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Cardiac implantable electronic devices establish proper therapy for the prevention of sudden cardiac death, significantly reducing the morbidity and mortality of patients with arrhythmias and heart failure. It is well-known that the number of electrodes increases the risk of complications. To preserve the benefit of atrial sensing without the need to implant an additional lead, a single-lead ICD system with a floating atrial dipole (DX ICD lead) has been developed. Besides all of the potential benefits, the necessity of a reliable and stable atrial sensing via the floating dipole could be the main concern against the use of this lead type. In the current generation of DX devices, the specially filtered atrial signal seems to be high enough and stable over time, which is crucial in the early detection of atrial arrhythmias, discrimination between different forms of tachycardias in order to prevent inappropriate ICD therapy, and achieving an optimal atrioventricular and interventricular synchrony in patients with a two-lead CRT-DX system. The present review summarizes the benefits and potential drawbacks of the DX ICD systems based on the available literature, furthermore, proposes an evidence-based algorithm of ICD type selection.

Inadvertent placement of pacemaker and implantable cardioverter-defibrillator (ICD) leads in the left ventricle is a rare but well-recognized complication of device implantation. We report a case of an unicameral ICD lead inadvertently placed through the left subclavian artery right positioned, across the aortic valve into the left ventricle, in a patient with situs viscerum inversus. A transthoracic echocardiogram about a month after the procedure showed an unusual course of the lead. The lead was successfully removed without complications or sequelae.

A 53-year-old man with a subcutaneous implantable cardioverter-defibrillator (S-ICD) presented with inappropriate shocks. He underwent device extraction, and the lead was freed using a rotating mechanical dilator sheath. As patients with S-ICDs get older, extractions will become more complicated and more common. We have described a novel method of S-ICD lead extraction. (Level of Difficulty: Advanced.), Central Illustration

AngioVac system (AngioDynamics) has already proved to be a useful tool in the treatment of thrombotic and endocarditic formations concerning the venous district. Herein, the AngioVac aspiration system combined with the bidirectional rotational Evolution mechanical sheath lead extraction was used for an effective and safety cardiac-device-related-infective-endocarditis removal in a grown-up congenital heart disease patient through a totally peripheral approach.

Ιn a 76-year old man with a dual-chamber ICD implanted five years ago, dizzy spells and significant bradycardia on Holter were not initially recognized as inhibition of bradycardia pacing, due to oversensing. Hospital admission was deemed necessary only after repetitive ICD shocks attributed to right ventricular pace-sense lead fracture. The need to ensure adequate ICD antibradycardia backup pacing in pacing-dependent patients when deleterious sensing errors occur, cannot be overemphasized.

Background Cardiac resynchronization therapy-defibrillator (CRT-D) implantation via the cephalic vein is feasible and safe. Recent evidence has suggested a higher implantable cardioverter-defibrillator (ICD) lead failure in multi-lead defibrillator therapy via the cephalic route. We evaluated the relationship between CRT-D implantation via the cephalic and ICD lead failure. Methods Data was collected from three CRT-D implanting centers between October 2008 and September 2017. In total 633 patients were included. Patient and lead characteristics with ICD lead failure were recorded. Comparison of "cephalic" (ICD lead via cephalic) versus "non-cephalic" (ICD lead via non-cephalic route) cohorts was performed. Kaplan-Meier survival and a Cox-regression analysis were applied to assess variables associated with lead failure. Results The cephalic and non-cephalic cohorts were equally male (81.9% vs. 78%; p = .26), similar in age (69.7 ± 11.5 vs. 68.7 ± 11.9; p = .33) and body mass index (BMI) (27.7 ± 5.1 vs. 27.1 ± 5.7; p = .33). Most ICD leads were implanted via the cephalic vein (73.5%) and patients had a mean of 2.9 ± 0.28 leads implanted via this route. The rate of ICD lead failure was low and statistically similar between both groups (0.36%/year vs. 0.13%/year; p = .12). Female gender was more common in the lead failure cohort than non-failure (55.6% vs. 17.9%, respectively; p = .004) as was hypertension (88.9% vs. 54.2%, respectively, p = .038). On multivariate Cox-regression, female sex (p = .008; HR, 7.12 [1.7-30.2]), and BMI (p = .047; HR, 1.12 [1.001-1.24]) were significantly associated with ICD lead failure. Conclusion CRT-D implantation via the cephalic route is not significantly associated with premature ICD lead failure. Female gender and BMI are predictors of lead failure.

Background After the reports of recalled leads, several technological improvements have been introduced and the durability of implantable cardioverter defibrillator (ICD) leads has improved. The incidence of lead failures is now less than in the previous studies. However, there are few reports that have shown the long-term durability of ICD leads as compared to pacemaker (PM) leads. This study analyzed the medium to long-term performance of transvenous ICD leads as compared to PM leads. Methods We retrospectively studied 1227 cases from April 2007 to December 2017 who underwent an initial transvenous ICD or PM implantation. The number of lead failures and patient background characteristics were analyzed. Results During a median 3-3.5 years follow up period, 1 (0.3%) ICD lead and 18 (2.4%) PM leads failed. The incidence of lead failures was significantly higher in the PM group than ICD group (p = .019). Males were associated with a higher incidence of lead failures in the PM group. Conclusion Since the era of recalled ICD leads, the durability of ICD leads has remarkably improved and the incidence of lead failures with non-recalled ICD leads has been less than that for PM leads.

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 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.

Six months after subcutaneous implantable cardioverter defibrillator (S-ICD) implantation a 26-year-old Brugada patient presented because of a beeping tone emitted by his device. Chest X-ray displayed two functionless transvenous shock leads and the S-ICD system with a lead fracture. During lead revision procedure, extensive preparation of the lead from unexpectedly firm surrounding fibrous tissue encapsulating the lead was necessary before it could be removed, and a new shock lead could be implanted. This is the first report of an S-ICD lead exchange due to very early lead fracture and unexpectedly severe fibrous tissue hampering surgical lead extraction.

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

Background: When an implantable-cardioverter defibrillator (ICD) lead becomes non-functional, a recommendation currently exists for either lead abandonment or removal. Lead abandonment and subcutaneous ICD (S-ICD) implantation may represent an additional option for patients who do not require pacing. The aim of this study was to investigate the outcomes of a strategy of lead abandonment and S-ICD implantation in the setting of lead malfunction.Methods: We analyzed all consecutive patients who underwent S-ICD implantation after abandonment of malfunctioning leads and compared their outcomes with those of patients who underwent extraction and subsequent reimplantation of a single-chamber transvenous ICD (T-ICD).Results: Forty-three patients underwent S-ICD implantation after abandonment of malfunctioning leads, while 62 patients underwent extraction and subsequent reimplantation of a new T-ICD. The two groups were comparable. In the extraction group, no major complications occurred during extraction, while the procedure failed and an S-ICD was implanted in 4 patients. During a median follow-up of 21 months, 3 major complications or deaths occurred in the S-ICD group and 11 in the T-ICD group (HR 1.07; 95% CI 0.29–3.94; P = 0.912). Minor complications were 4 in the S-ICD group and 5 in the T-ICD group (HR 2.13; 95% CI 0.49–9.24; P = 0.238).Conclusions: In the event of ICD lead malfunction, extraction avoids the potential long-term risks of abandoned leads. Nonetheless the strategy of lead abandonment and S-ICD implantation was feasible and safe, with no significant increase in adverse outcomes, and may represent an option in selected clinical settings. Further studies are needed to fully understand the potential risks of lead abandonment.Clinical Trial Registration: URL: ClinicalTrials.gov Identifier: NCT02275637

Purpose The Biotronik LinoxSmart DX implanted cardioverter defibrillator (ICD) lead is a novel VDD lead with the advantage of integrated atrial sensing dipole combined with a special augmentation and filtering mechanisms. We sought to determine the efficacy of the Biotronik LinoxSmart DX ICD lead. Methods Non-randomized consecutive patients implanted with Biotronik LinoxSmart DX lead at Sheba Medical Center were included in this study. Electrical parameters and arrhythmic events were recorded during follow up of one year. Results Seventy-three patients (69 males (94.5%), mean age 61 ± 12 years) were included. All patients were successfully implanted with a Biotronic VR-T DX device and LinoxSmart DX ICD lead (DX-17 in 37% and DX-15 in 63% patients). Mean P wave amplitude at time of implantation was 3.66 ± 2.9 mV and improved significantly throughout the follow-up (5.29 ± 4.39 mV, p = 0.009). Appropriate atrial sensing (defined as P wave amplitude of ≥0.8 mV) rate of 100% at implantation significantly decreased to 89% (p = 0.015) at 12 months. Three out of 67 (4.5%) patients without a known history of atrial fibrillation had documented new onset paroxysmal atrial fibrillation. Appropriate shocks occurred in 4 (5.5%) patients. One patient with atrial sensing less than 0.4 mV had inappropriate shock. Conclusions Among patients implanted with the Biotronik LinoxSmart DX ICD lead in our single center, appropriate atrial sensing rate decreased over 12 months. Larger studies are needed to evaluate the reliability of long term appropriate atrial sensing.

Background An early failure of Biotronik Linox implantable cardioverter defibrillator (ICD) leads has been reported from several centers. Aim To compare the performance of Linox ICD leads with different other ICD leads as a report of the Sheba Medical Center experience. Methods All patients who had implantation of Linox ICD leads between 2007 and 2016 were included in this study. ICD lead failure was defined as low- or high-voltage impedance; failure to capture, sense, or defibrillate; or the presence of nonphysiological signals not due to external interference. The survival probability of Linox leads was determined and compared to Medtronic Sprint Quattro ICD leads. Results A total of 340 patients (age 64.4 ± 1.8 years) were included in this analysis. They were followed up to 105 months (mean 45.7 ± 7, median 44 (Interquartile range (IQR) 26-63) months). Twelve patients (3.5%) met the criteria for lead failure within 61.2 ± 22.9 months (median 66.5 [IQR 48-85 months]) post implantation. Noise with inappropriate ventricular arrhythmias detection, with or without therapy, was seen in 10 patients (83%). High pacing thresholds and high impedances were detected in two patients (17%). The survival probability of Linox leads at 60 months (97.3%) was similar to the survival probability of Sprint Quattro leads (98.2%) (P = .58). Nevertheless, the survival probability at 105 months was much lower (81% vs 97%, Linox ICD lead and Sprint Quattro lead, respectively, P = .0039). Conclusion Linox ICD leads have higher late failure rates compared to Sprint Quattro leads. These findings need to be confirmed in larger scale studies.

Aims: Riata® implantable cardioverter-defibrillator (ICD) leads from St. Jude Medical are prone to malfunction. This study aimed to describe the rate of this lead's malfunction in a very long-term follow-up. Methods: This single-centre observational study included 50 patients who received a Riata 7Fr dual-coil lead between 2003 and 2008. Follow-up was conducted both in person and remotely, and analysed at 8-month intervals. We evaluated the rates of cable externalization (CE), electrical failure (EF), and the interaction of these two complications. Structural lead failure was defined as radiographic CE. Oversensing of non-cardiac signal or sudden changes in impedance, sensing, or pacing thresholds constituted EF. Results: During a mean follow-up of 10.2 ± 2.9 years, 16 patients (32%) died. We observed lead malfunction in 13 patients (26%): three (23%) due to CE, six (46%) to EF and four (31%) to both complications. Of the malfunctioning leads, 77% failed after seven years of follow-up. The incidence rate (IR) of overall malfunction per 100 patients per year was 0.9 during the first seven years post-implantation, increased to 7.0 after the 7th year and more than doubled (to 16.7) after 10 years. Beyond seven years post-implantation, IR per 100 patient-years increased in both EF and CE (from 0.6 to 5.6 vs. 0.3 to 4.2, respectively). Presence of CE was associated with a 4-fold increase in the proportion of EF. Conclusion: The incidence of Riata ICD lead malfunction, both for EF and CE, increased dramatically after seven years and then more than doubled after 10 years post-implantation. Keywords: Implantable cardioverter-defibrillator, Long-term follow-up, Malfunction, Cable externalization, Electrical failure

This case report demonstrates a late atrial lead dislodgement, ICD lead externalization and lead interaction due to the atrial lead screw‐helix catching the externalized loop of the ICD lead, leading to simultaneous dual lead over‐sensing in the post‐shock phase.

Background: Here we aimed to evaluate the respiratory and cardiac-induced motion of a ICD lead used as surrogate in the heart during stereotactic body radiotherapy (SBRT) of ventricular tachycardia (VT). Data provides insight regarding motion and motion variations during treatment. Materials and methods: We analyzed the log files of surrogate motion during SBRT of ventricular tachycardia performed in 20 patients. Evaluated parameters included the ICD lead motion amplitudes; intrafraction amplitude variability; correlation error between the ICD lead and external markers; and margin expansion in the superior-inferior (SI), latero-lateral (LL), and anterior-posterior (AP) directions to cover 90% or 95% of all amplitudes. Results: In the SI, LL, and AP directions, respectively, the mean motion amplitudes were 5.0 +/- 2.6, 3.4. +/- 1.9, and 3.1 +/- 1.6 mm. The mean intrafraction amplitude variability was 2.6 +/- 0.9, 1.9 +/- 1.3, and 1.6 +/- 0.8 mm in the SI, LL, and AP directions, respectively. The margins required to cover 95% of ICD lead motion amplitudes were 9.5, 6.7, and 5.5 mm in the SI, LL, and AP directions, respectively. The mean correlation error was 2.2 +/- 0.9 mm. Conclusions: Data from online tracking indicated motion irregularities and correlation errors, necessitating an increased CTV-PTV margin of 3 mm. In 35% of cases, the motion variability exceeded 3 mm in one or more directions. We recommend verifying the correlation between CTV and surrogate individually for every patient, especially for targets with posterobasal localization where we observed the highest difference between the lead and CTV motion. Web of Science 26 1 137 128

Since it was introduced 40 years ago, the implantable cardioverter-defibrillator (ICD) has become a mainstay of therapy for patients at risk for life-threatening ventricular tachycardia (VT) and fibrillation (VF). This chapter explores challenges and opportunities for future ICD therapy. Historically, transvenous leads have been the weak link in ICD systems. We review improved engineering standards for transvenous leads and methods to prevent proarrhythmia from ICD lead dislodgements, as well advantages and limitations of subcutaneous and substernal lead systems and their potential integration with leadless pacemakers. We consider better ways to ensure that necessary therapy is delivered for VT/VF while delivering fewer unnecessary and inappropriate shocks. Remote monitoring of ICD patients has become the standard of practice. We approach potential improvements in remote patient management related both to alerts generated in the ICD and potentially more computationally intensive analysis performed after device data is transmitted to servers. Perhaps the greatest unmet need is prediction and prevention of VT/VF. We review avenues for improvement both in long-term risk stratification to optimize utilization of ICDs and in short-term prediction of VT/VF to permit development of device-based preventive therapies.

Introduction: Pacemaker and ICD lead failure or vascular occlusion can require lead extraction. Predictors of a need for lead extraction due to venous occlusion are not well characterized. Hypothesis: Coronary artery disease (CAD) is an independent predictor of lead extraction due to venous occlusion. Methods: We performed a retrospective study of consecutive patients in a prospectively collected registry at a single center undergoing lead extraction due to either venous occlusion or lead failure from 10/2011 to 02/2020. Patients requiring lead extraction due to infection were excluded. Continuous variables are reported as mean ± standard deviation or total number reported as a percentage (%). Chi square test and logistic regression were used to estimate difference in rates and Odds Ratio. Statistically significant findings were identified with a p valve < 0.05. Results: Of 384 procedures included in the database, 131 patients met inclusion criteria for venous occlusion (17%) or lead failure (83%) (Table 1). Average age of the cohort was 55.1 ± 16.4 years and 51% were female. Baseline ejection fraction was 44.6 ± 15.5% and 19.7% of patients had NYHA class III or IV symptoms. 29.7% had a history of CAD. Average number of leads extracted was 1.3 ± 0.57 compared to 2.1 ± 0.82 leads in situ. Patients with CAD had a statistically significant increased risk for extraction as a result of venous occlusion Odds Ratio of 6.80, 95% CI 2.47-18.6, p = 0.0001. Conclusions: Identification of predictors of venous occlusion and risk stratification of these patients is an important component of procedural planning and shared decision making. CAD is a predictor of venous occlusion in patients undergoing lead extraction and should be assessed as a risk factor for complex lead management decisions. Further study is warranted to identify mechanisms by which this relationship can be used to predict need for extraction due to vascular occlusion.

Contains fulltext : 225390.pdf (Publisher’s version ) (Open Access) BACKGROUND: The subcutaneous implantable cardioverter-defibrillator (ICD) was designed to avoid complications related to the transvenous ICD lead by using an entirely extrathoracic placement. Evidence comparing these systems has been based primarily on observational studies. METHODS: We conducted a noninferiority trial in which patients with an indication for an ICD but no indication for pacing were assigned to receive a subcutaneous ICD or transvenous ICD. The primary end point was the composite of device-related complications and inappropriate shocks; the noninferiority margin for the upper boundary of the 95% confidence interval for the hazard ratio (subcutaneous ICD vs. transvenous ICD) was 1.45. A superiority analysis was prespecified if noninferiority was established. Secondary end points included death and appropriate shocks. RESULTS: A total of 849 patients (426 in the subcutaneous ICD group and 423 in the transvenous ICD group) were included in the analyses. At a median follow-up of 49.1 months, a primary end-point event occurred in 68 patients in the subcutaneous ICD group and in 68 patients in the transvenous ICD group (48-month Kaplan-Meier estimated cumulative incidence, 15.1% and 15.7%, respectively; hazard ratio, 0.99; 95% confidence interval [CI], 0.71 to 1.39; P = 0.01 for noninferiority; P = 0.95 for superiority). Device-related complications occurred in 31 patients in the subcutaneous ICD group and in 44 in the transvenous ICD group (hazard ratio, 0.69; 95% CI, 0.44 to 1.09); inappropriate shocks occurred in 41 and 29 patients, respectively (hazard ratio, 1.43; 95% CI, 0.89 to 2.30). Death occurred in 83 patients in the subcutaneous ICD group and in 68 in the transvenous ICD group (hazard ratio, 1.23; 95% CI, 0.89 to 1.70); appropriate shocks occurred in 83 and 57 patients, respectively (hazard ratio, 1.52; 95% CI, 1.08 to 2.12). CONCLUSIONS: In patients with an indication for an ICD but no indication for pacing, the subcutaneous ICD was noninferior to the transvenous ICD with respect to device-related complications and inappropriate shocks. (Funded by Boston Scientific; PRAETORIAN ClinicalTrials.gov number, NCT01296022.).

Background Implantable cardioverter-defibrillator (ICD) lead dysfunction has been reported after left ventricular assist device (LVAD) implantation in limited single-center studies. We aimed at describing and characterizing the incidence of ICD lead parameters dysfunction after LVAD implantation. Methods Among the 652 patients enrolled in the ASSIST-ICD study, only patients with an ICD prior to LVAD were included (n = 401). ICD lead parameters dysfunction following LVAD implantation is defined as follows: (a) >50% decrease in sensing threshold, (b) pacing lead impedance increase/decrease by >100Ω, and (c) >50% increase in pacing threshold. Results One hundred twenty-two patients with an ICD prior to LVAD had available ICD interrogation reports prior and after LVAD. A total of 67 (55%) patients exhibited at least one significant lead dysfunction: 17 (15%) exhibited >50% decrease in right ventricular (RV) sensing, 51 (42%) had >100 Ω increase/decrease in RV pacing impedance, and 24 (20%) experienced >50% increase in RV pacing threshold. A total of 52 patients experienced ventricular arrhythmia during follow-up and all were successfully detected and treated by the device. All lead dysfunction could be managed conservatively. Conclusion More than 50% of LVAD-recipients may experience >1 significant change in lead parameters but none had severe clinical consequences.

Funding Acknowledgements NO FUNDING OnBehalf Rhythm Detect Registry Background Currently, when an implantable-cardioverter defibrillator (ICD) lead becomes nonfunctional, a class IIa recommendation exists for either lead abandonment or for removal. The benefits of removal include creation of an access for insertion of a new lead. However, the subcutaneous ICD (S-ICD) does not require the insertion of any leads into the cardiovascular system, and may represent an additional option for patients not requiring pacing. Purpose To report outcomes associated with a strategy of lead abandonment and S-ICD implantation in the setting of lead malfunction. Methods We analyzed all consecutive patients who underwent S-ICD implantation after abandonment of malfunctioning leads and we compared outcomes with those of patients who underwent transvenous extraction and subsequent reimplantation of a single-chamber transvenous ICD (T- ICD). Results 43 patients were implanted with an S-ICD after abandonment of malfunctioning leads, while in 62 patients extraction and subsequent reimplantation of a T-ICD. The two groups were comparable (Age 55 ± 16 vs. 54 ± 33years, BMI 26 ± 3 vs. 24 ± 4kg/m2, LVEF 43 ± 15 vs. 48 ± 8%). S-ICD defibrillation test success rate at implantation was 96% at 65J. In the extraction group, no major complications were reported during extraction, while the procedure failed and an S-ICD was implanted in 4 patients. During a median follow-up of 21 months, the rate of major complications was not higher in the S-ICD group than in the T-ICD group (HR 1.07; 95%CI 0.29–3.94; P = 0 .912; Figure), as well as the rate of minor complications (HR 2.13; 95%CI 0.49–9.24; P = 0 .238). Conclusions In case of ICD lead malfunction, extraction prevents potential long-term risks of abandoned leads, e.g. increased complications for a possible future mandatory extraction indication such as infection, and allows magnetic resonance imaging. Nonetheless in this series, the strategy of lead abandonment and S-ICD implantation appeared to be feasible and safe with no significant increase in adverse outcomes for patients not requiring pacing and may represent an option in selected clinical settings (very high risk or failed extractions, older patients, etc.). Longer follow-up studies are needed to fully understand the potential risks of lead abandonment. Abstract Figure

The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to transvenous ICD in patients who do not need cardiac pacing. We report the case of a young isometric athlete who received S-ICD for primary prevention of sudden death. Lead dislodgement and myopotential noise oversensing during isometric training led to inappropriate shock, and a surgical revision was performed. During the procedure, strong fibrous adhesions were found, requiring polytetrafluoroethylene dilator sheaths. The S-ICD was finally reimplanted. Despite continued isometric training, no more myopotential oversensing occurred after 1-year follow-up. The present case highlights the possible higher risks of lead complication in an isometric athlete and the uncommon effort in removing an old-generation subcutaneous defibrillator lead.

A 62-year-old woman presented with intractable VT/VF precipitated by PVCs. Extreme externalization of multiple conductors of a Riata® ICD lead were thought to be precipitating the ventricular arrhythmias. The conductors were percutaneously removed as to avoid complete lead extraction.

BACKGROUND Subcutaneous implantable cardioverter-defibrillator (S-ICD) implantations are rapidly expanding. However, the subcutaneous detection and interpretation of cardiac signals in S-ICDs is much more challenging than by conventional devices. There is a complete paradigm shift in cardiac signal sensing with subcutaneous signal detection, leading in some cases to oversensing with restricted programming options.OBJECTIVES The aim of this single-center study was to quantify and describe cases where recurring oversensing made the extraction of the device necessary.METHODS Consecutive patients (n = 108) implanted with an S-ICD in our tertiary referral hospital were considered for analysis. Clinical and remote monitoring data were analyzed.RESULTS The S-ICD had to be explanted in 6 of 108 implanted patients (5.6%) because of refractory oversensing issues: myopotential oversensing, P- or T-wave oversensing, rate-dependent left bundle branch block aberrancy during exercise with R-wave double counting, and R-wave amplitude decrease after ventricular tachycardia ablation leading to noise detection. Seventeen of 108 patients experienced oversensing (15.7%): 9 patients had at least 1 inappropriate charge without a shock (8.3%), 3 patients had at least 1 inappropriate shock (2.8%), and 5 patients had both episodes (4.6%).CONCLUSION So far, cardiologists have had to deal with transvenous ICD lead fractures, but signal oversensing without correcting programming option could be the equivalent weakness of S-ICDs, despite an adequate screening.

Son yillarda ani kardiyak olum oranlarinda artis gorulmektedir. Gunumuzde, implante edilebilir kardiyoverter defibrilator (implantable cardioverter defibrilator, ICD) ani kardiyak olumleri onlemede kullanilan bir cihazdir. Travma sonucunda cihazda birtakim problemler meydana gelebilmektedir. Kablo kirigi bu problemlerden biridir. Literaturde, kunt travmaya bagli ICD komplikasyonlarinin, ozellikle kablo kiriginin oldukca nadir goruldugu belirtilmektedir. Bu olgu sunumunda; eski esi tarafindan sol kolu cekilerek kunt travmaya maruz kalan ve olusan kablo kirigi nedeniyle uygunsuz soklara maruz kalan kadin olgu medikolegal acidan degerlendirildi. Olguda, gogse direkt bir travma olmadan, sol kolun cekilmesine bagli olarak lead kirigi meydana gelmistir. Hafif siddetteki bir travmanin bile, yasamsal tehlike olusturabilecek, ciddi klinik sonuclara neden olabilecegine dikkat cekmek amaclandi.

Background As the transvenous defibrillator lead is fragile and its failure may cause a life‐threatening event, reliable insertion techniques are required. While the extrathoracic puncture has been introduced to avoid subclavian crush syndrome, the reports on the long‐term defibrillator lead survival using this approach, especially the comparison with the cephalic cutdown (CD), remain scarce. We aimed to evaluate the long‐term survival of the transvenous defibrillator lead inserted by the extrathoracic subclavian puncture (ESCP) compared with CD. Methods Between 1998 and 2011, 324 consecutive patients who underwent an implantable cardioverter‐defibrillator (ICD) implantation in Hokkaido University Hospital were included. ICD leads were inserted by CD from 1998 to 2003 and by contrast venography‐guided ESCP thereafter. Lead failure was defined as a nonphysiologic high‐rate oversensing with abnormal lead impedance or highly elevated sensing and pacing threshold. Results Of 324 patients, CD was used in 37 (11%) and ESCP in 287 patients (89%). During the median follow‐up of 6.2 years (IQR:3.2‐8.3), 7 leads (2 in CD and 5 leads in ESCP group) failed. All patients with lead failure in ESCP group were implanted with either SJM Riata (n = 1) or Medtronic Fidelis lead (n = 4). Five‐year lead survival was 93.8% (CI95%:77.3‐98.4%) in CD compared with 99.1% (CI95%:96.6‐99.8%) in ESCP group (P = 0.903). Univariate Cox regression analysis showed that the use of Fidelis or Riata lead was the strong predictor of the ICD lead failure (HR 13.8, CI95%:2.9‐96.5; P = 0.001). Conclusions Contrast venography‐guided extrathoracic puncture ensures the reliable long‐term survival in the transvenous defibrillator leads.

RATIONALE AND OBJECTIVE To identify the influence of various parameters for reducing artifacts in computed tomography (CT) of commonly used pacemakers or implantable cardioverter-defibrillator (ICD) lead tips. MATERIALS AND METHODS This ex vivo phantom study compared two CT techniques (Dual-Energy CT [DECT] vs. Dual-Source CT [DSCT]), as well as the influence of incremental alterations of current-time product and pacemaker lead-tip angle with respect to the gantry plane. Four pacemaker leads and one ICD lead were evaluated. The images were assessed visually on a five-point Likert scale (1 = artifact free to 5 = massive artifacts). Likert values 1-3 represent clinically relevant, diagnostic image quality. RESULTS 344 of 400 total images were rated with diagnostic image quality. The DECT and dual-source DSCT technique each scored 86% diagnostic image quality. Statistically, DECT images showed significantly improved image quality (P

Data on preferred ICD lead type and optimal RV lead position in patients undergoing CRT-D implantation are limited. To compare dual- versus single-coil ICD leads and non-apical versus apical RV lead position and their impact on clinical parameters and survival in CRT-D recipients. A total of 563 consecutive patients with advanced heart failure and indication for CRT-D implantation were enrolled in two European tertiary centers. Endpoints were improvement in NYHA functional class, changes in echo- and electrocardiographic parameters, and all-cause and cardiovascular mortality. In this retrospective analysis, a total of 313 (56%) dual- and 250 (44%) single-coil ICD leads were used. RV leads were placed non-apically in 262 (47%) and apically in 296 (53%) patients, respectively. Over a mean follow-up of 41 ± 34 months, all-cause mortality and cardiovascular mortality were similar for patients with dual- versus single-coil ICD lead (adjusted HR 0.81, 95% CI 0.58–1.12 and aHR 1.22, 95% CI 0.73–2.04) and non-apical versus apical RV lead position (aHR 0.98, 95% CI 0.71–1.36 and aHR 0.76, 95% CI 0.44–1.31). Non-apical RV lead position was associated with greater reduction in QRS duration after CRT implantation (− 14.4 ± 32.1 vs. − 4.3 ± 34.3 ms, p

Introduction ICD lead failure is a potential source of significant morbidity and mortality. This study investigates the survival rates of Sprint Quattro, Endotak Reliance, and Linox ICD leads. Methods and results A retrospective cohort study of all patients with an ICD implanted between January 2007 and December 2012 from the Wellington Hospital region, New Zealand, a tertiary referral center. Lead and patient details were established by review of clinical notes and the PaceArt Optima database. We analyzed a total of 287 implants using Sprint Quattro (n = 92), Endotak Reliance (n = 37), Linox (n = 151), Riata (n = 4), and Sprint Fidelis (n = 2) leads. Median follow-up was 61.6 (26.0-81.6) months for Sprint Quattro leads, 66.7 (53.3-88.8) months for Linox leads, and 82.9 (45.9-107.4) months for Endotak Reliance leads. There were 20 cases of lead failure of which 19 were in Linox leads. The 4-, 6-, and 8-year survival for Linox leads was 97% (92.6-99.1), 93% (85.5-96.5), and 76% (62.3-85.5), respectively. The predominant abnormality was detection of nonphysiological electrical signals. Linox lead failure was associated with a younger age of patient (49.2 vs. 57.7 years, P = 0.007). Conclusions The 7-year survival of Linox leads was significantly worse than shown in Biotronik surveillance reports, but in line with other single-center studies from around the world.

Subcutaneous implantable cardioverter defibrillators (S‐ICD) have become a reasonable alternative to single‐chamber transvenous ICD systems for patients who pass the screening protocol.1, 2 There is limited experience however in managing patients who require a sternotomy who have previously had a S‐ICD placed. Concerns over lead damage, lead positioning poststernotomy, and possible contact between the lead and the sternotomy wires are the main concerns that may result in device malfunction.