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The Heart Team approach has become an integral part of modern cardiovascular medicine. To evaluate current opinions and real-world practice among lead extraction practitioners, an online survey was created and distributed among a pool of lead extraction specialists participating in the International Lead Extraction Expert Meeting (ILEEM) 2018. The online survey consisted of 10 questions and was performed using an online survey tool (www.surveymonkey.com). The collector link was sent to 48 lead extraction experts via email. A total of 43 answers were collected (89% return rate) from lead extraction experts in 16 different countries. A great majority (83.7%) of the respondents performed more than 30 lead extraction procedures per year. The most common procedural environment in this survey was the hybrid operating room (67.4%). Most procedures were performed by electrophysiologists and cardiologists (80.9%). Important additional members of the current lead extraction teams were cardiac surgeons (79.1%), anesthesiologists (95.3%) and operating room scrub nurses (76.7%). An extended Heart Team is regarded beneficial for patient care by 86.0%, with potential further members being infectious diseases specialists, intensivists and radiologists. Team training activities are performed in 48.8% of participating centers. This survey supports the importance of establishing lead extraction Heart Teams in specialized lead extraction centers to potentially improve patient outcomes. The concept of a core and an extended Heart Team approach in lead extraction procedures is introduced.

Class 1C antiarrhythmic drugs (AAD) have been associated with harm in patients treated for ventricular arrhythmias with a prior myocardial infarction. Consensus guidelines have advocated that these drugs not be used in patients with stable coronary artery disease (CAD). However, long-term data are lacking to know if unique risks exist when these drugs are used for atrial fibrillation (AF) in patients with CAD without a prior myocardial infarction. In 24,315 patients treated with the initiation of AADs, two populations were evaluated: (1) propensity-matched AF patients with CAD were created based upon AAD class (flecainide, n = 1,114, vs class-3 AAD, n = 1,114) and (2) AF patients who had undergone a percutaneous coronary intervention or coronary artery bypass graft (flecainide, n = 150, and class-3 AAD, n = 1,453). Outcomes at 3 years for mortality, heart failure (HF) hospitalization, ventricular tachycardia (VT), and MACE were compared between the groups. At 3 years, mortality (9.1% vs 19.3%, P < .0001), HF hospitalization (12.5% vs 18.3%, P < .0001), MACE (22.9% vs 36.6%, P < .0001), and VT (5.8% vs 8.5%, P = .02) rates were significantly lower in the flecainide group for population 1. In population 2, adverse event rates were also lower, although not significantly, in the flecainide compared to the class-3 AAD group for mortality (20.9% vs 25.8%, P = .26), HF hospitalization (24.5% vs 26.1%, P = .73), VT (10.9% vs 14.7%, P = .28) and MACE (44.5% vs 49.5%, P = .32). Flecainide in select patients with stable CAD for AF has a favorable safety profile compared to class-3 AADs. These data suggest the need for prospective trials of flecainide in AF patients with CAD to determine if the current guideline-recommended exclusion is warranted. [Display omitted] .

In patients with sinus-node dysfunction who require permanent pacing for bradycardia, single-chamber ventricular pacing and dual-chamber atrioventricular pacing are alternative options. In this randomized trial, the frequency of the primary end point (death or nonfatal stroke) was not significantly different in the two groups. However, the dual-chamber group had a lower incidence of atrial fibrillation and end points related to heart failure, as well as a slightly better quality of life. The dual-chamber group had a lower incidence of end points related to heart failure. Since the first implantation of a cardiac pacemaker in a human in 1958, 1 technological advances have enhanced the sophistication of cardiac pacemakers, but there has been no clear evidence of the advantages of more complex devices. 2 – 4 For example, dual-chamber pacing maintains atrioventricular synchrony and may better preserve normal physiologic function as compared with single-chamber ventricular pacemakers, 5 – 7 but dual-chamber pacemakers are more expensive, are more complex to implant and program, and have a higher rate of complications. 8 Although retrospective studies and case series suggest benefits of dual-chamber or atrial-based pacing, 9 , 10 randomized trials have had divergent results with regard . . .

Background A 10-J energy safety margin has traditionally been used in programing implantable cardioverter defibrillators (ICDs). The Low Energy Safety Study (LESS) tests the hypothesis that programing shocks to lower energy margins is safe and effective. Methods Patients with standard ICD indications undergo defibrillation threshold testing (DFT) at the time of ICD implant, with reconfirmation of lowest successful energy twice (DFT++). Patients are randomized to 2 groups: the first has the initial 2 shocks for ventricular fibrillation conversion programed at 2 energy steps above DFT++ (typically 4-6 J, maximum 10 J) with subsequent shocks at maximum energy, and the second has all shocks programed at maximum energy. Patients are followed up every 3 months for 2 years to assess shock conversion efficacy of spontaneous arrhythmias. In a subgroup of patients, there is a second randomization to energy levels of 0, 1, 2, 3, or 4 steps above implant DFT++ for conversion testing of 3 induced ventricular fibrillation episodes at prehospital discharge, 3 months, and 12 months after implant. Results Enrollment is complete (702 patients), but follow-up results are pending. There were no significant variations in implant indications and baseline antiarrhythmic drug use over the 3-year enrollment period, although an increase in the percentage of dual-chamber ICDs implanted occurred, with the majority (65%) of implanted ICDs being dual-chamber devices by the end of the enrollment period. Conclusion The results of LESS should facilitate the development of algorithms for programing ICD energy safety margins. (Am Heart J 2002;143:199-204.)

The femoral approach to pacemaker and defibrillator lead extraction is an alternative and complementary approach to the more commonly practiced superior approach. Tools and methodology for the femoral approach have been developed after years of refinement. Whereas calcified or heavily fibrosed leads present a major challenge for extraction using superior techniques, they are readily removed using the femoral approach. Femoral extraction requires two basic categories of tools. These include outer femoral sheath and snares. The complication profile of femoral extraction differs somewhat from that of superior extraction. The most common life‐threatening complication of lead extraction from the femoral approach is myocardial perforation resulting from avulsion or tear with resulting hemopericardium and cardiac tamponade. In a comparison of femoral with laser superior approaches to lead extraction, total fluoroscopy time was found to be higher (21 min) for the femoral approach than the laser superior approach (7 min).