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

Abstract

Introduction Cardiac implantable electronic device (CIED) leads frequently develop echogenic masses. However, the nature of these masses is not well understood. In patients in whom atrial fibrillation (AF) catheter ablation is planned, there is concern that transseptal puncture may result in cerebrovascular embolism of these masses. The optimal therapeutic strategy in this setting remains undefined. Methods We describe six patients identified over a 6-year period (2008–2014) with device lead-based masses prior to or at the time of AF ablation. We examined the anticoagulation strategy and periprocedural management based on mass identification. Results In all six patients (age 39–73; four males), the device lead mass was found in the right atrium. The average mass size was 11 ± 1.3 mm. The majority of patients were already on anticoagulation (5/6; 83 %), and an intensified anticoagulation regimen was initiated (INR goal 3.0). In all six patients, the size of the device lead mass decreased on repeat imaging. In two sixths (33 %) patients, the lead-based mass completely resolved within 2 months. The remaining four patients had persistent lead-based masses (average follow-up of 10.9 ± 9.6 months). Discussion We describe a series of patients with CIED lead-based masses found at the time of ablation. These cases illustrate that lead-based masses can disappear while patients are on high-intensity anticoagulation, most compatible with a thrombotic origin. These early data will need to be assessed in larger cohorts for further validation and evaluation of safety.

Right Atrial Thrombosis and Pulmonary Embolism: A Narrative Review

“…It is essential to identify these masses in patients in whom AF catheter ablation is planned because there is a concern that transseptal puncture may result in cerebrovascular embolism. 54 Many questions remain unresolved regarding the relationships between PE and AF. Combination of AF and PE represents a vicious circle as these pathologies contribute to progression of each other.…”

“…It is important to identify the echogenic masses on device leads in patients in whom AF catheter ablation is planned to prevent transseptal puncture, which may result in cerebrovascular embolism. 54 The majority of such patients are already on anticoagulation and initiation of an intensified anticoagulation regimen (INR range of 2.0-3.0) in such cases allows for complete resolution of device lead masses in onethird of patients within 2 months. The remaining patients have persistent lead-based masses (average follow-up of approximately 11 months) decreasing in size.…”

“…Studies of large cohorts are required for further validation of early findings. 54 Electrophysiology studies can be performed noninvasively through the cardiac pacemaker to minimize intracardiac catheter manipulation and procedure time in high-risk patients with cardiac implantable electronic devices presenting with recurrent supraventricular tachycardia. 53 This approach has some limitations, but it significantly improves safety.…”

What Is New in Cardiovascular Medicine?

“…For patients in atrial fibrillation undergoing transvenous cardiac implantable electronic device (CIED) insertion, continued warfarin therapy has been shown to be safer than interrupted warfarin with heparin bridging among patients with the highest thromboembolic risk (>5 percent per year). Safety data, however, are Special editions ANUBiH CLXXXI, OMN 54, p. 39-53 limited for patients treated with direct oral anticoagulants (DOACs) rather than warfarin (21). In BRUISE CONTROL-2, which included patients undergoing transvenous CIED insertion with CHA2DS2-VASc scores ≥2 who were taking a DOAC for chronic anticoagulation, the incidence of the primary outcome (clinically significant pocket hematoma requiring prolonged hospital stay, interruption of anticoagulation therapy, or surgery for hematoma removal) was the same (2.1 percent) for patients randomized to device insertion while on continued DOAC therapy and for those in whom the DOAC was stopped (22).…”