Purpose The use of cardiac implantable electronic devices (CIEDs) has increased significantly over the last decades. With the development of transvenous lead extraction (TLE), procedural success rates also improved; however, data regarding long-term outcomes are still limited. The aim of our study was to analyze the outcomes after TLE, including reimplantation data, all-cause and cause-specific mortality. Methods Data from consecutive patients undergoing TLE in our institution between 2012 and 2020 were retrospectively analyzed. Periprocedural, 30-day, long-term, and cause-specific mortalities were calculated. We examined the original and the revised CIED indications and survival rate of patients with or without reimplantation. Results A total of 150 patients (age 66 ± 14 years) with 308 leads (dwelling time 7.8 ± 6.3 years) underwent TLE due to pocket infection (n = 105, 70%), endocarditis (n = 35, 23%), or non-infectious indications (n = 10, 7%). All-cause mortality data were available for all patients, detailed reimplantation data in 98 cases. Procedural death rate was 2% (n = 3), 30-day mortality rate 2.6% (n = 4). During the 3.5 ± 2.4 years of follow-up, 44 patients died. Arrhythmia, as the direct cause of death, was absent. Cardiovascular cause was responsible for mortality in 25%. There was no significant survival difference between groups with or without reimplantation (p = 0.136). Conclusions Despite the high number of pocket and systemic infection and long dwelling times in our cohort, the short-and longterm mortality after TLE proved to be favorable. Moreover, survival without a new device was not worse compared to patients who underwent a reimplantation procedure. Our study underlines the importance of individual reassessment of the original CIED indication, to avoid unnecessary reimplantation.
Purpose Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. Methods In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. Results Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure ] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786(3866 [ -5656] Ws vs. 2283(3866 [ [1694 Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. Conclusions ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
Although the clinical manifestations of SARS-CoV-2 viral infection affect mainly the respiratory system, cardiac complications are common and are associated with increased morbidity and mortality. While echocardiographic alterations indicating myocardial involvement are widely reported in patients hospitalized for acute COVID-19 infection, much fewer data available in non-hospitalized, mildly symptomatic COVID-19 patients. In our work, we aimed to investigate subclinical cardiac alterations characterized by parameters provided by advanced echocardiographic techniques following mild SARS-CoV-2 viral infection. A total of 86 patients (30 males, age: 39.5 ± 13.0 yrs) were assessed 59 ± 33 days after mild SARS-CoV-2 viral infection (requiring no hospital or <5 days in-hospital treatment) by advanced echocardiographic examination including 2-dimensional (2D) speckle tracking echocardiography and non-invasive myocardial work analysis, and were compared to an age-and sex-matched control group. Altogether, variables from eleven echocardiographic categories representing morphological or functional echocardiographic parameters showed statistical difference between the post-COVID patient group and the control group. The magnitude of change was subtle or mild in the case of these parameters, ranging from 1–11.7% of relative change. Among the parameters, global longitudinal strain [−20.3 (−21.1–−19.0) vs. −19.1 (−20.4–−17.6) %; p = 0.0007], global myocardial work index [1975 (1789–2105) vs. 1829 (1656–2057) Hgmm%; p = 0.007] and right ventricular free wall strain values (−26.6 ± 3.80 vs. −23.8 ± 4.0%; p = 0.0003) showed the most significant differences between the two groups. Subclinical cardiac alterations are present following even mild SARS-CoV-2 viral infection. These more subtle alterations are difficult to detect by routine echocardiography. Extended protocols, involving speckle-tracking echocardiography, non-invasive measurement of cardiac hemodynamics, and possibly myocardial work are necessary for detection and adequate follow-up.
Pulmonary vein isolation is associated with silent cerebral ischemic lesions detected by diffusion-weighted magnetic resonance imaging (MRI), with an incidence between 1% and 40%. Recent studies have shown that these cerebral lesions can occur after radiofrequency ablation for left ventricular extrasystole. Risk of these lesions in conventional ablation has not been evaluated. Aim of this study was to investigate silent cerebral ischemic lesions following left-sided conventional ablation. In a prospective study 296 consecutive patients scheduled for paroxysmal supraventricular tachycardia (PSVT) ablation were screened, and 26 patients meeting study criteria were enrolled. Patients were excluded for age under 18 years or over 80 years, clinically significant neurovascular or valvular disease, proven left atrial thrombus, thrombophilia, previous pacemaker or ICD implantation, documented paroxysmal atrial fibrillation, or any contraindication to MRI. Participants underwent cerebral MRI 24 hours prior and after the ablation, in case of new ischemic lesions a repeated MRI was planned within 3-6 months. Two sequences were used, a 3D T2-weighted fluid-attenuated inversion recovery (FLAIR) and an axial diffusion-weighted (DW) sequence. By definition acute lesions appear as hyperintensities on the postprocedural diffusion-weighted images which correlate with the hypointense signals on the apparent diffusion map and can not be detected on the preprocedural images. Patients were planned to be divided into three groups patients with and without silent cerebral ischemic lesions who underwent left-sided ablation, and a control group undergoing only right-sided ablation. Groups were compared based on clinical and procedural characteristics. The mean age was 43.9 ± 17.3 years, 42% (n = 11) were men, 35% (n = 9) had a history of hypertension. In all groups radiofrequency energy was used and the ablation was performed with a 4 mm tip non-irrigated catheter. In case of a left-sided procedure left atrium was approached by transseptal puncture controlled by intracardiac echocardiography. Before the transseptal puncture intravenous heparin was administered. Activated clotting time was aimed to be 200-300 seconds. None of the postprocedural MRI in the left-sided or the right-sided group revealed any evidence of new cerebral ischemic lesions. Mean procedural time of left-sided ablations was 176.9 ± 74.7 minutes which was significantly longer (p = 0.0077) compared to the right-sided procedures with 132 ± 72.2 minutes total time. Mean left atrial procedural time was 69.1 ± 7.8 minutes, average ACT was 265 ± 28.2 seconds. No silent ischemic cerebral lesions were detected by MRI after catheter ablation of left-sided PSVT substrate in comparison with the historical population undergoing ablation for atrial fibrillation or ventricular extrasystole. Presumably, cerebral lesions occur at a lower rate or might not appear at all after these less complex procedures.
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