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The use of wireless communication devices has increased rapidly, with current industry estimates of 50,000,000 subscribers of cellular telephone services, a number that is expected to double by the year 2000. Because wireless communication devices emit RF signals, they have the potential to interfere with implantable devices. The mechanisms of interference and the magnitude of interference must be considered in terms of the type of wireless communication device being used and the characteristics of the individual implantable device that is exposed to the RF emission of the cellular phone. This article reviews the potential effects of wireless communication devices on implantable devices and makes initial recommendations for patients with implantable devices. [ABSTRACT FROM AUTHOR]

Importance: Complete hardware removal is a class I recommendation for cardiovascular implantable electronic device (CIED) infection, but practice patterns and outcomes remain unknown., Objective: To quantify the number of Medicare patients with CIED infections who underwent implantation from 2006 to 2019 and lead extraction from 2007 to 2019 to analyze the outcomes in these patients in a nationwide clinical practice cohort., Design, Setting, and Participants: This cohort study included fee-for-service Medicare Part D beneficiaries from January 1, 2006, to December 31, 2019, who had a de novo CIED implantation and a CIED infection more than 1 year after implantation. Data were analyzed from January 1, 2005, to December 31, 2019., Exposure: A CIED infection, defined as (1) endocarditis or infection of a device implant and (2) documented antibiotic therapy., Main Outcomes and Measures: The primary outcomes of interest were device infection, device extraction, and all-cause mortality. Time-varying multivariable Cox proportional hazards regression models were used to evaluate the association between extraction and survival., Results: Among 1 065 549 patients (median age, 78.0 years [IQR, 72.0-84.0 years]; 50.9% male), mean (SD) follow-up was 4.6 (2.9) years after implantation. There were 11 304 patients (1.1%) with CIED infection (median age, 75.0 years [IQR, 67.0-82.0 years]); 60.1% were male, and 7724 (68.3%) had diabetes. A total of 2102 patients with CIED infection (18.6%) underwent extraction within 30 days of diagnosis. Infection occurred a mean (SD) of 3.7 (2.4) years after implantation, and 1-year survival was 68.3%. There was evidence of highly selective treatment, as most patients did not have extraction within 30 days of diagnosed infection (9202 [81.4%]), while 1511 (13.4%) had extraction within 6 days of diagnosis and 591 (5.2%) had extraction between days 7 and 30. Any extraction was associated with lower mortality compared with no extraction (adjusted hazard ratio [AHR], 0.82; 95% CI, 0.74-0.90; P < .001). Extraction within 6 days was associated with even lower risk of mortality (AHR, 0.69; 95% CI, 0.61-0.78; P < .001)., Conclusions and Relevance: In this study, a minority of patients with CIED infection underwent extraction. Extraction was associated with a lower risk of death compared with no extraction. The findings suggest a need to improve adherence to guideline-directed care among patients with CIED infection.

Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads., Competing Interests: Conflict of interest: R.D.S. has received speaking honoraria from Philips and Cook Medical. E.K. has received consulting fees from Abbott and Edwards Lifesciences. B.J.R. has received consulting fees from Abbott, Edwards Lifesciences, and Medtronic. R.G.C. has received consulting/speaking fees from Philips and has a research grant funded by Medtronic. L.M.E. has received consulting fees from Boston Scientific, Medtronic, and Philips. The other authors report no relevant disclosures., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

We report the first case of a patient with myxofibrosarcoma (MFS) who presented acutely with a rib fracture and developed a rapidly expanding loculated hemothorax after chest trauma. The patient was taken to the operating room for evacuation of hemothorax, and samples and biopsy specimens were taken for cytologic and pathologic examination. Final report with immunohistochemical staining showed a high-grade MFS. After the procedure, there was clinical and radiological improvement, and the patient was followed up as an outpatient. Myxofibrosarcoma is a very rare and aggressive connective tissue neoplasm with variable presentations. Surgical resection is the preferred treatment. Prompt diagnosis and adequate management of these tumors are important to reduce their high local recurrence and distant metastasis rates. Therefore, it is important to be aware of its common and uncommon presentations., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Superior vena cava (SVC) syndrome includes the clinical sequalae of facial and bilateral upper extremity edema, dizziness, and occasional syncope. Historically, most cases have been associated with malignancy and treatment is palliative. However, cardiac device leads have been identified as important nonmalignant causes of this syndrome. There are little data on the effectiveness of venoplasty and lead extraction in the management of these patients., Objective: The objective of this study was to report the findings associated with the use of balloon angioplasty and lead extraction in the management of 17 patients with lead induced SVC syndrome., Methods: Data collected from January 2003 to July 2019 identified 17 cases of SVC syndrome at our tertiary center. Their outcomes were compared to a control group of patients without SVC syndrome. A P value of <.05 was considered statistically significant., Results: Of the 17 patients, 13 (76%) underwent transvenous lead extraction and venoplasty. Three patients (18%) were treated with venoplasty alone, and 1 patient (6%) underwent surgical SVC reconstruction. In 10 patients (59%), transvenous reimplantation was necessary. Symptom resolution was achieved in all 17 patients and confirmed at both 6 and 12 months' follow-up. There was no significant difference in the rate of complications associated with transvenous lead extraction for SVC syndrome vs control., Conclusion: In patients with SVC syndrome, venoplasty and lead extraction are safe and effective for resolution of symptoms and maintaining SVC patency., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Small vegetations (<2.0 cm) associated with infected cardiac device leads can be managed percutaneously, whereas larger vegetations typically are removed via open heart surgery. Unfortunately, many patients with intracardiac vegetations are not candidates for open removal., Objective: The purpose of this study was to report our experience in the outcomes associated with the percutaneous management of large vegetations., Methods: Prospective data from January 2010 to August 2018 identified 826 patients with infections undergoing lead extraction. One hundred nineteen cases had vegetations measured in 2 dimensions (length and width) by transesophageal echocardiogram. Thirty-two patients had 3 characteristics: (1) at least 1 vegetation dimension ≥2.0 cm; (2) not a surgical candidate; and (3) had undergone transvenous lead extraction. The cohort was classified into 2 groups according to shape: (1) globular if the difference between dimensions was <30% between dimensions; and (2) nonglobular if the difference was >30%. The Fisher exact test and Pearson t test were used for analysis. P <.05 was considered significant., Results: Retrospective analysis of a single tertiary cardiac surgery center registry showed a significantly lower chance of being alive at discharge in patients with globular vegetations compared to patients with nonglobular vegetations (P = .002)., Conclusion: Vegetation size is an important determinant of outcomes in patients who are not surgical candidates undergoing transvenous lead extraction. However, vegetation shape is also a relevant factor, as globular vegetations may predict a worse result compared to nonglobular vegetations., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Enterococcal cardiovascular implantable electronic device (CIED) infections are not well characterized., Methods: Data from the Multicenter Electrophysiologic Device Infection Cohort, a prospective study of CIED infections, were used for descriptive analysis of adults with enterococcal CIED infections., Results: Of 433 patients, 21 (4.8%) had enterococcal CIED infection. Median age was 71 years. Twelve patients (57%) had permanent pacemakers, five (24%) implantable cardioverter defibrillators, and four (19%) biventricular devices. Median time from last procedure to infection was 570 days. CIED-related bloodstream infections occurred in three patients (14%) and 18 (86%) had infective endocarditis (IE), 14 (78%) of which were definite by the modified Duke criteria. IE cases were classified as follows: valvular IE, four; lead IE, eight; both valve and lead IE, six. Vegetations were demonstrated by transesophageal echocardiography in 17 patients (81%). Blood cultures were positive in 19/19 patients with confirmed results. The most common antimicrobial regimen was penicillin plus an aminoglycoside (33%). Antibiotics were given for a median of 43 days. Only 14 patients (67%) underwent device removal. There was one death during the index hospitalization with four additional deaths within 6 months (overall mortality 24%). There were no relapses., Conclusions: Enterococci caused 4.8% of CIED infections in our cohort. Based on the late onset after device placement or manipulation, most infections were likely hematogenous in origin. IE was the most common infection syndrome. Only 67% of patients underwent device removal. At 6 months follow-up, no CIED infection relapses had occurred, but overall mortality was 24%., (© 2019 Wiley Periodicals, Inc.)

Background: A history of open-heart surgery has been a heavily debated topic in transvenous lead extraction. This study evaluates the impact of prior sternotomy on transvenous lead extraction outcomes., Methods: Data for all patients undergoing transvenous lead extraction at a tertiary referral center were prospectively gathered from 2004 to 2017. Relevant clinical information was compared between patients with a history of sternotomy before transvenous lead extraction and those without. After considering baseline differences, multivariate regression, and propensity-matched analysis were performed. Outcome variables included major and minor complication rates, clinical success, and in-hospital mortality as defined by the 2017 Heart Rhythm Society consensus statement., Results: Of 1480 patients in the study period, 455 had a prior sternotomy. When compared with patients with no prior sternotomy, those with prior sternotomy were more likely to be older, male, and present with more comorbidities and leads targeted for extraction. No statistical differences were identified in major and minor complication rates ( P =0.75, P =0.41), clinical success rate ( P =0.26), and in-hospital mortality ( P =0.08). In patients with prior sternotomy, there were no instances of pericardial effusion after extraction. Prior sternotomy was not an independent predictor of clinical or procedural outcomes. No associations were elucidated after propensity-matched analysis., Conclusions: In a large, single-center series, no differences in clinical or procedural outcomes were elucidated between patients with a history of sternotomy and those without. Patients with sternotomies before lead extraction who experienced vascular or cardiac perforations clinically presented with hemothoraces rather than pericardial effusions.

Background: Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon., Methods: We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration-maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality., Results: From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used (P=0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04-0.40; P<0.001)., Conclusions: From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.

Background: The rate of cardiovascular implantable electronic device infections (CIEDIs) has mirrored or exceeded the increased use of implantable cardiac devices in the United States. The presence of racial and ethnic disparities associated with CIEDIs has not been published. Our aim is to describe the presence of racial and ethnic disparities with respect to the management of CIEDIs., Methods: We reviewed a prospective single-center registry for patients undergoing removal of an implantable cardiac device between 1/2004 and 1/2016. 1173 consecutive patients underwent device extraction. 699 patients were identified as having an infection, 305 were identified as Caucasian and 394 were minorities (91 African Americans, 303 Hispanics). Patients had pre-operative transesophageal echocardiograms (TEEs) and collection of blood and exudate cultures. All underwent complete hardware extraction; leads were removed through the use of locking stylets and traction or laser extraction. En-bloc capsulectomy was performed with intraoperative specimen collection from pocket tissue, exudate, lead tips, and vegetations., Results: Minority patients were: younger (67.9 ± 14.5 years vs 72.4 ± 13.2 years), had a higher proportion of male gender, diabetes, and chronic renal failure (p < 0.001). Minorities experienced a higher rate of complications during extraction and a longer hospitalization (15.3 ± 9.9 days versus 17.4 ± 13.4 days, p < 0.001). There was no significant difference between the proportion of types of infection in both groups., Conclusion: Minority patients with CIEDIs experienced more procedural complications during extraction and had a significantly longer length of index hospitalization than Caucasian patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background and Aim of Study: The treatment of inoperable patients with concomitant complex coronary artery disease and severe aortic stenosis unsuitable for conventional transcatheter aortic valve replacement (TAVR) poses a significant challenge. Effective treatment is even more difficult in those patients with complex coronary anatomy unamenable to percutaneous revascularization. Our manuscript aims to enlighten clinicians on the management of this complex patient., Methods: We conducted a contemporary review of the literature of combined off-pump coronary artery bypass grafting and transaortic TAVR in this patient population and describe our own successful experience in an inoperable patient with a porcelain aorta., Results: Including our report, 17 cases have been described in the literature. All patients had multiple comorbidities with elevated STS (range, 2.6-25; 6%) and EuroScore I (range, 13.7-83; 7%) and were not considered candidates for conventional CABG and SAVR. Most had severe, complex, multivessel CAD deemed unsuitable for PCI and structural findings precluding them from other standard percutaneous or alternative TAVR approaches (transfemoral/subclavian/transcaval/transapical). Out of the 17 cases, 5 (29%) had porcelain aortas. Most reports specify the decision-making process is driven by a multidisciplinary team., Conclusion: This report demonstrates that hybrid off-pump CABG surgery and transaortic TAVR can be successfully performed in high-risk patients with porcelain aortas who are not candidates for percutaneous methods, on-pump revascularization, transfemoral, subclavian, or transcaval valve implantations. It also highlights that careful study of the CTA scan could predict adequate access for a transaortic approach even in the presence of porcelain aorta in selected patients., (© 2019 Wiley Periodicals, Inc.)

Cardiac device lead extractions have increased in frequency over the past several years. Although most of these procedures are successfully performed through a percutaneous approach, certain cases may be unmanageable using conventional methods. The traditional approach for such complex cases has been median sternotomy. However, four surgical techniques offer a less-invasive alternative. These include the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy. In the present study, we reviewed data from patients who underwent minimally invasive, surgical lead extraction at our institution from January 2003 to October 2017 using an ongoing, prospective registry. Summary statistics were generated for age, sex, device extracted, lead dwell time (years), procedure indication, major/minor complications and procedural success as defined by the 2017 Heart Rhythm Society consensus statement, and survival at discharge. Between January 2003 and October 2017, 14 cases at our center were managed via a transatrial approach, whereas 11 involved the subxiphoid approach, 19 involved a left minithoracotomy or thoracoscopy, and one involved a ministernotomy. For the transatrial approach, all cases were classified as procedural successes and all patients were discharged alive. Additionally, for the subxiphoid approach, all cases were deemed procedural successes, whereas survival at discharge was 90.9%. For the left minithoracotomy/thoracoscopy, all cases were procedural successes and survival at discharge was 94.7%. Lastly, the ministernotomy was successfully used to remove an infected, retained lead fragment from the innominate vein. In conclusion, at our institution, the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy were used as minimally invasive, surgical approaches that represent fairly safe and effective alternatives to median sternotomy in complex cases unamenable to management via conventional, percutaneous approaches to lead extraction., Competing Interests: Dr. Carrillo has served as a consultant to Spectranetics and Sensormatic; has received a research grant from St. Jude Medical; and has served on the Speakers Bureau for Medtronic, St. Jude Medical, and the Sorin Group. Mr. Azarrafiy reports no conflicts of interest for the published content., (Copyright: © 2019 Innovations in Cardiac Rhythm Management.)

The rise in indications for cardiac implantable electronic devices has necessitated the development of tools for removal of the electrodes that connect the heart to these externally located pacemakers and defibrillators. After implant of a cardiac electrode, variable but progressive fibrous adhesion occurs. Removal of these adhesions can cause devastating complications with high risk of mortality if not treated surgically in a highly expeditious and appropriate manner. This article describes the incidence, risk factors, and diagnosis of these injuries followed by discussion of recent evidence for use of superior vena cava balloon occlusion, and conventional surgical repair of these injuries., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Surgical and hybrid lead extraction has developed considerably over the past several decades. Although transvenous lead extraction is the standard approach to remove infected or malfunctioning cardiac implantable electronic device leads, surgical approaches may be necessary in complex cases not amenable to transvenous lead extraction or in cases that involve concomitant pathologies, such as tricuspid valve regurgitation. We describe our experience with 4 minimally invasive surgical approaches to lead extraction as well as our experience with hybrid open heart surgery and transvenous lead extraction as an option for patients who present with concomitant conditions., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: We examined the outcomes of older adults undergoing nontrans-femoral (non-TF) transcatheter aortic valve replacement (TAVR) procedures including trans-apical (TA), trans-aortic (TAo), trans-subclavian (TSub), and trans-carotid (TCa) techniques., Methods and Results: This is an observational study of all consecutive older patients who underwent non-TF TAVR for symptomatic severe AS with Edwards Sapien (ES), Medtronic CoreValve, ES3 or Lotus Valve at three centers in France and the United States from 04/2008 to 02/2017. Baseline characteristics and clinical outcomes were defined according to VARC-2 criteria. Of 857 patients who received TAVR, 172 (20%) had an alternative access procedure. Of these, 45 (26%) were TA, 67 (39%) TAo, 17 (10%) TSub, and 43 (25%) TCa procedures. The preference for non-TF access site was different between the two countries (US: TA 39%, TAo 52%, TSub 9%; TCa 0% vs. France: TA 9%, TAo 23%, TSub 11%, and TCa 57%, P-value < .001). Most patients who underwent TAo TAVR were older women (median age: TA 82, TAo 84, TSub 81, TCa 81, P-value = 0.043; female gender: TA 32 (27%), TAo 30 (55%), TSub 10 (41%), TCa 27 (37%), P-value = .021). The predicted Society of Thoracic Surgery risk of mortality was similar among groups (TA 7%, TAo 7%, TSub 6%, TCa 7%, P-value= .738). No differences were observed in the frequency of para-valvular leak, intra-procedural bleeding, vascular complications, conversion to open-heart surgery, or development of acute kidney injury. The highest in-hospital mortality was observed in the TAo group (TA 2%, TAo 15%, TSub 0%, TCa 2%, P-value = .014). However, hospital length of stay, one-month, and one-year mortality were similar among non-TF techniques., Conclusion: Although regional differences exist in the choice of alternative access techniques, centers with high technical expertise can provide a safe alternative to traditional TF TAVR. TAo TAVR was associated with higher in-hospital mortality than other non-TF approaches, and this may have reflected patient rather than procedural factors. All alternative access techniques had similar mortality rates and clinical outcomes at one-year follow-up. Trans-carotid access is safe and feasible compared to other non-TF access techniques., (© 2018 Wiley Periodicals, Inc.)

The use of cardiac implantable electronic devices (CIEDs) has continued to rise along with indications for their removal. When confronted with challenging clinical scenarios such as device infection, malfunction or vessel occlusion, patients often require the prompt removal of CIED hardware, including associated leads. Recent advancements in percutaneous methods have enabled physicians to face a myriad of complex lead extractions with efficiency and safety. Looking ahead, emerging technologies hold great promise in making extractions safer and more accessible for patients worldwide. This review will provide the most up-to-date indications and procedural approaches for lead extractions and insight on the future trends in this novel field., Competing Interests: Disclosure: Darren Tsang, Adryan Perez and Frank Woo have no conflicts of interest to declare. Roger Carrillo reports receiving personal fees from Spectranetics, personal fees from Sensormatic, grants from St Jude Medical, personal fees from Medtronic, personal fees from St Jude Medical, and personal fees from The Sorin Group outside the submitted work.

Background: Published guidelines mandate complete device removal in cases of cardiovascular implantable electronic device (CIED) infection. Clinical predictors of successful salvage of infected CIEDs have not been defined., Methods: Data from the Multicenter Electrophysiologic Device Infection Collaboration, a prospective, observational, multinational cohort study of CIED infection, were used to investigate whether clinical predictors of successful salvage of infected devices could be identified., Results: Of 433 adult patients with CIED infections, 306 (71%) underwent immediate device explantation. Medical management with device retention and antimicrobial therapy was initially attempted in 127 patients (29%). "Early failure" of attempted salvage occurred in 74 patients (58%) who subsequently underwent device explantation during the index hospitalization. The remaining 53 patients (42%) in the attempted salvage group retained their CIED. Twenty-six (49%) had resolution of CIED infection (successful salvage group) whereas 27 patients (51%) experienced "late" salvage failure. Upon comparing the salvage failure group, early and late (N = 101), to the group experiencing successful salvage of an infected CIED (N = 26), no clinical or laboratory predictors of successful salvage were identified. However, by univariate analysis, coagulase-negative staphylococci as infecting pathogens (P = 0.0439) and the presence of a lead vegetation (P = 0.024) were associated with overall failed salvage., Conclusions: In patients with definite CIED infections, clinical and laboratory variables cannot predict successful device salvage. Until new data are forthcoming, device explantation should remain a mandatory and early management intervention in patients with CIED infection in keeping with existing expert guidelines unless medical contraindications exist or patients refuse device removal., (© 2018 Wiley Periodicals, Inc.)

Objective: To explore differences in clinical manifestations and outcomes in those patients who develop infection after undergoing initial implantation versus reoperation., Methods: We compared cases of cardiac implantable electronic device (CIED) infection based on initial implantation versus reoperation from 11 centres., Results: There were 432 patients with CIED infection, 178 occurring after initial device placement and 254 after repeat reoperation. No differences were seen in age, sex or device type. Those with infection after initial implant had a higher Charlson Comorbidity Score (median 3 (IQR 2-6) vs 2 (IQR 1-4), p<0.001), shorter time since last procedure (median 8.9 months (IQR 0.9-33.3) vs 19.5 months (IQR 1.1-62.9), p<0.0001) and fewer leads (2.0±0.6vs 2.5±0.9, p<0.001). Pocket infections were more likely to occur after a reoperation (70.1%vs48.9%, p<0.001) and coagulase negative staphylococci (CoNS) was the most frequently isolated organism in this group (p=0.029). In contrast, initial implant infections were more likely to present with higher white cell count (10.5±5.1 g/dL vs 9.5±5.4 g/dL, p=0.025), metastatic foci of infection (16.9%vs8.7%, p=0.016) and sepsis (30.9%vs19.3%, p=0.006). There were no differences in in-hospital (7.9%vs5.2%, p=0.31) or 6-month mortality (21.9%vs14.0%, p=0.056)., Conclusions: CIED infections after initial device implant occur earlier, more aggressively, and often due to Staphylococcus aureus . In contrast, CIED infections after reoperation occur later, are due to CoNS, and have more indolent manifestations with primary localisation to the pocket., Competing Interests: Competing interests: None declared.

Objectives: This study sought to evaluate the impact of abandoned cardiovascular implantable electronic device (CIED) leads on the presentation and management of device-related infections., Background: Device infection is a serious consequence of CIEDs and necessitates removal of all hardware for attempted cure. The merits of extracting or retaining presumed sterile but nonfunctioning leads is a subject of ongoing debate., Methods: The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled patients with CIED infections at 10 institutions in the United States and abroad between January 1, 2009, and December 31, 2012. Within a propensity-matched cohort, relevant clinical information was compared between patients who had 1 or more abandoned leads at the time of infection and those who had none., Results: Matching produced a cohort of 264 patients, including 176 with no abandoned leads and 88 with abandoned leads. The groups were balanced with respect to Charlson comorbidity index, oldest lead age, device type, sex, and race. At the time of admission, those with abandoned leads were less likely to demonstrate systemic signs of infection, including leukocytosis (p = 0.023) and positive blood cultures (p = 0.005). Conversely, patients with abandoned leads were more likely to demonstrate local signs of infections, including skin erosion (p = 0.031) and positive pocket cultures (p = 0.015). In addition, patients with abandoned leads were more likely to require laser extraction (p = 0.010)., Conclusions: The results of a large prospective registry of CIED infections demonstrated that patients with abandoned leads may present with different signs, symptoms, and microbiological findings and require laser extraction more than those without abandoned leads., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Many clinicians use the strategy of prophylactically placing an endovascular balloon before transvenous lead extraction, yet there are no data regarding this practice., Objective: This study assesses long-term outcomes of prophylactic placement of an endovascular balloon in the venae cavae of patients during transvenous lead extraction., Methods: From April 1, 2016 to March 31, 2017 data were prospectively collected at 2 international cardiovascular centers on patients who had the balloon prophylactically placed in the venae cavae. Patients were monitored for a minimum of 3 months to capture any associated adverse events., Results: Twenty-one patients had the balloon prophylactically placed in the venae cavae during lead extraction. Sixteen patients were male (76%); the mean age was 57.6 ± 18.7 years; and the mean body mass index was 26.1 ± 4.4 kg/m 2 . The mean lead dwell time was 11.2 ± 8.3 years, with an average of 2.2 ± 1.1 leads per case, and most indications for extraction were noninfectious (62%). Two minor complications (10%, pocket hematomas) and 1 major complication (5%, cardiac tamponade) occurred during the procedure. All cases (100%) were procedural successes, and all patients (100%) were discharged alive. On follow-up (6.8 ± 3.7 months), all patients were alive and reported no adverse events related to prophylactic balloon placement, such as pulmonary emboli or deep venous thrombi., Conclusion: During the study period, we observed no acute or long-term adverse outcomes associated with prophylactic placement of an endovascular balloon in the venae cavae of patients undergoing transvenous lead extraction., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Lead management is an increasingly important aspect of care in patients with cardiac implantable electronic devices; however, relatively little is known about long-term outcomes after capping and abandoning leads., Methods: Using the 5% Medicare sample, we identified patients with de novo cardiac implantable electronic device implantations between January 1, 2000, and December 31, 2013, and with a subsequent lead addition or extraction ≥12 months after the de novo implantation. Patients who underwent extraction for infection were excluded. Using multivariable Cox proportional hazards models, we compared cumulative incidence of all-cause mortality, device-related infection, device revision, and lead extraction at 1 and 5 years for the extraction versus the cap and abandon group., Results: Among 6859 patients, 1113 (16.2%) underwent extraction, whereas 5746 (83.8%) underwent capping and abandonment. Extraction patients tended to be younger (median, 78 versus 79 years; P <0.0001), were less likely to be male (65% versus 68%; P =0.05), and had shorter lead dwell time (median, 3.0 versus 4.0 years; P <0.0001) and fewer comorbidities. Over a median follow-up of 2.4 years (25th, 75th percentiles, 1.0, 4.3 years), the overall 1-year and 5-year cumulative incidence of mortality was 13.5% (95% confidence interval [CI], 12.7-14.4) and 54.3% (95% CI, 52.8-55.8), respectively. Extraction was associated with a lower risk of device infection at 5 years relative to capping (adjusted hazard ratio, 0.78; 95% CI, 0.62-0.97; P =0.027). There was no association between extraction and mortality, lead revision, or lead extraction at 5 years., Conclusions: Elective lead extraction for noninfectious indications had similar long-term survival to that for capping and abandoning leads in a Medicare population. However, extraction was associated with lower risk of device infections at 5 years., (© 2017 American Heart Association, Inc.)

Background: Superior vena cava (SVC) lacerations have been identified as the most lethal complication encountered during cardiac implantable electronic device lead extraction. The case fatality rate of these events approximates 50% due to rapid exsanguination. A novel, compliant balloon specifically designed for use in the SVC may provide hemostasis in the event of endovascular perforation. By temporarily occluding the compromised vessel, the endovascular balloon should delay hemodynamic collapse, provide a more controlled surgical field for repair, and thereby reduce the mortality of SVC tears complicating transvenous lead extraction., Objective: To assess the early impact of the compliant endovascular balloon on the management of SVC tears and survival outcomes., Methods: We searched a publicly available, United States Food and Drug Administration-maintained database for adverse events from 1 manufacturer of lead extraction tools. Reports from July 1, 2016, to December 31, 2016 were reviewed by 2 physicians to identify instances of SVC tears. Extracting physicians were contacted for further case details. Confirmed SVC tears were analyzed for patient demographics, repair strategies, and index hospitalization mortality., Results: Of the complications reported, 35 cases of surgically confirmed SVC tears were identified. One hundred percent of patients (9/9) were discharged alive when the endovascular balloon was properly utilized, compared to 50% of patients (13/26) when the device was not used (P = .0131). Differences between all other variables analyzed were statistically insignificant., Conclusion: During the study period, we observed a reduction in mortality in patients who suffered SVC tears while undergoing lead extraction when treatment included an endovascular balloon., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Infection is a serious complication of cardiovascular-implantable electronic device implantation and necessitates removal of all hardware for optimal treatment. Strategies for reimplanting hardware after infection vary widely and have not previously been analyzed using a large, multicenter study., Methods and Results: The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with cardiovascular-implantable electronic device infections at multiple institutions in the United States and abroad between 2009 and 2012. Reimplantation strategies were evaluated overall, and every patient who relapsed within 6 months was individually examined for clinical information that could help explain the negative outcome. Overall, 434 patients with cardiovascular-implantable electronic device infections were prospectively enrolled at participating centers. During the initial course of therapy, complete device removal was done in 381 patients (87.8%), and 220 of them (57.7%) were ultimately reimplanted with new devices. Overall, the median time between removal and reimplantation was 10 days, with an interquartile range of 6 to 19 days. Eleven of the 434 patients had another infection within 6 months, but only 4 of them were managed with cardiovascular-implantable electronic device removal and reimplantation during the initial infection. Thus, the repeat infection rate was low (1.8%) in those who were reimplanted. Patients who retained original hardware had a 11.3% repeat infection rate., Conclusions: Our study findings confirm that a broad range of reimplant strategies are used in clinical practice. They suggest that it is safe to reimplant cardiac devices after extraction of previously infected hardware and that the risk of a second infection is low, regardless of reimplant timing., (© 2017 American Heart Association, Inc.)

Background: Superior vena cava (SVC) perforation is a rare but potentially fatal complication of transvenous lead removal., Objective: The aim of this study was to evaluate the feasibility of hemodynamic stabilization using an occlusion balloon during SVC tear in a porcine model., Methods: A surgically induced SVC perforation was created in Yorkshire cross swine (n = 7). Three animals were used to develop and test surgical repair methods. Four animals were used to evaluate hemodynamic, behavioral, and neurological effects up to 5 days after SVC tear and repair. An occlusion balloon (Bridge Occlusion Balloon, Spectranetics Corporation, Colorado Springs, CO) was percutaneously delivered through the femoral vein to the location of the injury and inflated. Once hemodynamic control was achieved, the perforation was surgically repaired., Results: After SVC perforation and clamp release, the rate of blood loss was 7.0 ± 0.8 mL/s. Mean time from SVC tear to occlusion balloon deployment was 55 ± 12 seconds, during which mean arterial pressure decreased from 56 ± 2 to 25 ± 3 mm Hg and heart rate decreased from 76 ± 7 to 62 ± 7 beats/min. After the deployment of the occlusion balloon, the rate of blood loss decreased by 90%, to 0.7 ± 0.2 mL/s. The mean time of balloon occlusion of the SVC was 16 ± 4 minutes and hemodynamic measures returned to baseline levels during this time. Study animals experienced no major complications, demonstrated stable recovery, and exhibited normal neurological function at each postoperative assessment., Conclusion: Endovascular temporary balloon occlusion may be a feasible option to reduce blood loss, maintain hemodynamic control, and provide a bridge to surgery after SVC injury., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Electrocardiographic conduction abnormalities following transcatheter aortic valve replacement (TAVR) with the Edwards-Sapien valve (ESV) are not uncommon and may be transient. We sought to examine the clinical time-course of conduction abnormalities after TAVR with ESV and determine risk factors for persistent abnormalities., Methods: In this single-center prospective study, 116 consecutive patients underwent implantation of the ESV after approval by the Food and Drug Administration (FDA). Demographic, clinical, and intra-procedural variables were collected in a registry, including ECGs before, immediately after, and at discharge from hospital. Conduction abnormalities were analyzed including PR interval lengthening, QRS widening, left bundle branch block (LBBB), and high-grade AV block., Results: There were 92 patients included in the analysis. A total of 41 new conduction abnormalities were observed in 31 (34 %) patients: 7 new PR prolongation, 14 QRS widening, 14 new LBBB, and 5 high-grade AV block requiring permanent pacemaker. Of the 41 new CAs, 11 (27 %) were transient; of the transient abnormalities, 9 (82 %) resolved within 24 h of the index procedure. Chronic kidney disease was a risk factor for the development of a persistent abnormality and for need for PPM. Antegrade approach was associated with the development of persistent LBBB and persistent QRS widening., Conclusions: A significant proportion of conduction abnormalities after ESV implantation improved prior to discharge from the hospital, usually within 24 h. CKD is associated with persistence of abnormalities and with need for PPM. Antegrade approach increases risk for new intraventricular conduction delays, including LBBB.

Background: With the increasing prevalence of human immunodeficiency virus positive (HIV+) patients in the United States, and the association between HIV and cardiovascular morbidity and mortality, the use of cardiac implantable electronic devices (CIEDs) in patients with HIV has become more common. With the increasing incidence of device-related complications, lead extraction is becoming a topic of importance in this population. As the use of implantable devices increases in the HIV+ population, complications are to be expected; therefore, lead extraction in the HIV population must be addressed., Methods: From January 2004 to May 2013, 1,018 patients requiring lead extraction were referred to a single, high-volume tertiary cardiovascular center. Within this group of patients, 10 were HIV+. We retrospectively reviewed the charts of this cohort and reported clinical variables of interest., Results: Infection was the most common indication for lead extraction and device removal. Four patients were in advanced heart failure, and the overall average ejection fraction of the sample population was 32.7 ± 16.3%. In addition, the majority of patients had one or more medical comorbidities. Devices removed, in order of frequency, were implantable cardioverter defibrillators, permanent pacemakers, and cardiac resynchronization therapy devices. On average, 35.6 ± 41.6 months elapsed from implantation of the oldest lead to the date of extraction. There were no major or minor complications and all procedures were clinically successful., Conclusions: Laser lead extraction is both safe and effective in patients with HIV. This study sets a level of clinical precedent regarding the management of CIED infection or malfunction in patients with HIV., (©2015 Wiley Periodicals, Inc.)

Background: Prevention of sudden cardiac arrest (SCA) after removal of an infected implantable cardioverter-defibrillator (ICD) is a challenging clinical dilemma. The cost-effectiveness of the wearable cardioverter-defibrillator (WCD) in this setting remains uncertain., Objective: The purpose of this study was to compare the cost-effectiveness of the WCD with discharge home, discharge to a skilled nursing facility, or inpatient monitoring for the prevention of SCA after infected ICD removal., Methods: A decision model was developed to compare the cost-effectiveness of use of the WCD to several different strategies for patients who undergo ICD removal. One-way and 2-way sensitivity analyses were performed to account for uncertainties., Results: In the base-case analysis, the incremental cost-effectiveness of the WCD strategy was $20,300 per life-year (LY) or $26,436 per quality-adjusted life-year (QALY) compared to discharge home without a WCD. Discharge to a skilled nursing facility and in-hospital monitoring resulted in higher costs and worse clinical outcomes. The incremental cost-effectiveness ratio was as low as $15,392/QALY if the WCD successfully terminated 95% of SCA events and exceeded the $50,000/QALY willingness-to-pay threshold if the efficacy was <69%.The WCD strategy remained cost-effective, assuming 5.6% 2-month SCA risk, as long as the time to reimplantation was at least 2 weeks., Conclusion: The WCD likely is cost-effective in protecting patients against SCA after infected ICD removal while waiting for ICD reimplantation compared to keeping patients in the hospital or discharging them home or to a skilled nursing facility., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

We report a patient with a massive inferior vena cava (IVC) thrombus requiring immediate intervention. The patient underwent successful thrombectomy using a percutaneous catheter aspiration system. Percutaneous removal of an IVC thrombus is a safe and effective treatment option for severely ill patients., (© 2014 Wiley Periodicals, Inc.)

Background: In November 2011, the Food and Drug Administration issued a class I recall of Riata and Riata ST implantable cardioverter-defibrillator leads. Management recommendations regarding the recall have remained controversial., Objective: Data regarding the safety and feasibility of extraction of Riata implantable cardioverter-defibrillator leads are limited., Methods: We performed a retrospective study of patients undergoing extraction of Riata/Riata ST leads at 11 centers., Results: Between July 2003 and April 2013, 577 Riata/Riata ST leads were extracted from 577 patients (Riata 467, [84%]; Riata ST 89, [16%]). Complete procedural success achieved in 99.1%. The cohort was 78% men, with a mean age of 60 years and a mean left ventricular ejection fraction of 34% ± 14%. The mean implant duration was 44.7 months (range 0-124.6 months). The majority of leads extracted were for infection (305 [53.0%]) and 220 (35.7%) for lead malfunction. Evaluation for lead integrity was performed in 295 cases. Of these, 34.9% were found to have externalized cables. Implant duration was significantly longer in leads with externalized cables (P < .0001). No difference in lead integrity was noted between Riata and Riata ST leads (11.7% vs. 17.7% failure; P = .23). Among leads in which cable externalization was noted, laser sheaths were used more frequently (P = .01). Major complications included 3 superior vena cava/right ventricular perforations requiring surgical intervention with 1 death 12 days after the procedure and 1 pericardial effusion requiring percutaneous drainage (0.87%)., Conclusion: Extraction of the Riata/Riata ST leads can be challenging, and leads with externalized cables may require specific extraction techniques. Extraction of the Riata/Riata ST leads can be performed safely by experienced operators at high-volume centers with a complication rate comparable to published data., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: A higher frequency Excimer laser sheath using an 80-Hz pulse repetitive rate was approved by the Food and Drug Administration in April 2012. We reported our initial clinical experience with a high-frequency Excimer laser sheath and compared it with lower-frequency laser sheaths which have been previously used., Methods: In this single center, retrospective cohort study, we evaluated patients who underwent lead extraction from December 2008 to May 2013. Those who underwent lead removal without using a laser sheath or with approaches other than subclavian were excluded. Primary endpoints included total laser time, number of pulses, and complications. Data on clinical characteristics, lead type, indications, and outcomes were prospectively collected and analyzed., Results: A total of 427 patients were included in the study (72.6% male; age 67.9 ± 15.23 years). Lower frequency and higher frequency laser sheaths were used in 315 and 112 patients, respectively. A total of 821 leads were removed with 765 leads (93.2%) extracted using the Excimer laser sheath. Lead age was 5.71 ± 4.96 years. Complete extraction was seen in all patients. A higher-frequency laser sheath was associated with a lower laser time and a lower total number of laser pulses even after adjustments for the number of leads, type of leads, and lead age. In the higher frequency group, mortality rate was 0.9% and minor complication rate was 3.6%., Conclusions: When compared with the lower-frequency laser sheath, the higher-frequency laser sheath requires less laser times and more efficient amount of pulses for lead extraction with comparable success rate. Due to the rarity of major and minor complications, no statistical significance was found between the two groups., (©2014 Wiley Periodicals, Inc.)

Background: Cardiovascular implantable electronic device (CIED) pocket infections are often related to recent CIED placement or manipulation, but these infections are not well characterized. The clinical presentation of CIED pocket infection, based on temporal onset related to last CIED procedure, deserves further study., Methods: The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with CIED infection. Subjects were stratified into those whose infection occurred <12 months (early) or ≥ 12 months (late) since their last CIED-related procedure., Results: There were 132 subjects in the early group and 106 in the late group. There were more females (P = 0.009) and anticoagulation use (P = 0.039) in the early group. Subjects with early infections were more likely to have had a generator change or lead addition as their last procedure (P = 0.03) and had more prior CIED procedures (P = 0.023). Early infections were more likely to present with pocket erythema (P < 0.001), swelling (P < 0.001), and pain (P = 0.007). Late infections were more likely to have pocket erosion (P = 0.005) and valvular vegetations (P = 0.009). In bacteremic subjects, early infections were more likely healthcare-associated (P < 0.001). In-hospital and 6-month mortality were equivalent., Conclusion: A total of 45% of patients with CIED pocket infection presented >12 months following their last CIED-related procedure. Patients with early infection were more likely to be female, on anticoagulation, and present with localized inflammation, whereas those with late infection were more likely to have CIED erosion or valvular endocarditis., (©2014 Wiley Periodicals, Inc.)

Tricuspid valve (TV) perforation is a rare complication after implantable cardioverter defibrillator (ICD) and permanent pacemaker implantation. In reported cases of lead-related TV perforations, patients' present with symptoms months to years postimplantation. We describe a case where a patient presented with signs of severe TV regurgitation secondary to traumatic perforation of the septal leaflet two weeks after ICD implantation and review of the literature associated with this complication., (© 2014 Wiley Periodicals, Inc.)

Objectives: The purpose of this study was to determine whether the clinical presentation of lead-associated endocarditis (LAE) is related to the size of lead vegetations and how size is related to bacteriology and clinical outcomes., Background: Cardiac implantable electronic device (CIED) infection may present as either local pocket infection or bloodstream infection with or without LAE. LAE is associated with significant morbidity and mortality., Methods: The clinical presentation and course of LAE were evaluated by the MEDIC (Multicenter Electrophysiologic Device Cohort) registry, an international registry enrolling patients with CIED infection. Consecutive LAE patients enrolled in the MEDIC registry between January 1, 2009 and December 31, 2012 were analyzed. The clinical features and outcomes of 2 groups of patients were compared based on the size of the lead vegetation detected by echocardiography (> or <1 cm in diameter)., Results: There were 129 patients with LAE enrolled into the MEDIC registry. Of these, 61 patients had a vegetation <1 cm in diameter (Group I) whereas 68 patients had a vegetation ≥1 cm in diameter (Group II). Patients in Group I more often presented with signs of local pocket infection, whereas Group II patients presented with clinical evidence of systemic infection. Staphylococcus aureus was the organism most often responsible for LAE, whereas infection with coagulase-negative staphylococci was associated with larger vegetations. Outcomes were improved among those who underwent complete device removal. However, major complications were associated with an open surgical approach for device removal., Conclusions: The clinical presentation of LAE is influenced by the size of the lead vegetation. Prompt recognition and management of LAE depends on obtaining blood cultures and echocardiography, including transesophageal echocardiography, in CIED patients who present with either signs of local pocket or systemic infection., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: An implantable cardioverter defibrillator (ICD) is effective in preventing sudden cardiac death (SCD). Once an ICD is removed and reimplantation is not feasible, a wearable cardioverter defibrillator (WCD) may be an alternative option. We determined the effectiveness of WCD for SCD prevention in patients who were discharged after ICD removal., Methods: A retrospective study was conducted on all WCD (LifeVest, ZOLL, Pittsburgh, PA, USA) patients who underwent ICD removal due to cardiac device infections (CDIs) at two referral centers between January 1, 2005 and December 31, 2009. Clinical characteristics, device information, and WCD data were analyzed. Sudden cardiac arrest was defined as all sustained ventricular tachycardia (VT) and ventricular fibrillation occurring within a single 24-hour period., Results: Ninety-seven patients (mean age 62.8 ± 13.3, male 80.4%) were included in the study. The median duration of antibiotic use was 14.7 days (interquartile range [IQR] 10-30). The median daily WCD use was 20 hours/day and the median length of use was 21 days (IQR 5-47). A total of three patients were shocked by WCD. Two patients had four episodes of sustained VT, successfully terminated by the WCD. A third patient experienced two inappropriate treatments due to oversensitivity of the signal artifact. Three patients experienced sudden death outside the hospital while not wearing the device. Five patients died while hospitalized., Conclusion: WCD can prevent SCD, until ICD reimplantation is feasible in patients who underwent device removals for CDI. However, patient compliance is essential for the effective use of this device., (©2013 Wiley Periodicals, Inc.)

Objectives: This study sought to determine the incidence of new-onset atrial fibrillation (AF) associated with different methods of isolated aortic valve replacement (AVR)-transfemoral (TF), transapical (TA), and transaortic (TAo) catheter-based valve replacement and conventional surgical approaches., Background: The relative incidences of AF associated with the various access routes for AVR have not been well characterized., Methods: In this single-center, retrospective cohort study, we evaluated a total of 231 consecutive patients who underwent AVR for degenerative aortic stenosis (AS) between March 2010 and September 2012. Patients with a history of paroxysmal, persistent, or chronic AF, with bicuspid aortic valves, and patients who died within 48 h after AVR were excluded. A total of 123 patients (53% of total group) qualified for inclusion. Data on documented episodes of new-onset AF, along with all clinical, echocardiographic, procedural, and 30-day follow-up data, were collated., Results: AF occurred in 52 patients (42.3%). AF incidence varied according to the procedural method. AF occurred in 60% of patients who underwent surgical AVR (SAVR), in 53% after TA-TAVR, in 33% after TAo-TAVR cases, and 14% after TF-TAVR. The episodes occurred at a median time interval of 53 (25th to 75th percentile, 41 to 87) h after completion of the procedure. Procedures without pericardiotomy had an 82% risk reduction of AF compared with those with pericardiotomy (adjusted odds ratio: 0.18; 95% confidence interval: 0.05 to 0.59)., Conclusions: AF was a common complication of AVR with a cumulative incidence of >40% in elderly patients with degenerative AS who underwent either SAVR or TAVR. AF was most common with SAVR and least common with TF-TAVR. Procedures without pericardiotomy were associated with a lower incidence of AF., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The use of laser lead extraction (LLE) to remove pacemaker and implantable cardiac defibrillator leads has become more prevalent in the past decade. Though the procedure is associated with a low rate of complications, LLE still poses some risks to patients. Some reports have suggested an increase in tricuspid insufficiency (TI) associated with LLE. We present a series of patients who underwent both LLE and complete evaluation for TI with echocardiographic techniques., Methods: From August 2008 to January 2010, 173 prospective, consecutive patients underwent LLE in a single center. All patients had transesophageal echocardiograms (TEE) during the extraction. Fifty-three patients had tricuspid valve function evaluated a day before the procedure with a transthoracic echocardiogram (TTE), during the procedure with a TEE and 2 days postoperatively with a TTE., Results: All 173 patients experienced no change in tricuspid valve function during the procedure with TEE. Of the 53 patients who underwent a complete TI evaluation, 38 were males (72%) and 15 females (38%), with a mean age of 69.45 ± 14.08. Mean ejection fraction was 35.82 ± 14.72. Three (6%) patients experienced TI after the procedure (two mild and one severe, all with tricuspid valve endocarditis); 16 (30%) patients were found to have TI before LLE that returned to normal valve function during or after the procedure. Thirty-four (64%) patients did not experience any significant change of the tricuspid valve performance after LLE., Conclusion: LLE was not associated with increased TI., (©2013, The Authors. Journal compilation ©2013 Wiley Periodicals, Inc.)

Background: The prevalence of cardiac device-related infections (CDIs) has mirrored the unprecedented increase in device usage. CDIs are currently one of the leading indications for extraction. Despite this, there is limited data regarding the clinical trends, management and outcomes associated with this complication., Methods: A review of a prospective registry of all patients undergoing device extraction between January 1, 2004, and June 15, 2009, at a single high-volume tertiary referral center was performed., Results: A total of 506 consecutive patients were identified. From these, 350 patients were identified as having a CDI (205 ICD, 145 PPM). The mean age was 69.9 ± 13.7. Although most patients presented clinically with signs of a pocket infection (PI) (42%), the most common final diagnosis was cardiac device infective endocarditis (CDIE) (57%). The two most common pathogens were methicillin-resistant Staphylococcus aureus (27%) and methicillin-resistant Staphylococcus epidermidis (23%); they accounted for 69% of all deaths. Cultures taken from pocket tissue as opposed to exudates displayed higher concordance with lead-tip cultures (56% and 31% respectively). The mean time from explantation to device reimplantation for PIs, bacteremia and CDIE was 6.7 ± 4.7, 10.25 ± 4.7 and 11.39 ± 16.6 days respectively., Conclusion: CDIs are a serious complication associated with device usage. Diagnosis and management protocols for CDIs should feature transesophageal echocardiography; complete hardware extraction; broad-spectrum antibiotics that cover methicillin-resistant Staphylococci and cultures derived from lead-tips and preferably pocket tissue. Immediate device reimplantation is possible in noninfectious cases; several factors should be considered regarding reimplantation in cases involving CDIs., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)