Mobile thrombus on cardiac implantable electronic device leads of patients undergoing cardiac ablation: incidence, management, and outcomes

Abstract

Purpose The rates of cardiovascular implantable electronic device (CIED) implantations and cardiac ablation procedures are increasing worldwide. To date, the management of CIED lead thrombi in the periablation period remains undefined and key clinical management questions remained unanswered. We sought to describe the clinical course and management strategies of patients with a CIED lead thrombus detected in the periablative setting. Methods We performed a retrospective analysis of all patients who underwent a cardiac ablation procedure at Mayo Clinic Rochester from 2000-2014. Patients were included in our study cohort if they had documented CIED lead thrombus noted on periablation imaging studies. Electronic medical records were reviewed to determine the overall management strategy, outcomes, and embolic complications in these patients. Results Our overall cohort included 1833 patients, with 27(1.4%) having both cardiac ablation procedures as well as CIED lead thrombus detected on imaging. Of these 27 patients, 21 were male (77%), and the mean age was 59.2 years. The mean duration of follow-up was 16.5 months (range; 3 days – 48.3 months). Anticoagulation was an effective therapeutic strategy, with 11/14 (78.6%) patients experiencing either resolution of the thrombus or reduction in size on re-imaging. For atrial fibrillation ablation, the most common management strategy was a deferment in ablation with initiation/intensification of anticoagulation medication. For ventricular tachycardia ablations, most procedures involved a modified approach with the use of a retrograde aortic approach to access the left ventricle. No patient had any documented embolic complications. Conclusions The incidence of lead thrombi in patients undergoing an ablation was small in our study cohort (1.4%). Anticoagulation and deferral of ablation represented successful management strategies for atrial fibrillation ablation. For patients undergoing ventricular tachycardia ablation, a modified approach using retrograde aortic access to the ventricle was successful. In patients who are not on warfarin anticoagulation at the time of thrombus detection, we recommend initiation of this medication, with a goal INR of 2-3. For patients on warfarin at the time of thrombus detection, we recommend an intensification of anticoagulation with a goal INR of 3.0.

Echocardiographic findings in patients with cardiac implantable electronic devices—analysis of factors predisposing to lead‐associated changes

“…With the use of TEE the incidence of AMEL increased to 28% (Downey et al, 2011; Dundar et al, 2011; Golzio et al, 2019; Lo et al, 2006). Intracardiac echocardiography during ablation procedures revealed incidental masses on the leads in 30% of patients (Dundar et al, 2011; Sugrue et al, 2016). In the present study, AMEL were found in 58.7% of patients undergoing TLE.…”

Evaluation of lead‐based echodensities on transesophageal echocardiogram in patients with cardiac implantable electronic devices

“…The finding of LBE in this clinical context was historically felt to be proof of endocarditis. However, there are numerous studies demonstrating that LBEs can often be present without any evidence of infection 10–13 . The optimal management of these findings, which are often incidental, needs to be elucidated.…”

“… 6 , 7 , 8 , 9 However, there is growing evidence that not all LBEs seen on TEE are suggestive of CIED infections, particularly when the TEE study was obtained for noninfectious indications. 10 , 11 , 12 , 13 We sought to evaluate patients who underwent TEE and had an indwelling CIED; detailed imaging review and chart review was conducted to determine if there were differences in clinical and echocardiographic features in patients with noninfectious versus infectious LBEs.…”

The prognostic value of transesophageal echocardiography after transvenous lead extraction: landscape after battle

“…Another important TEE finding that deserves attention after TLE is dislodgement of vegetations and residual fibrosis. Previous research in preoperative TTE, TEE and ICE has found movable masses attached to the leads, representing vegetations or connective tissue both in asymptomatic and symptomatic patients (30)(31)(32)(33)(34). Some of them may remain in cardiac cavities after TLE whereas others may emerge during lead dissection.…”