The high predisposition to pulmonary embolism (PE) in CoViD-19-patients increases with its seriousness, even under anticoagulation. Because neither clinical nor laboratory parameters seem to be specific in this case, the CTPA stays the gold standard for further diagnostic, with the risk however of overuse.

Abstract Funding Acknowledgements Type of funding sources: None. Background Device complications, such as infection or lead dysfunction necessitating transvenous lead extraction (TLE) are continuously rising amongst patients with indwelling transvenous implantable cardioverter-defibrillator (ICD). Objectives Aim of this study was to characterize the procedural outcome and risk factors of patients with indwelling 1- and 2-chamber ICD undergoing TLE. Methods We conducted a subgroup analysis of all 1- and 2-chamber ICD patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for procedural failure and all-cause mortality were assessed. Results A total of 854 patients with ICD undergoing TLE were identified, who were younger (62.9±13.8 vs. 70.7±13.0 years; p<0.001), less likely to be female (20.8 vs. 27.1%; p<0.001) and had a higher proportion of patients with coronary artery disease (51.5 vs. 38.6%; p<0.001) and highly reduced ejection fraction (32.0 vs. 23.0%; p>0.001), when compared to non-ICD patients. Leading extraction indication was lead dysfunction (48.0 vs. 21.9%; p<0.001), followed by device-related infection (45.6 vs. 73.0%; p<0.001). There were no differences in overall procedural complications (4.3 vs. 4.3%; p=0.980), clinical success rate (97.9 vs. 97.8%; p=0.861) or procedure-related (0.8 vs. 0.5%; p=0.292) and all-cause mortality (3.4 vs. 3.7%; 0.742) between groups. Multivariate analysis revealed lead age≥10 years (OR:5.75, 95%CI:2.0-16.2; p=0.001) as independent predictor for procedural failure. Systemic infection as extraction indication (OR:9.57, 95%CI:2.2-42.4; p=0.003) and procedural complications (OR:8.0, 95%CI:2.8-23.3; p<0.001) were identified as risk factors for all-cause mortality. Predictors for systemic infection in ICD patients were atrial fibrillation (OR: 2.22, 95%CI: 1.51-3.27; p<0.001), diabetes mellitus (OR: 2.28, 95%CI: 1.59-3.25; p<0.001) and chronic kidney disease (OR: 2.0, 95%CI: 1.39-2.89; p<0.001). Conclusions Transvenous lead extraction is safe and efficacious in patients with 1- and 2-chamber ICD. Although lead dysfunction is the leading indication for extraction, systemic device-related infection is the main driver of all-cause mortality for ICD patients undergoing TLE.

In den vergangenen Jahren wurden zwei wesentliche internationale Experten-Empfehlungen zum Sondenmanagement kardialer implantierbarer elektronischer Devices (CIED) überarbeitet. So veröffentlichte zum einen die Heart Rhythm Society (HRS) 2017 einen Expertenkonsensus zum Thema Sondenmanagement unter Einschluss der Aspekte Haltbarkeit, Fehlfunktionen und Rückrufe, der Indikationen von Revisionseingriffen, des periprozeduralen Managements, einschließlich der personellen und logistischen Voraussetzungen von Sondenextraktionen, und gab zudem Empfehlungen zur Qualitätssicherung und zum Datenmanagement. Zum anderen publizierte die European Heart Rhythm Association (EHRA) 2018 Empfehlungen zum Design von klinischen Studien und Registern und forderte zudem eine intensivere wissenschaftliche Aufarbeitung der Sondenextraktionsprozeduren und benannte bestehende Wissenslücken („gaps in evidence“). Beide Manuskripte ergänzen sich thematisch und verfolgen das gemeinsame Ziel einer flächendeckenden qualitativ hochwertigen klinischen Versorgung sowie einer zukünftig fundierteren Aufarbeitung offenstehender wissenschaftlicher Fragen. Die gewählten Schwerpunkte adressieren explizit nicht ausschließlich Elektroden-revidierende Zentren, sondern alle in die Behandlung von CIED-Patienten involvierten Ärzte. Der vorliegende Kommentar der Arbeitsgemeinschaft Herzrhythmusstörungen der DGTHG fasst die wesentlichen Empfehlungen der beiden Stellungnahmen zusammen, erläutert Hintergründe und diskutiert kritisch kontroverse Auffassungen.

In the past few years two major international expert recommendations on lead management of cardiac implantable electronic devices (CIED) have been revised. Accordingly, in 2017 an expert consensus on lead management under the patronage of the Heart Rhythm Society (HRS) was published. It focused mainly on aspects of durability, malfunctions and recalls, indications for revision interventions, periprocedural management including personnel and logistic requirements for lead removal. Additionally, the recommendations on quality assurance and data management were addressed as well. Subsequently, the European Heart Rhythm Association (EHRA) published expert recommendations in 2018, which mainly dealt with the design of clinical studies and registries and requested a comprehensive analysis of lead extraction procedures and specified existing gaps in evidence. The papers complemented each other in terms of content and had a common denominator for high-quality clinical care that was based on well-supported clinical evidence. Importantly, both consensus statements address, besides lead extraction centers, explicitly all physicians involved in the treatment of CIED patients. The present comments by the Working Group on Heart Rhythm Disorders of the German Society for Thoracic, Cardiac and Vascular Surgery (DGTHG) summarizes the most important recommendations of the two statements, explains the background and discusses critical controversies.

Abstract OnBehalf GALLERY investigators Background The number of cardiac implantable electronic device (CIED)-associated complications such as infection, lead dysfunction or thrombotic events is continuously rising and thus making transvenous lead extraction (TLE) an ever more needed procedure in clinical practice today. Patients with abandoned leads represent a special cohort with a potentially higher susceptibility to CIED-related infections and vascular complications. Moreover, according to literature abandoned leads seem to be associated with more procedural complications and mortality during TLE. Aim The aim of this study was to provide an insight on safety, procedural outcome and risk prediction on pacemaker patients with abandoned leads undergoing TLE from the largest national laser-sheath registry to date. Methods + Results: We conducted a retrospective analysis of the GALLERY database, which collected 2533 patients undergoing TLE in Germany between 2013 and 2017. Out of 903 pacemaker patients, who underwent TLE, 226 patients (25.0%) with abandoned leads were identified. Those patients had a higher number of leads per patient (3.2 ± 0.8 vs. 1.9 ± 0.3; ns) and longer lead dwell-times (168.0 ± 89.7 vs. 123.0 ± 69.2 months; p < 0.0001) compared to pacemaker patients without abandoned leads. There were no differences in age (71.5 vs. 72.3 years; ns), body mass index (26.5 ± 4.5 vs. 26.78 ± 4.8 kg/m2; ns) or gender distribution (69.0 vs. 66.5% male; ns). Leading indication for TLE was device infection with no difference between groups (79.7 vs 77.8 %; ns). There were no differences in terms of pacemaker dependency, length of hospitalization or comorbidities. Patients with abandoned leads had longer procedure times (112.0 ± 69.0 vs. 86.4 ± 53.0 minutes; p < 0.0001) and a higher incidence of procedural complications (6.6 vs. 3.1%; p = 0.03), but there were no differences in neither procedural and clinical success rates (96.5 vs. 97.3%; ns), nor all-cause mortality (1.33 vs. 2.66%; ns). Multivariate logistic regression revealed abandoned leads (OR 2.1, CI 1.0-4.4, p = 0.04) and female gender (OR 2.4, CI 1.2-4.9, p = 0.02) as independent predictors for procedural complications. Systemic infection (OR 5.4, CI 2.0-14.8, p = 0.001) and chronic kidney disease (OR 4.0, CI 1.5-10.7, p = 0.007) were strong predictors for all-cause mortality in patients with indwelling pacemaker. Patient age > 75 years (OR 3.9, CI 2.7-5.6, p < 0.0001) and a lead dwell-time > 10 years (OR 1.6, CI 1.1-2.2, p = 0.01) were identified as risk factors for an infectious cause for TLE. Conclusion Abandoned leads are frequently encountered in pacemaker patients undergoing TLE and pose an important risk factor for procedural complications. Systemic CIED-related infections are the strongest driver of mortality in this patient cohort and urgently call for further improvements in early diagnosis and prevention.

Objective: This case report describes the clinical course of a 19-year-old patient suffering from repeated septicemia after complete removal of an infected transvenous pacemaker system. The initial symptom of repetitive septicemia persisted even after complete removal of the pacemaker system immediately when antibiotic therapy was discontinued. The patient already developed an antibiotic-induced renal insufficiency. In the total course, two university hospitals and a specialized pediatric cardiological center were involved. However, similar cases are likely to be observed anywhere else.

Die Therapie mithilfe eines subkutan implantierbaren Kardioverter-Defibrillator (S-ICD) ist für ausgewählte Patienten mit entsprechender Indikation eine Option, die im Gegensatz zur konventionellen ICD-Therapie ohne intravasale bzw. intrakardiale Elektroden auskommt. Sofern präoperativ anhand der Indikation und eines Screenings sichergestellt ist, dass sich die Therapieform für den Patienten eignet, lässt sich der Eingriff rasch und mit wenig Aufwand durchführen. Ideal erscheint die S‑ICD-Therapie für Patienten mit primärprophylaktischer Indikation, z. B. im Rahmen einer verminderten Ejektionsfraktion bei ischämischer Kardiomyopathie sowie zu Primär- und Sekundärprävention von Erkrankungen, die mit primärem Kammerflimmern einhergehen (z. B. bei Long-QT-Syndrom, Brugada-Syndrom etc.). Der Erfolg der S‑ICD-Therapie ist davon abhängig, dass das System auf die individuellen anatomischen Verhältnisse des Patienten angepasst implantiert wird. Vorteil des Systems ist neben dem Verzicht auf intravasale Elektroden der Erhalt uneingeschränkter Aktivität im Bereich des Schultergürtels. Die S‑ICD-Therapie eignet sich derzeit nicht zur Behandlung ventrikulärer Tachykardien, da der S‑ICD im Gegensatz zum konventionellen ICD keine antitachykarde Stimulation ausführen kann. Ebenso ist, abgesehen von der kurzen Phase einer Postschockstimulation, keine antibradykarde Therapie möglich, sodass für Patienten mit bradykarden, schrittmacherpflichtigen Herzrhythmusstörungen konventionelle ICD-Systeme die Methode der Wahl bleiben. Inwieweit sich die S‑ICD-Therapie in Verbindung mit sondenlosen Systemen zu einem neuen Standard entwickelt, ist derzeit nicht absehbar.

Objective: The steadily increasing implantation numbers at ∼1000 implant sites in Germany over years creates an obvious higher proportion especially of more complex revisions. The beneficial effects of advanced heart failure therapy but also the growing number of very young patients with early transvenous lead implantation contribute to a remarkable increase in the need for lead extraction. The aim of our study is to focus the exceptional increase of complex lead revisions.

Die ärztliche Qualifikation zur Durchführung von Eingriffen mit kardialen Rhythmusimplantaten sowie der entsprechenden prä- und postoperativen Therapie, einschließlich der Nachuntersuchungen, ist bisher kaum definiert. Basierend auf dem interdisziplinär erarbeiteten und in 2008 publizierten Strukturpapier wurde von der Arbeitsgruppe Elektrophysiologische Chirurgie der Deutschen Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) ein Zertifikat mit 3 Modulen erarbeitet, das Kriterien und Anforderungen für diesen Bereich nachvollziehbar definiert. Die ersten Prüfungen zur Erlangung des Zertifikats werden noch in 2013 erfolgen; eine zeitlich begrenzte Übergangsregelung ist bis zum 01. April 2014 vorgesehen. Weitere Details sind auf der Homepage der DGTHG zu finden.

Objectives: In recent years increased number of reports highlighted the low benefit/risk ratio of intraoperative defibrillation testing (DT) and thereby argued against its routine application. Moreover, implementation of high energy-defibrillators into the clinical practice seemed to make the intraoperative DT obsolete. Currently, some clinical trials were launched in order to underline this opinion. In order to explain the bias of our clinical experience with some of these reports we evaluated the effectiveness and necessity of intraoperative DT in a multicenter study.

Die Schrittmachertherapie umfasst heute deutlich mehr als nur das Schaffen eines Venenzugangs, die Platzierung einer oder mehrerer Elektroden und das Präparieren einer Gerätetasche. Wenngleich diese Aspekte mit ein paar Tipps und Tricks auch hier breiten Raum einnehmen, besitzt die Rhythmuschirurgie viele Facetten wie die Interaktion mit dem Patienten oder die intensive Beschäftigung mit z. B. Indikation und Material und ermöglicht Perspektiven, die im Rahmen der sonstigen Herzchirurgie ansonsten kaum gegeben sind.

Objectives: In a previous series, a percentage of patients with insufficient safety margin during intraoperative DFT-testing as high as 6.3% has been presented. A growing number of implanting physicians favour to implant ICD devices without intraoperative DFT testing.

The superiority of left internal thoracic artery (LITA) grafting to the left anterior descending artery (LAD) is well established. Patency rates of 80%–90% have been reported at 10-year follow-up. However, the superiority of sequential LITA grafting has not been proven. Our aim was to compare patency rates after sequential LITA grafting to a diagonal branch and the LAD with patency rates of LITA grafting to the LAD and separate vein grafting to a diagonal branch.

OBJECTIVE:The EuroSCORE risk stratification model has been developed in 1995 and is still widely used to assess individual patient risk prior to cardiac surgery. Furthermore, the score advanced to a decision tool to determine so-called "high-risk patients" and in consequence serves as an important selection criterion in new technologies, such as the catheter-based aortic valve replacement. Several studies with relatively small patient numbers showed a substantial overestimation of risk by the EuroSCORE. The aim of our study was to evaluate whether the nationwide data support this finding.METHODS:A subgroup of the registry of the German Society of Thoracic and Cardiovascular Surgery from 2006 and 2007, with 32,806 patients undergoing isolated coronary surgery and isolated aortic valve replacement was investigated.RESULTS:The overall hospital mortality in isolated coronary surgery in this patient cohort (n = 26,501 patients) was 2.6% (n = 695). The overall hospital mortality in isolated aortic valve replacement in this patient cohort (n = 6,305 patients) was 3.9% (n = 245). The logistic EuroSCORE predicted a proportion of 5.2% for patients with isolated CABG and 7.3% for patients with isolated aortic valve replacement. The area under the receiver operating characteristic curve was 0.77 for isolated CABG procedures and 0.69 for isolated valve procedures, supporting the substantial lack of predictive value of the EuroSCORE.CONCLUSION:The logistic EuroSCORE insufficiently evaluates the risk of the current patient population and therefore should be carefully used as a tool for important therapeutic decision-making.

Objective: The superiority of use of IMA versus venous grafts concerning long-term survival especially for LAD grafting has been repeatedly published. Since from a clinical point of view, the differences appear less impressive, the aim of our study was to apply current statistical techniques to reevaluate the effect of the graft (venous or IMA to LAD) on long-term survival.

Scores reached for different applications in cardiovascular medicine a high ranking in terms of risk adjustment. In the original publication of most scores on the lack of predictive power for individual risk calculation is indicated. Nevertheless, the EuroSCORE as a prominent example presents an internet-based individual risk calculator. The aim of our study was to illustrate the potential misconduct by application of the generally accepted EuroSCORE.

Caregiver's education level and child's dental caries in African Americans: a path analytic study.Heima M, Lee W, Milgrom P, Nelson S.Caries Res 2015;49(2):177-83.Woosung Sohn, DDS, PhD, DrPHThe authors conducted path analysis to test various models for an association between caregiver education and child dental caries and its mediating pathways via oral health-related behaviors.This study was supported by the Health Resources and Services Administration (HRSA/MCHB R40- MC07838) and the National Center for Research Resources (CTSC UL1 RR024989).Cross-sectional study (secondary analysis of cross-sectional data collected in a longitudinal study)Level 3: Other evidenceNot applicable