Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
Division of Electrophysiology, Yale University School of Medicine, New Haven, Connecticut.
J Cardiovasc Electrophysiol. 2020 Jun;31(6):1509-1518. doi: 10.1111/jce.14487. Epub 2020 Apr 29.
Lead dysfunction can lead to serious consequences including failure to treat ventricular tachycardia or fibrillation (VT/VF). The incidence and mechanisms of lead dysfunction following left ventricular assist device (LVAD) implantation are not well-described. We sought to determine the incidence, mechanisms, timing, and complications of right ventricular lead dysfunction requiring revision following LVAD implantation.
Retrospective observational chart review of all LVAD recipients with pre-existing implantable cardioverter-defibrillator (ICD) from 2009 to 2018 was performed including device interrogation reports, laboratory and imaging data, procedural reports, and clinical outcomes.
Among 583 patients with an ICD in situ undergoing LVAD implant, the median (interquartile range) age was 62.5 (15.7) years, 21% were female, and the types of LVADs included HeartWare HVAD (26%), HeartMate II (52%), and HeartMate III (22%). Right ventricular lead revision was performed in 38 patients (6.5%) at a median (25th, 75th) of 16.4 (3.6, 29.2) months following LVAD. Mechanisms of lead dysfunction included macrodislodgement (n = 4), surgical lead injury (n = 4), recall (n = 3), insulation failure (n = 8) or conductor fracture (n = 7), and alterations in the lead-myocardial interface (n = 12). Undersensing requiring revision occurred in 22 (58%) cases. Clinical sequelae of undersensing included failure to detect VT/VF (n = 4) and pacing-induced torsade de pointes (n = 1). Oversensing occurred in 12 (32%) and sequelae included inappropriate antitachycardia pacing ([ATP], n = 8), inappropriate ICD shock (n = 6), and ATP-induced VT (n = 1).
The incidence of right ventricular lead dysfunction following LVAD implantation is significant and has important clinical sequelae. Physicians should remain vigilant for lead dysfunction after LVAD surgery and test lead function before discharge.
铅功能障碍可导致严重后果，包括无法治疗室性心动过速或心室颤动（VT/VF）。左心室辅助装置（LVAD）植入后铅功能障碍的发生率和机制尚不清楚。我们旨在确定 LVAD 植入后需要修正的右心室导联功能障碍的发生率、机制、时间和并发症。
对 2009 年至 2018 年所有植入式心脏复律除颤器（ICD）的 LVAD 受者进行回顾性观察性图表回顾，包括设备检测报告、实验室和影像学数据、程序报告和临床结果。
在 583 名植入 ICD 的患者中，植入 LVAD 的中位（四分位间距）年龄为 62.5（15.7）岁，21%为女性，LVAD 类型包括 HeartWare HVAD（26%）、HeartMate II（52%）和 HeartMate III（22%）。LVAD 后中位（25 百分位，75 百分位）时间为 16.4（3.6，29.2）个月时，38 名患者（6.5%）进行了右心室导联修正。导联功能障碍的机制包括微脱位（n=4）、手术导联损伤（n=4）、召回（n=3）、绝缘故障（n=8）或导体断裂（n=7），以及导联-心肌界面改变（n=12）。需要修正的欠感知发生率为 58%（22/38）。欠感知的临床后果包括无法检测 VT/VF（n=4）和起搏诱导尖端扭转型室性心动过速（n=1）。过感知发生率为 32%（12/38），后果包括不适当的抗心动过速起搏（ATP，n=8）、不适当的 ICD 电击（n=6）和 ATP 诱导的 VT（n=1）。
LVAD 植入后右心室导联功能障碍的发生率很高，并有重要的临床后果。医生应在 LVAD 手术后保持警惕，并在出院前测试导联功能。
