Evaluation of right ventricular functions at acute period after lead extraction by strain echocardiography in patients with cardiovascular implantable electronic devices

Background: Cardiovascular implantable electronic devices (CIEDs) are widely used to treat symptomatic arrhythmias, prevent sudden cardiac death and improve symptoms and cardiac function. On-going population growth and expanding indications have resulted in a progressive increase in the number of CIEDs. Reflecting this growth, an increasing number of leads need to be removed for various indications. There are no studies showing the acute effect of lead removal on right ventricular (RV) functions. In this study, we aimed to evaluate the acute effect of lead extraction on patients RV functions by strain echocardiography. Method: The study included 64 patients who were evaluated in the cardiology outpatient clinic or emergency room between December 2021 and June 2022 and were planned for ICEDs lead extraction for various reasons and were hospitalized in the cardiology service or coronary intensive care unit. Detailed physical examinations of these patients were performed, and wound and blood cultures were taken. In addition to routine blood tests, infection biomarkers C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and procalcitonin levels were studied. All patients underwent detailed transthoracic echocardiography (TTE) on the first day of hospitalization and within 24 hours of lead removal. RV functions in TTE were evaluated with 2-dimensional Doppler and strain/strain rate echocardiography. Results: The mean age of the patients participating in the study was 61.3 ± 15 years and 51 (79.7%) were male. Of these, 59.4% had hypertension, 39.1% had diabetes mellitus, 31% had heart failure and 29% had coronary artery disease. The reasons for battery removal were infection in 89.1% (n=57) patients and lead dysfunction in 10.9% (n=7) patients. The mean time after initial implantation was 72 months (median 13-264 months). In the battery pocket examination, 86% of the patients had an infective appearance (such as discharge, skin erosion, collection), while 14% had no visible signs of infection. While there was no growth in wound and blood cultures in 76.6% (n=49) of the patients, the most reproduced microorganism was staphylococcus epidermidis with 7.8% (n=5) in the patients with growth. While there was no growth in 67.1% (n=43) of the extracted material, the most common microorganism seen in those that did reproduce was staphylococcus epidermidis with 7.8% (n=5). Of the patients who underwent extraction, 2 leads were removed in 45.3% (n=29), 1 lead in 34.4% (n=22) and 3 leads in 20.3% (n=13). An extraction device was used in 43.8% (n=28) of the patients for lead extraction. In the TTE results of the patients, there was a significant decrease in strain echocardiography at the base of the right ventricular free wall (-20.5 vs -18.6%, p< 0.001) and apical (respectively -17.4 vs -16%, p< 0.001) after the procedure compared to the pre-procedural values. In addition, a significant decrease was observed in the tricuspid annular plane systolic movement (TAPSE) value after the procedure (1.6 vs 1.5 cm, respectively, p<0.016). The mean hospitalization period of the patients was determined as 22 days (meadian 5-75 days). Conclusion: Infections are the most common cause of ICED lead extractions. Staphylococcus epidermidis, a skin flora pathogen, is the most common microorganism that reproduces from wounds and excised materials. Lead extraction causes deterioration in the RV functions of these patients in the acute period. For this reason, it may be vital for patients to keep in mind the complications such as hypotension, dizziness, congestion and syncope that may develop due to decreased RV functions immediately after the extraction procedure in patients with ICED and to plan the treatment accordingly. More importantly, organizing awareness meetings to prevent infections in these patients and, if necessary, antibiotic prophylaxis before non-cardiac surgeries or interventional procedures can reduce ICED lead extraction rates. Keywords: Implantable cardiac electronic device, lead extraction, strain echocardiography, right ventricular function