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Cardiac implantable electronic device lead-based masses and atrial fibrillation ablation: a case-based illustration of periprocedural anticoagulation management strategies

Abstract

Introduction

Cardiac implantable electronic device (CIED) leads frequently develop echogenic masses. However, the nature of these masses is not well understood. In patients in whom atrial fibrillation (AF) catheter ablation is planned, there is concern that transseptal puncture may result in cerebrovascular embolism of these masses. The optimal therapeutic strategy in this setting remains undefined.

Methods

We describe six patients identified over a 6-year period (2008–2014) with device lead-based masses prior to or at the time of AF ablation. We examined the anticoagulation strategy and periprocedural management based on mass identification.

Results

In all six patients (age 39–73; four males), the device lead mass was found in the right atrium. The average mass size was 11 ± 1.3 mm. The majority of patients were already on anticoagulation (5/6; 83 %), and an intensified anticoagulation regimen was initiated (INR goal 3.0). In all six patients, the size of the device lead mass decreased on repeat imaging. In two sixths (33 %) patients, the lead-based mass completely resolved within 2 months. The remaining four patients had persistent lead-based masses (average follow-up of 10.9 ± 9.6 months).

Discussion

We describe a series of patients with CIED lead-based masses found at the time of ablation. These cases illustrate that lead-based masses can disappear while patients are on high-intensity anticoagulation, most compatible with a thrombotic origin. These early data will need to be assessed in larger cohorts for further validation and evaluation of safety.

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Abbreviations

AF:

Atrial fibrillation

CIED:

Cardiac implantable electronic device

ICE:

Intracardiac echocardiography

PPM:

Permanent pacemakers

RA:

Right atrial

RV:

Right ventricular

TEE:

Transesophageal echocardiogram

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Author information

Correspondence to Samuel J. Asirvatham.

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Financial support

CVD is supported by NIH T32 Training grant no. HL007111.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Consecutive frames from a 3D-transesophageal echocardiogram view of the right atrium demonstrating mobility of a 12-mm mass within the atrium and attachment of the mass to the right ventricular lead. A second mass not seen with 2D-imaging can be seen moving independently of the first mass. (AVI 1882 kb)

Transesophageal echocardiogram four-chamber view with focus on right atrial and right ventricular views shows the RA lead of the permanent pacemaker, an 11-mm mass within the RA, and the attachment of the mass to the RA lead. (AVI 2430 kb)

Transesophageal echocardiogram biplane right atrial view shows mobile mass of unclear size attached to the right atrial lead. (AVI 7051 kb)

3D-transesophageal echocardiogram view focusing on the right atrium demonstrates appearance and disappearance of multiple RA lead-based masses indicating mobility of masses associated with stationary mass identified on traditional TEE. (AVI 7874 kb)

Intracardiac echocardiography of the right atrium clearly demonstrates large size of mobile mass on the right atrial lead. (AVI 8082 kb)

Supplemental Video 1

Right ventricular inflow view on transesophageal echocardiogram focusing on right atrium demonstrates ventricular and atrial CIED leads with a single lead-based 12 mass attached to the right ventricular lead. (AVI 6569 kb)

Supplemental Video 2

Consecutive frames from a 3D-transesophageal echocardiogram view of the right atrium demonstrating mobility of a 12-mm mass within the atrium and attachment of the mass to the right ventricular lead. A second mass not seen with 2D-imaging can be seen moving independently of the first mass. (AVI 1882 kb)

Supplemental Video 3

Transesophageal echocardiogram four-chamber view with focus on right atrial and right ventricular views shows the RA lead of the permanent pacemaker, an 11-mm mass within the RA, and the attachment of the mass to the RA lead. (AVI 2430 kb)

Supplemental Video 4

Transesophageal echocardiogram biplane right atrial view shows mobile mass of unclear size attached to the right atrial lead. (AVI 7051 kb)

Supplemental Video 5

3D-transesophageal echocardiogram view focusing on the right atrium demonstrates appearance and disappearance of multiple RA lead-based masses indicating mobility of masses associated with stationary mass identified on traditional TEE. (AVI 7874 kb)

Supplemental Video 6

Intracardiac echocardiography of the right atrium clearly demonstrates large size of mobile mass on the right atrial lead. (AVI 8082 kb)

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Cite this article

Lenz, C.J., DeSimone, C.V., Ponamgi, S.P. et al. Cardiac implantable electronic device lead-based masses and atrial fibrillation ablation: a case-based illustration of periprocedural anticoagulation management strategies. J Interv Card Electrophysiol 46, 237–243 (2016). https://doi.org/10.1007/s10840-016-0110-0

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Keywords

  • Catheter ablation
  • Lead-based masses
  • Lead thrombus
  • Anticoagulation
  • Cardiac implantable electronic device