ClinicalDevicesPrognosis of patients with severe left ventricular dysfunction after transvenous lead extraction and the need for additional hemodynamic support in the perioperative period
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.
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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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Funding sources: The authors have no funding sources to disclose.
Disclosures: The authors have no conflicts of interest to disclose.