Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes. We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately. The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9–12.5%; range, 0.4–100%), 3.3% (IQR, 1.3–7.1%; range, 0.2–87.0%), and 2.5% (IQR, 0.5–24.0%; range, 0.1–55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3–2.0 V] vs 0.8 V [0.6–1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0–5.0 mV] vs. 10.0 mV [7.0–12.0 mV], p < 0.0001). In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary.

The aging population, particularly the thin and frail, has an increased risk of long-term cardiac implantable electronic device complications. This case is that of an elderly, thin-skinned patient who presented with a pacemaker pocket erosion 4 years after elective generator change, potentiated by a small pocket size with a superficial suture fixating the generator in the subcutaneous pocket. The risk for device erosion may have been mitigated during the generator change by increasing the size of the pocket, using a submuscular pocket, and potentially an absorbable antibacterial envelope. Fixation of the generator is considered optional.

Background: Contemporary guidelines recommend that atrial fibrillation (AF) be classified into paroxysmal and persistent AF based on clinical assessment, with these categorizations forming the basis of therapeutic recommendations. While pragmatic, clinical assessment may introduce misclassification errors, which may impact treatment decisions. We sought to determine the relationship between AF classification, baseline AF burden, and post-ablation arrhythmia outcomes. Design: The current study is a sub-analysis of a prospective, parallel-group, multicenter, single-blinded randomized clinical trial. All 346 patients enrolled in CIRCA-DOSE received an implantable cardiac monitor a median of 72 days prior to ablation. AF was classified as low burden paroxysmal, high burden paroxysmal, or persistent based on clinical assessment prior to device implantation. Prior to ablation patients were re-classified using the same definitions based on device monitoring data. Correlation between classifications, AF burden, and post-ablation arrhythmia outcomes were assessed. Results: There was poor agreement between clinical and device-based AF classification (Cohen's kappa: 0.192). AF classification derived from pre-ablation continuous monitoring reflected baseline and post-ablation AF burden with greater accuracy andwith less overlap between the AF classes (P < 0.01 for all categorical comparisons). Patients objectively classified as "Low Burden" paroxysmal by continuous monitoring data had significantly greater freedom from recurrent AF/AT/AFL compared to those classified as "High Burden" paroxysmal (hazard ratio [HR] 0.57 for AF/AT/AFL recurrence) or persistent AF (HR 0.19 for AF/AT/AFL recurrence). Conclusions: Classification of AF pattern based on pre-ablation continuous cardiac rhythm monitoring better predicted AF burden and freedom from recurrent AF post ablation. Despite the use of standardized definitions, classification of AF based on clinical assessment did not predict baseline AF burden, post ablation AF burden, or freedom from recurrent AF post ablation. (C) 2020 Elsevier Inc. All rights reserved.

OBJECTIVES This study evaluated the impact of contact force-guided radiofrequency ablation versus cryoballoon ablation on quality of life and health care utilization. BACKGROUND Traditional outcome parameters, such as arrhythmia-free survival, are insufficient to evaluate the clinical impact of atrial fibrillation (AF), as it fails to the capture patient- and health system-level differences in treatment approaches. METHODS The CIRCA-DOSE (Cryoballoon Vs. Contact-Force Atrial Fibrillation Ablation) study randomly assigned 346 patients with drug-refractory paroxysmal AF to contact force-guided radiofrequency or cryoballoon ablation. Health-related quality-of-life (HRQOL) was assessed at baseline, and at 6 and 12 months post-ablation using a disease-specific and generic HRQOL instruments. Health care utilization (hospitalization, emergency department visits, and cardioversion) and antiarrhythmic drug use for the 12 months preceding ablation was compared with the 12 months following ablation. RESULTS Disease-specific and generic HRQOL was moderately to severely impaired at baseline and improved significantly at 6 and 12 months of follow-up (median improvement in AFEQT [Atrial Fibrillation Effect on QualiTy of Life] score 32.4 [interquartile range: 17.7 to 48.9]). When compared with the 12 months pre-ablation, the proportion and absolute number of cardioversions decreased significantly (41.1% vs. 10.1% of patients, 137 vs. 35 events; p < 0.0001). Similar significant reductions in emergency department visits (66.7% vs. 25.1% of patients, 224 vs. 87 events; p < 0.0001), and hospitalizations (25.5% vs. 14.5% of patients, 86 vs. 50 events; p < 0.001) were observed. There were no significant differences between randomized groups. CONCLUSIONS In this multicenter randomized trial, catheter ablation with advanced-generation technologies resulted in a significant improvement in HRQOL and a significant reduction in health care utilization in the year following AF ablation. (C) 2020 by the American College of Cardiology Foundation.

SummaryImplantable cardiac electronic device lead dislodgment is a relatively common complication and carries significant comorbidities. A potential cause of lead dislodgement includes inadequate anchoring along the lead suture sleeve at thevenous insertion site. We assessed which of the 3 commonly applied knot-tying techniques results in the most effective anchoring of a pacing lead along its suture sleeve, which could be associated with minimized lead motion postimplant.Following controlled traction force measurements, the anchor knot technique offered the greatest amount of lead stability when compared with the simple knot and the looping knot techniques.

Background: Advanced generation ablation technologies have been developed to achieve more effective pulmonary vein isolation (PVI) and minimize arrhythmia recurrence after atrial fibrillation (AF) ablation. Methods: We randomly assigned 346 patients with drug-refractory paroxysmal AF to contact force–guided radiofrequency ablation (CF-RF; n=115), 4-minute cryoballoon ablation (Cryo-4; n=115), or 2-minute cryoballoon ablation (Cryo-2; n=116). Follow-up was 12 months. The primary outcome was time to first documented recurrence of symptomatic or asymptomatic atrial tachyarrhythmia (AF, atrial flutter, or atrial tachycardia) between days 91 and 365 after ablation or a repeat ablation procedure at any time. Secondary end points included freedom from symptomatic arrhythmia and AF burden. All patients received an implantable loop recorder. Results: One-year freedom from atrial tachyarrhythmia defined by continuous rhythm monitoring was 53.9%, 52.2%, and 51.7% with CF-RF, Cryo-4, and Cryo-2, respectively ( P =0.87). One-year freedom from symptomatic atrial tachyarrhythmia defined by continuous rhythm monitoring was 79.1%, 78.2%, and 73.3% with CF-RF, Cryo-4, and Cryo-2, respectively ( P =0.26). Compared with the monitoring period before ablation, AF burden was reduced by a median of 99.3% (interquartile range, 67.8%–100.0%) with CF-RF, 99.9% (interquartile range, 65.3%–100.0%) with Cryo-4, and 98.4% (interquartile range, 56.2%–100.0%) with Cryo-2 ( P =0.36). Serious adverse events occurred in 3 patients (2.6%) in the CF-RF group, 6 patients (5.3%) in the Cryo-4 group, and 7 patients (6.0%) in the Cryo-2 group, with no significant difference between groups ( P =0.24). The CF-RF group had a significantly longer procedure duration but significantly shorter fluoroscopy exposure ( P <0.001 vs cryoballoon groups). Conclusions: In this multicenter, randomized, single-blinded trial, CF-RF and 2 different regimens of cryoballoon ablation resulted in no difference in 1-year efficacy, which was 53% by time to first recurrence but >98% burden reduction as assessed by continuous cardiac rhythm monitoring. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01913522.

Dronedarone is a benzofuran derivative resembling amiodarone that was intended to reduce the iodine-associated tissue deposition and organ toxicity seen with the latter. The utility of dronedarone for patients with ventricular arrhythmias has not been thoroughly evaluated. We present our experience with its use to treat refractory ventricular tachycardia storm and review the literature.

IntroductionTabled 1KEY TEACHING POINTS•The management of failed cardiac electronic device leads continues to be clinically challenging. The chosen treatment option should be individualized based on the patient’s clinical status and physician’s surgical experience.•Lead-on-lead interaction and insulation damage is a real concern when a new lead is implanted adjacent to an abandoned one, and can be avoided with lead extraction when clinically indicated.•Lead extraction procedures after careful clinical evaluation are relatively safe when performed in an experienced center. Open table in a new tab Lead failure rates of implantable cardioverter-defibrillators (ICDs) vary depending on design and composition, and can be as high as 40% a few years post implant.1Atwater B.D. Daubert J.P. Implantable cardioverter defibrillators: risks accompany the life-saving benefits.Heart. 2012; 98: 764-772Crossref PubMed Scopus (24) Google Scholar The Sprint Fidelis lead (Medtronic, Minneapolis, MN) was recalled in 2007 because it is prone to fracture, particularly to its pace-sense conductor, which predisposes patients to inappropriate shocks;2Hauser R.G. Hayes D.L. Increasing hazard of Sprint Fidelis implantable cardioverter-defibrillator lead failure.Heart Rhythm. 2009; 6: 605-610Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar its yearly failure rate is estimated at 3.75%, with acceleration in failure rates after first implant year.2Hauser R.G. Hayes D.L. Increasing hazard of Sprint Fidelis implantable cardioverter-defibrillator lead failure.Heart Rhythm. 2009; 6: 605-610Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar Management of patients with Fidelis leads is based on lead status and patient profile and can include noninvasive monitoring of a functional lead, abandoning the old and adding a new ICD or a pace-sense lead, and complete extraction and reimplant of a new lead. We present a case where an abandoned Fidelis lead damaged its neighboring lead from lead-on-lead friction and discuss our proposed management of such cases.Case reportA 48-year-old man with nonischemic dilated cardiomyopathy had an ICD implant for secondary prevention, which included a dual-coil Sprint Fidelis (6949) lead. In 2010, the Fidelis lead was capped and abandoned owing to fracture and a new St Jude Medical 7121 Durata lead (St Jude Medical, St Paul, MN) was added. The patient sought medical attention after his St Jude Medical Fortify ICD alarm was triggered owing to reduced lead impedance at 180 ohms; impedance trend was gradually decreasing but never led to oversensing or inappropriate therapies. Radiographs did not show any clear insulation breach; however, they did demonstrate the new ICD lead crossing the old one (Figure 1). Given that a reliably functioning ICD lead was necessary for this patient, discussions regarding treatment options culminated in a complete system extraction and reimplant strategy. Successful extraction of both ICD leads was performed as previously described using an LLD and 16 F laser sheath (Spectranetics, Colorado Springs, CO). The site of the Durata lead insulation breach was proximal to the distal defibrillation coil where it crossed the right ventricular coil of the abandoned Sprint Fidelis lead (Figure 2). The mechanism of insulation breach was very likely lead-on-lead friction between the 2 leads at the atrioventricular junction where they crossed the tricuspid valve (Figure 1).Figure 2Insulation breach in the extracted St Jude Medical Durata lead near the distal defibrillation coil.View Large Image Figure ViewerDownload (PPT)DiscussionThis case illustrates one of the many potential pitfalls of abandoning a failed ICD lead. Lead-on-lead interaction and insulation abrasion from friction with another have been reported in St Jude Medical Riata and Durata ICD leads.3Hauser R.G. Abdelhadi R.H. McGriff D.M. Kallinen Retel L. Failure of a novel silicone-polyurethane copolymer (Optim) to prevent implantable cardioverter-defibrillator lead insulation abrasions.Europace. 2013; 15: 278-283Crossref PubMed Scopus (49) Google Scholar To eliminate the risk of similar lead-on-lead insulation abrasion, it is thus ideal to have a failed lead completely extracted prior to adding a new one. The major concern with this approach is the risk of complications that can be associated with extraction. Fortunately, with improved techniques and operator experience over time, lead extractions can now be performed safely at high-volume centers with negligible rates of major procedural complications or deaths.4Maytin M. Love C.J. Fischer A. Carrillo R.G. Garisto J.D. Bongiomi M.G. Segreti L. John R.M. Michaud G.F. Albert C.M. Epstein L.M. Multicenter experience with extraction of the Sprint Fidelis implantable cardioverter-defibrillator lead.J Am Coll Cardiol. 2010; 56: 646-650Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Although this case involved a recalled Fidelis lead, the recalled Riata lead may pose an even higher risk of abandonment. The extrusion of cables has been associated not only with lead–lead interaction, but also with thrombus formation and cable migration. In addition to lead–lead interactions, lead abandonment has been associated with an increased risk of infection, issues with venous occlusion, future difficultly of extraction, and the prohibition of future magnetic resonance imaging scanning.5Wilkoff B.L. Love C.J. Byrd C.L. Bongiorni M.G. Carrillo R.G. Crossley G.H. Epstein L.M. Friedman R.A. Kennergren C.E.H. Mitkowski P. Schaerf R.H.M. Wazni O.M. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA).Heart Rhythm. 2009; 6: 1085-1104Abstract Full Text Full Text PDF PubMed Scopus (864) Google Scholar As always, treatment decisions should be made on a case-by-case, individual basis. However, if extraction can be offered with a high success and low complication rate, it should be considered for patients with failed ICD leads and with a reasonable life expectancy.ConclusionThe management of failed cardiac electronic device leads continues to be clinically challenging. Physicians are often confronted with the option of abandoning or extracting failed leads prior to adding a novel one. The chosen treatment option should be individualized based on the patient’s clinical status and physician’s surgical experience. Lead-on-lead interaction and insulation damage is a real concern when a new lead is implanted adjacent to an abandoned one, and can be avoided with lead extraction when clinically indicated. IntroductionTabled 1KEY TEACHING POINTS•The management of failed cardiac electronic device leads continues to be clinically challenging. The chosen treatment option should be individualized based on the patient’s clinical status and physician’s surgical experience.•Lead-on-lead interaction and insulation damage is a real concern when a new lead is implanted adjacent to an abandoned one, and can be avoided with lead extraction when clinically indicated.•Lead extraction procedures after careful clinical evaluation are relatively safe when performed in an experienced center. Open table in a new tab Lead failure rates of implantable cardioverter-defibrillators (ICDs) vary depending on design and composition, and can be as high as 40% a few years post implant.1Atwater B.D. Daubert J.P. Implantable cardioverter defibrillators: risks accompany the life-saving benefits.Heart. 2012; 98: 764-772Crossref PubMed Scopus (24) Google Scholar The Sprint Fidelis lead (Medtronic, Minneapolis, MN) was recalled in 2007 because it is prone to fracture, particularly to its pace-sense conductor, which predisposes patients to inappropriate shocks;2Hauser R.G. Hayes D.L. Increasing hazard of Sprint Fidelis implantable cardioverter-defibrillator lead failure.Heart Rhythm. 2009; 6: 605-610Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar its yearly failure rate is estimated at 3.75%, with acceleration in failure rates after first implant year.2Hauser R.G. Hayes D.L. Increasing hazard of Sprint Fidelis implantable cardioverter-defibrillator lead failure.Heart Rhythm. 2009; 6: 605-610Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar Management of patients with Fidelis leads is based on lead status and patient profile and can include noninvasive monitoring of a functional lead, abandoning the old and adding a new ICD or a pace-sense lead, and complete extraction and reimplant of a new lead. We present a case where an abandoned Fidelis lead damaged its neighboring lead from lead-on-lead friction and discuss our proposed management of such cases.Case reportA 48-year-old man with nonischemic dilated cardiomyopathy had an ICD implant for secondary prevention, which included a dual-coil Sprint Fidelis (6949) lead. In 2010, the Fidelis lead was capped and abandoned owing to fracture and a new St Jude Medical 7121 Durata lead (St Jude Medical, St Paul, MN) was added. The patient sought medical attention after his St Jude Medical Fortify ICD alarm was triggered owing to reduced lead impedance at 180 ohms; impedance trend was gradually decreasing but never led to oversensing or inappropriate therapies. Radiographs did not show any clear insulation breach; however, they did demonstrate the new ICD lead crossing the old one (Figure 1). Given that a reliably functioning ICD lead was necessary for this patient, discussions regarding treatment options culminated in a complete system extraction and reimplant strategy. Successful extraction of both ICD leads was performed as previously described using an LLD and 16 F laser sheath (Spectranetics, Colorado Springs, CO). The site of the Durata lead insulation breach was proximal to the distal defibrillation coil where it crossed the right ventricular coil of the abandoned Sprint Fidelis lead (Figure 2). The mechanism of insulation breach was very likely lead-on-lead friction between the 2 leads at the atrioventricular junction where they crossed the tricuspid valve (Figure 1). Lead failure rates of implantable cardioverter-defibrillators (ICDs) vary depending on design and composition, and can be as high as 40% a few years post implant.1Atwater B.D. Daubert J.P. Implantable cardioverter defibrillators: risks accompany the life-saving benefits.Heart. 2012; 98: 764-772Crossref PubMed Scopus (24) Google Scholar The Sprint Fidelis lead (Medtronic, Minneapolis, MN) was recalled in 2007 because it is prone to fracture, particularly to its pace-sense conductor, which predisposes patients to inappropriate shocks;2Hauser R.G. Hayes D.L. Increasing hazard of Sprint Fidelis implantable cardioverter-defibrillator lead failure.Heart Rhythm. 2009; 6: 605-610Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar its yearly failure rate is estimated at 3.75%, with acceleration in failure rates after first implant year.2Hauser R.G. Hayes D.L. Increasing hazard of Sprint Fidelis implantable cardioverter-defibrillator lead failure.Heart Rhythm. 2009; 6: 605-610Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar Management of patients with Fidelis leads is based on lead status and patient profile and can include noninvasive monitoring of a functional lead, abandoning the old and adding a new ICD or a pace-sense lead, and complete extraction and reimplant of a new lead. We present a case where an abandoned Fidelis lead damaged its neighboring lead from lead-on-lead friction and discuss our proposed management of such cases. Case reportA 48-year-old man with nonischemic dilated cardiomyopathy had an ICD implant for secondary prevention, which included a dual-coil Sprint Fidelis (6949) lead. In 2010, the Fidelis lead was capped and abandoned owing to fracture and a new St Jude Medical 7121 Durata lead (St Jude Medical, St Paul, MN) was added. The patient sought medical attention after his St Jude Medical Fortify ICD alarm was triggered owing to reduced lead impedance at 180 ohms; impedance trend was gradually decreasing but never led to oversensing or inappropriate therapies. Radiographs did not show any clear insulation breach; however, they did demonstrate the new ICD lead crossing the old one (Figure 1). Given that a reliably functioning ICD lead was necessary for this patient, discussions regarding treatment options culminated in a complete system extraction and reimplant strategy. Successful extraction of both ICD leads was performed as previously described using an LLD and 16 F laser sheath (Spectranetics, Colorado Springs, CO). The site of the Durata lead insulation breach was proximal to the distal defibrillation coil where it crossed the right ventricular coil of the abandoned Sprint Fidelis lead (Figure 2). The mechanism of insulation breach was very likely lead-on-lead friction between the 2 leads at the atrioventricular junction where they crossed the tricuspid valve (Figure 1). A 48-year-old man with nonischemic dilated cardiomyopathy had an ICD implant for secondary prevention, which included a dual-coil Sprint Fidelis (6949) lead. In 2010, the Fidelis lead was capped and abandoned owing to fracture and a new St Jude Medical 7121 Durata lead (St Jude Medical, St Paul, MN) was added. The patient sought medical attention after his St Jude Medical Fortify ICD alarm was triggered owing to reduced lead impedance at 180 ohms; impedance trend was gradually decreasing but never led to oversensing or inappropriate therapies. Radiographs did not show any clear insulation breach; however, they did demonstrate the new ICD lead crossing the old one (Figure 1). Given that a reliably functioning ICD lead was necessary for this patient, discussions regarding treatment options culminated in a complete system extraction and reimplant strategy. Successful extraction of both ICD leads was performed as previously described using an LLD and 16 F laser sheath (Spectranetics, Colorado Springs, CO). The site of the Durata lead insulation breach was proximal to the distal defibrillation coil where it crossed the right ventricular coil of the abandoned Sprint Fidelis lead (Figure 2). The mechanism of insulation breach was very likely lead-on-lead friction between the 2 leads at the atrioventricular junction where they crossed the tricuspid valve (Figure 1). DiscussionThis case illustrates one of the many potential pitfalls of abandoning a failed ICD lead. Lead-on-lead interaction and insulation abrasion from friction with another have been reported in St Jude Medical Riata and Durata ICD leads.3Hauser R.G. Abdelhadi R.H. McGriff D.M. Kallinen Retel L. Failure of a novel silicone-polyurethane copolymer (Optim) to prevent implantable cardioverter-defibrillator lead insulation abrasions.Europace. 2013; 15: 278-283Crossref PubMed Scopus (49) Google Scholar To eliminate the risk of similar lead-on-lead insulation abrasion, it is thus ideal to have a failed lead completely extracted prior to adding a new one. The major concern with this approach is the risk of complications that can be associated with extraction. Fortunately, with improved techniques and operator experience over time, lead extractions can now be performed safely at high-volume centers with negligible rates of major procedural complications or deaths.4Maytin M. Love C.J. Fischer A. Carrillo R.G. Garisto J.D. Bongiomi M.G. Segreti L. John R.M. Michaud G.F. Albert C.M. Epstein L.M. Multicenter experience with extraction of the Sprint Fidelis implantable cardioverter-defibrillator lead.J Am Coll Cardiol. 2010; 56: 646-650Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Although this case involved a recalled Fidelis lead, the recalled Riata lead may pose an even higher risk of abandonment. The extrusion of cables has been associated not only with lead–lead interaction, but also with thrombus formation and cable migration. In addition to lead–lead interactions, lead abandonment has been associated with an increased risk of infection, issues with venous occlusion, future difficultly of extraction, and the prohibition of future magnetic resonance imaging scanning.5Wilkoff B.L. Love C.J. Byrd C.L. Bongiorni M.G. Carrillo R.G. Crossley G.H. Epstein L.M. Friedman R.A. Kennergren C.E.H. Mitkowski P. Schaerf R.H.M. Wazni O.M. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA).Heart Rhythm. 2009; 6: 1085-1104Abstract Full Text Full Text PDF PubMed Scopus (864) Google Scholar As always, treatment decisions should be made on a case-by-case, individual basis. However, if extraction can be offered with a high success and low complication rate, it should be considered for patients with failed ICD leads and with a reasonable life expectancy. This case illustrates one of the many potential pitfalls of abandoning a failed ICD lead. Lead-on-lead interaction and insulation abrasion from friction with another have been reported in St Jude Medical Riata and Durata ICD leads.3Hauser R.G. Abdelhadi R.H. McGriff D.M. Kallinen Retel L. Failure of a novel silicone-polyurethane copolymer (Optim) to prevent implantable cardioverter-defibrillator lead insulation abrasions.Europace. 2013; 15: 278-283Crossref PubMed Scopus (49) Google Scholar To eliminate the risk of similar lead-on-lead insulation abrasion, it is thus ideal to have a failed lead completely extracted prior to adding a new one. The major concern with this approach is the risk of complications that can be associated with extraction. Fortunately, with improved techniques and operator experience over time, lead extractions can now be performed safely at high-volume centers with negligible rates of major procedural complications or deaths.4Maytin M. Love C.J. Fischer A. Carrillo R.G. Garisto J.D. Bongiomi M.G. Segreti L. John R.M. Michaud G.F. Albert C.M. Epstein L.M. Multicenter experience with extraction of the Sprint Fidelis implantable cardioverter-defibrillator lead.J Am Coll Cardiol. 2010; 56: 646-650Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Although this case involved a recalled Fidelis lead, the recalled Riata lead may pose an even higher risk of abandonment. The extrusion of cables has been associated not only with lead–lead interaction, but also with thrombus formation and cable migration. In addition to lead–lead interactions, lead abandonment has been associated with an increased risk of infection, issues with venous occlusion, future difficultly of extraction, and the prohibition of future magnetic resonance imaging scanning.5Wilkoff B.L. Love C.J. Byrd C.L. Bongiorni M.G. Carrillo R.G. Crossley G.H. Epstein L.M. Friedman R.A. Kennergren C.E.H. Mitkowski P. Schaerf R.H.M. Wazni O.M. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA).Heart Rhythm. 2009; 6: 1085-1104Abstract Full Text Full Text PDF PubMed Scopus (864) Google Scholar As always, treatment decisions should be made on a case-by-case, individual basis. However, if extraction can be offered with a high success and low complication rate, it should be considered for patients with failed ICD leads and with a reasonable life expectancy. ConclusionThe management of failed cardiac electronic device leads continues to be clinically challenging. Physicians are often confronted with the option of abandoning or extracting failed leads prior to adding a novel one. The chosen treatment option should be individualized based on the patient’s clinical status and physician’s surgical experience. Lead-on-lead interaction and insulation damage is a real concern when a new lead is implanted adjacent to an abandoned one, and can be avoided with lead extraction when clinically indicated. The management of failed cardiac electronic device leads continues to be clinically challenging. Physicians are often confronted with the option of abandoning or extracting failed leads prior to adding a novel one. The chosen treatment option should be individualized based on the patient’s clinical status and physician’s surgical experience. Lead-on-lead interaction and insulation damage is a real concern when a new lead is implanted adjacent to an abandoned one, and can be avoided with lead extraction when clinically indicated.

BACKGROUND:The use of cardiac implantable electrical devices continues to increase with the validation of new beneficial indications. While the risks of device implantation decreased significantly over time, significant risk remains associated with their extraction when indicated. A high-risk pacemaker lead extraction case is described, wherein a chronically implanted lead that had perforated the right atrium was successfully removed without the need for cardiopulmonary bypass. In this report we share our approach to this challenging extraction case and describe an infrequently utilized off-pump hybrid technique that we term the "lead-inverting stitch".CASE PRESENTATION:A 74 year-old Caucasian woman with complete heart block and remote pacemaker implantation presents with a swollen and erythematous infected pacemaker pocket necessitating device extraction. Chest computerized tomographic imaging revealed a chronically perforating right atrial lead tip approximately 2 cm within the pericardial space. A successful hybrid transvenous and open surgical extraction approach was undertaken without the need for cardiopulmonary bypass; this was made possible due to a successfully positioned "lead-inverting stitch".CONCLUSION:Implantable cardiac electrical device infections are amongst the most dreaded post implant complications. Risks of device extraction are further complicated in cases of chronic lead perforations. Extraction strategies that avoid cardiopulmonary bypass initiation are preferred.

The ability to tie surgical knots efficiently and effectively is an essential surgical skill for medical procedures, especially pacemaker implantation. Device generators and their leads need to be safely anchored with sutures during implantation to prevent dislodgement and inadequate packaging in the pacemaker pocket. With most knot tying techniques, a generous amount of suture slack is required. We introduce a new technique that is a variation of the 2-handed surgical square knot and the 1-handed surgeon's knot that allows one to finish or tie a knot when left with little slack.

A subset of patients receiving first-time permanent pacemakers (PPM) may also benefit from an implantable cardioverter defibrillator (ICD) based on the presence of left ventricular systolic dysfunction (LVSD). Routine screening using pocket-sized echocardiography (PSE) may be useful in identifying such patients.

Background Noninvasive evaluation of central venous pressure (CVP) can be achieved by assessing the Jugular Venous Pressure (JVP), Peripheral Venous Collapse (PVC), and ultrasound visualization of the inferior vena cava. The relative accuracy of these techniques compared to one another and their application by trainees of varying experience remains uncertain. We compare the application and utility of the JVP, PVC, and handheld Mini Echo amongst trainees of varying experience including a medical student, internal medicine resident, and cardiology fellow. We also introduce and validate a new physical exam technique to assess central venous pressures, the Anthem sign. Methods Patients presenting for their regularly scheduled echocardiograms at the hospital echo department had clinical evaluations of their CVP using these non-invasive bedside techniques. The examiners were blinded to the echo results, each other's assessments, and patient history; their CVP estimates were compared to the gold standard level 3 echo-cardiographer's estimates at the completion of the study. Results 325 patients combined were examined (mean age 65, s.d. 16 years). When compared to the gold standard of central venous pressure by a level 3 echocardiographer, the JVP was the most sensitive at 86%, improving with clinical experience (p<0.01). The classic PVC technique and Anthem sign had better specificity compared to the JVP. Mini Echo estimates were comparable to physical exam assessments. Conclusions JVP evaluation is the most sensitive physical examination technique in CVP assessments. The PVC techniques along with the newly described Anthem sign may be of value for the early learner who still has not mastered the art of JVP assessment and in obese patients in whom JVP evaluation is problematic. Mini Echo estimates of CVPs are comparable to physical examination by trained clinicians and require less instruction. The use of Mini Echo in medical training should be further evaluated and encouraged.

Background Venous anomalies of the thorax can occur in isolation or in association with complex congenital heart disease. The incidence of an absent right superior vena cava in the setting of a persistent left superior vena cava is very rare in the general population with only a dozen cases documented in the medical literature. Such venous anomalies can make for very challenging electronic cardiac device implantation. We report our challenging dual chamber pacemaker implant in a patient with such complex anatomy and focus on our implantation technique that helped achieve adequate lead positioning. Case presentation A 73-year-old Caucasian female with degenerative complete heart block presented for dual chamber permanent pacemaker implant. Lead implantation was very challenging due to abnormal and rare vena cava anatomy; a persistent left superior vena cava drained directly into the coronary sinus and the right brachiocephalic vein drained directly into the left persistent superior vena cava as the patient had an absent right superior vena cava . Adequate right ventricular lead positioning was achieved following numerous lead-stylet manipulations and careful looping in the atria to redirect its trajectory to the ventricular apex. Conclusion Abnormal superior vena cava development is uncommon and can lead to technical challenges when venous access is required during various interventional procedures. Pre-operative imaging can help identify such challenging anatomy allowing appropriate operative planning; careful patient selection is warranted for venography given the risk of contrast nephrotoxicity.

We present a case of cardiac lipofibromatosis associated with atrial fibrillation and complete heart block requiring permanent pacemaker implantation. Multimodality cardiac imaging including transthoracic echocardiography and cardiac magnetic resonance were useful for tissue characterization of this rare cardiac diagnosis.

Idiopathic ventricular tachycardia (VT) is usually a benign arrhythmia with good prognosis that can be managed with antiarrhythmic agents and is often cured using ablation. There is, however, a malignant potential in a subset of patients with idiopathic VT as was the case for our patient whom we discuss in this case report. After a review of the medical literature, and to our knowledge, this is the first case of a successful idiopathic VT ablation in an adult while extracorporeal membrane oxygenation was being used.

BACKGROUNDPeritoneal dialysis (PD) for long-term management of diuretic resistant volume overload in heart failure (HF) may provide potential benefit with few adverse consequences. We examined the impact of PD on clinical status hospitalizations, and complications of therapy in severe end-stage HF.METHODSA consecutive case series of 10 transplant ineligible patients receiving PD solely for HF volume management between 2007 and 2011 was evaluated with clinical data reviewed pre- and post-PD initiation.RESULTSThe mean ejection fraction (EF) pre-PD was 24.5 ± 6.0% with the majority of patients having NYHA class IIIB symptoms and moderate-severe right ventricular dysfunction. 9/10 patients were Stage 3 chronic kidney disease (CKD) or worse. After PD initiation, average weight loss was almost 7 kg (p = 0.016) with improvement in diuretic response, peripheral edema, and functional class. There was a significant decrease in re-hospitalization from an average of 3.2 ± 2.5 to 0.1 ± 0.3 admissions per patient (p = 0.007) and reduced average length of stay from 37 ± 36.7 to 0.78 ± 2.3 days (p = 0.019).SUMMARYObjective criteriabased institution of PD for the treatment of diuretic refractory severe-end-stage HF was well tolerated and demonstrated favorable outcomes; these included improved clinical status, reduced hospitalizations and length of stay, with very few and easily treatable PDrelated complications. PD appears to be a viable option in refractory, end-stage congestive heart failure (CHF).

Background Eosinophilic myocarditis is a rare and often under-diagnosed subtype of myocarditis with only around 30 cases published in the medical literature. In this article we present two patients with eosinophilic myocarditis with the aim to demonstrate the often elusive nature of the disease and present the current scientific literature on this topic. Case presentation A 76 years old Caucasian gentleman and a 36 years old Aboriginal gentleman both presenting with heart failure symptoms were eventually diagnosed with eosinophilic myocarditis after extensive evaluation. Their presentation, assessment, and medical management is explored in this article. Conclusions Eosinophilic myocarditis remains a rare and likely under-diagnosed subtype of myocarditis. The key features of this disease include myocardial injury in the setting of non-contributory coronary artery disease. Endomyocardial biopsy remains the definitive gold standard for diagnosis of noninfectious eosinophilic myocarditis. Non-invasive cardiac imaging in the setting of peripheral eosinophilia can be strongly suggestive of eosinophilic myocarditis with potential for earlier diagnosis. Failure to diagnose eosinophilic myocarditis and the delay of therapy may lead to irreversible myocardial injury. Therapies for this disease have yet to be validated in large prospective studies.

Serum sickness (SS) after antithymocyte globulin (ATG) administration is documented in liver, pancreas, and renal transplants along with aplastic anemia (1–4). To our knowledge, although a few SS cases in the adult cardiac transplant population are reported online, none have been previously documented in the scientific literature. CLINICAL HISTORY A 57-year-old gentleman with allo-geneic heart transplantation for nonischemic cardiomyopathy developed nonspecific graft dysfunction 3 years posttransplant. He had no documented cellular or antibody-mediated rejection, graft vasculopathy, and donor-specific antibodies on panel reactive antibody testing. Plasmapheresis and IV immunoglobulin infusions were initiated in addition to increases in maintenance immuno-suppression therapy with no significant impact on his reduced ejection fraction. Because of recurrent presentations of decompensated heart failure despite escalation of care, ATG therapy was initiated with 75 mg of IV rabbit ATG daily for 3 days followed by 50 mg IV for 1 day. Nine days after IV thymoglobulin therapy, he presents with fever, chills, lip swelling, and myalgias. Physical examination revealed mild congestive heart failure and an erythematous and pruritic maculopapular rash. He had tender polyarthritis in his extremities with significant restriction to active and passive range of motion (Fig. 1). Laboratory investigations revealed mild leukocytosis, elevated C-reactive protein, and acute renal insufficiency with no evidence of active sediments on urinalysis. Cytomegalovirus testing was unremarkable. Based on this inflammatory presentation and clinical context, he was diagnosed with SS secondary to IV ATG and started on IV methylprednisolone 1 g daily for 6 days. Failing to show significant improvement at 48 hours, plasmapheresis was initiated for 5 days with marked symptomatic relief after the first exchange. He was discharged home on his 10th day of admission with complete resolution of his presenting symptoms.FIGURE 1: A, Maculo-papular-pruritic rash. B, Limited range of motion on hand grip secondary to arthritis. C, Inflammatory effacement of metacarpophalangeal joints.DISCUSSION Antithymocyte globulins are antibodies used in immunosuppression against human T cells and typically derived from the injection of human thymocytes into animals such as horses and rabbits. Exposure to such heterologous proteins may precipitate SS by the generation of host immunoglobulins and activation of the complement cascade (5). Antithymocyte globulin has been used in human transplantation since the late 1960s and has many inherent benefits (6). It is thought to protect the allograft by dampening inflammatory damage, allorecognition processes, and development and intensity of immune response and may increase the sensibility to oral maintenance immunosuppressive agents (7). The administration of rabbit or horse ATG has been associated with SS in 1% to 10% of cases. Risk factors for developing SS include older age, greater levels of heterologous protein, type of preparation, prior exposure to the antigen or source animal, along with a history of hypergammaglobulinemia and cryoglobulinemia (8–11). Serum sickness is characterized by fever, lymphadenopathy, pruritic rash, polyarthralgias, and polyarthritis, which can develop 7 to 10 days after administration of the exogenous antigen. The maculopapular or urticarial rash is usually the first sign, and in severe cases, patients may develop glomerulonephritis as a conglomeration of immune-complex mediated small vessel vasculitis and tissue injury. Angioedema may also be present (5). The polyarthritis commonly involves large joints, but occasionally, the spine or the temporal-mandibular joint may be affected (8). Laboratory investigations may mirror the clinical inflammatory processes with elevated markers such the ESR and leukocytosis along with hypocomplementemia. The urinalysis may show evidence of glomerulonephritis with hematuria,proteinuria, and red cell casts (5). The clinical presentation of SS can be nonspecific and confused for common conditions, such as acute infections or rheumatism, leading to therapeutic delay (1). Serum sickness is a clinical diagnosis, and therapy should not be delayed for any supportive laboratory results (8). Serum sickness is typically self-limited, resolving spontaneously when the trigger for the immune-inflammatory processes is cleared (5). Given the rarity of this condition, all current treatment recommendations are based on clinical experience and case-based reports. Discontinuation or avoidance of re-exposure to the offending agent is paramount when SS is suspected. In mild cases, treatment can be symptom directed with nonsteroidal anti-inflammatory drugs for arthralgias and fevers, along with antihistamines and topical corticosteroids for the pruritic rash. High-dose oral or IV corticosteroids are reserved for severe forms especially with evidence of disabling symptoms, hemodynamic compromise, glomerulonephritis, and other manifestations of vasculitis (5). High-dose steroids can be administered for 3 days, followed by a rapid prednisone taper with anticipated symptom resolution within 10±2 days (1). Plasma exchange is another treatment modality considered an adjuvant to corticosteroids especially in refractory cases (1, 4). It is often initiated for 1 to 2 exchanges when patients remain symptomatic with minimal improvement after 3 days of corticosteroid use (1). Some investigators even advocate plasma exchange as the initial and only treatment modality for SS (8). Jacques Rizkallah Francisco Cordova Amrit Malik Shelley Zieroth Section of Cardiology Department of Medicine St Boniface Hospital University of Manitoba Winnipeg, Manitoba, Canada.