†Deceased (see In Memoriam at the end of this document) *Representative of the Pediatric and Congenital Electrophysiology Society (PACES) ‡Representative of the European Heart Rhythm Association (EHRA) xRepresentative of the Society of Thoracic Surgeons (STS) {Representative of the American College of Cardiology (ACC) #Representative of the Latin American Heart Rhythm Society (LAHRS) **Representative of the Infectious Diseases Society of America (IDSA) ‡ ‡Representative of the American Heart Association (AHA) xxRepresentative of the American Society of Anesthesiologists (ASA) {{Representative of the Asia Pacific Heart Rhythm Society (APHRS)

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Clinical evaluation of a 64-year-old male patient with a permanent pacemaker showed a right bundle branch block in his ECG that led to the suspicion of catheter misplacement. A two-dimensional echocardiogram and bilateral venogram demonstrated that the pacemaker lead was not in the venous system and that its course was from the axillary artery to the left ventricle passing through the aortic valve. Thirty-three days after implant, replacement of the pacemaker lead through the venous system to stimulate the right ventricular endocardium was performed. At 7 month follow-up the patient has had no complication from his previous arterial pacemaker implantation.

Programming the right heart AV interval to a normal value may cause a nonphysiological left heart AV due to interatrial and interventricular conduction delays, thus affecting cardiac performance. Since AV normalization at rest and exercise may be invalidated by pacing or sensing (mode) changes, the aim of this study was to (1) study the feasibility of a mode independent pacemaker (PM) algorithm for automatic beat-to-beat left AV normalization, (2) establish normal values for the time between mitral flow A wave (Af) and ventricular activation (Va), the AfVa interval, the mechanical surrogate of left AV, and (C) determine the range of values of the interatrial electromechanical delays (IAEMDs) and the effect of RA pacing. To pace with the proper right AV, the previously reported RV-paced interventricular electromechanical delay and the interatrial electromechanical delay, either P-sensed (IAEMDs) or atrial-paced (IAEMDp) are required inputs. Data were collected during diagnostic echo Doppler studies in 84 subjects divided in three groups: (1) control with narrow QRS and no structural heart disease (n = 33, age 50 +/- 21 years, 42% men); (2) patients in sinus rhythm with diverse cardiac pathologies except LBBB (n = 39, age 69 +/- 14 years, 56% men), and (3) DDD-paced patients (n = 12, mean age 71 +/- 6 years). Normal values of AfVa were established from the control group, while IAEMDs and IAEMDp and active atrial flow time (A-peak), in all subjects. The algorithm was tested by computer simulation under all possible modes with the following calculation: RAV = N + IAEMD - IVD, where RAV is the right AV, N is the desired normal AfVa value, IAEMD is either P-sensed or A-paced, and IVD is close to zero for intrinsic narrow QRS and biventricular pacing, or 79 ms for RV pacing. The results demonstrated (1) Normal (controls) AfVa: 85 +/- 15 ms (range 52-110 ms); (2) IAEMDs (All): 84 +/- 16 ms; (3) atrial pacing prolonged IAEMDs by 57 +/- 18 ms (from 93 +/- 15 to 150 +/- 25 ms, P < 0.0001); and (4) Computer simulation of rate and mode changes validated the normalization algorithm. An automatic, beat-to-beat left AV normalization algorithm to preserve a normal AfVa without a hemodynamic sensor is feasible. The normal value of AfVa is 85 +/- 15 ms.

Background: According to published evidence, treatment of infective endocarditis (IE) associated with cardiovascular implantable electronic devices (CIEDs) should include complete removal of the system. Several publications have shown that transvenous removal is an effective and safe nonthoracotomy approach in patients with large vegetations, but experiences with vegetations larger than 20 mm have rarely been reported. Hypothesis: Our aim was to describe our experience in percutaneous removal of CIEDs in patients with IE with large vegetations. Methods: The data were collected retrospectively and analyzed prospectively. We evaluated in-hospital morbidity and mortality related to percutaneous removal of vegetations ≥20 mm. This included 8 cases with a follow-up period of 20 months. We removed 100% of leads in the study population. Results: Two patients experienced minor complications. No patient experienced subclavian vein laceration, hemothorax and lead fracture, or severe tricuspid regurgitation. After the removal procedure, 2 patients had symptoms compatible with pulmonary embolism. Both in-hospital mortality and mortality at follow-up were zero. Conclusions: Transvenous extraction of pacing leads with larger vegetations is a feasible technique. There was a tendency toward symptomatic pulmonary embolism in patients with vegetations larger than 20 mm; however, morbidity and mortality were not influenced. We agree with the consensus that this procedure is highly useful and that the selection of the removal techniques will depend not only on the size of vegetation but also on prior cardiopulmonary conditions, concomitant cardiac surgery, atrial septal defect with risk of paradoxical embolism, center experience, and the possibility of complete removal of the device. IntroductionSeveral publications and scientific lectures on percutaneous extraction of cardiovascular implantable electronic devices (CIEDs) in patients with infective endocarditis (IE) have focused on factors associated with complications related to the procedure. Investigators have discussed fibrosis around the electrode and adherence to the surrounding cardiac tissue (myocardium, tricuspid valve, and vein) with risk of damage during removal.

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Endocardite em marca-passo: abordagem na extração do cabo-eletrodo em endocardite com grandes vegetações Pacemaker endocarditis: approach for lead extraction in endocarditis with large vegetations AbstractThe presence of large lead vegetations poses additional difficulties for explantation because many methods cannot be used due to the potential hazard of embolism. We report two patients with large vegetation on the ventricular lead due to endocarditis and one of them with an atrial septal defect associated. It was applied a combined technique of transvenous lead removal and sternotomy with cardiopulmonary bypass for the complete removal of pacemaker wires. This procedure resolved the pacemakers endocarditis safely and subsequently a new transvenous device was placed on the opposite site.Descriptors: Endocarditis. Endocarditis, bacterial. Pacemaker, artificial. ResumoA presença de grande crescimento vegetativo no eletrodo do marca-passo impõe dificuldades adicionais para a sua extração, pois alguns métodos não podem ser aplicados pelo risco potencial de embolismo. Reportamos dois pacientes com grande crescimento vegetativo no eletrodo ventricular, devido a endocardites, um deles com comunicação intraventricular associada. Foi aplicada uma técnica combinada de extração de eletrodo transvenosa e esternotomia com circulação extracorpórea para remoção completa dos cabos do marcapasso. Este procedimento resolveu a endocardite de marcapasso de maneira segura e, subsequentemente, foi colocado um novo dispositivo intravenoso no lado oposto. Descritores INTRODUCTIONInfections involving implantable electrophysiologic cardiac devices are increasing due to the wide use of these implants all over the world. It causes severe morbidity and mortality outcomes and requires complete device replacement [1]. Several studies of pacemaker endocarditis strongly support the complete removal of the device, and the availability of technology that allows the extraction of the device by percutaneous route has facilitated the non-operative removal [2]. Sometimes, such approach is not possible to perform. The presence of large lead vegetations or a septal atrial defect poses additional difficulties for explantation as many methods cannot be used because the potential hazard of embolism. Besides this, the procedure is not 100% effective and it could fail. In a few cases, combined techniques (transvenous lead removal and by sternotomy with cardiopulmonary bypass) are necessary [3].We described both patients with large vegetation on the ventricular lead due to endocarditis and one of them with an atrial septal defect associated. 571VACCARINO, GN ET AL -Pacemaker endocarditis: approach for lead extraction in endocarditis with large vegetations Bras Cir Cardiovasc 2009; 24(4): 570-573 Rev

This technique is especially useful if the leads to be extracted were previously cut and had retracted into the central circulation. Although our experience is based only on 18 patients and 22 leads, we can conclude that the success rate we have achieved was high and the complication rate was very low.