead and we removed it over a wire. However, unbreachable resistances occurred with a new lead deployed over the enclosed wire and interventional endovascular techniques were performed to reimplant a new fully functioning system. This first report demonstrates TPNS lead exchange is possible but can be challenging. Interventional maneuvers and techniques, including balloon angioplasty, can facilitate this procedure. [ABSTRACT FROM AUTHOR]

Background: No comparative study of outcomes in Riata and Sprint Fidelis leads undergoing lead extraction (LE), lead abandonment (LA), and generator change only (GC) has been published.Objectives: Determine outcomes (major complications [MC]; death, extended hospitalization, or rehospitalization within 60 days [RH]; lead malfunction) of LE, LA, and GC for recalled leads.Methods: Retrospective, multicenter, comparative study.Results: A total of 298 LE, 85 LA, and 310 GC were performed. In the clinical setting of a lead intervention, there was no difference in a composite of MC, death, RH, lead revision, inappropriate shocks, or device infection between LE and LA groups (15% vs 22%, P = .140). In the clinical setting of a device at elective replacement interval (ERI), there were significantly more acute events at 60 days (MC, death, and RH) in the LE and LA groups at 15.4% (4) and 15.4% (4), and this was significantly (P = .017) higher than the GC group at 5.1% (16). There was no difference (P = 1.000) in the composite of MC, death, RH, lead malfunction, lead revisions, device infections, or inappropriate shocks between LE, LA, and GC groups at 15.4% (4), 15.4% (4), and 17.4% (54), respectively. Following generator change, 14 of 175 Fidelis leads and 3 of 135 Riata leads failed over a total of 12,714 months of follow-up.Conclusions: The failure rate of recalled leads was substantially lower compared to previous reports. It may be prudent to perform generator change only when the device is at ERI, especially when the recalled lead has historical performance that likely outweighs the risks of extraction/abandonment. [ABSTRACT FROM AUTHOR]

As the number of patients with cardiac implantable electronic devices (CIEDs) grows, they are likely to present with issues to diverse groups of physicians. Guideline-adherent management is associated with improved prognosis in patients with CIED infection or lead problems but is insufficiently implemented in practice. The European Heart Rhythm Association (EHRA) with the support of the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery, performed a multinational educational needs assessment study in ESC member countries, directed at physicians who might be confronted with CIED patients with complications. A total of 336 physicians from 43 countries, reached through the ESC mailing list, participated. They included a mix of electrophysiologists, cardiologists general physicians and cardiac surgeons .One hundred and twenty-nine (38%) of the respondents performed lead extraction. The survey included eight clinical cases and a self-evaluation question of knowledge and skills to apply that knowledge. The survey looked at 14 areas of care across five stages of the patient journey. Of the non-extracting physicians over 50% felt they lacked the knowledge and skills to make the diagnosis and refer for lead extraction and over 75% felt they lacked knowledge and skills to manage aspects of extraction and post-extraction care. Barriers to correct referral were logistic and attitudinal. Extracting physicians reported significantly higher rates of adequate skills and knowledge across all five stages of the patient journey (P < 0.05). We identified major gaps in physicians' knowledge and skills across all stages of CIED care. These gaps should be addressed by targeted educational activities and streamlining referral pathways. [ABSTRACT FROM AUTHOR]

Introduction: Venous stenosis is a late complication of the atrial switch (Mustard/Senning) procedure seen in patients with transposition of the great arteries (d‐TGA). Many atrial switch patients require cardiac implantable electronic devices (CIEDs) which further increases the incidence of venous stenosis. Stenosis of the superior limb of the systemic venous pathway (SLSVP) in the presence of CIED leads presents a management challenge. We propose a method for navigating SLSVP stenosis in atrial switch patients with CIEDs. Methods: The pulse generator and leads were removed using standard extraction techniques. Axillary access was retained via existing leads or new access was obtained. The interventional cardiology team, via groin access, performed stent‐angioplasty of the stenotic SLSVP. After stent deployment, the axillary access wire was snared from below, guided through the stent, and pulled into a long groin sheath. A sheath was then advanced over the axillary wire and into the groin sheath creating a path for passage of leads through the stent. New leads were advanced through the axillary sheath into the heart. Leads were secured using standard techniques. Results: All patients had a history of d‐TGA and prior atrial switch procedures. In each case, there was stenosis of the SLSVP in the setting of a CIED lead. There were no immediate complications and there was no restenosis on follow‐up. Conclusion: Post‐atrial switch patients with CIEDs can develop stenosis of the SLSVP. A collaboration between electrophysiology and interventional cardiology can allow for device extraction, stent‐angioplasty, and lead reimplantation to avoid "jailing" the leads. [ABSTRACT FROM AUTHOR]

Background: Transvenous lead extractions (TLEs) in Japan have grown to become the standard therapy since the approval of the laser extraction system in 2008. However, little is known about the current indications, methods, success rate, and acute complications in the real‐world setting. Methods: The Japanese Lead EXtraction (J‐LEX) registry is a nationwide, multicenter, observational registry, performed by the Japanese Heart Rhythm Society (JHRS) in collaboration with the National Cerebral and Cardiovascular Center. This study is a nationwide registry ordered by the JHRS and its data are collected prospectively using the Research Electronic Data Capture (REDCap) system. The acute success rate at discharge and complications associated with TLEs will be collected in all cases. Based on the provided information, the annual incidence and predictive factors for the outcomes will be investigated by the Event Assessment Committee (EAC). This registry started in July 2018 and the number of participating medical institutions will be more than 50 hospitals and the target number of procedures will be 500‐1000 per year. We will also compare the results with other registries in foreign countries. Result: The results of this study are currently under investigation. Conclusion: The J‐LEX registry will provide real‐world data regarding the results and complications of TLEs for the various types of indications, methods, and performing hospitals in Japan. [ABSTRACT FROM AUTHOR]

Aims: Optimal management of redundant or malfunctioning leads is controversial. We aimed to assess safety and efficacy of mechanical transvenous lead extraction (TLE) in patients with abandoned leads.Methods and Results: Consecutive TLE procedures performed in our centre from January 2009 to December 2017 were considered. We evaluated the safety and efficacy of mechanical TLE in patients with abandoned (Group 1) compared to non-abandoned (Group 2) leads. We analysed 1210 consecutive patients that required transvenous removal of 2343 leads. Group 1 accounted for 250 patients (21%) with a total of 617 abandoned leads (26%). Group 2 comprised 960 patients (79%) with 1726 leads (74%). The total number of leads (3.0 vs. 2.0), dwelling time of the oldest lead (108.00 months vs. 60.00 months) and infectious indications for TLE were higher in Group 1. Clinical success was achieved in 1168 patients (96.5%) with a lower rate in Group 1 (90.4% vs. 98.1%; P < 0.001). Major complications occurred in only 9 patients (0.7%), without significant differences among the two groups. The presence of one or more abandoned leads [odds ratio (OR) 3.47; 95% confidence interval (CI) 1.07-11.19; P = 0.037] and dwelling time of the oldest lead (OR 1.01 for a month; 95% CI 1.01-1.02; P < 0.001) were associated with a higher risk of clinical failure.Conclusion: Transvenous mechanical lead extraction is a safe procedure also in high-risk settings, as patients with abandoned leads. Success rate resulted a bit lower, especially in the presence of abandoned leads with long implantation time. [ABSTRACT FROM AUTHOR]

Background: Studies on femoral approach during transvenous lead extraction (TLE) are limited. Methods: We retrospectively evaluated 75 patients undergoing TLE from September 2014 through November 2019 via supportive femoral approach (Femoral/Superior group; n = 22) and superior approach alone (Superior group; n = 53). Results: No significant between‐group differences were observed regarding patients' baseline characteristics except for a higher incidence of access vein occlusion in the Femoral/Superior group (59.1% vs. 31.4%; P =.037). The Femoral/Superior group exhibited significantly longer dwell times of the oldest extracted lead (median: 13.4 years; interquartile range [IQR]: 8.8‐21.2 years vs. median, 7.2 years; IQR: 3.7‐10.8 years; P <.001) and a higher incidence of passive fixation ventricular pacemaker lead (81.8% vs. 39.6%; P =.001). Multivariate logistic analysis showed that access vein occlusion (odds ratio [OR]: 4.07, 95% confidence interval [CI]: 1.08‐15.3; P <.001) and dwell time of the oldest extracted lead (per year) (OR: 1.22, 95% CI: 1.09‐1.37; P =.038) were predictors of the need for supportive femoral approach. Receiver operating characteristic curve analysis revealed that 11.8 years from implant was the cutoff for the need for supportive femoral approach (sensitivity 68.2%, specificity of 81.1%, area under the curve 0.81). Conclusions: Access vein occlusion and long dwell time of the oldest extracted lead predict a high probability of the need for supportive femoral approach. Supportive femoral approach may be necessary in patients with leads that are implanted for >11.8 years and whose access veins are occluded. [ABSTRACT FROM AUTHOR]

Background The Attain Stability Quadripolar 4798 lead is a relatively new quadripolar active fixation coronary sinus (CS) lead. No cases of extraction of a chronically implanted 4798 lead have been published to date. Case summary A 52-year-old man with a history of previous cardiac resynchronization therapy pacemaker (CRT-P) insertion and atrioventricular node ablation presented to our institution with a pocket infection 69 weeks after implantation. Directed intravenous antibiotic therapy was commenced and an extraction was performed the following day. Extraction of the right atrial and right ventricular leads was simple and achieved with gentle manual traction. Extraction of the CS lead was more difficult. Significant traction was required due to the formation of adhesions inside the CS but extraction of the lead was eventually successful without complication. Specialized extraction equipment was not required. A new contralateral CRT-P device was implanted, and the patient was discharged home. He remains well at 3 months of follow-up. Discussion We present the first case of extraction of a chronically implanted active fixation Attain Stability Quadripolar lead. Our experience demonstrates that this has been performed successfully without specialist tools and with preservation of the CS branch. Significant adhesion was noted at the site of active fixation, however. Potential difficulty with this lead's extraction should therefore be considered when contemplating its use. [ABSTRACT FROM AUTHOR]

Due to the growing number of patients treated with cardiac implantable electronic devices (CIEDs) there is an increased need for lead management, evaluation, and extraction. While CIED lead extraction has many indications, a consistent approach to preprocedural planning should be applied in all cases, including a thorough consultation with careful review of the patient's medical and device history, as well as a discussion of informed consent and shared decision‐making with the patient and their loved ones. The use of chest X‐ray, echocardiography, and computed tomography (CT) scan can further help with risk stratification and procedural planning. Intraprocedural echocardiography (transesophageal or intracardiac) is recommended and allows early recognition of cardiothoracic injury. Establishing an extraction team with cardiology/electrophysiology, anesthesiology, and CT surgery is is crucial to a successful and safe CIED extraction practice, including immediately available surgical backup. This hands‐on review will address how to approach patients who are undergoing lead extraction, as well as several innovations in preprocedure and intraprocedural risk assessment. [ABSTRACT FROM AUTHOR]

Introduction: In adult congenital patients with transposition of the great arteries originally treated with the Mustard (atrial switch) procedure, the most common reason for re-intervention is baffle stenosis. This may be exacerbated by permanent transvenous pacemaker lead placement across the baffle.Case Report: A 47-year-old female status post Mustard procedure performed at 15 months old presented with a high-grade stenosis of the superior vena cava (SVC) baffle from the SVC to the left atrium, with a nonfunctional permanent pacemaker lead passing through the baffle. A mechanical rotating dilator sheath was used for attempted lead extraction, relieving the baffle stenosis almost completely as a secondary effect, before the placement of a 10 × 27 mm Visipro balloon-expandable stent in the SVC baffle.Conclusions: Use of the mechanical rotating dilator sheath is an evolving treatment strategy in adult congenital heart disease to minimize the risk of bleeding, trauma to surrounding structures, and death. Its ability to fully alleviate baffle stenosis even when full lead extraction is not feasible or is associated with significant procedural risk, further demonstrates its expanded role in this patient population. A multidisciplinary approach and great diligence must be employed to avoid potential complications. [ABSTRACT FROM AUTHOR]

Little is known about rates of re-implantation and outcomes of patients not implanted with a device after transvenous lead extraction (TLE) in cardiac device related infections (CDRI). All patients with CDRI were included in a prospective registry. After TLE, the indication for re-implantation was evaluated according to the patients' history and most recent cardiac examinations. All patients were followed for complications and mortality. In addition, in patients discharged without device the frequency of device implantations was analyzed. Among 302 patients, only 123 (40.7%) met the indication for implantation of the same cardiac implantable electronic device (CIED), 68 (22.5%) received a different device and 111 (36.8%) patients were discharged without CIED. Reimplanted patients were younger (70 ± 11 vs. 73 ± 13 years; p = 0.004), more often male (83 vs. 69%, p = 0.006), had less systemic infection (38 vs. 60%; p < 0.001) and a higher prevalence of complete heart block (28 vs. 7%, p < 0.001). Reasons against re-implantation were: loss of indication (45%), never met indication (27%), patients' preference (17%), persistent infection (8%) and advanced age (3%). During 26 ± 18 months of follow-up, mortality in both groups was similar after adjusting for cofactors (HR 0.79; 95% CI 0.49–1.29; p = 0.352). More than one third of patients undergoing TLE for CDRI in our study are not implanted with a new device. Careful evaluation of the initial CIED indication allows for detection of over treated patients and may avoid unnecessary device–related complications. • Complete extraction is the adequate treatment for device-related infection. • Data on the rate of reimplantation after transvenous lead extraction are scarce. • Only 63% of our patients had an indication for ongoing device therapy. • All-cause mortality is not dependent from reimplantation. • A critical evaluation of the device indication is necessary after lead extraction. [ABSTRACT FROM AUTHOR]

Introduction: Implantable cardioverter defibrillators (ICDs) are proven to prevent sudden death in patients at elevated risk for sustained ventricular tachycardia or fibrillation. Complications related to ICD failure can stem from lead dysfunction, manufacturing defects, patient characteristics, or implantation technique. We conducted a review of all ICD leads implanted at our center from 2011 to 2017 to determine risk factors for premature lead failure. Methods: We conducted a retrospective review of patients of all ICD leads implanted from December 2011 to June 2017 at our institution. A total of 660 patients (Biotronik Linox S/SD, n = 281; Sprint Quatro, n = 207; Durata, n = 121; Endotak, n = 51) underwent ICD implantations. Patient and lead characteristics, procedural outcomes and complications were recorded. Lead failure was defined per Heart Rhythm Society lead‐management consensus as a lack of procedural or clinical success, thus requiring an extraction of the lead. Patient and lead outcomes were recorded and variables associated with lead failure were assessed by the Kaplan‐Meier method. Results: Overall failure rate was similar for all leads: Linox S/SD—0.29%/year; Sprint Quattro—0.21%/year, Durata—0.39%/year and Endotak Reliance—0.0% (P =.769). No difference was found in overall survival when comparing all ICD manufacturers during the study period. Subgroup analysis revealed the risk of premature lead failure was particularly pronounced in multi‐lead ICD systems implanted via cephalic access (P <.001). The estimated failure rate of Linox leads implanted via cephalic access in multi‐lead systems was 19%/year. The estimated failure rate of non‐Linox leads implanted via cephalic access in multi‐lead systems was 11%/year. Neither age, nor gender were risk factors for lead failure in the Linox, or non‐Linox cohorts. Conclusion: All analyzed ICD leads were found to have a similar overall risk of premature failure. ICD lead implantation via cephalic access in multilead ICD systems may be a previously unidentified risk factor for premature ICD lead failure, although these findings require further validation. [ABSTRACT FROM AUTHOR]

Background: The number of lead extractions is growing because of the greater population and increasing age of individuals with a cardiac implantable electronic device. Lead extraction procedures can be complex undertakings with risk of significant mortality, and vascular tears in the superior vena cava are of greatest concern.Objective: The purpose of this study was to study whether a novel algorithm that analyzes pre-extraction computed tomographic (CT) images can determine the likelihood and location of lead-lead interactions and lead-vessel attachment within patients' venous vasculatures. This information can be used to identify potential case challenges in the planning stages.Methods: We developed an algorithm to estimate the presence and position of lead-lead interactions and lead-vessel adherences by tracking distance between the leads and distance between the lead and superior vena cava in a sample of 12 patients referred to the United Heart and Vascular Clinic for lead extractions due to infection (n = 5), lead failure (n = 5), and tricuspid regurgitation (n = 2).Results: Preliminary results indicate that the developed algorithm successfully identified lead-lead and lead-vascular attachments compared to review of CT images by medical experts.Conclusion: With future validation and clinical implementation, this algorithm could aid physician preparedness by minimizing intraprocedural emergencies and may improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: The prognosis of patients with untreated cardiac implantable electronic device (CIED) infection is poor. Whether removal of all leads by a successful transvenous lead extraction (TLE) procedure changes the prognosis is unclear. Objective: To identify predictors of mortality in patients with CIED infection despite successful TLE. Methods: Retrospective single‐center analysis of prospectively collected database from consecutive patients undergoing TLE at our center. Predictors for mortality were identified and a score predicting high mortality rate was calculated. Results: A total of 371 consecutive patients underwent TLE, of whom 337 (90.8%) had complete hardware removal. Most were extracted due to infectious causes (81.3%). Approximately one‐third (35%) died during a mean follow‐up of 1056 ± 868 days. There was significantly higher mortality observed in the infectious group. Multivariate logistic regression models for infectious group only identified creatinine and albumin measurements as risk markers for 30 days mortality (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.19‐2.38; P =.003 and OR, 0.4; 95% CI, 0.16‐0.97; P =.039, respectively). A risk score was created based on cutoff values of creatinine ≥2md/dL (1 point) and albumin ≤3.5 g/dL (1 point). A value of 2 points predicted a 50% chance of 30‐day mortality and a 75% chance of 1‐year mortality (P <.0001 for both). Conclusions: Creatinine and albumin can be used as a combined risk score to successfully identify patients at risk of death despite undergoing a successful TLE procedure for infectious reasons. This score could help decision making when contemplating on conservative antibiotic treatment vs TLE. [ABSTRACT FROM AUTHOR]

Background: Many patients awaiting heart transplantation (HTX) have a cardiac implantable electronic device (CIED). Lead removal is often still a part of the HTX procedure. Abandoned lead fragments carry a risk for infections and prohibit magnetic resonance imaging (MRI) imaging. This study evaluated the concept of an elective lead management algorithm after HTX. Methods and Results: Between 2009 and 2018, 102 consecutive patients with previously implanted CIED underwent HTX. Lead removal by manual traction during HTX was performed in 74 patients until December 2014. Afterward, treatment strategy was changed and 28 patients received elective lead extraction procedures in a hybrid operating room (OR) using specialized extraction tools. Total of 74 patients with 157 leads underwent lead extraction by manual traction during HTX. The mean lead age was 32.3 ± 38.7 months. Postoperative X‐ray revealed abandoned intravascular lead fragments in 31(41.9%) patients, resulting in a complete lead extraction rate of only 58.1%. The high rate of unsuccessful lead extractions led to the change in the extraction strategy in 2015. Since then, HTX was performed in 28 CIED patients. In those patients, 64 leads with a mean lead age of 53.8 ± 42.8 months were treated in an elective lead extraction procedure. No major or minor complications occurred during lead extraction. All leads could be removed completely, resulting in a procedural success rate of 100%. Conclusion: Our results demonstrate that chronically implanted leads should be removed in an elective procedure, using appropriate extraction tools. This enables complete lead extraction, which reduces the infection risk in this patient population with the necessity for permanent immunosuppressive therapy and allows further MRI surveillance. [ABSTRACT FROM AUTHOR]

Background: Managing elderly patients with infection or malfunction deriving from a cardiac implantable electronic device (CIED) may be challenging. The aim of this study was to evaluate safety and efficacy of mechanical transvenous lead extraction (TLE) in elderly patients. Methods: Patients who had undergone TLE in single tertiary referral center were divided in two groups (group 1: ≥ 80 years; group 2: < 80 years) and their acute and chronic outcomes were compared. All patients were treated with manual traction or mechanical dilatation. Results: Our analysis included 1316 patients (group 1: 202; group 2: 1114 patients), with a total of 2513 leads extracted. Group 1 presented more comorbidities, more pacemakers than implantable cardioverter‐defibrillators, whereas the dwelling time of the oldest lead and the number of leads were similar, irrespective of patient's age. In group 1, the radiological success rate for lead was higher (99.0% vs 95.9%; P <.001) and the fluoroscopy time lower (13.0 vs 15.0 min; P =.04) than in group 2. Clinical success was reached in 1273 patients (96.7%), without significant differences between groups (group 1: 98.0% vs group 2: 96.4%; P =.36). Major complications occurred in 10 patients (0.7%) without significative differences between patients with more or less than 80 years (group 1: 1.5% vs group 2: 0.6%; P =.24) and with no procedure‐related deaths in elderly group. Conclusions: Mechanical TLE in elderly patients is a safe and effective procedure. In the over‐80s, a comparable incidence of major complications with younger patients was observed, with at least a similar efficacy of the procedure. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study is to assess the safety and efficacy of the new bidirectional rotational mechanical sheath TightRail™ (Spectranetics) for lead extraction. Methods and results: This is a bicentric prospective study that included patients who underwent a transvenous lead extraction (TLE) in two Italian centers (San Raffaele Hospital and Humanitas Gavazzeni Hospital). From November 2016 to December 2018, 26 patients underwent a TLE procedure in which the TightRail™ was used. The new TightRail Sub‐C was used in 20 (76%) patients to overcome the fibrosis between the vessel and the first rib. Median age was 69 (IQR 60.7‐79.5) years. The indication for TLE were infection (57.7%) or lead dysfunction (42.3%). A total of 57 leads (range 1‐4), 40 of which using the TightRail (range 1‐4), were extracted. Overall mean implant duration was 98.2.0 ± 66.5 months. Mean age of the lead extracted with the TightRail sheath was 99.1 ± 70.2 months and was higher compared to that of the leads extracted manually (84.4 ± 60.3 months, P =.001). The overall clinical success was 100% and complete procedural success without the use of a snare was achieved in 98.3%. There were no cases of death or major complications and only two minor complications occurred. All patients were event‐free at 6‐month follow‐up. Conclusion: This initial experience using the TightRail™ suggests a high safety and efficacy profile for extractions in a wide range of lead age. [ABSTRACT FROM AUTHOR]

Background: Small vegetations (<2.0 cm) associated with infected cardiac device leads can be managed percutaneously, whereas larger vegetations typically are removed via open heart surgery. Unfortunately, many patients with intracardiac vegetations are not candidates for open removal.Objective: The purpose of this study was to report our experience in the outcomes associated with the percutaneous management of large vegetations.Methods: Prospective data from January 2010 to August 2018 identified 826 patients with infections undergoing lead extraction. One hundred nineteen cases had vegetations measured in 2 dimensions (length and width) by transesophageal echocardiogram. Thirty-two patients had 3 characteristics: (1) at least 1 vegetation dimension ≥2.0 cm; (2) not a surgical candidate; and (3) had undergone transvenous lead extraction. The cohort was classified into 2 groups according to shape: (1) globular if the difference between dimensions was <30% between dimensions; and (2) nonglobular if the difference was >30%. The Fisher exact test and Pearson t test were used for analysis. P <.05 was considered significant.Results: Retrospective analysis of a single tertiary cardiac surgery center registry showed a significantly lower chance of being alive at discharge in patients with globular vegetations compared to patients with nonglobular vegetations (P = .002).Conclusion: Vegetation size is an important determinant of outcomes in patients who are not surgical candidates undergoing transvenous lead extraction. However, vegetation shape is also a relevant factor, as globular vegetations may predict a worse result compared to nonglobular vegetations. [ABSTRACT FROM AUTHOR]

Aims: A validated risk stratification schema for transvenous lead extraction (TLE) could improve the management of these procedures. We aimed to derive and validate a scoring system to efficiently predict the need for advanced tools to achieve TLE success.Methods and Results: Between November 2013 and March 2018, 1960 leads were extracted in 973 consecutive TLE procedures in two national referral sites using a stepwise approach. A procedure was defined as advanced extraction if required the use of powered sheaths and/or snares. The study population was a posteriori 1:1 randomized in derivation and validation cohorts. In the derivation cohort, presence of more than two targeted leads (odds ratio [OR] 1.76, P = 0.049), 3-year-old (OR 3.04, P = 0.001), 5-year-old (OR 3.48, P < 0.001), 10-year-old (OR 3.58, P = 0.008) oldest lead, implantable cardioverter-defibrillator (OR 3.84, P < 0.001), and passive fixation lead (OR 1.91, P = 0.032) were selected by a stepwise procedure and constituted the MB score showing a C-statistics of 0.82. In the validation group, the MB score was significantly associated with the risk of advanced extraction (OR 2.40, 95% confidence interval 2.02-2.86, P < 0.001) and showed an increase in event rate with increasing score. A low value (threshold = 1) ensured 100% sensibility and 100% negative predictive value, while a high value (threshold = 5) allowed a specificity of 92.8% and a positive predictive value of 91.9%.Conclusion: In this study, we developed and tested a simple point-based scoring system able to efficiently identify patients at low and high risk of needing advanced tools during TLE procedures. [ABSTRACT FROM AUTHOR]

Cardiac implantable electronic devices (CIEDs) frequently need to be extracted due to infection, hardware failure, and other causes. The extraction of the CIED is typically performed using percutaneous methods. While these procedures are mostly performed without incident there is a small risk of significant complications. Dedicated imaging pre‐CEID removal to include the central veins and heart with multidetector computed tomography (MDCT) can be utilized to evaluate the lead course and termination, the integrity of the central veins and cardiac chambers, and identify potential complications that may alter the lead extraction procedure as well as reimplantation of subsequent leads. Indications for preprocedural imaging, the technique of dedicated preprocedural lead extraction MDCT, and the approach to the interpretation of the images is discussed in this review. [ABSTRACT FROM AUTHOR]

Introduction: Late lead perforation (LLP), defined as perforation ≥30 days from cardiac implantable electronic device implant, is a rare diagnosis and little data exist regarding management practices and outcomes. The purpose of this study was to evaluate the occurrence, safety, and efficacy of transvenous management of clinically significant LLP. Methods: The electronic medical records of a single‐center tertiary hospital were reviewed for all patients who were referred for LLP or its sequelae. Results: Eleven consecutive patients were identified from October 2011 to December 2018 with clinically significant LLP. Patients most often presented with pericardial symptoms with the exception of one asymptomatic patient. The median time from lead implant to intervention for LLP was 246 days. Nine patients were managed with an initial transvenous approach, with one requiring sternotomy (lead 6.3 years old). Two patients had a surgical approach, one performed at an outside hospital with subsequent death and another had a mini‐thoracotomy, but the lead was removed percutaneously with no surgical repair. In this small cohort, there was no association between the lead extending beyond the parietal pericardium and surgical repair (P =.99). Conclusion: Our single‐center experience suggests that LLP can be initially managed with a cautious transvenous approach in most patients, but intraprocedural ultrasound for pericardial monitoring and a rescue plan with immediate surgical back up is mandatory. [ABSTRACT FROM AUTHOR]

Aims: Treatment of patients with systemic cardiac implantable electronic device (CIED) infection with large lead vegetations is challenging and associated with relevant morbidity and mortality. To avoid complications from open surgical extraction, a novel approach with percutaneous aspiration of large vegetations prior to transvenous lead extraction was instituted. The results of this treatment concept were retrospectively analysed in this multicentre study.Methods and Results: One hundred and one patients [mean age 68.2 ± 13.1 (30-92) years] were treated in four centres for endovascular CIED infection with large lead vegetations. Mean lead vegetation size was 30.7 ± 13.5 mm. Two hundred and forty-seven leads were targeted for extraction (170 pacemaker leads, 77 implantable cardioverter-defibrillator leads). Mean lead implant duration was 81.7 (1-254) months. The transcatheter aspiration system with a specialized long venous drainage cannula and a funnel-shaped tip was based on a veno-venous extracorporeal circuit with an in-line filter. The aspiration of vegetations showed complete procedural success in 94.0% (n = 95), partial success in 5.0% (n = 5). Three major complications (3.0%) were encountered. Complete procedural success (per lead) of the subsequently performed transvenous lead extraction procedure was 99.2% (n = 245). Thirty-day mortality was 3.0% (n = 3). Five patients (5.0%) died in the further course on Days 51, 54, 68, 134, and 182 post-procedure (septic complications: n = 4; heart failure: n = 1).Conclusion: The percutaneous aspiration procedure is highly effective and is associated with a low complication profile. The aspiration of vegetations immediately prior and during the lead extraction procedure may avoid septic embolization into the pulmonary circulation. This may potentially lead to a long-term survival benefit. [ABSTRACT FROM AUTHOR]

Inadvertent malposition of a pacemaker lead in the left ventricle is uncommon, but it should not be misdiagnosed. We report the case of a 68-year-old woman with symptomatic sick-sinus syndrome requiring pacemaker implantation. Shortly afterwards the lead was extracted and a new pacemaker was contralaterally implanted due to pocket hematoma and suspected lead fracture. Three months later, she was referred to our echocardiography laboratory complaining of asthenia. At transthoracic echocardiography an echo-bright linear structure was recognized in left atrium, passing through the mitral valve and leaning against the posterior left ventricular wall. In short-axis and apical views, the lead apparently crossed the interatrial septum through patent foramen ovale. The QRS-paced electrocardiogram showed right bundle branch block morphology. The lead was apparently well positioned, examining the chest X-ray postero-anterior view. On the contrary, by latero-lateral view and left-anterior oblique view, lead curvature was consistent with misplacement into the left ventricle. Malposition was confirmed by transesophageal echocardiography. Given the relatively recent implant, system revision with lead extraction was scheduled and completed without complications. This case report is intended to improve our awareness in the prevention and in the prompt detection of misplaced pacemaker leads in order to manage an immediate correction. < Learning objective: During lead implantation, fluoroscopic left-anterior oblique view should be always used to ensure correct positioning. At least 3–6 limb leads should be carefully monitored during the procedure, and a 12-lead standard electrocardiogram should be performed shortly afterwards for the paced QRS morphology. Lateral chest X-ray should always be taken after implantation. In cases of doubt, echocardiography (transthoracic or transesophageal) may confirm abnormal lead placement defining the route covered by the catheter.> [ABSTRACT FROM AUTHOR]

Aims: The present study sought to determine predictors for success and outcomes of patients who underwent cardiac implantable electronic devices (CIED) extraction indicated for systemic or local CIED related infection in particular where complete lead removal could not be achieved.Methods and Results: ESC-EORP ELECTRa (European Lead Extraction ConTRolled Registry) is a European prospective lead extraction registry. Out of the total cohort, 1865/3510 (52.5%) patients underwent removal due to CIED related infection. Predictors and outcomes of failure were analysed. Complete removal was achieved in 1743 (93.5%) patients, partial (<4 cm of lead left) in 88 (4.7%), and failed (>4 cm of lead left) in 32 (1.8%) patients. Removal success was unrelated to type of CIED infection (pocket or systemic). Predictors for failure were older leads and older patients [odds ratio (OR) 1.14 (1.08-1.19), P < 0.0001 and OR 2.68 (1.22-5.91), P = 0.0146, respectively]. In analysis by lead, predictors for failure were: pacemaker vs. defibrillator removal and failure to engage the locking stylet all the way to the tip [OR 0.20 (0.04-0.95), P = 0.03 and OR 0.32 (0.13-0.74), P = 0.008, respectively]. Significantly higher complication rates were noted in the failure group (40.6% vs. 15.9 for partial and 8.7% for success groups, P < 0.0001). Failure to remove a lead was a strong predictor for in hospital mortality [hazard ratio of 2.05 (1.01-4.16), P = 0.046].Conclusion: A total of 6.5% of infected CIED patients failed attempted extraction. Only were >4 cm of lead remained resulted in higher procedural complications and mortality rates. [ABSTRACT FROM AUTHOR]

Abstract An 86‐year‐old woman suffering from repeated methicillin‐resistant Staphylococcus aureus (MRSA) bacteremia underwent percutaneous lead extraction using an excimer laser. Since negative blood cultures were confirmed three times after lead extraction under intravenous infusion of anti‐MRSA drugs, a Micra transcatheter pacing system (Micra TPS) was implanted 7 days after the lead extraction. Although infusion of anti‐MRSA drugs was continued for 5 weeks, MRSA was isolated in four separate samples of blood cultures 3 weeks after the discontinuation of the anti‐MRSA therapy. The micra TPS was successfully retrieved using a steerable sheath and snare at 8 weeks after implantation.

Analysingthe example of unusual case of a successful direct constant His bundle pacing, we would like to draw specialist’s attention to details of procedure and some important electrophysiological particularities we have come across during operation. Long-term (7 years) results ( pacing options, ECG data, changes of left ventricle ejection fraction and patient’s quality of life) were considered too.