Autopsy and clinical context in deceased patients with implanted pacemakers and defibrillators: intracardiac findings near their leads and electrodes

Novák, Miroslav; Dvorák, P; Kamarýt, Pavel; Slaná, Bronislava; Lipoldová, Jolana

doi:10.1093/europace/eup216

Cited by 84 publications

(51 citation statements)

References 17 publications

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“…18,19 However, these studies did not specifically include patients with endovascular pacemakers and defibrillators. The fact that endovascular leads are a nidus for thrombus development 6,9 and adopt an intracardiac course that frequently is in juxtaposition to the interatrial septum likely accounts for the strong association we observed between PFO and stroke/TIA in device recipients (Figure 3). This is the first systematic evaluation of the risk of systemic embolic events among patients with implanted endocardial pacemaker or defibrillator leads who have an incidentally identified PFO on echocardiography.…”

Section: Discussionmentioning

confidence: 85%

“…6 A study using intracardiac echocardiography at the time of a planned electrophysiological procedure found mobile thrombi attached to leads in 30% of patients. 9 These thrombi were rarely seen with the use of transthoracic echocardiography (TTE), reflecting their small size.…”

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confidence: 99%

“…1,2 However, an endovascular lead within the right atrium or ventricle represents a foreign body that can promote the formation of mobile thrombi that may dislodge to the pulmonary circulation. 3,4 Although symptomatic pulmonary embolism after pacemaker or defibrillator implantation is uncommon, asymptomatic emboli may be present far more frequently, [4][5][6][7] and endovascular lead-related thrombi are likely underdetected. With the use of ventilation perfusion scanning, 1 study showed asymptomatic pulmonary emboli inUp to 25% of the population may have a PFO detectable on autopsy, with persistence after the birth of a connection between the right and left atria.…”

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confidence: 99%

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Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

et al. 2013

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15% of patients within 2 weeks of device implantation without heparin prophylaxis, 8 and, at autopsy, pulmonary emboli were present in 21% of patients with CIEDs. 6 A study using intracardiac echocardiography at the time of a planned electrophysiological procedure found mobile thrombi attached to leads in 30% of patients. 9 These thrombi were rarely seen with the use of transthoracic echocardiography (TTE), reflecting their small size. Moreover, the presence of lead-related thrombi was associated with increased pulmonary artery systolic pressure, suggesting subclinical pulmonary embolic events.9 Elevated pulmonary artery pressures may in turn increase the likelihood of right-to-left shunting across a patent foramen ovale (PFO). Clinical Perspective on p 1441Background-A patent foramen ovale (PFO) may permit arterial embolization of thrombi that accumulate on the leads of cardiac implantable electronic devices in the right-sided cardiac chambers. We sought to determine whether a PFO increases the risk of stroke/transient ischemic attack (TIA) in patients with endocardial leads. Methods and Results-We retrospectively evaluated all patients who had endocardial leads implanted between January 1, 2000, and October 25, 2010, at Mayo Clinic Rochester. Echocardiography was used to establish definite PFO and non-PFO cohorts. The primary end point of stroke/TIA consistent with a cardioembolic etiology and the secondary end point of mortality during postimplantation follow-up were compared in PFO versus non-PFO patients with the use of Cox proportional hazards models. We analyzed 6075 patients (364 with PFO) followed for a mean 4.7±3.1 years. The primary end point of stroke/TIA was met in 30/364 (8.2%) PFO versus 117/5711 (2.0%) non-PFO patients (hazard ratio, 3.49; 95% confidence interval, 2.33-5.25; P<0.0001). The association of PFO with stroke/TIA remained significant after multivariable adjustment for age, sex, history of stroke/TIA, atrial fibrillation, and baseline aspirin/warfarin use (hazard ratio, 3.30; 95% confidence interval, 2.19-4.96; P<0.0001). There was no significant difference in all-cause mortality between PFO and non-PFO patients (hazard ratio, 0.91; 95% confidence interval, 0.77-1.07; P=0.25). Conclusions-In patients with endocardial leads, the presence of a PFO on routine echocardiography is associated with a substantially increased risk of embolic stroke/TIA. This finding suggests a role of screening for Up to 25% of the population may have a PFO detectable on autopsy, with persistence after the birth of a connection between the right and left atria. 10,11 In patients with elevated right-sided pressures, flow through a PFO provides a mechanism of blood flow from the right heart to the left-sided circulation. In patients with a PFO, endovascular leads may pose a unique hazard, because the thrombi that develop on leads may shunt across the PFO to the systemic circulation, resulting in ischemic cerebrovascular events or other systemic thromboembolisms. We have previously published 2 case series on device...

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Section: Discussionmentioning

confidence: 85%

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confidence: 99%

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confidence: 99%

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Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

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“…63 A study of autopsy findings of patients with CIEDs found other issues relating to leads such as thrombi on ventricular/atrial leads (48 %), bipolar lead rings fixed by fibrous tissue (22 %), connective tissue bridges or tunnels in ventricle/atrium (71 %) and ventricular leads fixed to valve or penetrating chordae (46 %). 64 Depending on their location, such connective tissue surrounding the leads, as well as leads partially positioned outside the vessels or the heart, may increase the risk of complications during lead extraction. The present HRS and EHRA recommendations do not fully cover the timing of reimplantion or the treatment of pacemaker and ICD dependent patients, partially due to lack of studies comparing strategies.…”

Section: Management Of Cardiac Implantable Electronic Device Infectionmentioning

confidence: 99%

Cardiac Implantable Electronic Device Infection in Patients at Risk

Tarakji

Ellis

Defaye

et al. 2016

Arrhythmia &Amp; Electrophysiology Review

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Device TherapyOver the last few decades an increasing body of evidence has supported the role of cardiovascular implantable electronic devices However, the cost and complications of device implantation, including infection or hardware malfunction in patients receiving CIEDs, have led to the concern that negative outcomes may partially counteract the expected benefits. The rate of CIED infection has been estimated at 0.5 % with primary implants and 1-7 % with secondary interventions.3,5-8 It is difficult to give accurate estimates of infection rates, given the fact that figures are partly based on retrospective series of varying duration, and that different definitions of infection exist. However, the incidence of CIED infection is increasing out of proportion to CIED implantation. 3,5,9 A US study reported a 12 % increase in the number of CIED implantations from 2004 to 2006, with a 57 % increment in CIED infections during the same period. 9Reasons for this rise in CIED infections include the fact that younger patients are receiving CIEDs, and therefore surviving long enough to require more pulse generator changes and lead revisions, which are associated with a higher infection rate. 7,10 In addition, there has been an increase in comorbidities, such as diabetes and kidney disease, resulting in poor wound healing and diminished immune responses. 3,9,11,12 Expanding indications for CIED use, coupled with an ageing population with more comorbidities, mean this trend is likely to increase.2 Better awareness and improved reporting of CIED infections may, however, help to decrease the higher complication rates noted in recent years.CIED infections also impose a substantial financial burden resulting from prolonged hospital stays, long duration of antibiotic therapy, management of sepsis and complications, device extraction and reimplantation.3 These infections typically cost at least $52,000 13 and may exceed $100,000. 14 This article will review strategies for management and prevention of CIED infections, including lead extraction and the use of an absorbable antibacterial envelope. Risk Factors for Cardiac Implantable Electronic Device Infections

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“…Venous obstruction is caused mainly by the adhesions between the lead and the vascular wall. Their presence is a cause of the most severe difficulties related to lead extraction [10,14]. Adhesions are often found in the subclavian or/and innominate vein, particularly in young people.…”

Section: Konsekwencje Uszkodzenia Elektrody Przedstawionego Na Poprmentioning

confidence: 99%

Usefulness of the Evolution mechanical dilator sheath for endocardial lead extraction – preliminary results

Przybylski¹,

Syska²,

Oręziak³

et al. 2010

pwki

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A b s t r a c tBackground: Due to the growing use of pacemakers, implantable cardioverter-defibrillators (ICD) and cardiac resynchronization therapy units as well as the prolongation of life of the devices' recipients, an increasing number of patients require lead extraction. There are several methods of transvenous extraction.Aim: To report the first Polish experience with the new, mechanical system for lead extraction (Evolution). Methods: Between January 2008 and April 2010 45 patients underwent extraction of 76 leads. Median implantation time was 3.3 years (range 0.1-26 years). There were 68 pacing leads and 11 ICD leads. Thirty one (41%) leads were removed with manual traction, in other cases the Byrd dilatators or femoral approach were used. The Evolution system was used only if the other methods were not successful.Results: Seventy two (95%) leads were completely and two partially extracted. Two leads (2.5%) could not be removed. The Evolution system was used in 3 patients (6 leads, 8%). All but one lead were successfully extracted with the Evolution sheaths. There were no major complications. One patient required blood transfusion due to intraoperative bleeding (minor complication).Conclusion: The Evolution system seems to be a safe method to improve success rates of lead extraction.

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Autopsy and clinical context in deceased patients with implanted pacemakers and defibrillators: intracardiac findings near their leads and electrodes

Cited by 84 publications

References 17 publications

Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

Cardiac Implantable Electronic Device Infection in Patients at Risk

Usefulness of the Evolution mechanical dilator sheath for endocardial lead extraction – preliminary results

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