Lead fragment characteristics and detection by radiographic imaging after heart transplant.

BACKGROUND: During orthotopic heart transplant (OHT), removal of a cardiac implantable electronic device involves traction from the device pocket, frequently leaving behind lead fragments. OBJECTIVE: This study aimed to determine fragment locations, risk factors, chest radiograph (CXR) sensitivity of fragment detection, and risk of fragment-related sequelae. METHODS: Among consecutive OHT patients with cardiac implantable electronic devices (2017-2024) at our institution, the prevalence and location of fragments were determined by CXR and computed tomography (CT) scan. Using a CT scan as the gold standard, the sensitivity of CXR and radiology reports for lead fragments was determined. Regression identified factors associated with fragments, bacteremia, and fragment-related sequelae. RESULTS: Of 116 patients, 20.7% (n = 24) had fragments (79% by CXR, 21% visible on CT scan only), mostly in the innominate vein (75%). CXR sensitivity for fragments was 79%. Only 7 of 19 fragments (37%) visible by initial post-OHT CXR were reported. Of 20 initial post-OHT CTs, 13 noted fragments (65%). Incremental 5-year lead dwell time (odds ratio [OR] 1.9; 95% confidence interval [CI] 1.1-3.1; P = .017), dual-coil implantable cardioverter-defibrillator (OR 4.4; 95% CI 1.4-13.8; P = .011), and increasing number of leads (OR 1.9; 95% CI 1.1-3.6; P = .023) were associated with fragments. Bacteremia occurred in 23% (33% with fragments vs 21% without; OR 1.9; 95% CI 0.7-5.2; P = .19). Magnetic resonance imaging was deferred in 21% of patients (n = 5) with fragments. Neither deep vein thrombosis nor fragment embolization occurred. CONCLUSION: At least 20% of OHT patients have retained lead fragments, usually in the innominate vein. CXR is insensitive in identifying fragments. Bacteremia is common after OHT, and longer lead dwell time, dual-coil defibrillator leads, and an increasing number of leads were associated with fragment retention.