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Abstract

Summary: This article describes the frequent (30% of patients) presence of sizable mobile thrombus on pacemaker and defibrillator leads identified with careful intracardiac echocardiographic assessment during ablation procedures for atrial fibrillation and ventricular tachycardia. These thrombi were more frequently seen on the atrial portion of the leads. Prior use of oral anticoagulants or antiplatelet agents, the number and age of leads, and presence of a superior vena cava coil were not specifically associated with lead thrombi during the procedure. The group with thrombus had a higher pulmonary artery pressure, suggesting the possibility that patients with lead thrombi may have subclinical pulmonary emboli elevating the pressure and/or that higher pulmonary artery pressure predisposes to thrombus formation in right-sided cardiac chambers. Further study is warranted to identify hematologic or other clinical factors that may increase patients' risk of forming device lead thrombi and to assess the potential clinical impact of these thrombi. Conclusion:Mobile thrombi on cardiovascular implantable electronic device leads are present in 30% of patients undergoing ablation and are readily identified with intracardiac echocardiography despite being underrecognized with transthoracic echocardiography. Further study is warranted to determine whether lead thrombi are a clinically relevant source of pulmonary emboli in some patients with cardiovascular implantable electronic devices. 1 Reversal of Severe Heart Failure With a Continuous-Flow Left Ventricular Assist Device and Pharmacological Therapy: A Prospective StudySummary: Myocardial recovery sufficient to allow pump removal is thought to be rare after left ventricular assist device support. We have previously shown that a specific combination of drug therapy and left ventricular assist device unloading results in recovery in two thirds of patients with dilated cardiomyopathy receiving a pulsatile device. However, there has been a transition to rotary devices, and this protocol has not been previously used with nonpulsatile devices. We report the results of a prospective study of 20 Heartmate II bridge to transplantation patients receiving a specific drug regimen consisting of a combination of angiotensin-converting enzymes, ␤-blockers, angiotensin II inhibitors, and aldosterone antagonists to maximize reverse remodeling, followed by the ␤2-agonist clenbuterol to promote "physiological hypertrophy" to maximize the incidence and durability of recovery. Patients were regularly tested (echocardiograms, exercise tests, catheterizations) with the pump at low speed. One patient was lost to follow-up and died. Of the remaining 19, 12 (63.2%) were explanted. Before explantation at low flow, echocardiographic, exercise test, and hemodynamic data were excellent. Actuarial survival without recurrence of heart failure was 83.3% at 1 and 3 years. Hence, a high rate of reversal of end-stage heart failure secondary to nonischemic cardiomyopathy can be achieved with nonpulsatile fl...