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Transvenous removal of cardiac implantable electronic device leadsTransvenous removal of cardiac implantable electronic device leads
Extração transvenosa de eletrocateteres de dispositivos cardíacos implantáveis
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cardiac implantable electronic device leadsTransvenous removal of cardiac implantable electronic device leads" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "739" "paginaFinal" => "744" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sílvia Ribeiro, Luís Leite, João Oliveira, Maria João Pereira, Carla Pinheiro, Paulo Ermida, Natália António, Miguel Ventura, João Cristóvão, Luís Elvas, Luís Providência" "autores" => array:11 [ 0 => array:4 [ "nombre" => "Sílvia" "apellidos" => "Ribeiro" "email" => array:1 [ 0 => "silviamartinsribeiro@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Luís" "apellidos" => "Leite" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "João" "apellidos" => "Oliveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Maria João" "apellidos" => "Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Carla" "apellidos" => "Pinheiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Paulo" "apellidos" => "Ermida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Natália" "apellidos" => "António" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "Miguel" "apellidos" => "Ventura" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 8 => array:3 [ "nombre" => "João" "apellidos" => "Cristóvão" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 9 => array:3 [ "nombre" => "Luís" "apellidos" => "Elvas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 10 => array:3 [ "nombre" => "Luís" "apellidos" => "Providência" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital de Guimarães, Guimarães, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Extração transvenosa de eletrocateteres de dispositivos cardíacos implantáveis" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The number and complexity of cardiac implantable electronic devices have increased, leading to a growing incidence of related complications.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> There has thus been a significant increase in procedures to remove pacemakers, implantable cardioverter-defibrillators (ICDs) and coronary sinus leads, the most common reason being device infection.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2–4</span></a> Various techniques are used for device extraction, all associated with a significant risk of complications.The aim of this study was to characterize device removal procedures in a reference center.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">This was a descriptive observational study of patients consecutively admitted to a reference center for lead extraction from January 2009 to May 2014.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Pocket infection was defined as the presence of an abscess, purulent drainage, suture dehiscence, skin erosion or skin adherence. Device-related endocarditis was defined as persistent bacteremia or sepsis in the absence of another identifiable source or vegetations on the device.All patients undergoing lead extraction were informed of possible complications and gave written informed consent.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The procedures were performed in the pacing and electrophysiology unit of the cardiology department, with cardiothoracic surgical backup in case a patient required emergent surgical intervention, under sedoanalgesia and continuous hemodynamic and electrocardiographic monitoring.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cook Medical devices were used for the extraction procedures, this choice being dictated by their availability at the center and by the medical team's experience with these techniques of lead extraction. In all cases, an initial attempt was made to remove the leads by simple traction; if this was unsuccessful, a Liberator<span class="elsevierStyleSup">®</span> Beacon<span class="elsevierStyleSup">®</span> Tip Locking Stylet (Cook Medical Inc., Bloomington, USA) was employed, followed by an Evolution<span class="elsevierStyleSup">®</span> RL Controlled-rotation Sheath Dilator Set (Cook Medical Inc., Bloomington, USA), which has a manually rotated steel tip for tissue debridement.Patients remained in the cardiac intensive care unit for 24 hours after the procedure.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Procedural and clinical success were defined according to the 2009 Heart Rhythm Society (HRS) Expert Consensus on transvenous lead extraction.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Complete procedural success was defined as removal of all targeted leads and all lead material from the vascular space, with the absence of any permanently disabling complication or procedure-related death. Retention of a small part (≤4 cm) of the lead (coil or insulation) of the lead was considered partial success. Clinical success was defined as removal of all targeted leads and all lead material from the vascular space, or retention of only residual material that does not negatively impact the outcome goals of the procedure. Failure was defined as inability to achieve either complete procedural or clinical success, or the development of any permanently disabling complication or procedure-related death. Major and minor complications were defined according to the HRS expert consensus statement.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Patient and procedural data were collected, including demographic characteristics, echocardiographic data, laboratory and blood culture results, lead removal technique and complications. The statistical analysis was performed using SPSS version 17.0.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The study included 109 patients, with a mean age of 64.6±16.62 years, 73.1% male. In one case the reason for extraction was lead fracture, in another the patient requested removal of an ICD implanted for primary prevention for psychological reasons, while in the remaining cases the reason was device infection. The mean time from first implantation to lead extraction was 5.6±4.89 years (3 weeks–24 years).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Type 2 diabetes was present in 26.8% of the sample; 25% had been under anticoagulant therapy and 5.5% had had significant pocket hematoma. Since a significant proportion of the patients had been transferred from other hospitals, several had undergone bridging with low molecular weight heparin, while others were under warfarin at the time of the procedure. Signs of pocket infection (erosion, adhesion, erythema, purulent drainage, device or lead exteriorization) were seen in 63.8% of cases, and three patients presented in septic shock. Around 36% of patients had a history of previous infection treated conservatively (with antibiotic therapy or generator replacement, or by removing the generator, cutting the leads, and reimplanting on the contralateral side). Laboratory tests showed elevated C-reactive protein (CRP) (>5.0 mg/l) in 63% of patients, although with only slight rises in most cases (mean 4.8 mg/l). Leukocytosis was seen in 11.7%, renal failure in 31.6% and hemoglobin below reference values in 30%. Blood cultures were positive in 32.8% of cases, and vegetations were observed on transthoracic and/or transesophageal echocardiography in 29%, the largest of which was 30 mm at its widest point. Echocardiographic assessment revealed 52% of patients had impaired left ventricular systolic function.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The procedures in the 109 patients involved the removal of 228 leads: 58.8% right ventricular, 32.4% atrial and 8.8% coronary sinus. The devices removed were 70 pacemakers, 16 cardiac resynchronization devices (two cardiac resynchronization therapy pacemakers [CRT-P] and 14 cardiac resynchronization therapy defibrillators [CRT-D]) and 23 ICDs (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Extraction of leads was performed in 84.3% of cases and simple explantation in the others. The mean times from implantation to explantation and to extraction were 0.39±0.28 years and 6.78±4.7 years, respectively. In patients who had been implanted less than one year previously (2.8%), 62% of procedures were explantations. One extraction of a fractured lead was carried out by femoral access using a Needle's Eye Snare<span class="elsevierStyleSup">®</span> (Cook Medical Inc., Bloomington, USA), by pulling the lead after its free end had been snared. All the other leads were removed by the same superior venous access used for implantation: 17.5% of leads were removed by simple traction after inserting a conventional guidewire, 6.5% with the Liberator<span class="elsevierStyleSup">®</span> Beacon<span class="elsevierStyleSup">®</span> Tip Locking Stylet (Cook Medical Inc., Bloomington, USA), and the others (the majority) using the Evolution<span class="elsevierStyleSup">®</span> sheath (Cook Medical Inc., Bloomington, USA).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Clinical success was achieved in 97.2% of patients, complete procedural success in 93.5% and partial success in 5.3%. The procedure failed in only three cases, in which right ventricular leads could not be extracted (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">There were few complications: three cases of cardiac tamponade, effectively treated by pericardiocentesis; one small pericardial effusion without hemodynamic compromise; one case of subclavian vein thrombosis; and three of significant pocket hematoma.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Device infection is the leading indication for removal of cardiac implantable electronic devices.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,5</span></a> The increasing number and complexity of these devices, together with an aging target population with more comorbidities, are leading to a growing incidence of infections.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Greenspon et al. conducted a descriptive analysis of the infection burden for pacemakers and ICDs in the USA and found that over a 16-year period the incidence of four major comorbidities (renal failure, heart failure, respiratory failure, and diabetes) increased in parallel with increases in numbers of device implantations (96%), in infection rate (from 1.53% to 2.41%) and in mortality associated with device infection (from 2.91% to 4.69%). Risk factors for infection included reintervention to replace a depleted battery and implantation of cardiac resynchronization systems or ICDs, due to their longer life and hence need for more generator replacements.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Similarly, in our population there were high prevalences of type 2 diabetes (26.8%), renal failure (31.6%) and impaired left ventricular systolic function (51.5%). In a follow-up of patients four years after first CRT-D implantation in an Italian registry, Landolina et al. reported that 50% of patients required surgical revision for battery depletion and 14% for unanticipated events. The infection rate was 1%/year, and the risk of infection increased after device replacement procedures.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> It is thus to be expected that with widening indications for implantation of cardiac resynchronization systems, the incidence of complications – and therefore of extractions – will increase.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Infection of cardiac electronic devices has a wide spectrum of manifestations, ranging from pocket infection to sepsis and death. Pocket infection may present with skin erosion or erythema, abscess, purulent drainage and/or suture dehiscence, and may be accompanied by local pain with no other initial symptoms.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,3–5</span></a> In our study 63.8% of patients presented signs of pocket infection; previous infection was identified in 36%, who had been treated conservatively on the basis of the patient's general condition and comorbidities. As the study was conducted in a reference center for extraction of cardiac electronic devices, many patients had been referred from other centers and no information was available on the reasons for their initial conservative treatment. The 2000 North American Society of Pacing and Electrophysiology guidance document stated that it was acceptable to remove the device and cut the exposed parts of the leads in cases of pocket infection in which the intravascular portion of the system was not involved. However, such a strategy is proving to be unsuccessful, with a high risk of recurrence of reinfection and potentially serious consequences such as device-related or valvular endocarditis and sepsis, putting the patient at unacceptable risk. Mortality in cases of persistent infection can be as high as 66% if the leads are not removed.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> The HRS consensus document recommends complete removal of the system (device, leads, adapters, sutures) and as much of the infected tissue as possible when an infection is identified, even if only of the pocket. However, in specific situations, particularly when the patient has a poor prognosis or comorbidities that carry an excessively high risk of complications, it is acceptable to adopt a more conservative strategy.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Although most device infections involve only the pocket, around 10% manifest as endocarditis.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> In our study, blood cultures were positive in 32.8% of cases and vegetations were identified by transthoracic and/or transesophageal echocardiography in 29% of patients. According to the literature, inflammatory markers are not reliable indicators of infection, since they may be normal even in the presence of endocarditis.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,5</span></a> Laboratory tests in our population showed elevated CRP in 63% of patients, although with only slight rises in most cases (mean 4.8 mg/l); leukocytosis was seen in 11.7%. One reason that these patients often did not present high levels of inflammatory markers or positive blood cultures is that they had been taking antibiotics prior to the diagnosis of device infection.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Studies have identified various risk factors for device infection, including diabetes, heart failure, renal failure, oral anticoagulation, chronic corticosteroid therapy, fever 24 hours before device implantation, temporary transvenous pacing prior to implantation of a permanent pacemaker, early reintervention, failure to use prophylactic antibiotic therapy before the procedure, operator experience, device revision or replacement, and amount of indwelling hardware. In a Danish study of 46<span class="elsevierStyleHsp" style=""></span>299 patients, Johansen et al. showed that repeat procedures were associated with a substantial rise in risk of infection; independent predictors of pacemaker infection were the number of interventions (including replacements), male gender, younger age, implantation during the early stages of the study, and absence of antibiotic therapy, while female gender, older age, and antibiotic prophylaxis before the procedure were associated with lower risk of infection.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Lead extraction is a technically challenging procedure. After initial implantation, areas of thrombus form along the leads that then organize and fibrose, hampering extraction. In general, the longer the lead has been in place, the greater the extent of fibrosis, further complicating removal. Lead removal involves not only retracting the lead from its attachment to the myocardium, but also freeing the lead from the fibrous sheath that anchors it to the vasculature.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9,10</span></a> The points most likely to fibrose include the initial entry to the subclavian vein, the superior vena cava and the lead/myocardial interface, although there are often several areas of adherence along the vein that hinder extraction. Calcification of the fibrous tissue may occur over time, especially in young patients.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> The presence of multiple leads and the time since implantation are critical factors in the success of the removal procedure. In our study, simple explantation was associated with shorter mean time since implantation (0.39±0.28 years) than extraction (6.78±4.7 years). In the subgroup with less than one year since implantation, the device was removed by simple traction in 62% of cases.</p><p id="par0090" class="elsevierStylePara elsevierViewall">There are various extraction techniques, all associated with potentially serious complications, including death. Early techniques involved simple manual traction that frequently proved ineffective and carried a high risk of complications including myocardial avulsion, tamponade, and death. The past 30 years have witnessed significant advances in lead extraction technology, resulting in safer and more efficacious techniques.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> A 2013 study on 206 lead extraction procedures in 122 patients showed comparable procedural success and safety in transvenous laser extraction and a mechanical approach, and clinical success and cost-effectiveness analysis favored the mechanical approach.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> In the majority of cases leads are extracted by the same venous access as used in implantation (superior approach) by simple traction or using locking stylets and special sheaths. If the leads are not accessible via the implant site, particularly if they had been previously cut and retracted into the venous system, femoral or jugular access are options.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">12–14</span></a> Bongiorni et al. described a method used to extract 2062 leads with a single mechanical dilating sheath via a subclavian approach but using a femoral approach combined with an internal transjugular approach when the superior approach failed, with a high success rate and few complications.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> In our population, only one extraction was by the femoral approach, using a Needle's Eye Snare<span class="elsevierStyleSup">®</span> (Cook Medical Inc., Bloomington, USA); in all other cases the superior approach was used.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Nowadays the success rate for transvenous extraction is high, with few complications.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11,16</span></a> Nevertheless, complications can be serious or even fatal. Whatever technique is used, a high level of operator experience is essential for the success of the procedure. In our study there were only three major complications, pericardial effusion with tamponade, effectively treated by pericardiocentesis; emergency surgical intervention was not required in any of the cases. Even so, given the possible need for emergent intervention, cardiothoracic surgical backup should be available at all times.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">There has been an exponential increase in the number and complexity of cardiac implantable electronic devices. The need for removal of these devices is also increasing, by explantation or extraction, in most cases due to device infection. All available techniques are associated with significant risk of complications, most of them minor, but potentially fatal complications can arise. In our experience the removal techniques used were effective, with few complications.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres823901" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec820491" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres823902" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec820492" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-13" "fechaAceptado" => "2015-07-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec820491" "palabras" => array:5 [ 0 => "Pacemaker" 1 => "Implantable cardioverter-defibrillator" 2 => "Cardiac resynchronization therapy" 3 => "Lead extraction" 4 => "Infection" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec820492" "palabras" => array:5 [ 0 => "<span class="elsevierStyleItalic">Pacemaker</span>" 1 => "Cardioversor desfibrilhador implantável" 2 => "Terapia de ressincronização cardíaca" 3 => "Extração de eletrocateteres" 4 => "Infeção" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The number and complexity of cardiac implantable electronic devices (CIEDs) have increased, as has the number of related complications, often leading to removal of the implanted system. The aim of this study was to characterize transvenous explantation/extraction of CIED leads in a reference center.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a descriptive observational study of patients consecutively admitted from January 2009 to May 2014 for transvenous lead extraction.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The sample consisted of 109 patients, with a mean age of 64.6±16.62 years, 73.1% male. The main indication for lead extraction was CIED infection. The mean time from first implantation to lead removal was 5.6±4.89 years. Blood cultures were positive in 32.8% of cases and 29% of patients had vegetations on echocardiography. A total of 228 cardiac leads were removed, of which 58.8% were ventricular, 32.4% atrial and 8.8% coronary sinus. Complete clinical success was achieved in 97.2% of cases, while procedural success was complete in 93.4% and partial in 5.3%. The complications reported were three cases of significant pocket hematoma, one of subclavian vein thrombosis and three of cardiac tamponade, effectively treated by pericardiocentesis.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transvenous explantion or extraction of CIED leads was highly effective. A high level of experience is an essential factor in the success and safety of the procedure.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdução e objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O número e a complexidade dos dispositivos cardíacos implantáveis têm vindo a aumentar assim como as suas complicações, conduzindo frequentemente à remoção dos mesmos. O objetivo deste estudo foi caraterizar a população envolvida e os procedimentos utilizados na remoção transvenosa de eletrocateteres cardíacos num centro de referência.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo observacional descritivo dos procedimentos de remoção transvenosa de eletrocateteres cardíacos de janeiro de 2009 a maio de 2014.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A amostra incluiu 109 doentes, com idade média de 64,6 anos (± 16,62), 73,1% do género masculino. A principal indicação para remoção de eletrocateteres foi infeção do dispositivo. O tempo médio desde a primeira implantação à remoção foi de 5,6 anos (± 4,89). As hemoculturas foram positivas em 32,8% dos casos e cerca de 29% dos doentes apresentavam no estudo ecocardiográfico vegetações. Foram removidos 228 eletrocateteres, 58,8% ventriculares, 32,4% auriculares e 8,8% do seio coronário. O sucesso clínico do procedimento foi completo em 97,2%; o sucesso do procedimento foi completo em 93,4% dos casos e parcial em 5,3%. Como complicações registaram-se três hematomas volumosos da loca, uma trombose da veia subclávia e três tamponamentos cardíacos, tratados eficazmente com pericardiocentese.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusões</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A explantação/extração transvenosa dos eletrocateteres mostrou-se altamente eficaz. Contudo, experiência com o sistema é um fator preponderante para o sucesso e segurança do procedimento.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ribeiro S, Leite L, Oliveira J, Pereira MJ, Pinheiro C, Ermida P, et al. Extração transvenosa de eletrocateteres de dispositivos cardíacos implantáveis. Rev Port Cardiol. 2015;34:739–744.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CRT: cardiac resynchronization therapy device; CRT-D: cardiac resynchronization therapy with defibrillator; CRT-P: cardiac resynchronization therapy with pacemaker; ICD: implantable cardioverter-defibrillator.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pacemakers</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DDD (R) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>VDD (R) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>VVI (R) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">CRTs</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CRT-P \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CRT-D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ICDs</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ICD-VR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ICD-DR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ICD-VDD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385243.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Cardiac implantable electronic devices removed in the study population.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Procedural success (leads)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Partial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (5.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">213 (93.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (1.30%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Clinical success (patients)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Success \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 (97.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385244.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Clinical and procedural success.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States: 1993 to 2008" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 4 | 8 |
| 2024 October | 24 | 24 | 48 |
| 2024 September | 47 | 25 | 72 |
| 2024 August | 35 | 23 | 58 |
| 2024 July | 28 | 22 | 50 |
| 2024 June | 26 | 22 | 48 |
| 2024 May | 38 | 24 | 62 |
| 2024 April | 31 | 26 | 57 |
| 2024 March | 26 | 24 | 50 |
| 2024 February | 27 | 23 | 50 |
| 2024 January | 22 | 26 | 48 |
| 2023 December | 17 | 27 | 44 |
| 2023 November | 27 | 21 | 48 |
| 2023 October | 31 | 16 | 47 |
| 2023 September | 25 | 19 | 44 |
| 2023 August | 23 | 15 | 38 |
| 2023 July | 23 | 13 | 36 |
| 2023 June | 23 | 10 | 33 |
| 2023 May | 29 | 26 | 55 |
| 2023 April | 11 | 0 | 11 |
| 2023 March | 33 | 27 | 60 |
| 2023 February | 23 | 20 | 43 |
| 2023 January | 19 | 17 | 36 |
| 2022 December | 37 | 20 | 57 |
| 2022 November | 40 | 25 | 65 |
| 2022 October | 26 | 18 | 44 |
| 2022 September | 23 | 33 | 56 |
| 2022 August | 21 | 30 | 51 |
| 2022 July | 34 | 34 | 68 |
| 2022 June | 34 | 21 | 55 |
| 2022 May | 25 | 31 | 56 |
| 2022 April | 27 | 27 | 54 |
| 2022 March | 29 | 38 | 67 |
| 2022 February | 39 | 31 | 70 |
| 2022 January | 27 | 22 | 49 |
| 2021 December | 24 | 22 | 46 |
| 2021 November | 46 | 36 | 82 |
| 2021 October | 30 | 33 | 63 |
| 2021 September | 22 | 29 | 51 |
| 2021 August | 22 | 36 | 58 |
| 2021 July | 21 | 28 | 49 |
| 2021 June | 27 | 15 | 42 |
| 2021 May | 23 | 36 | 59 |
| 2021 April | 36 | 28 | 64 |
| 2021 March | 59 | 19 | 78 |
| 2021 February | 61 | 6 | 67 |
| 2021 January | 23 | 14 | 37 |
| 2020 December | 40 | 4 | 44 |
| 2020 November | 37 | 14 | 51 |
| 2020 October | 15 | 22 | 37 |
| 2020 September | 72 | 15 | 87 |
| 2020 August | 14 | 9 | 23 |
| 2020 July | 51 | 12 | 63 |
| 2020 June | 35 | 8 | 43 |
| 2020 May | 33 | 6 | 39 |
| 2020 April | 35 | 18 | 53 |
| 2020 March | 40 | 9 | 49 |
| 2020 February | 70 | 25 | 95 |
| 2020 January | 28 | 7 | 35 |
| 2019 December | 26 | 4 | 30 |
| 2019 November | 26 | 9 | 35 |
| 2019 October | 40 | 5 | 45 |
| 2019 September | 26 | 16 | 42 |
| 2019 August | 32 | 6 | 38 |
| 2019 July | 40 | 11 | 51 |
| 2019 June | 25 | 8 | 33 |
| 2019 May | 38 | 16 | 54 |
| 2019 April | 21 | 17 | 38 |
| 2019 March | 25 | 9 | 34 |
| 2019 February | 52 | 12 | 64 |
| 2019 January | 26 | 5 | 31 |
| 2018 December | 47 | 11 | 58 |
| 2018 November | 147 | 7 | 154 |
| 2018 October | 344 | 16 | 360 |
| 2018 September | 113 | 15 | 128 |
| 2018 August | 70 | 9 | 79 |
| 2018 July | 24 | 7 | 31 |
| 2018 June | 46 | 5 | 51 |
| 2018 May | 63 | 4 | 67 |
| 2018 April | 92 | 8 | 100 |
| 2018 March | 110 | 7 | 117 |
| 2018 February | 45 | 9 | 54 |
| 2018 January | 107 | 8 | 115 |
| 2017 December | 185 | 5 | 190 |
| 2017 November | 66 | 5 | 71 |
| 2017 October | 33 | 10 | 43 |
| 2017 September | 22 | 4 | 26 |
| 2017 August | 29 | 8 | 37 |
| 2017 July | 28 | 10 | 38 |
| 2017 June | 30 | 20 | 50 |
| 2017 May | 38 | 11 | 49 |
| 2017 April | 20 | 10 | 30 |
| 2017 March | 41 | 16 | 57 |
| 2017 February | 33 | 5 | 38 |
| 2017 January | 31 | 6 | 37 |
| 2016 December | 24 | 19 | 43 |
| 2016 November | 19 | 4 | 23 |
| 2016 October | 51 | 9 | 60 |
| 2016 September | 22 | 5 | 27 |
| 2016 August | 7 | 3 | 10 |
| 2016 July | 18 | 5 | 23 |
| 2016 June | 13 | 6 | 19 |
| 2016 May | 15 | 10 | 25 |
| 2016 April | 38 | 3 | 41 |
| 2016 March | 31 | 19 | 50 |
| 2016 February | 57 | 41 | 98 |
| 2016 January | 98 | 46 | 144 |
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