Background: Consensus statements on lead extraction give consideration to open surgicalremoval in the setting of large vegetations, to mitigate the risk of massive embolism that may occur with percutaneous lead removal. Vacuum-assisted debulking (VD) of large vegetations as an adjunct to percutaneous lead extraction may provide an opportunity to mitigate these risks. Methods:We retrospectively identified all patients undergoing lead extraction at our institution for endovascular infection from 2012 to 2018 and stratified them into two groups based on presence of adjunctive VD (n = 6) or without VD (no-VD, n = 39). VD was performed with the AngioVac system (Angio-Dynamics, Latham, NY, USA).Results: Across the cohort, mean age was 62 ± 15 years, ejection fraction was 41 ± 16%, and 39% had end-stage renal disease on dialysis. Defibrillator systems were present in 71%, and 22% had cardiac resynchronization devices. Mean duration of the oldest extracted lead was 6.3 ± 4.9 years. There were no significant differences in baseline covariates between groups. Those in the VD group were significantly less likely to have Staphylococcus aureus as a causative organism (P = .04). In the VD group, vegetations targeted for debulking ranged in size from 1.8 to 6 cm (longest dimension). There were no operative deaths or clinically evident embolic events in either group. The overall nonfatal complication rate in the VD group was higher (33.3% vs 2.3%, P = .043). Conclusion:: VD can be performed as an adjunct to percutaneous lead extraction with a reasonable safety profile. The relative safety and efficacy of this approach removal requires further study. K E Y W O R D S electrophysiology-clinical, instrumentation, new technology

Background: There are limited data on cardiac implantable electronic device implantation (CIED) in patients with persistent left superior vena cava (PLSVC).Objective: To describe the outcomes of implanting CIEDs with a focus on cardiac resynchronization therapy (CRT) in patients with PLSVC. Methods:We identified all patients with a PLSVC that underwent CIED implantation from December 2008 until February 2019 at our institution by querying the electronic medical record (n = 34). We then identified controls in a 3:1 fashion (n = 102) by matching on device type (CRT vs non-CRT). Procedure success, complications, fluoroscopy and procedural time were recorded. Outcomes were compared using a two-way analysis of variance test and conditional regression modeling for continuous and categorical variables, respectively.Results: A total of 34 patients with PLSVC underwent 38 procedures. Four patients underwent dual chamber system implantation followed by a subsequent upgrade to CRT. Thirteen patients underwent CRT implantation: one was implanted via the right subclavian while the rest were implanted via the PLSVC. Left ventricular (P = .06). Procedure and fluoroscopy times were significantly higher in the PLSVC as compared with the control group (97.7 vs 66.1 minute, P < .001 and 18.1 minute vs 8.7 minutes, P = .005, respectively).Conclusion: CIED implant in patients with PLSVC is feasible but technically more challenging and appears to be associated with higher risk of right ventricular lead dislodgment. K E Y W O R D S cardiac implantable electronic devices, ICD, left ventricular lead, pacemakers, persistent left superior vena cava † Bahjat Ghazzal and Dean Sabayon contributed equally to this study.This single center retrospective study demonstrates that although technically more difficult, implanting CIEDs through a persistent left SVC is feasible but seems to be associated with a higher risk of RV lead dislodgment. ORCID Soroosh Kianihttp://orcid.org/0000-0001-6389-0643Michael S. Lloyd http://orcid.org/0000-0002-0708-9330Mikhael F. El-Chami http://orcid.org/0000-0003-4978-7177 SUPPORTING INFORMATIONAdditional supporting information may be found online in the Supporting Information section.How to cite this article: Ghazzal B, Sabayon D, Kiani S, et al.Cardiac implantable electronic devices in patients with persistent left superior vena cava-A single center experience.

Radiofrequency catheter ablation has become the standard of care for the management of various arrhythmias and, in fact, the first-line therapy for many tachyarrhythmias. It entails creating scar tissue in the heart in regions where abnormal impulses form or propagate to restore normal cardiac conduction. As the heart is a complex organ and is surrounded by and related to many other anatomical structures, it is important to avoid the collateral damage that can happen from radiofrequency (RF) ablation on the endocardium as well as on the epicardium. This review explores methods for mitigating or limiting collateral damage during catheter ablation.