Implanted endocardial lead characteristics and risk of stroke or transient ischemic attack

Abstract

Introduction Patent foramen ovale (PFO) has been recently implicated as a strong predictor of stroke or transient ischemic attack (TIA) in patients with implanted pacemaker or defibrillation leads. Leads in the right heart can form thrombi that embolize to the pulmonary circulation and raise pulmonary pressure. This increases right-to-left shunting through PFO or intrapulmonary shunts and can result in paradoxical embolism. We sought to determine whether certain lead characteristics confer a higher thrombogenic risk resulting in stroke/ TIAs in patients either with or without a PFO. Methods We retrospectively analyzed 5,646 patients (mean age 67.3±16.3 years, 64 % male) who had endocardial device leads implanted in 2000–2010. We performed univariate and multivariate-adjusted proportional hazards models to determine association of lead characteristics with stroke/TIA during follow-up. Results On univariate analysis, passively fixated tined leads were associated with more stroke/TIAs (HR 1.77, 95 % CI 1.27, 2.47; p<0.001), whereas presence of defibrillation coil was associated with fewer stroke/TIAs (HR 0.59, 95 % CI 0.42–0.84; p=0.003). Number of leads per patient, presence of atrial lead, maximum lead size, tip shape, and type of insulating material were not associated with stoke/TIA. On multivariate analyses adjusting for age, sex, diagnosis of PFO, and prior history of stroke/TIA, the presence of tined leads was associated with stroke/TIA (HR 1.41, 95 % CI 1.00–1.97; p=0.049). Defibrillation coils were no longer associated with lower stroke/TIA on multivariate analysis. Conclusions Most physical characteristics of contemporary leads do not impact rate of stroke/TIA among patients receiving implantable devices. The presence of a PFO is a major risk factor for stroke/TIA in patients with endovascular leads.

Cardiac implantable electronic device lead-based masses and atrial fibrillation ablation: a case-based illustration of periprocedural anticoagulation management strategies

“…No clinically significant emboli were identified but that does not rule out silent thromboembolism in this retrospective study. It has previously been shown that passively fixated tined RA leads are associated with a higher risk of TIA [19]. In our study, there were no masses identified on passively fixated tined RA leads, and there was only one mass located on a passively fixated tined RV lead.…”

Iatrogenic Atrial Septal Defect

“…In addtion, she also has permenant pacemaker leads which may increase her risk for paradoxial embolism. 18 I would therefore consider percutaneous iASD closure in this patient. A suggested algorithm for the assessment and management of iASD is illustrated in Figure 3.…”

Endocardial Device Leads in Patients with Patent Foramen Ovale: Echocardiographic Correlates of Stroke/TIA and Mortality

“…We obtained patients for this study from the population of patients with CIEDs and endocardial device leads reported in earlier studies on risk of stroke/TIA 2,6 and pulmonary embolism (PE). 17 Patients who underwent implantation of either transvenous ICD or pacemaker at the Mayo Clinic, Rochester, MN between January 1, 2000 and October 25, 2010 were included in this study if they were diagnosed with a definite PFO on echocardiography, and had a baseline (see below for definition of “baseline”) echocardiogram to obtain information on study predictors.…”