Search Results for: Il pacemaker si ricarica con il battito del cuore

Circulation, Volume 150, Issue Suppl_1, Page A4143219-A4143219, November 12, 2024. Background:Left ventricular (LV) efficiency is a key pathophysiological marker in heart failure (HF). LV pressure curve estimation and three-dimensional (3D) volumes via echocardiography allows for non-invasive pressure-volume (PV) analysis and calculation of an index of efficiency (Figure 1).Aim:Validate efficiency index by 3D echocardiography by comparing it to invasive measurements and efficiency derived from Positron Emission Tomography (PET) metabolism.Methods:Two experimental models were utilized – one with canines (n=21) and another with sheep (n=12). In canines, echocardiography provided 3D LV volumes and valve event timings. The pressure curve was estimated by adjusting the time axis of a reference pressure curve to the valve events and its amplitude to measured peak LV pressure, which in clinical practice would be approximated as systolic brachial cuff pressure. Invasive pressure was measured by micromanometer and volume by subendocardial piezoelectric crystals. Non-invasive and invasive efficiency indices, calculated as the ratio of stroke work to total mechanical energy (Figure 1), were compared during baseline, right ventricular pacing, aortic constriction and dobutamine infusion.Twelve sheep implanted with a pacemaker underwent 8 weeks of rapid dyssynchronous DDD pacing to induce dilated HF. LV efficiency index was calculated as in Figure 1, using measurements from a PV-catheter calibrated to end-diastolic volume by cardiac MRI, and compared to efficiency calculated as stroke work divided by total LV glucose metabolism via PET/CT. Recordings were performed during AAI and DDD pacing, at baseline (n=3) and following 8 weeks pacing-induced HF (n=12).Results:In canines, non-invasive and invasive efficiency indices showed excellent agreement (r=0.95, p

Circulation, Volume 150, Issue Suppl_1, Page A4140192-A4140192, November 12, 2024. Background:The research on the outcomes of transcatheter aortic valve replacement with balloon-expandable valves (BEV) and self-expanding valves (SEV) are limited.Hypothesis:This study aims to compare the clinical and hemodynamic outcomes of BEV and SEV at short-term (30 days), mid-term (1 year), and long-term ( >1 year) endpoints.Methods:PubMed, Embase, Scopus, and Cochrane Library databases were searched up to April 25, 2024, for randomized controlled trials (RCTs). Random-effect model (DerSimonian–Laird method) was used to pool the risk ratios (RR), mean differences (MD) and 95% confidence interval (CI) for binary and continuous outcomes, respectively.Results:A total of 11 RCTs comprising 4,325 patients (2,295 BEV, 2,030 SEV) were included. At short-term, the risk of cardiovascular (RR: 0.56, 95% CI: 0.36-0.87) and all-cause mortality (RR: 0.54, 95% CI: 0.35-0.81) were lower in the BEV group. However, no differences were noted between the two treatment modalities in longer follow-ups despite the lower risk of moderate to severe paravalvular leak (PVL) among BEV patients. The risk of stroke was comparable between two groups across all three follow-up endpoints, albeit a limited number of studies suggesting the BEV group showed a greater risk of clinical valve thrombosis in mid-term and long-term assessments. The need for permanent pacemaker implantation was lower in BEV arm in short-term (RR: 0.56, 95% CI: 0.37-0.87) and mid-term (RR: 0.78, 95% CI: 0.64-0.94). Yet, this difference was not observed in long-term follow-ups. Conversely, the SEV group had a larger effective orifice area with lower mean transvalvular pressure gradient from short-term (MD: 0.17, 95% CI: 0.07-0.26 and MD: 3.71, 95% CI: 2.64-4.78, respectively) to long-term (MD: 0.25, 95% CI: 0.17-0.32 and MD: 3.73, 95% CI: 3.19-4.27, respectively) periods.Conclusions:BEV is associated with reduced risk of clinical outcomes at short-term; however, most differences diminish in longer evaluations, except for moderate to severe PVL. Conversely, SEV is linked to better hemodynamic outcomes and a lower risk of clinical valve thrombosis across all follow-up durations.

Circulation, Volume 150, Issue Suppl_1, Page A4136989-A4136989, November 12, 2024. Background:We previously observed a positive correlation between QRS duration and the preceding RP interval in sinus rhythm in certain patients experiencing new onset left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR). This unique phenomenon, termed inverse decremental conduction (IDC) or Yan conduction, prompted us to investigate whetherIDCin the left bundle could manifest as AV conduction in anIDCpattern in patients with preexisting right bundle branch block (RBBB) and its association with atrioventricular block (AVB).Methods:12 lead ECGs, available in-patient telemetry and mobile cardiac outpatient telemetry were reviewed in patients with sinus rhythm and preexisting RBBB who developed paroxysmal AVB requiring temporary or permanent pacemaker within 7 days following any types of cardiac surgery from 2014 to 2023 in Lankenau Medical Center.Results:A total of 9 patients (5 males) with a mean age of 71±15 years were identified to exhibit PR interval changes consistent withIDCprior to paroxysmal AVB. Among these patients, 6 had undergone TAVR, while the remaining 3 had undergone surgical aortic valve replacement, mitral valve repair, and ventricular septal defect repair, respectively. Specifically, PR interval alternation in the setting of RBBB occurred during sinus rhythm in a pattern that the longer RP interval is followed by a longer PR interval (Figure 1). This pattern exhibits the following features: 1) 8 of 9 patients had RBBB plus left anterior fascicular block (LAFB); 2) PR alternation occurred at sinus rates from 68 to 91 bpm within 5 days following surgical procedures; 3) proximal AVB occurred within 1 to 12 hours after PR interval alternation began. A positive correlation was established between PR and preceding RP interval in 2 of 9 patients whose telemetry data were available for analysis (Figure 2A). In a patient with RBBB who developed paroxysmal AVB withoutIDCchanges in the PR interval post TAVR, intracardiac recording showed a decrease in AH interval but an increase in HV interval with slowing heart rates (Figure 2B), indicating that decremental conduction in AV node can maskIDCin Purkinje system.Conclusion:1) PR alternation with longer PR following longer preceding RP interval in presence of RBBB, likely due toIDCin left bundle, heralds paroxysmal AVB; 2) PR interval changes resulting fromIDCin left bundle in the setting of RBBB may be masked by decremental conduction in AV node.

Circulation, Volume 150, Issue Suppl_1, Page A4143217-A4143217, November 12, 2024. Background:Transcatheter aortic valve replacement (TAVR) has revolutionized the management of aortic stenosis, offering a less invasive alternative to surgical valve replacement, particularly for high-risk patients. While TAVR has demonstrated efficacy and safety in various patient populations, there is growing recognition of gender-specific differences in clinical outcomes post-procedure.Understanding gender-related variations in TAVR outcomes is crucial for optimizing patient care and ensuring equitable access to this life-saving therapy.Methods:Using the National Inpatient Sample (2017-2020), we analyzed the characteristics and comorbidities of male and female patients undergoing TAVR. We then assessed the incidence of clinical outcomes between genders, including in-hospital mortality, mechanical ventilation, length of stay, hospital charges, vasopressor requirement, heart block, pacemaker insertion, stroke, acute kidney injury (AKI), vascular complications, and discharge disposition. Multivariate analysis was performed to evaluate mortality risk among congestive heart failure (CHF) patients.Results:Among 234,860 total admissions, females comprised 44.5% (104,365) of the population. Females were slightly older (mean age 79.4 vs. 78.5 years, p < 0.001) and had a lower mean Charlson Comorbidity Index (2.8 vs. 3.1, p < 0.001) compared to males. After adjusting for confounding factors, females had a higher odds ratio for in-hospital mortality (OR 1.48, 95% CI 1.37-1.60, p < 0.001), mechanical ventilation (OR 1.14, 95% CI 1.07-1.20, p < 0.001), stroke (OR 1.55, 95% CI 1.46-1.65, p < 0.001), and vascular complications (OR 1.24, 95% CI 1.19-1.31, p < 0.001). Length of stay (mean difference 0.37 days, 95% CI 0.32-0.42, p < 0.001) and hospital charges (mean difference $3,795, 95% CI 2,488-5,102, p < 0.001) were also significantly higher in females (p < 0.001 for both).Conclusion:The divergent clinical profile and poorer outcomes observed among females undergoing TAVR, characterized by elevated in-hospital mortality, stroke, and vascular complications compared to males, may emphasize the need for gender-specific approaches in TAVR management.

Circulation, Volume 150, Issue Suppl_1, Page A4116639-A4116639, November 12, 2024. Background:Surgical aortic valve replacement (SAVR) is the preferred treatment option for patients with severe aortic regurgitation (AR). Recently, several patients with mixed aortic valve disease, comprising severe aortic stenosis (AS) and at least moderate AR, have been successfully treated with TAVR. However, the treatment of severe native aortic valve regurgitation (NAVR) without AS remains a matter of contention, and the efficacy of TAVR remains uncertain.Aims:The primary outcomes were 30-day mortality and the incidence of device success. The secondary outcomes included incidence of myocardial infarction (MI), stroke, major bleeding, acute kidney injury (AKI) ≥ stage 2, moderate-to-severe paravalvular leak (PVL), permanent pacemaker implantation (PPM), and post-procedural moderate-to-severe AR.Methods:We systematically searched PubMed, Cochrane Library, Scopus and ClinicalTrials.gov for published articles from inception until 2nd April 2024 to evaluate clinical outcomes of TAVR in patients with NAVR. The statistical analysis was conducted using R-Studio 5.3.3. The rates of events with 95% confidence intervals (CI) and the heterogeneity was assessed using p-value and I2statistics.Results:A total of 23 published articles with 4,397 patients were included. All-cause mortality at 30 days was 12% (95% CI: 6% to 23%), while device success was 86% (95% CI: 81% to 92%). The incidence of complications such as MI (3%, 95% CI: 2% to 4%), stroke (3%, 95% CI: 2% to 3%), major bleeding (8%, 95% CI: 5% to 11%), AKI ≥ stage 2 (8%, 95% CI: 5% to 12%), and major vascular complications were relatively low (6%, 95% CI: 4% to 7%). PPM was required for 15% of patients (95% CI: 11% to 18%). PVL was observed in 10% of patients (95% CI: 2% to 41%) and post-procedural moderate-to-severe AR occurred in 9% of patients (95% CI: 4% to 20%).Conclusion:TAVR is a viable and reasonable option for a specific population with NAVR. Nevertheless, it is imperative to conduct larger studies with a longer duration of follow-up to obtain more robust evidence of the feasibility of TAVR in patients with NAVR.

Circulation, Volume 150, Issue Suppl_1, Page A4145057-A4145057, November 12, 2024. Introduction:Cardiovascular Implantable Electronic Device (CIED) infection is class I indication for complete transvenous lead removal (LR). The reimplantation strategies post-LR, especially in pacemaker-dependent patients or those necessitating cardiac resynchronization therapy (CRT) and/or implantable defibrillators, remain complex. Considering the limitations and risks associated with traditional approaches, the exploration of alternative devices such as leadless pacemakers (LP) have garnered attention due to their purported lower infection risk.Methods:We meticulously reviewed literature sources including PubMed, Scopus, and Embase utilizing a combination of search terms. The inclusion criterion was LP implantation post-LR of infected CIED, while the exclusion criterion was LR for noninfectious indications. Study endpoints encompassed patients’ outcomes during follow-up.Results:Our literature review yielded 818 articles, of which 21 met the inclusion criteria, encompassing a cohort of 612 patients who underwent LR followed by LP implantation (Table 1). A total of 250 (40.8%) patients underwent concurrent LP implantation during the LR procedure. The rest underwent staged procedures and the overall duration between LR of infected CIED and LP implantation was 4.32 ± 3.9 days. In our cohort, 172 (28.1%) patients had systemic CIED infections, whereas 130 (21.2%) had isolated pocket infections, with Staphylococcus aureus as the predominant causative organism in 96 (39.3%) cases. Procedural complications were scarce. Over a mean follow-up period of 13.2 ± 8.1 months, pacemaker syndrome was observed in 3 (0.67%) patients, while 1 (0.16%) patient had a re-infection related to LP.Conclusion:The remarkably low incidence of complications and re-infections following LP implantation underscores its potential utility as a viable implantation option after LR, particularly in pacing-dependent patients at higher risk of CIED infections.

Circulation, Volume 150, Issue Suppl_1, Page A4134340-A4134340, November 12, 2024. Introduction:Previous studies have noted racial and ethnic disparities in access to leadless pacemaker implantation (LPI), but none have evaluated the socioeconomic disadvantaged (SED). Additionally, few studies have evaluated outcomes of LPI beyond thirty days on a large scale. This study aimed to determine which comorbidities are associated with one-year readmissions and mortality after LPI, including SED via the Social Deprivation Index (SDI).Methods:Patients ages ≥18 were identified in the Healthcare Cost and Utilization Project State Inpatient Databases in New York and Florida from 2016-2019 with follow-up into 2020. These states were chosen due to availability for linkage of the 2018 SDI (1-100, higher scores representing more disadvantage). International Classification of Diseases 10 codes for LPI were used. The risk of readmission and mortality was assessed using Cox proportional hazards first in an unadjusted fashion for each comorbidity in the Charlson Comorbidity Index. In addition to demographic variables, only significant variables from the unadjusted analysis were included in the final adjusted multivariable models.Results:3,094 patients met inclusion criteria. The readmission and mortality rates at one, three, and twelve months were 17.2%, 31.3%, 50.2% and 5.7%, 7.1%, 10.7%, respectively. The most common diagnoses for readmission were dyspnea/chest pain (9.4%), heart failure (4%), and sepsis (3.8%). Federal insurance, heart failure (CHF), pulmonary disease, diabetes without complications, and renal disease (CKD) were associated with increased risk for twelve-month readmissions. African American race, myocardial infarction, CHF, CKD, and higher SDI were associated with increased risk for twelve-month mortality.Conclusion:CHF and CKD put patients at high risk of readmission and mortality. Sepsis was among the most common causes of readmission at twelve months. Patients of higher SED are at increased risk of mortality within one year after LPI.

Circulation, Volume 150, Issue Suppl_1, Page A4144790-A4144790, November 12, 2024. Background:A prolonged PR interval has been demonstrated as a predictor of increased risk for incident atrial fibrillation (AF), coronary artery disease, heart failure, and pacemaker implantation.Purpose:We aim to investigate the impact of prolonged PR interval > 200 ms on AF recurrence after catheter ablation.Methods:We comprehensively searched PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through May 2024. We conducted a pair-wise and prognostic systematic review and meta-analysis with a reconstructed time-to-event data meta-analysis. All analyses were performed using R V. 4.3.1.Results:With the inclusion of four studies, our cohort comprised a total of 2,790 patients. Regarding pair-wise meta-analysis, PR interval > 200 ms was significantly associated with an increased incidence of AF recurrence compared to PR interval ≤ 200 ms (RR: 1.50 with 95% CI [1.33, 1.70], P< 0.01). Regarding adjusted prognostic meta-analysis, PR interval > 200 ms was significantly associated with a 92% increase in the risk of AF recurrence compared to PR interval ≤ 200 ms (HR: 1.92 with 95% CI [1.61, 2.30], P< 0.01). Our reconstructed Kaplan Meier showed that a PR interval > 200 ms was significantly associated with a 65% increase in the risk of AF recurrence compared to a PR interval ≤ 200 ms (HR: 1.65 with 95% CI [1.42, 1.92], P< 0.00001) over 120 months follow-up.Conclusion:Our meta-analysis concluded that a prolonged PR interval greater than 200 ms is a significant predictor of AF recurrence after catheter ablation, reflecting atrial remodeling, and since the PR interval can be easily measured by a surface 12-lead ECG, patients with a prolonged PR interval may require additional treatment strategies.

Circulation, Volume 150, Issue Suppl_1, Page A4141033-A4141033, November 12, 2024. Introduction:Pain discomfort increases procedural time in electrophysiology laboratory and prolongs surgical length. Virtual reality-based analgesia (VR-A) improves patient’s acceptance of the procedural steps, mostly in the emergency context. To date, routine adoption of VR-A is limited in cardiology since it is recommended for other surgeries.Hypothesis:we postulated that administration of VR-A would facilitate patient’s compliance, allowing to increasing number of electrophysiology procedures, to reducing burden of complications, and to accelerating discharge.Methods:from April 2024 to May 2024 patients admitted to our academic hospital for cardiac rhythm disorders requiring pacemaker (PM) or implantable cardioverter/defibrillator (ICD) were enrolled. They were randomized in two groups (allocation ratio 1:1) by including either standard sedation protocol, or VR-A for cardiac device implants. Numeric rating scale score was used to assess pain. Variation of vital parameters was measured at baseline, 15, 30 and 60 min after procedural start, as well as at 30 min after procedural ending for an objective evaluation of pain. Statistical analysis was performed with SPSS.Results:Baseline clinical characteristics did not differ between groups. Patients underwent PM (N=12) and ICD (N=8) implantations, showing similar allocation and mean procedural durations (69.5±23.4 min vs 69.5±10.9 min,p=0.3), but significant difference in numeric rating scale score (4.5±0.8 vs.5.9±1.7,p=0.02) in VR-A vs standard group. Standard protocol registered significant differences in blood pressure [F(4, 45)=6.95;p

Circulation, Volume 150, Issue Suppl_1, Page A4123563-A4123563, November 12, 2024. Background:Patients with chronic obstructive pulmonary disease (COPD) are at high risk for developing arrhythmias due to hypoxemia, right heart failure and use of beta-agonists inhalers. Symptoms related to arrhythmias can often be masked or confounded by symptoms related to COPD exacerbation and remain undiagnosed.Objective:To identify the incidence of actionable arrhythmias in patients with no prior cardiology follow-up and moderate–severe COPD with continuous monitoring.Methods:An automatic referral for electrophysiology (EP) consult was generated in patients with moderate-severe COPD if they answered yes to one of the following: palpitations, dizziness, abnormal ECG, near syncope. Upon consultation with EP specialist, implantation of loop reorder was discussed (ILR) with the patient. Patients were then monitored for 12 months via remote monitoring. Actionable arrhythmia was defined the arrhythmia that correlated with symptoms triggered by the patient, necessitated adjustment of medications (including initiation of anticoagulation), catheter ablation and implantation of implantable cardiac defibrillator (ICD) or permanent pacemaker (PPM).Results:Out of 62 patients referred 22 (35.5%) agreed to undergo ILR implantation. Of the 22 (50.0% female, 62 ± 9.5 years) patients implanted with an ILR, 15 (68.2%) had an actionable arrhythmia after a mean follow-up of 2.7± .3 months. These included 14 symptomatic events requiring medication adjustment (10 atrial tachycardias, 4 ventricular events), 7 cases of atrial fibrillation (requiring initiation of anticoagulation in all cases and catheter ablation in 1), 1 case of sinus node dysfunction requiring pacemaker implantation, and 1 episodes of sustained ventricular tachycardia requiring ICD implantation.Conclusion:Continuous monitoring had high yield in diagnosing significant arrhythmic events in patients with moderate-severe COPD. Awareness should be raised about the high arrhythmic risk of this population and the role of continuous monitoring should be sought in larger studies.

Circulation, Volume 150, Issue Suppl_1, Page A4139327-A4139327, November 12, 2024. Leadless pacemakers (LPMs) represent a significant advancement in cardiac pacing technology, offering several advantages over traditional transvenous systems. However, they are not without complications such as leadless pacemaker-induced cardiomyopathy (LPM-CMP). We present a case of cardiogenic shock from LPM-CMP requiring cardiac resynchronization therapy (CRT) as a rescue strategy.A 77-year-old female with a history of heart failure with reduced ejection fraction, coronary artery disease status post recent percutaneous coronary intervention to the proximal-to-mid left anterior descending artery, complete heart block status post LPM implantation, and chronic kidney disease stage 3b, presented to the emergency department after a syncopal event. Initial vital signs were blood pressure 96/64 mmHg and heart rate 62 bpm, while LPM interrogation showed 100% right ventricular pacing burden. Physical exam revealed congestion with jugular venous distension and 2+ pitting bilateral lower extremity edema. Initial labs (BNP 4792 pg/mL, hs-troponin 202 ng/L, lactate 5.5 mmol/L, AST/ALT 68/30 U/L, and creatinine 3.3 mg/dL (baseline 1.5 mg/dL)) were consistent with SCAI Stage B cardiogenic shock. She was transferred to the cardiovascular intensive care unit for inotropic and vasopressor support. By hospital day 10, she was on 10 mcg/kg/min of dobutamine, 3 mcg/min of epinephrine, and 14 mcg/min of norepinephrine. Despite this and extensive diuresis, she continued to deteriorate. After ruling out acute coronary syndrome, LPM-CMP was suspected as the etiology, and CRT-D was implanted on day 14. Echocardiography-assessed stroke volume correspondingly improved from 25 mL on pressors to 30 mL after CRT-D and off pressors. She was subsequently optimized on heart failure guideline-directed medical therapy, and discharged home on day 19.LPM-CMP is a rare but potentially serious complication of LPM implantation. Early recognition and appropriate management are essential for optimizing patient outcomes. In this case, CRT-D implantation proved to be a successful intervention, resulting in significant clinical improvement and symptom resolution. This underscores the importance of individualized patient management and the role of advanced device therapies in the treatment of LPM-induced complications. Further research is needed to better understand the risk factors, pathophysiology, and optimal management strategies for LPM-CMP, especially as a rescue strategy in cardiogenic shock.

Circulation, Volume 150, Issue Suppl_1, Page A4144651-A4144651, November 12, 2024. Introduction:Post-transcatheter aortic valve replacement (TAVR) pacemaker (PPM) implantation is a known complication. Chronic total occlusion (CTO) of coronary arteries is common in TAVR patients and is a marker of advanced coronary calcification. Its influence on the requirement for PPM post-TAVR remains unclear. We investigated the association between pre-existing CTO and the incidence of PPM post-TAVR.Methods:A retrospective cohort study was conducted using the National Inpatient Sample database from 2018-2020 with 205,565 patients who underwent TAVR. Propensity score matching was utilized to create a matched cohort of patients with and without CTO, balancing key variables such as age, sex, elective procedure status, and comorbid conditions (heart failure, arrhythmias, pulmonary circulation disorders, peripheral vascular disorders, and complicated diabetes). Outcomes measured included the requirement for PPM implantation post-TAVR, in-hospital mortality, and major adverse cardiac events (MACE). Weighted samples were utilized and p-value

Circulation, Volume 150, Issue Suppl_1, Page A4144700-A4144700, November 12, 2024. Background:Long term right ventricular apex pacing has been reported to affect myocardial metabolism and perfusion to lead to impaired left ventricular function. However, there is little information available on the effect on fatty acid metabolism, myocardial perfusion and function in RV septal or His bundle pacing.Methods and Results:We studied 94 patients (mean age 77±11 years, male 40%, AV block 71%) admitted for pacemaker implantation in our prospective cohort study, excluding patients with coronary artery disease who had past histories of coronary arterial revascularization and severe stenosis in coronary CT or coronary angiography. Forty-five patients had right ventricular apex pacing (RVA; n=10) or right ventricular septal pacing (RVS; n=35), 17 had selective or non-selective His bundle pacing (HIS) and, as a control, 32 had right atrial pacing (RA). The patients underwent 123I-β-methyl-P-iodophenyl-pentadecanoic acid (BMIPP) SPECT imaging and Tc-99m- methoxyisobutylisonitrile (MIBI) SPECT imaging between 3 months and 1 year after implantation. The uptakes of both tracers were displayed on a polar map, which was divided into 17 segments. Regional tracer activity at each segment was quantified as %uptake. Left ventricular ejection fraction (LVEF) was also obtained in MIBI imaging.There were no significant differences in baseline characteristics such as age, gender, or underlying heart disease between the four groups. LVEF in MIBI rest imaging in RVA group was significantly lower than RA group (58.3±2.1% vs 64.9±1.2%, p=0.013), while there was no significant difference in LVEF among RVS, HIS and RA groups, with non-significantly (p=0.25) lower LVEF in RVS (62.5±1.1%) than HIS (65.3±1.6%) groups. The average of BMIPP %uptake in 17 segments significantly correlated with LVEF (r=-0.259, p=0.01). BMIPP and MIBI (stress and rest) %uptake were significantly lower in RVA group and RVS group than RA group in the septal or anterolateral area. Especially, BMIPP %uptake in RVA group was significantly lower at the broad area. On the other hand, BMIPP and MIBI (stress and rest) %uptake in HIS group were almost similar to those in RA group.Conclusion:His bundle pacing, but not RV septal pacing, maintains myocardial metabolism, perfusion and function.

Circulation, Volume 150, Issue Suppl_1, Page A4134594-A4134594, November 12, 2024. Description of Cases:Case 1: A 72 year old male with atrial fibrillation (AF) and tachy-brady syndrome underwent Micra implantation. On post-procedure day 2, pacing thresholds were unacceptably elevated. A new Micra device was deployed; subsequently, a microsnare was placed through the Micra delivery catheter and the docking button of the old Micra was successfully snared (Figure A). The old Micra was then captured over the delivery catheter and removed from the body.Case 2:A 76 year old male underwent Micra implantation and AV node ablation for AF with persistent tachycardia. One month later, he presented with heart failure and interval decrease in ejection fraction from 66% to 33%. After biventricular leads were implanted, an Agilis catheter was advanced towards the Micra. The docking button was successfully snared with a gooseneck snare (Figure B), and the Micra was extracted with gentle traction.Case 3:A 76 year old male with complete heart block and longstanding persistent AF received a Micra. Nine months later, he presented with heart failure and interval decrease in ejection fraction from 55% to 25%. A defibrillator lead was implanted but no suitable CS branch was identified. The Aveir retrieval catheter was advanced and the Micra docking button was captured with the triloop snare (Figure C). The protective sleeve was advanced over the Micra and it was successfully removed. Subsequently, a left bundle area lead was placed.Discussion:Although uncommon, extraction of the tined leadless pacemaker (Micra) may be indicated at times. As rates of implantation continue to increase, establishing uniform procedures for extraction becomes increasingly important. These three cases highlight unique options for Micra extraction, and the feasibility of each approach. However, a dedicated tool and protocol would be ideal for patient safety and consistency. No complications occurred with the above cases.

Circulation, Volume 150, Issue Suppl_1, Page A4142758-A4142758, November 12, 2024. Introduction/Background:Binding sites in the costoclavicular space are commonly encountered during transvenous lead extraction. Severe adhesions may warrant use of more aggressive rotational cutting tools or surgical intervention.Research Questions/Hypothesis:It is not known whether pre-procedural CT can provide information about the likelihood that a patient will require costoclavicular intervention.Goals/Aims:The purpose of this study was to determine if there are pre-procedural CT findings associated with need for intervention in the costoclavicular space during lead extraction.Methods/Approach:In this retrospective, single-center, observational study, patients who underwent lead extraction between 2013 and 2024 and required use of stiffer rotational cutting tools (TightRail Sub-C) or surgical intervention in the costoclavicular space were included. Controls who did not require costoclavicular intervention and had at least one lead with dwell time >10 years were matched to cases based on age and sex. Pre-procedural CT was evaluated for patterns of lead tethering to bone and adjacent calcification. Data were analyzed with descriptive statistics.Results/Data:Overall, 56 patients were included (n=20 Sub-C only, n=8 surgical intervention, and n=28 matched controls). The mean patient age of interventional cases was 65.0 ± 14.7 years, 18% were female, and the mean lead age was 12.3 ± 6.2 years. Four major patterns were identified on imaging: fat plane between lead and bone preserved by ≥1 mm (Sub-C intervention rate 5/24 patients, surgical intervention rate 0/24); fat plane not preserved (180° was associated with a 100% rate of costoclavicular intervention and the highest rate of surgical intervention (56%). Absence of any degree of bone tethering or adjacent calcifications was associated with a 0% rate of surgical intervention. CT may be useful in pre-procedural planning for adhesions in the costoclavicular space.

Circulation, Volume 150, Issue Suppl_1, Page A4141344-A4141344, November 12, 2024. Background:Leadless pacemakers offer a safe and effective alternative pacing strategy, crucial for patients with end-stage renal disease (ESRD) overcoming vascular access isues. However, there is limited data available on their use in this population.Methods:We utilized the Nationwide Readmission Database to extract data on all adult patients with ESRD who received either traditional transvenous or leadless pacemaker implantation from 2016 to 2021. We then compared in-hospital mortality, in-hospital complications, healthcare resource utilization, and 30-day readmission rates between these two groups.Results:A total of 6,384 patients (81.2%) were included in the transvenous pacemaker cohort, while 1,481 patients (18.8%) were in the leadless pacemaker cohort. In ESRD patients, leadless pacemaker implantation was associated with higher in-hospital complications compared to transvenous pacemakers, including cardiac complications (aOR 4.12, CI 1.70-9.98, p