Implantable defibrillator lead extraction with optimized standard extraction techniques

Background Implantable cardioverter-defibrillator (ICD) leads might not be extracted especially in developing countries because of the high cost and lack of specialized tools. We aimed to evaluate transvenous extraction of ICD leads using optimized standard techniques. Methods We prospectively analyzed clinical characteristics, optimized extraction techniques and the feasibility of extraction for 40 patients (33 males; mean age 47.9 ? 16.1 years) with 42 ICD leads. Results Complete procedural success rate was 95.2% (40/42), and the clinical success rate was 97.6% (41/42). One ICD lead required cardiothoracic surgery. Minor complications occurred in three cases (7.5%), and no major complications or death occurred. Locking stylets were used to extract most leads (34, 81.0%) and almost half of the leads (20, 47.6%) required mechanical dilatation to free fibrotic adhesions; these leads had been implanted for a longer period of time than the others (43.7 ± 18.2 vs. 18.4 ± 13.4 months, P < 0.05). Three-quarters of the leads (30, 71.4%) were extracted with locking stylets plus manual traction (12, 28.6%), or mechanical dilatation with counter-traction (18, 42.8%) by the superior vena cava approach and one-quarter of the leads (11, 26.2%) were removed by optimized snare techniques using the femoral vein approach. Median extraction time was 20 min (range 2–68 min) per lead. Linear regression analysis showed that the extraction time was significantly correlated with implant duration (r = 0.70, P < 0.001). Median follow-up was 14.5 months (range 1–58 months), no infection, or procedure-related death occurred in our series. Conclusions Our optimized procedure for transvenous extraction of ICD leads provides a practical and low-cost method for standard procedures.     

双心室同步房室顺序起搏植入型心律转复除颤器

目的 观察双心室同步房室顺序起搏植入型心律转复除颤器(ICD)对扩张性或缺血性心肌病出现顽固性充血性心力衰竭同时伴有恶性室性心律失常时的治疗效果。方法 5例患者均为男性。心功能(NYHA分级)Ⅲ～Ⅳ级。QRS时限120～183ms，左心室射血分数(LVEF)≤0．30，左心室舒张末直径≥60mm，均有室性心动过速(室速)及心室颤动(室颤)发作史。药物治疗无效。分别植入右心房和心脏静脉左心室分支起搏电极导线，并植入右心室除颤电极导线，行房室顺序双心室同步起搏及抗室性心律失常治疗。随访观察患者临床症状、心功能、LVEF及室性心律失常的变化。结果 右心房、右心室和左心室导线感知和起搏参数均符合要求、右心室导线除颤阈值佳。起搏后QRS时限明显缩短，起搏前平均155ms，起搏后平均133ms，随访3～20个月，心功能术前平均3．4级，术后3个月平均2．4级；LVEF术前平均0．25，术后3个月0．29，1例术后6个月LVEF为0．34；5例患者共发生室速4次，均以31J的能量1次除颤成功。结论 双心室同步房室顺序起搏可改善心力衰竭患者的临床症状，增加LVEF，改善心功能。双心室同步起搏ICD具有良好的抗室性心律失常的功能。     

Implantable cardioverter defibrillator: a review.

Sudden cardiac death claims 400,000 to 450,000 lives annually. It is believed that sudden cardiac death results predominantly from ventricular fibrillation or sustained ventricular tachycardia that deteriorates into ventricular fibrillation. Conventional treatments for patients who suffer from ventricular arrhythmias have been limited to antiarrhythmic drugs or surgery. These treatments have proved ineffective to a portion of arrhythmia sufferers. The implantable cardioverter defibrillator offers hope to a segment of ventricular arrhythmia sufferers whose disease is resistant to conventional therapies.     

Implantable defibrillator and ventricular resynchronisation

Ventricular resynchronisation by pacing, introduced at the end of the 1990s, has revolutionised the management of advanced chronic cardiac failure. Its value in the reduction of haemodynamic mortality has been demonstrated in the latest studies. However, despite these decisive advances, patients with cardiac failure continue to have a high incidence of sudden death which, classically, according to its stage of progression, represents 28 to 68% of deaths in this condition. The implantable automatic defibrillator (IAD) has been shown to be effective in preventing sudden death, mainly in patients with severe left ventricular dysfunction. Based on these data, and in a context of rapid technological progress, devices capable of both defibrillating and resylchronising the heart have been introduced. The problems experienced at the beginning of their utilisation, mainly related to "double-counting" of left and right ventricular electrical activation have been resolved and the method is now technically feasible. A complication rate >10%, mainly due to the implantation of the left heart catheter, continues to bear witness to the difficulties of this technique and to the severity of the condition of patients referred for the treatment. The COMPANION trial has shown a greater reduction in mortality of patients treated by resynchronisation associated with IAD compared with resynchronisation alone or medical therapy in > or = Stage III cardiac failure. The SCD-HeFT trial has recently demonstrated that the primary prevention of global mortality by the IAD is effective in cardiac failure irrespective of the underlying cardiac pathology, especially in functional Stage II. These results should lead to significant increase in the indications for implantation of devices capable of both resynchronisation and defibrillation. However, the obvious problems of cost associated with the difficulty of the technique mean that a systematic attitude cannot be recommended. A case-by-case discussion has its place but the causal cardiac disease, ischaemic or not, does not seem to be a determining factor.     

Implantable cardioverter defibrillator therapy in athletes

Implantable cardioverter defibrillators (ICD) prevent recurrent arrhythmic death in sudden death survivors or may prevent its development in physically active patients with an underlying risk for malignant ventricular arrhythmias. Although ICD do not substitute for the usual recommendations to refrain from intensive or competitive exercise because of an underlying arrhythmic disorder, they often provide a means for safe continuation of mild to moderate recreational sports activity. Long-term quality of life will be highly dependent on the prevention of inappropriate ICD shocks. This requires the choice of a durable lead and device system, careful programming tailored to the characteristics of the patient's physiologic and pathologic heart rhythms, preventive bradycardic medication, and guided rehabilitation with psychologic counseling.     

植入型心房除颤器治疗心房颤动的临床应用

目的 评估入型心房除颤器（ｉｍｐｌａｎｔａｂｌｅ ａｔｒｉａｌ ｄｅｆｉｂｒｉｌｌａｔｏｒ,ＩＡＤ）治疗阵发性和持续性心房颤动（房颤）患者的有效性和安全性。方法 １１例患者（８例阵发性房颤,３例持续性房颤）安装了ＩＡＤ,型吨Ｍｅｔｒｉｘ＾ＴＭ３０００和Ｍｅｔｒｉｘ＾ＴＭ３０２０。所有的患者在室功能正常,４５％存在高血压等基础心脏病。ＩＡＤ在识别房颤和心室同步化后,通过右房－冠状静脉窦电流路线,发放     

植入型心律转复除颤器在遗传性心律失常患者中的应用及术后随访

目的 了解因遗传性心律失常植入心律转复除颤器(ICD)的患者术后情况及ICD的治疗效果.方法 回顾性分析阜外医院从2004年6月到2011年6月诊断为长QT综合征、Brugada综合征、致心律失常性右心室心肌病(ARVC)以及肥厚型心肌病并且植入了ICD的全部患者,通过定期随访及调阅患者的ICD内存储的数据了解患者术后的一般情况、ICD植入术后室性心律失常的发作情况以及ICD的工作情况.结果 共入选患者43例,其中男25例,女18例,年龄8～78(41.5±15.8)岁,随访8 ～84 (37.0±20.6)个月.21例(48.8％)患者在随访期内发生室性心动过速/心室颤动(室速/室颤)事件,其中有5例(11.6％)患者发生的室速/室颤事件属于不恰当识别.1例患者在植入ICD后发生未识别事件.ICD共记录到室速/室颤事件382次,植入ICD后首次发生室速/室颤事件的时间为术后1～36(6.4±8.9)个月,84.6％的室速/室颤事件发生于1年内.ICD共启动治疗程序498次,包括抗心动过速起搏381次,同步电复律83次,高能量除颤34次.结论 遗传性心律失常患者恶性室性心律失常复发率高且复发早.二级预防植入ICD可有效预防患者猝死的发生.     

Implantable cardioverter defibrillator therapy in patients with cardiac sarcoidosis

ICD Shocks in Cardiac Sarcoidosis . Background: An implantable cardioverter defibrillator (ICD) is indicated for some patients with cardiac sarcoidosis (CS) for prevention of sudden death. However, there are little data regarding the event rates of ICD therapies in these patients. We sought to identify the incidence and characteristics of ICD therapies in this patient population. Methods: We performed a cohort study of patients with ICDs at 3 institutions. Cases were those patients with CS and an ICD implanted for primary or secondary prevention of sudden death. Additionally, we included a comparison with historical controls of ICD therapy rates reported in clinical trials evaluating the ICD for primary and secondary prevention of sudden death. Results: Of the 112 CS subjects identified, 36 (32.1%) received appropriate therapies for ventricular tachyarrhythmias (VT) over a mean follow‐up period of 29.2 months. VT storm (>3 episodes in 24 hours) occurred in 16 (14.2%) CS subjects. Inappropriate therapies occurred in 13 CS subjects (11.6%). Covariates associated with appropriate ICD therapies included left ventricular ejection fraction (LVEF) <55% (OR 6.52 [95% CI 2.43–17.5]), right ventricular dysfunction (OR 6.73 [95% CI 2.69–16.8]), and symptomatic heart failure (OR 4.33 [95% CI 1.86–10.1]). Conclusions: In our cohort of patients with CS and ICDs, almost one‐third receive appropriate therapies. This may be due to a myocardial inflammatory process leading to increased triggered activity and subsequent scarring leading to reentrant tachyarrhythmias. Adjusted predictors of ICD therapies in this population include left or right ventricular dysfunction. (J Cardiovasc Electrophysiol, Vol. 23, pp. 925‐929, September 2012)     

Implantable cardioverter defibrillator therapy in postinfarction patients

PURPOSE OF REVIEW: In the past few years, new clinical trials were conducted to determine the effectiveness of implantable cardioverter defibrillators (ICDs) for prevention of mortality in patients with ischemic and nonischemic cardiomyopathies. This paper aims to provide an overview of the current state of knowledge regarding ICD therapy in postinfarction patients. RECENT FINDINGS: Postinfarction patients with severe left ventricular dysfunction are at high risk of sudden cardiac death. Antiarrhythmic therapy does not improve survival in such patients and, therefore, ICDs emerged as treatment of choice for both primary and secondary prevention of mortality after MI. The MADIT (Multicenter Automatic Defibrillator Implantation Trial) and MUSTT (Multicenter Unsustained Tachycardia Trial) trials were the first primary prevention ICD trials documenting a substantial reduction in mortality with an ICD in postinfarction patients with depressed ejection fraction, nonsustained ventricular tachycardia, and inducible sustained ventricular tachycardia. The recently completed MADIT II trial broadened indications for prophylactic use of ICD in postinfarction patients with ejection fraction of 30% or less without a requirement for additional risk stratifiers. The benefit from ICD therapy in patients with low ejection fraction was recently confirmed by results from the SCD-HeFT (Sudden Cardiac Death in Heart Failure) and COMPANION (Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure) trials. SUMMARY: Recent clinical trials established ICD as an important therapeutic modality for primary and secondary prevention of mortality in postinfarction patients.     

A wandering defibrillator lead

A 53-year-old woman was admitted because of sudden onset ofsevere chest pain and palpitations. Her medical history revealedan out-of-hospital cardiac arrest due to ventricular tachycardiacaused by arrhythmogenic right ventricular cardiomyopathy forwhich an implantable cardioverter-defibrillator was implantedwith epicardial patches. On 2D echocardiography, a mobile pieceof lead was seen in the right atrium and right ventricle, looselyattached to the free wall of the right ventricule; 3D reconstructionconfirmed this suggestion. Remarkably, the lead disappearedwhile performing the echocardiogram. A pulmonary artery fluoroscopywas performed. It had positioned itself in the right pulmonaryartery. The lead could be extracted from the right pulmonaryartery using an extraction device. We suggest that during aperiod of frequent bending physical activity, the lead musthave started its journey by perforating through the free wallof the right ventricle and had then been carried away by theblood flow towards the right pulmonary artery. The lead mustbe a residue of an epicardial defibrillation lead, which hasnot been removed completely after the heart transplantationperformed 10 years earlier. Perforations of pacemaker leadsare not uncommon but as far as we know, such a witnessed dislocationand migration of an epicardial defibrillator lead has not beendescribed before.     

Implantable cardioverter defibrillator trials: what's new?

The implantable cardioverter defibrillator (ICD) has been in clinical use for 20 years and its clinical role is becoming increasingly clear. A number of well-designed trials demonstrated its effectiveness in high-risk patients who have already experienced a malignant arrhythmia. A more controversial role for the ICD is in patients who are at high risk but have not yet had an arrhythmic event. Randomized clinical trials published in the late 1990s demonstrated survival benefit with the ICD in narrowly defined high-risk populations. These populations are presently defined by a low ejection fraction and inducible ventricular tachyarrhythmia. Clinical trials still in progress will determine whether broader populations will benefit from prophylactic ICD implantation. These trials will have broad clinical importance.     

植入型心律转复除颤器在致心律失常性右心室心肌病患者中的应用

目的 总结阜外心血管病医院应用植入型心律转复除颤器(ICD)治疗致心律失常性右心室心肌病(ARVC)的经验.方法 入选我院2004年3月至2012年3月确诊并植入ICD的ARVC患者,收集临床资料,进行常规电话及门诊随诊.结果 共18例患者[男12例,女6例,平均年龄(46.4±13.8)岁]入选,平均随访(46.6±30.5)个月,有6例患者出现了111次室性心动过速(VT)/心室颤动(VF)事件,其中仅1次VF事件,其余均为VT事件,其中3例患者术后共出现了7次电风暴.ICD治疗组中的C反应蛋白(CRP)明显高于ICD未治疗组.111次VT/VF事件中,12次经电除颤终止心动过速,其余均通过抗心动过速起搏(ATP)终止了心动过速.结论 ARVC患者ICD植入后的VT/VF事件以VT为主,多数可经ATP终止;出现电风暴的ARVC患者易反复发作恶性心律失常;CRP可能对ICD治疗具有预测价值.