Deering, Thomas F.

ABSTRACTIntroductionDurable left ventricular assist devices (LVADs) are susceptible to infection. The presence of a transvenous cardiac implantable electronic device (CIED) may further elevate this risk, making it necessary to remove the CIED system. This report presents the procedural characteristics and outcomes of CIED system extraction in patients with LVADs.MethodsThis is a single‐center retrospective study that included patients with durable LVADs who underwent transvenous CIED extraction at our institution from 2017 to 2023.ResultsTwenty patients with LVAD (HeartMate II = 14; HeartMate III = 6) underwent CIED removal during the study period. The median age was 52.5 (IQR = 42.5–56.5) years, and 7 patients had ischemic cardiomyopathy. Ninety percent (n = 18) of the extractions were due to infection, while 10% (n = 2) were for lead management. Complete removal of all leads was accomplished in 19 patients (95%). Overall, 40 out of 45 leads were removed during 20 procedures. Simple traction was used in 8 patients and specialized extraction tools were used in 12 (laser sheaths = 10; mechanical rotational sheaths = 7; both = 5). No leads were removed in one patient (5 leads; 2 abandoned leads with 42.5 years intravascular dwell time). There were no major procedure‐related complications. Two minor procedure‐related complications included a femoral arterial pseudoaneurysm and one pocket revision due to persistent surgical site bleeding. During a median follow‐up of 17 (IQR = 8.0–22.3) months, 8 patients underwent pump exchange due to persistent infection, and 15 remained on chronic suppressive antibiotics. Nine patients died during the follow‐up.ConclusionThe extraction of CIED systems in patients with LVAD is safe and feasible, exhibiting low procedure‐related morbidity and mortality. However, the long‐term prognosis for these patients remains poor despite the removal of CIEDs.

AbstractIntroductionPercutaneous left atrial appendage occlusion (LAAO) is traditionally performed under general anesthesia with trans‐esophageal echocardiography guidance. Intracardiac echo (ICE)‐guided LAAO closure is increasing in clinical use. The ICE catheter is crossed into LA via interatrial septum (IAS) after the septum is dilated with LAAO delivery sheath. This step can be time‐consuming and requires significant ICE catheter manipulation, which increases the risk of cardiac perforation. Pre‐emptive septal balloon dilation can potentially help with ICE advancement in the LA. We sought to evaluate the effect of pre‐dilation of the IAS with an 8 mm balloon on the ease of crossing the ICE catheter, fluoroscopy time for crossing, and overall procedure time.MethodsThe Piedmont LAAO registry was used to identify consecutive patients who underwent LAAO. The initial 25 patients in whom balloon dilation of the IAS was performed served as the experimental cohort, and the 25 consecutive patients before that in whom balloon dilation was not performed served as controls. In the experimental group, after a trans‐septal puncture, the sheath was retracted to the right atrium with a guidewire still in the LA. An 8 × 40 mm Evercoss™ over the wire balloon was inflated across the IAS. The ICE catheter was then crossed into the LA using the fluoroscopic landmark of the guide wire and the ICE imaging. The sheath was then advanced along the ICE catheter via the transseptal puncture (TSP) and the procedure continued. Follow‐up compputed tomography imaging was obtained at 4–8 weeks.ResultsEach group consisted of 25 patients. There were no significant differences in baseline characteristics. All procedures were performed successfully under conscious sedation and ICE guidance. There was a significant reduction in the overall procedure time, fluoroscopy time, and time for transseptal puncture to ICE in LA. There was no difference in the size of the acute residual interatrial shunt, as measured via ICE, or the size and presence of iatrogenic ASD at follow‐up.ConclusionBalloon dilation of TSP is safe and is associated with increased efficiency in ICE‐guided LAAO procedures.

Background: Percutaneous left atrial appendage occlusion (LAAO) is traditionally performed under general anesthesia with trans-esophageal echocardiography guidance. Intracardiac echo (ICE) guided LAAO closure is increasing in clinical use. The ICE catheter is crossed into LA via interatrial septum (IAS) after the septum is dilated with LAAO delivery sheath. This step can be time-consuming and requires significant ICE catheter manipulation increasing the risk of cardiac perforation. Pre-emptive septal balloon dilation can potentially help with the advancement of ICE in LA. Objective: Evaluate the effect of pre-dilation of IAS with an 8 mm balloon on ease of crossing the ICE catheter, fluoroscopy time for crossing, and overall procedure time. Methods: The Piedmont LAAO registry was used to identify consecutive patients undergoing LAAO. The initial 25 patients where balloon dilation of IAS was performed served as the experimental cohort, and the 25 consecutive patients prior to that in whom balloon dilation was not performed, served as controls. For the experimental group, after a trans-septal puncture, the sheath was retracted to the right atrium with guide wire still in the LA. An 8x40 mm Evercoss™ over the wire balloon was inflated across the IAS. The ICE catheter was then crossed into the LA using the fluoroscopic landmark of the guide wire and the ICE imaging. The sheath was then advanced along the ICE catheter via the transseptal puncture (TSP) and the procedure continued. Follow up CT imaging was obtained in 4-8 weeks. Results: Each group included 25 patients. There were no significant differences in baseline characteristics. All procedures were performed successfully with the use of conscious sedation and ICE guidance. There was a significant reduction in overall procedure time, fluoroscopy time, and time for trans-septal puncture to ICE in LA. There was no difference in the size of the acute residual interatrial shunt as measured via ICE or size and presence of iatrogenic ASD at follow up. Conclusion: Balloon dilation of TSP is safe and associated with increased efficiencies in ICE guided LAAO procedures.

Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted healthcare delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for patients with arrhythmia. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serological testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.