Mechanical extraction of cardiac implantable electronic devices leads with long dwell time: Efficacy and safety of the step up approach

The aim of this study was to evaluate the efficacy and safety of the stepwise mechanical transvenous lead extraction approach in a patient population with chronically implanted transvenous leads with a long dwell time. From January 2014 till December 2018, all lead extractions with lead dwell time ≥5 years performed at our tertiary centre were retrospectively analysed. A total of 173 leads, from 78 patients (median age 68 years; 81% male) with a median dwell time of 9 years (interquartile range [IQR] 5) were extracted, with three or more leads in 42% of the patients. Right atrial leads: 41%; right ventricular pacing leads: 16%; implantable cardioverter‐defibrillator (ICD) leads: 31% (72% dual coil); coronary sinus leads: 12%. The majority (75%) of the leads had an active fixation. Most frequent indication for extraction was pocket infection/erosion (76%). Overall clinical success was 97%, and complete procedural success was 93%. Venous patency, assessed with venous angiography, was well preserved in 93% of the cases. The overall procedural complication rate was 3.8% (2.6% major and 1.3% minor). Despite the complexity of the population and a very long dwell time (median 9 years), a clinical success rate of 97% was achieved with the stepwise mechanical approach. Analysis of impeding progression of pectoral extraction suggests that dense fibrosis and sharp lead curvature in the transvenous trajectory pose a challenge. Complication rate was low, and acute venous patency was generally well preserved.     

Electroconvulsive therapy in patients with cardiac pacemakers and implantable cardioverter defibrillators

Electroconvulsive therapy (ECT) is used to treat major depressive illness, especially in elderly and medically frail patients. Not uncommonly, these patients have cardiac pacemakers or implantable cardioverter defibrillators (ICDs). Only a few case reports in the literature describe the use of ECT in such patients. Herein we review our ECT experience treating 26 pacemaker patients and 3 ICD patients. All patients obtained significant antidepressant benefits with ETC. Only one serious cardiac event occurred, a case of supraventricular tachycardia (SVT) requiring a stay on the cardiac intensive care unit. The SVT resolved and the patient went on to receive further uncomplicated ECT treatments. We conclude from this experience that with proper pre-ECT cardiac and pacemaker/defibrillator assessment, ECT can be safely and effectively administered to patients with an implanted cardiac device.     

Management of cardiac implantable electronic device infections: the challenges of understanding the scope of the problem and its associated mortality

The indications for cardiac implantable electronic devices (CIEDs) have increased significantly over the last two decades. This has led to a surge in device implants in an expanding cohort of recipients who are in general older and who have more comorbidities. Implantation of CIED is carried out under sterile techniques and with the use of perioperative antibiotics; however, despite all these preventive measures, CIED infection remains a significant complication. Many recent reports and data from national registries have suggested an increased rate of CIED infection. However, our understanding of its true incidence remains limited due to the lack of a clear denominator as the number of patients living with CIEDs continues to expand and the pool of patients who are at risk for developing infection is growing. The importance of CIED infection has been emphasized in many recent studies that have also suggested significant morbidity and mortality risk associated with this complication that spans beyond the extraction procedure of the infected device.     

Projection-based motion compensation and reconstruction of coronary segments and cardiac implantable devices using rotational X-ray angiography

Cardiologists use two-dimensional projection images in conventional X-ray coronary angiography for the assessment of three-dimensional structures. During minimally invasive interventions there is a need to clearly visualize and analyze contrast filled coronary arteries, surrounding tissue, and implanted devices. Three-dimensional reconstruction of these structures is challenging due to the cardiac and respiratory motion. In this paper we describe a method to automatically generate motion compensated reconstructions of various structures using rotational X-ray angiography.The method uses markers on a device or guide wire to identify and estimate the motion of an object or region of interest in order to register and motion compensate the projection images to generate a motion compensated reconstruction. The method is evaluated on 20 rotational acquisitions and the average marker couple detection rate is 84% for cardiac stents, 90% for closure devices and 20% for contrast filled coronaries. The projection images are motion compensated based on the semi-automatically detected markers and subsequently used for reconstruction. We conclude that it is feasible to reconstruct cardiac stents, closure devices, contrast filled coronaries, and calcified plaques using rotational X-ray angiography.     

Potential cardiac risk of immune‐checkpoint blockade as anticancer treatment: What we know,what we do not know,and what we can do to prevent adverse effects

Cancer immunotherapy has become a well‐established treatment option for some cancers after the development of a family of drugs targeting the so‐called immune checkpoints, such as CTLA4 and PD‐1 with PD‐L1. These co‐receptors/ligands inhibit the activation of T‐cell, thus preventing an excessive inflammatory response. Tumors exploit these pathways to induce immune tolerance to themselves. Thus, the main effect of checkpoint‐blocking drugs is to awake an immune response primarily directed against cancer cells. Nonetheless, as the immune response elicited by these drugs is not completely tumor‐specific, their use may actually cause several adverse effects, including adverse cardiovascular effects. In this review, we will discuss the principles and potentiality of immunotherapy for cancer treatment, the experimental and clinical data on the role of CTLA4 and PD‐1 with PD‐L1 as immune‐checkpoints in the cancer environment and in the cardiovascular system, and strategies aimed at preventing possible cardiovascular adverse effects of immune‐checkpoint blockers.     

Survey of the information given to patients about blood transfusion and the need for consent before transfusion

There is no current requirement in the United Kingdom to provide patients with information about blood transfusion or to seek their written consent to transfusion. To study patients' attitudes to these questions, a questionnaire survey was carried out on 51 patients during an admission to hospital in which they received a blood transfusion. The patients in this survey, although mostly satisfied about the information they were given before they were transfused, would have welcomed more general information about transfusion, mainly because of concerns about the risk of viral infections. Nearly 40% of patients thought that written consent should be obtained before transfusion, but the ethical and practical aspects of this issue are complex. Further debate would be required before implementation of written consent to transfusion could be considered as a routine policy.     

The relationship between age and outcome in out-of-hospital cardiac arrest patients

AimTo determine the association between age and outcome in a large multicenter cohort of out-of-hospital cardiac arrest patients.MethodsRetrospective, observational, cohort study of out-of-hospital cardiac arrest from the CARES registry between 2006 and 2013. Age was categorized into 5-year intervals and the association between age group and outcomes (return of spontaneous circulation (ROSC), survival and good neurological outcome) was assessed in univariable and multivariable analysis. We performed a subgroup analysis in patients who had return of spontaneous circulation.ResultsA total of 101,968 people were included. The median age was 66 years (quartiles: 54, 78) and 39% were female. 31,236 (30.6%) of the included patients had sustained ROSC, 9761 (9.6%) survived to hospital discharge and 8058 (7.9%) survived with a good neurological outcome. The proportion of patients with ROSC was highest in those with age <20 years (34.1%) and lowest in those with age 95–99 years (23.5%). Patients with age <20 years had the highest proportion of survival (16.7%) and good neurological outcome (14.8%) whereas those with age 95–99 years had the lowest proportion of survival (1.7%) and good neurological outcome (1.2%). In the full cohort and in the patients with ROSC there appeared to be a progressive decline in survival and good neurological outcome after the age of approximately 45–64 years. Age alone was not a good predictor of outcome.ConclusionsAdvanced age is associated with outcomes in out-of-hospital cardiac arrest. We did not identify a specific age threshold beyond which the chance of a meaningful recovery was excluded.