Elsevier

Heart Rhythm

Volume 18, Issue 6, June 2021, Pages 962-969
Heart Rhythm

Clinical
Devices
Prognosis of patients with severe left ventricular dysfunction after transvenous lead extraction and the need for additional hemodynamic support in the perioperative period

https://doi.org/10.1016/j.hrthm.2021.01.026Get rights and content

Background

Transvenous lead extraction (TLE) is necessary because of system infection, lead malfunction, or system upgrade. Patients with severe left ventricular dysfunction (SLVD) undergoing TLE may be at a higher risk because hemodynamic parameters may change unfavorably during or after TLE; however, this has not yet been clarified.

Objective

The purpose of this study was to examine whether patients with SLVD undergoing TLE have higher mortality.

Methods

All patients who underwent TLE were stratified as follows: patients with ejection fraction ≤ 35% (SLVD group) and those with ejection fraction > 35% (non-SLVD group).

Results

We assessed the data of 200 patients [SLVD group, 36 (18%); non-SLVD group, 164 (82%)]). Brain natriuretic peptide level and cardiac resynchronization therapy rate were higher in the SLVD group than in the non-SLVD group. There were no significant between-group differences in major complications and clinical success rates. Patients with SLVD were more likely to require additional hemodynamic support, such as catecholamine infusion, temporary atrium-ventricle sequential pacing, and temporary cardiac resynchronization therapy pacing (27.8% vs 1.2%; P < .001). The survival rate was not significantly different between the groups at 30 days and 1 year after TLE (SLVD vs non-SLVD: 30 days: 97.2% vs 99.4%; P = .215; 1 year: 80.6% vs 91.5%; P = .053). Multivariate Cox regression analysis revealed log brain natriuretic peptide and serum hemoglobin levels as predictors for 1-year mortality.

Conclusion

The prognosis after TLE was comparable between patients with and without SLVD. However, additional hemodynamic support was often necessary for patients with SLVD.

Introduction

The growing evidence of the importance of cardiac implantable electronic devices (CIEDs) in improving both quality of life and survival in specific patients with heart diseases has led to a significant increase in the number of implantations.1,2 Hence, the number of complications, including CIED-related infection or lead failure, has also increased. Transvenous lead extractions (TLEs) are considered the first-line approach when lead extraction is indicated, and significant advances in the techniques and equipment have improved patient safety and procedural outcomes.3,4 The decision to proceed with CIED extraction should be a multidisciplinary approach with appropriate indications as detailed in the 2009 and 2017 Heart Rhythm Society (HRS) consensus documents.5,6 TLE has the risk of catastrophic complications, including death. Thus, deciding whether TLE should be used can be difficult, especially in patients with multiple comorbidities or severe left ventricular dysfunction (SLVD). TLE in patients with SLVD theoretically carries a higher risk than in those without SLVD because of the significant morbidity and mortality associated with heart failure. Patients with SLVD with minimal pacing are not expected to have a significant alteration in hemodynamics. In patients with cardiac resynchronization therapy (CRT), alterations in hemodynamics may arise from abrupt termination of electromechanical synchrony. Lack of sequential pacing may or may not play a role. Moreover, these patients may have ventricular arrhythmia, which sometimes results in death without the underlying role of any device. Hence, the prognosis after TLE in patients with SLVD may also worsen. Additional hemodynamic support, such as catecholamine infusion, temporary atrium-ventricle sequential pacing, temporary CRT pacing, or ventricular arrhythmic management, is often necessary in such patients. Although the complication rate, success rate, and prognosis of patients with CRT have been reported,7, 8, 9, 10 current evidence is limited to whether there is an increased risk of TLE in patients with SLVD. Therefore, in this study, we sought to estimate the complication rate, success rate, and prognosis after TLE in patients with SLVD compared with those without SLVD.

Section snippets

Patients

The medical records of all consecutive patients who underwent TLE at the Okayama University Hospital from 2010 to 2019 were retrospectively reviewed. Patients were divided into 2 groups: SLVD (ejection fraction ≤ 35%) and non-SLVD (ejection fraction > 35%). The data for several parameters, including patients’ demographic characteristics, comorbidities, device and lead type, indication for extraction, procedural success, major complications, and 30-day and 1-year mortality rates, were collected.

Patient characteristics

Of the 200 patients included in this study, 36 (18%) were in the SLVD group and 164 (82%) were in the non-SLVD group. Patients in the SLVD group had higher log brain natriuretic peptide (BNP), higher serum creatinine level, higher proportion of patients in New York Heart Association class III/IV, and a higher rate of CRT than did patients in the non-SLVD group (Table 1).

Lead extraction

In total, 367 leads were extracted using various lead extraction techniques (Figure 1). Of these, 190 (51.8%) were active

Discussion

To our knowledge, this is the first report comparing 30-day and 1-year prognoses after TLE in patients with and without SLVD. The main finding of this study was that the prognosis of patients with SLVD was comparable to that of patients without SLVD at 30 days and 1 year. However, additional hemodynamic support, such as catecholamine infusion, temporary atrium-ventricle sequential pacing, temporary CRT pacing, or ventricular arrhythmic management was required for patients with SLVD.

Conclusion

The prognosis of patients with SLVD after TLE is comparable to that of patients without SLVD. However, some additional hemodynamic support, such as catecholamine infusion, temporary atrium-ventricle sequential pacing, temporary CRT pacing, or ventricular arrhythmic management, is often necessary in patients with SLVD.

Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We thank Roger Carrillo, MD, PhD; Maria Grazia Bongiorni, MD, PhD; and Morio Shoda, MD, PhD, for education regarding lead extraction; Takuya Kawabata, MD, PhD; Masaki Hirota, MD, PhD; Takanori Suezawa, MD, PhD; Zenitsu Masuda, MD, PhD; Masami Takagaki, MD, PhD; Yosuke Kuroko, MD, PhD; and Hiroki Eto, MD, for the surgical backup; Keisuke Ohnishi, Hirotaka Iguchi, Norihiro

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