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Human in vivo data on the chemical stability of different transvenous lead materials, particularly OptimTM leads, are lacking. The purpose of this study was to determine the chemical reactivity of insulation materials by analyzing the molar mass of extracted pacing and defibrillator leads We collected extracted leads at Emory University Hospitals and sent the leads with thermoplastic outer insulation material for molar mass analysis, a material characteristic that informs biostability. Leads were separated based on the chemical identity of the outer insulation material, and the molar mass was measured by an independent party. The extent of chemical reaction was compared across leads having different materials: poly(ether)urethane 55D, poly(ether)urethane 80A, and Optim. A total of 70 leads were extracted. The subset of extracted leads having outer insulation materials composed of PEU or Optim were analyzed for molar mass, where implant times ranged from 0.12 to 16.26 years. The rate of chemical degradation was compared by plotting the extent of reaction [M n (t = 0)/M n (t)] as a function of implant time. The Optim molar mass decreased to 40% of its initial value at 10 years of implant. No change in the molar mass of the PEU insulations could be resolved over the same 10-year implant time. Because the molar mass of a polymer is directly related to its mechanical integrity, the observed decrease in molar mass of Optim likely translates into premature insulation defects and is consistent with the observed increased rate of electrical malfunction/noise in this subset of cardiac leads. [ABSTRACT FROM AUTHOR]

Background: Over 100,000 Abbott Riata® were implanted in the United States before they were recalled in 2010. There are still a significant number of Abbott Riata® leads in use, and it is unclear how these leads should be managed at the time of generator change or lead malfunction. Although data comparing both Sprint Fidelis® and Abbott Riata® leads in this setting is available, there are no multicenter comparative studies of outcomes for various lead management strategies, including lead extraction (LE), lead abandonment/revision (LA), and generator change (GC) only at the time of device at elective replacement interval (ERI) for Abbott Riata® leads. Methods: A retrospective, multicenter study was undertaken to compare short-term outcomes (major complications—MC, death, extended or re-hospitalizations within 60 days—RH, lead malfunction—LM) and total outcomes (short-term outcomes & lead malfunction during follow-up) of patients with Riata® leads undergoing LE, LA, or GC. Results: 152 patients (65 ± 13 years, 68% male) were followed for a mean 33 ± 30 months following intervention. Out of 166 procedures, 13 patients underwent LE, 16 patients underwent LA, and 137 patients underwent GC. There was 1 major complication in each group, yielding an event rate of 7.7% for LE, 6.3% for LA, and 0.7% for GC cohorts. There were significantly more short-term and total adverse outcomes in the group of patients getting LE and LA versus GC only (38.5% & 31.3% vs 7.3%, P < 0.001). Total Riata® lead dwell time follow-up was 17,067 months. A total of 3 Riata® lead malfunctions were noted during long-term follow-up. Inappropriate shocks were similar between LE 7.7% (1/13), LA 6.3% (1/16). and GC 11.0% (4/136); P = 0.57. Conclusions: There were more short-term and total adverse outcomes in more invasive management strategies (LE and LA) versus GC alone. The failure rate of Riata® leads was substantially lower compared to previous reports. Therefore, we recommend only performing battery exchange when a device with an active Riata® lead is at ERI, unless there is malfunction of the Riata® lead noted on testing. There were significantly more short-term adverse outcomes in the lead extraction (5/13) and lead abandonment/revision (5/16) groups than the generator only (8/137) group (P < 0.001). GIB – Gastrointestinal bleed, CHF – congestive heart failure, NSTEMI – non-ST elevation MI [ABSTRACT FROM AUTHOR]

Introduction: Cardiac implantable electronic device (CIED) complications present significant challenges in clinical practice, especially in elderly patients with multiple comorbidities. Common adverse events include infection, lead malfunction, and device migration. Twiddler's Syndrome, a rare but serious CIED complication characterised by patient manipulation causing lead displacement and device malfunction, is often underreported. The literature consists mainly of case reports and small series, providing limited guidance on prevention and management. As CIEDs are critical for managing cardiac arrhythmias and heart failure, understanding and addressing Twiddler's Syndrome is essential. This case report aims to contribute to the literature by detailing a case of Twiddler's Syndrome, emphasising the importance of a multidisciplinary approach for optimal management. Case Presentation: A 59-year-old male presented with discomfort around his implantable cardioverter defibrillator (ICD) site and the sternal area over the past two days. He denied pain, dyspnoea, or dizziness. Clinical examination revealed a normal heart rhythm and no peripheral pulse deficit. Ultrasound revealed a reduced left ventricular ejection fraction. The atrial lead was not visible, and the shock coil was misplaced. ICD interrogation showed inappropriate shocks due to sensing artifacts and exit block in both leads, with no arrhythmias detected. An X-ray confirmed lead dislodgement and significant entanglement in the pocket. The patient was diagnosed with Twiddler's Syndrome and scheduled for surgical revision. Discussion/Conclusions: Dilated cardiomyopathy (DCM), characterised by left ventricular dilatation and dysfunction, accounts for a significant proportion of systolic heart failure cases. Despite advancements in heart failure management, DCM patients remain at high risk for sudden cardiac death (SCD), making ICD implantation crucial. However, CIED placement carries risks of complications, including Twiddler's Syndrome. This condition can lead to lead dislodgement and device malfunction, resulting in inappropriate shocks and potential patient harm. In this case, a single-session extraction and re-implantation were successfully performed using a multidisciplinary approach, emphasising the importance of comprehensive management strategies to address such complications effectively. Regular follow-up showed no adverse events, highlighting the procedure's success and the potential benefits of using advanced antimicrobial adjuncts to prevent infections. This case underscores the need for awareness and standardised protocols for managing Twiddler's Syndrome to improve patient outcomes in the growing population of CIED recipients. [ABSTRACT FROM AUTHOR]

Background Objective Methods Results Conclusion The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject.To identify CT characteristics associated with increased TLE difficulty.All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac‐gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead‐removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty.A total of 343 patients were analyzed. The mean age of the study population was 63.8 ± 15.4 years; 71% were male. The mean lead dwell‐in duration was 8.6 ± 5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead‐removal fluoroscopy time (p = 0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p < 0.001, 95% CI: 2.54–10.46) and (odds ratio:3.72, p < 0.001, 95% CI: 1.89–7.35), respectively.In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead‐associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath. [ABSTRACT FROM AUTHOR]

Abstract Introduction Cardiac implantable electronic device (CIED) complications present significant challenges in clinical practice, especially in elderly patients with multiple comorbidities. Common adverse events include infection, lead malfunction, and device migration. Twiddler’s Syndrome, a rare but serious CIED complication characterised by patient manipulation causing lead displacement and device malfunction, is often underreported. The literature consists mainly of case reports and small series, providing limited guidance on prevention and management. As CIEDs are critical for managing cardiac arrhythmias and heart failure, understanding and addressing Twiddler’s Syndrome is essential. This case report aims to contribute to the literature by detailing a case of Twiddler’s Syndrome, emphasising the importance of a multidisciplinary approach for optimal management. Case Presentation A 59-year-old male presented with discomfort around his implantable cardioverter defibrillator (ICD) site and the sternal area over the past two days. He denied pain, dyspnoea, or dizziness. Clinical examination revealed a normal heart rhythm and no peripheral pulse deficit. Ultrasound revealed a reduced left ventricular ejection fraction. The atrial lead was not visible, and the shock coil was misplaced. ICD interrogation showed inappropriate shocks due to sensing artifacts and exit block in both leads, with no arrhythmias detected. An X-ray confirmed lead dislodgement and significant entanglement in the pocket. The patient was diagnosed with Twiddler’s Syndrome and scheduled for surgical revision. Discussion/Conclusions Dilated cardiomyopathy (DCM), characterised by left ventricular dilatation and dysfunction, accounts for a significant proportion of systolic heart failure cases. Despite advancements in heart failure management, DCM patients remain at high risk for sudden cardiac death (SCD), making ICD implantation crucial. However, CIED placement carries risks of complications, including Twiddler’s Syndrome. This condition can lead to lead dislodgement and device malfunction, resulting in inappropriate shocks and potential patient harm. In this case, a single-session extraction and re-implantation were successfully performed using a multidisciplinary approach, emphasising the importance of comprehensive management strategies to address such complications effectively. Regular follow-up showed no adverse events, highlighting the procedure’s success and the potential benefits of using advanced antimicrobial adjuncts to prevent infections. This case underscores the need for awareness and standardised protocols for managing Twiddler’s Syndrome to improve patient outcomes in the growing population of CIED recipients.

Cardiac implantable electronic device leads can contribute to tricuspid regurgitation and also complicate surgical and transcatheter interventions to manage tricuspid regurgitation. Here we present a case of a patient with sinus node dysfunction and complete heart block who underwent extraction of a right ventricular pacing lead before tricuspid valve surgery. We review the data regarding the contribution of leads to tricuspid regurgitation and the benefits of lead extraction, risks of jailing leads during tricuspid interventions, and pacing considerations around tricuspid valve procedures. [ABSTRACT FROM AUTHOR]

We present a complex case of cardiac implantable electronic device infection and extraction in the setting of bacteremia, large lead vegetation, and patent foramen ovale. Following a comprehensive preprocedural workup including transesophageal echocardiogram and computed tomography lead extraction protocol, in addition to the involvement of multiple subspecialties, an open chest approach to extraction was deemed a safer option for eradication of the patient's infection. Despite percutaneous techniques having evolved as the preferred extraction method during the last few decades, this case demonstrates the importance of a thorough evaluation at an experienced center to determine the need for open chest extraction. [ABSTRACT FROM AUTHOR]

Persistent left superior vena cava (PLSVC) is an anatomic variant that is relatively uncommon in the general population. Lead extraction through PLSVC is extremely rare. Due to unusual anatomy, the procedure carries challenges that require special considerations and careful planning. The authors report a case of lead extraction through a PLSVC with occluded right superior vena cava and highlight the challenges and outcomes of the procedure. [ABSTRACT FROM AUTHOR]

Introduction: Transvenous leads have been implicated in tricuspid valve (TV) dysfunction, but limited data are available regarding the effect of extracting leads across the TV on valve regurgitation. The aim of this study is to quantify tricuspid regurgitation (TR) before and after lead extraction and identify predictors of worsening TR. Methods: We studied 321 patients who had echocardiographic data before and after lead extraction. TR was graded on a scale (0 = none/trivial, 1 = mild, 2 = moderate, 3 = severe). A change of >1 grade following extraction was considered significant. Results: A total of 321 patients underwent extraction of a total of 338 leads across the TV (1.05 ± 0.31 leads across the TV per patient). There was no significant difference on average TR grade pre‐ and postextraction (1.18 ± 0.91 vs. 1.15 ± 0.87; p = 0.79). TR severity increased after extraction in 84 patients, but was classified as significantly worse (i.e., >1 grade change in severity) in only 8 patients (2.5%). Use of laser lead extraction was associated with a higher rate of worsening TR postextraction (44.0% vs. 31.6%, p = 0.04). Conclusion: In our single‐center analysis, extraction of leads across the TV did not significantly affect the extent of TR in most patients. Laser lead extraction was associated with a higher rate of worsening TR after extraction. [ABSTRACT FROM AUTHOR]

Key Clinical Message: This case highlights the pitfalls and provides tips for the extraction of deeply implanted lumenless leads, and encourages careful lead selection in the current era of widespread left bundle branch area pacing. The extraction of cardiovascular implantable electronic device leads is sometimes complicated. We describe a case with difficult but successful extraction of SelectSecure, a lumenless permanent pacemaker lead, implanted deep in the ventricular septum, highlighting its pitfalls and tips in the current era of left bundle branch area pacing. [ABSTRACT FROM AUTHOR]

Introduction: Management of transvenous leads in patients with congenital heart disease (CHD) can be complicated by venous obstructions and residual shunts. We present our experience performing concurrent lead extraction and dilation/stenting of venous pathways, including patients with complete venous obstruction. Methods: All cases of concurrent lead extraction and recanalization of vena cavae/baffles between 2017 and 2021 at Boston Children's Hospital were retrospectively included and reviewed for safety and efficacy. Results: Eight patients, 4 female, median 38.5 years of age (range 16.7−49 years) and 81.6 kg weight (range 41.3−97.8 kg) at time of procedure were included. All patients had CHD, a majority (n = 7) having transposition of the great arteries palliated via atrial switch. All leads were removed in their entirety, with most patients having two leads extracted (n = 7). Median lead dwell time was 13.8 years (range 3.6−35.3 years). Three patients had complete obstructions, three required stenting of their innominate veins and three required recanalization of their femoral vessels. Median procedure time was 9.8 h (range 5.4−12.8 h). Complications included blood transfusion (n = 2), arrhythmia (n = 3), pleural effusion (n = 1), and pressure ulcer (n = 1). There were no cardiac perforations, venous tears, or deaths. Conclusion: Lead extraction along with dilation and stenting of venous anomalies, though long in duration, proved effective with minimal complications. This combined procedure can safely and effectively resolve complete obstructions secondary to transvenous leads. [ABSTRACT FROM AUTHOR]

Background: Lead dwell time is the single strongest predictor of failure and complications in transvenous lead extraction. Objectives: To report the success rate and complications of transvenous lead extractions with implant dwell time of at least 15 years. Methods: Procedural and patient data were prospectively collected into a database. The excimer laser was the primary method for lead extraction with the use of mechanical rotational sheaths and femoral snares at operator discretion. Results: A total of 442 patients between 2011 and 2020 underwent lead extraction (705 leads) primarily for infection or device failure at our high‐volume center. Forty‐one patients with 71 leads > 15 years old were included in this cohort. Mean patient age was 53.5 ± 18.5 years, 67.5% were male. Mean lead dwell time was 19.6 ± 4.4 years. Thirty‐six of 41 (88%) patients had successful extraction of all leads compared to 96% in the remaining 401 patients, p value.004. Of the five patients without fully successful extractions two of these patients had abandoned leads (three total) that were clinically significant. There were two (4.9%) major complications in the very old lead group and six (1.5%) in the other group. In the very old lead group, one patient experienced right atrial appendage perforation requiring surgical repair and recovered well. One patient experienced new complete heart block requiring 2 min of CPR but did well thereafter. There was no procedure‐related mortality. Conclusions: Despite challenges posed by older leads, very old leads can be safely and effectively extracted with low complication rates. [ABSTRACT FROM AUTHOR]

Key Clinical Message This case highlights the pitfalls and provides tips for the extraction of deeply implanted lumenless leads, and encourages careful lead selection in the current era of widespread left bundle branch area pacing. Abstract The extraction of cardiovascular implantable electronic device leads is sometimes complicated. We describe a case with difficult but successful extraction of SelectSecure, a lumenless permanent pacemaker lead, implanted deep in the ventricular septum, highlighting its pitfalls and tips in the current era of left bundle branch area pacing.

BACKGROUND: Limited data exists for outcomes in patients undergoing cardiovascular implantable electronic device (CIED) transvenous lead extraction (TLE) without clear indications for device reimplantation. The implantable loop recorder (ILR) may be an effective strategy for continuous monitoring in select individuals. OBJECTIVE: This retrospective analysis aims to investigate patients who have undergone ILR implant following TLE without CIED reimplantation. METHODS: Clinical data from consecutive patients who have undergone TLE with ILR implant and without CIED reimplantation from October 2016 to May 2020 at a single center were collected. RESULTS: Among 380 patients undergoing TLE, 28 (7.7%) underwent ILR placement without CIED reimplantation. TLE indications were systemic infection (n = 13, 46.4%), pain at the site (n = 8, 28.6%), device/lead malfunction (n = 4, 14.2%), and other. Devices extracted included: dual-chamber and single-chamber pacemaker (n = 14, 50%; n = 4, 14.2%), dual-chamber implantable cardiac defibrillator (n = 10; 35.7%), and cardiac-resynchronization therapy with defibrillator (n = 1, 3.5%). Reasons for no reimplantation included no longer meeting CIED criteria (n = 14, 50%), patient preference (n = 9, 32.1%), and no clear or inappropriate indication for initial CIED implantation (n = 5, 18%). During an average of 12.3 ± 13.1 months of follow-up, there were no lethal arrhythmias, and four (13.3%) patients underwent permanent pacemaker reimplantation due to symptomatic sinus bradycardia and atrioventricular block with syncope as discovered on ILR. Three patients died due to unknown causes (n = 1), noncardiac (n = 1), and acute coronary syndrome (n = 1). CONCLUSIONS: In patients undergoing TLE without reimplantation, an ILR may be an effective monitoring strategy in patients at low risk for cardiac arrhythmia.

Abstract Background During transvenous lead extraction (TLE), a GlideLight laser sheath (Philips) cannot always be advanced over the lead, and crossover to the Evolution system (i.e., an Evolution RL sheath or Evolution Shortie RL sheath [Cook Medical]) is required. We aimed to determine the associated factors and outcomes of such device crossover. Methods This observational study included 112 patients who underwent TLE. The patients were divided into crossover and non‐crossover groups. Outcomes and associated factors of crossover were evaluated. Results Overall, 57 (50.9%) patients required crossover to the Evolution system (crossover group), whereas 55 (49.1%) patients did not require crossover (non‐crossover group). Clinical success rate was similar between the two groups (98.3% vs. 100%; p = 1.00). No major intraprocedural complications related to powered sheaths occurred. Multivariate logistic regression analysis results showed that dwell time of the oldest extracted lead (per year) (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02–1.36; p = .026), number of leads extracted per procedure (OR: 7.23, 95% CI: 1.74–29.99; p = .007), and use of a femoral approach (OR: 21.09, 95% CI: 2.33–190.67; p = .007) were associated factors of crossover. The cutoff for crossover was 7.7 years from the implant (sensitivity 90.5%, specificity 64.9%, area under the curve 0.80). Conclusions Both groups showed a high rate of clinical success. Switching to the Evolution system may facilitate a safe and effective TLE when a laser sheath does not advance despite laser activation.

Cardiac implantable electronic devices (CIEDs) implantation procedure has a complication rate of 5-6% according to most studies. Lead perforation is a possible and serious adverse event which can present with a spectrum of symptoms from asymptomatic to sudden death. Diagnostic tools in case of suspected lead perforation are X-ray, transthoracic echocardiography, pacemaker interrogation and computed tomography with the last one being the gold standard. Lead extraction could be done endovascularly or surgically. Transvenous removal is a possible option for active fi xation leads, while removal of passive fi xation leads is preferably done surgically, because of the bulky tip of the lead, which could damage the heart chambers and the vessels. In this article, we present a case of a massive ventricular perforation from a passive fi xation lead, further complicated by a cardiac tamponade. Surgical removal was the treatment of choice with subsequent implantation of a permanent dual-chamber pacemaker.

Background: During transvenous lead extraction (TLE), a GlideLight laser sheath (Philips) cannot always be advanced over the lead, and crossover to the Evolution system (i.e., an Evolution RL sheath or Evolution Shortie RL sheath [Cook Medical]) is required. We aimed to determine the associated factors and outcomes of such device crossover. Methods: This observational study included 112 patients who underwent TLE. The patients were divided into crossover and non‐crossover groups. Outcomes and associated factors of crossover were evaluated. Results: Overall, 57 (50.9%) patients required crossover to the Evolution system (crossover group), whereas 55 (49.1%) patients did not require crossover (non‐crossover group). Clinical success rate was similar between the two groups (98.3% vs. 100%; p = 1.00). No major intraprocedural complications related to powered sheaths occurred. Multivariate logistic regression analysis results showed that dwell time of the oldest extracted lead (per year) (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02–1.36; p =.026), number of leads extracted per procedure (OR: 7.23, 95% CI: 1.74–29.99; p =.007), and use of a femoral approach (OR: 21.09, 95% CI: 2.33–190.67; p =.007) were associated factors of crossover. The cutoff for crossover was 7.7 years from the implant (sensitivity 90.5%, specificity 64.9%, area under the curve 0.80). Conclusions: Both groups showed a high rate of clinical success. Switching to the Evolution system may facilitate a safe and effective TLE when a laser sheath does not advance despite laser activation. [ABSTRACT FROM AUTHOR]

Same-day discharge (SDD) after cardiovascular procedures is rapidly gaining ground. We sought to evaluate the safety of SDD after transvenous lead extraction (TLE). We performed a retrospective chart review of patients who underwent elective TLE between January 2020 and October 2021 at our institution. The primary outcome was SDD, and major procedural complications and readmissions within 30 days of the procedure were secondary outcomes. In this analysis of 111 patients who underwent elective TLE, 80 patients (72%) were discharged on the same day (SDD group) while 31 patients (28%) stayed overnight (overnight group). Lead malfunction was the most common indication for TLE in both groups. Patients in the overnight group were more likely to have a lead dwell time of ≤10 years than those in the SDD group (38.7% vs 20% of all leads in each group; P =.042), have laser sheaths used for extraction and a higher number of leads extracted. No major complications were reported in both groups. In a multivariate analysis, lower body mass index and the use of laser sheath during TLE were predictors of overnight stay. Patients who underwent a procedure using advanced extraction techniques were 3.5 times more likely to stay overnight (95% confidence interval 1.27–9.78; P =.016). In appropriately selected patients undergoing elective lead extraction, SDD is feasible and safe. Higher body mass index, fewer extracted leads, shorter lead dwell times (<10 years), and less frequent use of laser-powered extraction sheaths were associated with an increased likelihood of SDD. [ABSTRACT FROM AUTHOR]

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Despite progress in implantation technology and prophylactic measures, infection complications related to cardiac implantable electronic devices (CIED) are still a major concern with negative impacts on patient outcomes and the health system's resources. Infective endocarditis (IE) represents one of the most threatening CIED-related infections associated with high mortality rates and requires prompt diagnosis and management. Transvenous lead extraction (TLE), combined with prolonged antibiotic therapy, has been validated as an effective approach to treat patients with CIED-related IE. Though early complete removal is undoubtedly recommended for CIED-related IE or systemic infection, device reimplantation still represents a clinical challenge in these patients at high risk of reinfection, with many gaps in the current knowledge and international guidelines. Based on the available literature data and authors' experience, this review aims to address the practical and clinical considerations regarding CIED reimplantation following lead extraction for related IE, focusing on the reassessment of CIED indication, procedure timing, and the reimplanted CIED type and site. A tailored, multidisciplinary approach involving clinical cardiologists, electrophysiologists, cardiac imaging experts, cardiac surgeons, and infectious disease specialists is crucial to optimize these patients' management and clinical outcomes. [ABSTRACT FROM AUTHOR]

Aims Transvenous lead extraction (TLE) is important in the management of cardiac implantable electronic devices but carries risk. It is most commonly completed from the superior access, often with 'bail-out' support via the femoral approach. Superior and inferior access may be used in tandem, which has been proposed as an advance in safety and efficacy. The aim of this study is to evaluate the safety and efficacy of the Tandem approach. Method The 'Tandem' procedure entailed grasping of the targeted lead in the right atrium to provide countertraction as a rotational dissecting sheath was advanced over the lead from the subclavian access. Consecutive 'Tandem' procedures performed by a single operator between December 2020 and March 2023 in a single large-volume TLE centre were included and compared with the conventional superior approach (control) using 1:1 propensity score matching; patients were statistically matched for demographics. Results The Tandem in comparison with the conventional approach extracted leads of much greater dwell time (148.9 ± 79 vs. 108.6 ± 77 months, P < 0.01) in a shorter procedure duration (96 ± 36 vs. 127 ± 67 min, P < 0.01) but requiring more fluoroscopy (16.4 ± 10.9 vs. 10.8 ± 14.9 min, P < 0.01). The Tandem and control groups had similar clinical (100% vs. 94.7%, P = 0.07) and complete (94.8% vs. 92.8%, P = 0.42) success, with comparable minor (4% vs. 6.7%, P = 0.72) and major (0% vs. 4%, P = 0.25) complications; procedural (0% vs. 1.3%, P = 1) and 30-day (1.3% vs. 4%, P = 0.62) mortality were also similar. Conclusion The Tandem procedure is as safe and effective as the conventional TLE. It can be applied to leads of a long dwell time with a potentially shorter procedure duration. [ABSTRACT FROM AUTHOR]

Aims Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature. We sought to compare non-laser and laser TLE in a meta-analysis. Methods and results We searched Medline, Embase, Scopus, ClinicalTrials.gov, and CENTRAL databases for TLE studies published between 1991 and 2021. From the included 68 studies, safety and efficacy data were carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR), and pooled rates were synthesized from eligible studies to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed. Non-laser in comparison with laser had lower procedural mortality (pooled rate 0% vs. 0.1%, P < 0.01), major complications (pooled rate 0.7% vs. 1.7%, P < 0.01), and superior vena cava (SVC) injury (pooled rate 0% vs. 0.5%, P < 0.001), with higher complete success (pooled rate 96.5% vs. 93.8%, P < 0.01). Non-laser comparatively to laser was more likely to achieve clinical [OR 2.16 (1.77–2.63), P < 0.01] and complete [OR 1.87 (1.69–2.08), P < 0.01] success, with a lower procedural mortality risk [OR 1.6 (1.02–2.5), P < 0.05]. In the subgroup analysis, rotational tool compared with laser achieved greater complete success (pooled rate 97.4% vs. 95%, P < 0.01) with lower SVC injury (pooled rate 0% vs. 0.7%, P < 0.01). Conclusion Non-laser TLE is associated with a better safety and efficacy profile when compared with laser methods. There is a greater risk of SVC injury associated with laser sheath extraction. [ABSTRACT FROM AUTHOR]

Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads. [ABSTRACT FROM AUTHOR]

The difficulty and complexity of lead extraction procedures increase with the age of the lead to be extracted. The extraction of old (>20 years) leads is more time-consuming and requires advanced tools and a complex technique. In this case, we retrieved a very old (>30 years) lead using a loop formed by a catheter and a gooseneck snare. The catheter was rotated to remove the lead-bound sites. The lead was successfully retrieved using a Needle's Eye Snare.

Resumen: Actualmente existe controversia con respecto a la necesidad de extracción de electrodos abandonados o no funcionantes, sin infección y que no están suponiendo un riesgo evidente para el paciente.Esta situación puede presentarse en pacientes en los que, bien por disfunción de algún electrodo o por la necesidad de actualizar un dispositivo anterior, es necesario implantar nuevos electrodos. En estos casos ¿qué es lo más indicado, extracción o abandono de los electrodos previos? También en pacientes mayores, frágiles o con poca expectativa de esperanza de vida es frecuente replantearse la necesidad de someter al paciente al potencial riesgo de un procedimiento de extracción de electrodos abandonados.Aunque son varios los argumentos que suelen aludirse a la hora de inclinarnos hacia una postura más o menos conservadora en estas situaciones, cuando analizamos la evidencia publicada, es frecuente encontrar estudios con resultados contrapuestos en torno a estos argumentos. No obstante, el progresivo aumento de los procedimientos de extracción durante los últimos años, los avances técnicos producidos en este terreno y los buenos resultados conseguidos deberían favorecer una tendencia cada vez más favorable hacia la indicación de extracción en estos casos. Abstract: There is currently controversy regarding the need to remove abandoned or non-functioning electrodes, without infection and that are not posing an obvious risk to the patient.This situation can occur in patients in whom, either due to dysfunction of an electrode or the need to update a previous device, it is necessary to implant new electrodes. What is the most indicated, extraction or abandonment of the previous electrodes? Similarly, in elderly, frail patients or those with short life expectancy, it is common to rethink the need to subject the patient to the potential risks of the extraction procedure.There are several arguments that can be used when leaning towards a more or less conservative position in these situations. However, when we analyze the published evidence, it is common to find studies with conflicting results regarding these arguments. However, the progressive increase in extraction procedures, the technical advances produced in this field and the good results achieved should favor an increasingly favorable trend towards the indication of extraction in these cases.

Resumen: El implante de dispositivos electrónicos implantables cardíacos ha aumentado significativamente en respuesta al incremento de sus indicaciones basadas en la evidencia y, paralelamente, ha asociado también un ascenso en el número de dispositivos electrónicos implantables cardíacos a extraer por diferentes causas. Los electrodos de dispositivos electrónicos implantables cardíacos crónicamente implantados desarrollan frecuentemente tejido fibroso a nivel de la interfase entre electrodos adyacentes, endotelio venoso y endocardio, lo que implica una extracción de electrodos transvenosa facilitada por herramientas especializadas para liberar dichas adherencias.La extracción de electrodos transvenosa con láser excimer proporciona excelentes tasas de éxito completo del procedimiento y de éxito clínico, permitiendo tratar algunos pacientes que difícilmente podrían ser abordados con las otras técnicas existentes.El abordaje multidisciplinar «Heart Team» en un entorno apropiado para el procedimiento, con adecuado entrenamiento del personal, es fundamental para la detección precoz y el manejo exitoso de las complicaciones cardiovasculares de la extracción de electrodos transvenosa facilitada con láser. Abstract: The increase in the implantation rate of cardiac implantable electronic devices in the last decade has given rise to the need for transvenous lead extraction techniques, frequently in high-risk patients. Chronically implanted cardiac leads tend to develop a fibrous scar tissue surrounding them and among the venous endothelium and cardiac endocardium. This phenomenon makes necessary to resort to powered sheaths for TLE procedures.Laser-facilitated transvenous lead extraction of cardiac implantable electronic devices is a safe and highly effective procedure even in high-risk patients.A multidisciplinary “Heart Team” approach and an appropriate surgical work-up are mandatory for early identification and treatment of major cardiovascular complications.

Introduction: In an aging population with cardiac implantable electronic devices, an increasing number of octo‐ and even nonagenarians present for lead extraction procedures. Those patients are considered at increased risk for surgical procedures including lead extraction. Here, we investigated safety and efficacy of transvenous lead extraction in a large patient cohort of octo‐ and nonagenarians. Methods and Results: A subgroup analysis of all patients aged ≥80 years (n = 499) in the German Laser Lead Extraction Registry (GALLERY) was performed. Outcomes were compared to the nonoctogenarians from the registry. Primary extraction method was Laser lead extraction, with additional use of mechanical rotational sheaths or femoral snares, if necessary. An analysis of patient‐ and device characteristics, as well as an assessment of predictors for adverse events via multivariate analyses was conducted. Mean patients age was 84.3 ± 3.7 years in the octogenarians group and 64.1 ± 12.4 years in the nonoctogenarians group. The median lead dwell time was 118.0 months (78; 167) and 92.0 months [60; 133], p <.001 in the octogenarians and nonoctogenarians group, respectively. Clinical procedural success rate was achieved in 97.6% of the cases in octogenarians and 97.9% in nonoctogenarians (p =.70). Overall complication rate was 4.4% in octogenarians and 4.3% in nonoctogenarians (0.91). In octogenarians procedure‐related mortality was 0.8% and all‐cause in‐hospital mortality was 5.4%, while in nonoctogenarians, procedure related and all‐cause in‐hospital mortality were 0.5% and 3.1%, respectively. A body mass index (BMI) <20 kg/m2, was the only statistically significant predictor for procedure‐related complications in octogenarians, while systemic infection, BMI ≤20 kg/m2, procedural complications and chronic kidney disease were predictors for in‐hospital mortality. Conclusions: Laser lead extraction in octo‐ and nonagenarians is safe and effective. BMI ≤20 kg/m2 was the only statistically significant predictor for procedural complications. According to our data, advanced age should not be considered as contraindication for laser lead extraction. [ABSTRACT FROM AUTHOR]

Background: With the growing use of implantable cardiac devices, the need for transvenous lead extraction has increased, which translates to increased procedural volumes. Sex differences in lead extraction outcomes are not well studied. Objective: The present study aims at evaluating the impact of sex on outcomes of lead extraction. Methods: We identified 71,754 patients who presented between 2016 and 2019 and underwent transvenous lead extraction. Their clinical data were retrospectively accrued from the National Readmission Database (NRD) using the corresponding diagnosis codes. We compared clinical outcomes between male and female patients. Odds ratios (ORs) for the primary and secondary outcomes were calculated, and multivariable regression analysis was utilized to adjust for confounding variables. Results: Compared to male patients, female patients had higher in-hospital complications including pneumothorax (OR 1.26, 95% CI (1.07–1.4), P < 0.01), hemopericardium (OR 1.39, 95% CI (1.02–1.88), P = 0.036), injury to superior vena cava and innominate vein requiring repair (OR 1.88, 95% CI (1.14–3.1), P = 0.014; OR 3.4, 95% CI (1.8–6.5), P < 0.01), need for blood transfusion (OR 1.28, 95% CI (1.18–1.38), P < 0.01), and pericardiocentesis (OR 1.6, 95% CI (1.3–2), P < 0.01). Thirty-day readmission was also significantly higher in female patients (OR 1.09, 95% CI (1.02–1.17), P < 0.01). There was no significant difference regarding in-hospital mortality (OR 0.99, 95% CI (0.87–1.14), P = 0.95). Conclusion: In female patients, lead extraction is associated with worse clinical outcomes and higher 30-day readmission rate. [ABSTRACT FROM AUTHOR]

Background: Extraction of the implantable cardioverter-defibrillator (ICD) leads could be a difficult procedure due to fibrous tissue around the lead and anatomical variations. In this report, we present our experience in the radiographic predictors of failure of simple manual traction (SMT) in patients with dual-coil ICD requiring lead extraction (LE). Methods: Between January 2017 and February 2021, 103 leads were removed in 65 consecutive patients; 65 (63.1%) were dual-coil ICD leads, 22 (21.4%) were atrial, and 16 (15.5%) were coronary sinus leads. Patient-based and procedural data were collected and analyzed retrospectively. Clinical and procedural characteristics were compared and radiographic predictors of failure of SMT of ICD leads were assessed. Projected anteroposterior (AP) lead tortuosity was measured and lead slack score was estimated on chest X-ray (CXR). Results: Simple manual traction failed in 27 (42%) of the ICD leads. Ottawa slack score (odds ratio [OR] 2.368, 95% CI [1.261–4.447]; P = 0.007), AP lead tortuosity > 1.10 (OR 7.477, 95% CI [1.718–35.542]; P = 0.007), and number of previous interventions (OR 6.016, 95% CI [1.184–30.557]; P < 0.030) were found to be independently related to the failure of SMT. Receiver–operator characteristic curve analysis yielded an AP lead tortuosity cutoff value of > 1.10 for predicting the failure of SMT. The area under the curve was 0.744; the 95% confidence interval (CI) was 0.617 to 0.871 (P = 0.001), with a sensitivity of 63% and a specificity of 73%. Conclusion: Simple manual traction success in our study varied based on radiographic lead-related parameters. Before planning the procedure, increased AP lead tortuosity in vasculature and higher lead slack score can be easily determined on CXR and may be associated with more fibrous adherences, the complexity of the LE, and failure of SMT. [ABSTRACT FROM AUTHOR]

Background Reducing venous drainage of the coronary sinus is a promising intervention for refractory angina. Coronary Sinus Reducer (CSR) System™ effectively treats patients with refractory angina, possibly by increasing coronary collateral circulation, and leads to an improvement in their symptoms and quality of life. In patients with impaired left ventricular function and electrocardiographic dyssynchrony, cardiac resynchronization therapy (CRT) is an established treatment. However, there is only one published case report of CRT in a patient implanted with a CSR system. We present the first case series of CRT in patients implanted with the CSR system. Case summary This case series describes three patients. The first case demonstrated that CRT is feasible in patients implanted with a CSR system. The second case is the first report of a left ventricular lead extraction after CSR, and the third case was complicated due to the patient's medical history; however, CSR system implantation was feasible without major complications. Discussion Our results suggest that CRT is feasible in patients implanted with a CSR system, and lead extraction after CSR system implantation is possible. However, lead extraction in cases of severe adhesions around the CSR system and the coronary sinus may be associated with a high risk of complications; alternative options should be discussed at an early stage. [ABSTRACT FROM AUTHOR]

Pacemaker-dependent (PM) patients with cardiac implantable electronic device (CIED) infection require implantation of a temporary-pacemaker (TP) and delayed endocardial reimplantation or implantation of an epicardial-pacing-system (EPI) before device extraction. Our aim was to compare the TP and EPI-strategy after CIED extraction through a meta-analysis. We searched electronic databases up to 25 March 2022, for observational studies that reported clinical outcomes of PM-dependent patients implanted with TP or EPI-strategy after device extraction. 3 studies were included enrolling 339 patients (TP: 156 patients; EPI: 183 patients). TP compared to EPI showed reduction in the composite outcome of relevant complications (all-cause death, infections, need for revision or upgrading of the reimplanted CIED) (12.1% vs 28.9%; RR: 0.45; 95%CI: 0.25–0.81; p = 0.008) and a trend in reduction of all-cause death (8.9% vs 14.2%; RR: 0.58; 95%CI: 0.33–1.05; p = 0.07). Furthermore, TP-strategy proved to reduce need of upgrading (0% vs 12%; RR: 0.07; 95%CI: 0.01–0.52; p = 0.009), reintervention on reimplanted CIED (1.9% vs 14.7%; RR: 0.15; 95%CI: 0.05–0.48; p = 0.001) and significant increase in pacing threshold (0% vs 5.4%; RR: 0.17; 95%CI: 0.03–0.92; p = 0.04), with a longer discharge time (MD: 9.60 days; 95%CI: 1.98–17.22; p = 0.01). TP-strategy led to a reduction of the composite outcome of all-cause death and complications, upgrading, reintervention on reimplanted CIED, and risk of increase in pacing threshold compared to EPI-strategy, with longer discharge time. [ABSTRACT FROM AUTHOR]

Introduction: RENEDI (“Registro Nacional de Extracción de Dispositivos”) is the first inter-societary, observational and prospective registry on lead extraction designed in Argentina. Objective: To allow the observation of the implementation of this type of intervention in our country. Materials and method: an online database platform was designed. Data were supervised by a committee. Results: a total of 621 leads were extracted from 325 patients (average age of 59 years; 71% male). The targeted leads included 374 pacemaker leads, 176 implantable cardioverter-defibrillator leads and 71 cardiac resynchronization therapy defibrillators; 233 atrial, 367 ventricular and 21 coronary sinus leads placement. The average lead dwell time was 105.9 months. The commonest indication for removal was infection (68% - local 71%). Vascular or cardiovascular surgeons were usually the primary operator (81%). The presence of stand-by was reported in 72% of cases. Percutaneous approach (98%) was predominant. Minithoracotomy/sternotomy was performed in only 7 patients (16 leads). A total of 158 (25%) leads with a median dwell time of 33.3 months were extracted using simple traction. Additional tools were used in 75% of cases. Overall complications rate was 4%. Only one major complication was reported. Minor complications occurred in 3.6% of procedures. Complete procedural success was 96.2%. No deaths were reported. Conclusions: Argentinian practice has demonstrated that transvenous lead extraction is a safe and effective procedure associated with a low incidence of complications and high success rate when it is performed in well-trained hands. [ABSTRACT FROM AUTHOR]

Background: The gold standard for the treatment of cardiac implantable electronic devices (CIEDs)-related infection and lead malfunction is transvenous lead extraction (TLE). To date, the risk of mortality directly related to TLE procedures is relatively low, but data on post-procedural and long-term mortality are limited, even more in the aging population. Methods: Consecutive patients with CIEDs who underwent TLE were retrospectively studied. The primary outcome was the endpoint of death, considering independent predictors of long-term clinical outcomes in the TLE aging population comparing patients with and without infection. Results: One hundred nineteen patients (male 77%; median age 76 years) were included in the analysis. Eighty-two patients (69%) documented infection, and thirty-seven (31%) were extracted for a different reason. Infected patients were older (80 vs. 68 years, p-value > 0.001) with more implanted catheters (p-value < 0.001). At the last follow-up (FU) available (median FU 4.1 years), mortality reached 37% of the patient population, showing a statistically significant difference between infected versus non-infected groups. At univariable analysis, age at TLE, atrial fibrillation, and anemia remained significant correlates of mortality; at multivariable analysis, only patients with anemia and atrial fibrillation have a 2.3-fold (HR 2.34; CI 1.16–4.75) and a 2.5-fold (HR 2.46; CI 1.33–4.54) increased rate of death, respectively. Conclusion: Our long-term data showed that aging patients who underwent TLE for CIED-related infection exhibit a high mortality risk during a long-term follow-up, potentially leading to a rapid and effective procedural approach in this patient population. [ABSTRACT FROM AUTHOR]

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Resumen: Paciente varón de 80 años con primer implante de marcapasos DDD Medtronic Kappa el año 2000, con recambio de generador el 2008 y el 2014. El año 2020 se indica actualización del dispositivo a DAI-TRC. Ingresa en septiembre del 2021 por infección del dispositivo, con cultivo positivo a Staphyloccocus aureus y hemocultivos negativos. En la región del bolsillo del generador presenta lesión granulomatosa con exudado hemático. En el ecocardiograma transtorácico se observan un electrodo ventricular totalmente adherido al velo septal de la válvula tricúspide y el otro en ventrículo derecho que interfiere con el movimiento del velo anterior que condiciona una insuficiencia tricúspide severa. Se indica extracción completa del dispositivo y reimplante contralateral de un nuevo sistema DAI-TRC. Para el procedimiento se realizó una tomografía axial computarizada, donde se observa el recorrido de los electrodos más antiguos apoyados completamente en la cara posterior y lateral de la innominada y cava, dando la impresión de estar situados en el espesor de la grasa perivascular y sin poder descartar su curso extravascular. Se realizó extracción completa del dispositivo y reimplante contralateral. Se implantó un electrodo epicárdico de ventrículo izquierdo a través de una pequeña toracotomía izquierda y un electrodo de desfibrilación endocavitario en ventrículo derecho, a través de subclavia derecha. Luego, mediante la utilización de vainas de extracción con láser excimer se consiguió la extracción completa de los electrodos previos. Finalmente, se tuneliza el electrodo de ventrículo izquierdo a la región subclavicular derecha y se conectan los electrodos al generador. Abstract: An 80-year-old male patient with the first DDD Medtronic Kappa pacemaker implantation in 2000, with generator replacement in 2008 and 2014. In 2020, a device upgrade to CRT-ICD is indicated. He was admitted in September 2021 due to device infection, with a positive culture for Staphyloccocus aureus and negative blood cultures. In the region of the generator pocket, he presented a granulomatous lesion with hematic exudate. The transthoracic echocardiogram shows one ventricular electrode totally adhered to the septal leaflet of the tricuspid valve and the other in the right ventricle that interferes with the movement of the anterior leaflet, leading to severe tricuspid insufficiency. Complete removal of the device and contralateral reimplantation of a new ICD-CRT system is indicated. For the procedure, a computed tomography was performed. Where the path of the oldest leads supported completely on the posterior and lateral face of the innominate and vena cava are observed, giving the impression of being located in the thickness of the perivascular fat and without being able to rule out their extravascular course. Complete removal of the device and contralateral reimplantation were performed. A left ventricular epicardial electrode was implanted through a small left thoracotomy and an endocavitary defibrillation electrode in the right ventricle, through the right subclavian artery. Then, by using excimer laser extraction sheaths, complete extraction of the previous leads was achieved. Finally, the left ventricular lead is tunneled to the right subclavicular region and the leads are connected to the generator.

With the advent of conduction system pacing, use of the Medtronic SelectSecure Model 3830 lead has increased substantially. However, with this increased use, the potential need for lead extraction also will increase. Lumenless lead construction requires an understanding of both applicable tensile forces as well as lead preparation techniques that can influence consistent extraction. The purpose of this study was to use bench testing methodologies to characterize the physical properties of lumenless leads and to describe related lead preparation methods that support known extraction techniques. Multiple 3830 lead preparation techniques, commonly used in extraction practices, were compared on the bench to assess rail strength (RS) in simple traction and use conditions with simulated scar. Retention of the IS1 connector vs severing the lead body preparation techniques were compared. Distal snare and rotational extraction tools were evaluated. The retained connector method provided higher RS compared to the modified cut lead method: mean 11.42 lbf (9.85–12.73 lbf) vs 8.51 lbf (1.66–14.32 lbf), respectively. Snare use distally did not significantly affect RS: mean 11.05 lbf (8.58–13.95 lbf). Lead damage occurred with the TightRail extraction tool at angles ≥90°, which could occur with right-sided implants. When extracting SelectSecure leads, the retained connector method to maintain cable engagement benefits preservation of the extraction RS. Limiting traction force to <10 lbf (4.5 kgf) and avoiding poor lead preparation methods are critical to consistent extraction. Femoral snaring does not change RS when needed and offers a method to regain lead rail in cases of distal cable fracture. [ABSTRACT FROM AUTHOR]

Purpose: The use of cardiac implantable electronic devices (CIEDs) has increased significantly over the last decades. With the development of transvenous lead extraction (TLE), procedural success rates also improved; however, data regarding long-term outcomes are still limited. The aim of our study was to analyze the outcomes after TLE, including reimplantation data, all-cause and cause-specific mortality. Methods: Data from consecutive patients undergoing TLE in our institution between 2012 and 2020 were retrospectively analyzed. Periprocedural, 30-day, long-term, and cause-specific mortalities were calculated. We examined the original and the revised CIED indications and survival rate of patients with or without reimplantation. Results: A total of 150 patients (age 66 ± 14 years) with 308 leads (dwelling time 7.8 ± 6.3 years) underwent TLE due to pocket infection (n = 105, 70%), endocarditis (n = 35, 23%), or non-infectious indications (n = 10, 7%). All-cause mortality data were available for all patients, detailed reimplantation data in 98 cases. Procedural death rate was 2% (n = 3), 30-day mortality rate 2.6% (n = 4). During the 3.5 ± 2.4 years of follow-up, 44 patients died. Arrhythmia, as the direct cause of death, was absent. Cardiovascular cause was responsible for mortality in 25%. There was no significant survival difference between groups with or without reimplantation (p = 0.136). Conclusions: Despite the high number of pocket and systemic infection and long dwelling times in our cohort, the short- and long-term mortality after TLE proved to be favorable. Moreover, survival without a new device was not worse compared to patients who underwent a reimplantation procedure. Our study underlines the importance of individual reassessment of the original CIED indication, to avoid unnecessary reimplantation. [ABSTRACT FROM AUTHOR]

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Abstract Background An exponential rise in clinical demand for cardiac implantable electronic device (CIED) therapy is observed all over the world due to the rapidly expanding lifespan. Accordingly, appropriate lead management including lead extraction is becoming increasingly essential components for the comprehensive care of patients with various CIEDs. Main body With a high success rate and a low complication rate, transvenous lead extraction (TLE) has now been established as first-line therapy for lead extraction. However, TLE is often challenging when there are heavily calcified fibrous adhesions between leads and cardiovascular structures. Recently, rotational mechanical dilator (RMD) sheaths were introduced to resolve this issue and facilitate TLE procedure. There are two types of commercially available RMD sheaths, Evolution® systems and TightRail™. Thorough knowledge of the proper use of the RMD devices is essential to increase success rate and to reduce complications of TLE. In the present review, mechanical features, various techniques, and clinical data of RMD sheaths will be described. Conclusion According to recent advancement of device technology, the clinical outcomes of TLE using the RMD sheaths are continuously improving. However, as the RMD sheath is a potentially aggressive tool, special care should be taken when used in patients with longer lead ages. Author names: Please confirm if the author names are presented accurately and in the correct sequence (given name, family name). Author 2 Given name: Ju Youn, Family name: Kim; Author 4 Given name: Young Keun, Family name: On; Author 5 Given name: June Soo, Family name: Kim. Also, kindly confirm the details in the metadata are correct.All of the author names are correct.