Introduction:
Increasing cardiovascular implantable electronic devices (CIED) implantation has been associated with a rising incidence of CIED infection. Treatment includes targeted antimicrobial therapy and device hardware removal although larger lead vegetations have historically undergone surgical removal. As many CIED recipients are at high surgical risk, there is growing need for transvenous approaches for safe debulking of vegetation mass.
Case:
An 80-year-old man with a history of ischemic cardiomyopathy and an indwelling dual chamber implantable cardioverter defibrillator (ICD) for 17 years with previous appropriate shocks was found to have
Enterococcus faecalis
bacteremia. Transthoracic echocardiography revealed a 3 cm vegetation on the right ventricular lead involving the tricuspid valve in addition to a large patent foramen ovale (PFO). He was started on intravenous antibiotics. Blood cultures revealed no growth.
Decision-making:
The large-sized vegetation in presence of a PFO posed a risk for pulmonary or systemic embolization from transvenous lead extraction. A multidisciplinary approach was developed which included temporary PFO occlusion, thrombus aspiration with the Inari FlowTriever thrombus aspiration system, and transvenous laser lead extraction (Figure 1). No residual material remained and the Amplatzer was retrieved. Cultures from the pocket, lead tips, and vegetation were collected. The vegetation culture grew
E. faecalis.
He underwent subcutaneous ICD implant six weeks later following antibiotic therapy.
Conclusions:
Vegetation suction with a simple handheld device can be safe and effective for vegetation removal in high-risk cases. Furthermore, temporary PFO occlusion can be performed during vegetation debulking and device extraction. These management strategies may gain wider application with an increasing need for lead extraction in older patients with comorbidities that preclude surgical candidacy.
Introduction:
In the context of mild-to-moderate systolic dysfunction (ejection fraction (EF) 36-50%), cardiac resynchronization therapy (CRT) is indicated only in patients with expected high burden of pacing but not in those with intrinsic ventricular conduction abnormalities.
Hypothesis:
Ventricular conduction delay is associated with a higher risk of mortality and HF hospitalization in patients with mild to moderate systolic dysfunction.
Methods:
We analyzed 5,966 patients with mild-to-moderate systolic dysfunction. Of those, 1,741 (29%) had a QRS duration of ≥120 milliseconds (ms). In the latter group, 68 (4%) patients were implanted with a CRT device. Patients were followed to the endpoints of death and the composite outcome of death or heart failure (HF) hospitalization.
Results:
Of the 1,741 patients with mild-to-moderate cardiomyopathy and wide QRS duration, 849 (51%) died and 1,004 (58%) had a HF hospitalization over a median follow-up of 3.35 years. Compared to patients with QRS<120 ms, patients with QRS>120 ms were at a higher risk of all-cause mortality (HR 1.11, CI 1.00-1.23, P=0.046) and of the composite of mortality or HF hospitalization (HR 1.10, CI 1.01-1.20, P=0.037) (Figure 1). Among patients with QRS>120 ms, those who underwent CRT implant, had a lower risk of all-cause mortality (HR 0.44, CI 0.45-0.89, P=0.02) and of mortality or HF hospitalization (HR 0.58, CI 0.39-0.87, P=0.008).
Conclusions:
Among patients with HF and intermediate EF, a wide QRS is associated with higher risk of mortality and heart failure hospitalization. CRT is associated with a reduction in these adverse outcomes. Randomized trials are needed to assess role of CRT in this patient population.
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