Upgrade procedures of pacemakers or implantable cardioverter-defibrillators require creative clinical decision making and careful planning that begins at the first implantation

To the editor:

Keene et al.¹ presented their comprehensive clinical consensus statement from several professional rhythm societies on pacemaker or implantable cardioverter-defibrillator (ICD) upgrades and downgrades. We would like to congratulate the authors with their insightful review of this important topic.

While this manuscript covers all aspects of the subject matter, we would like to bring several points the attention of the authors and readers:

The consensus statement provides advice on how to act when an additional lead is needed because of additional pacing capabilities such as upgrade to cardiac resynchronization therapy (CRT).² In our view the whole concept can be translated into strategies when an active pacemaker or ICD lead has become dysfunctional. Even though adding a new lead and deactivating a defective old lead is not technically an upgrade procedure, the same clinical decision making can be applied. The only exception might be that extracting a non-functional lead may be more readily considered to create access or reduce the risk for lead-lead interactions.

The first section of the workflow is about optimizing initial choice of the device. We would like to get the view of the authors about optimal choice of the electrode. In our view, there may still be a role for using a DF-1 lead. As downgrade procedures are limited by current hardware, we and others³ propose to consider a DF-1 lead in all patients scheduled for ICD with a pacing indication, including CRT patients. When upgrading from a bradycardia pacemaker to an ICD, it could be considered to use a DF-1 lead and connect the ventricular pacing electrode to the ICD when it shows acceptable electrical values. Using a functional pacemaker electrode has the advantage of reducing immediate postoperative risks such as lead dislocation or increasing thresholds. In addition, longevity of pacemaker leads might be much longer than that of ICD leads even if it has been active for many years.

In patients with a DF-4 lead that could be downgraded to a pacemaker, the additional risk of placing a new pacing lead weigh higher than the cost and size of an ICD and may be reserved for patients where the ventricular lead shows signs of electrical deterioration.

The last remarks concern patients with venous obstructions and we would like to get the view of the authors on the preferred strategy to overcome this problem. Venoplasty is increasingly used with high success rates. Our strategy has been published, and we would like to emphasize that venous access can be created from a peripheral (brachial) vein.⁴ This approach has the advantage of more working room for occlusions of the subclavian vein. In addition, the device pocket can remain closed until access has been established reducing infection risk but also obviating the need to escalate to lead extraction in the same session. The contralateral approach should be avoided as much as possible. Even though a recent manuscript has demonstrated safety of these procedures,⁵ in our experience virtually all patients with symptoms arising from vena cava superior syndrome that is not cause by cancer had bilateral pacemaker leads and/or other indwelling catheters.

We hope that our remarks can provide valuable additions to this comprehensive clinical consensus statement.

A.H.M. is chair of the Dutch Heart Registration (NHR) pacemaker and ICD committee and reports research funding for the DUTCH-ICD study by ZE&GG and ZonMW, grant number 10330052310001. All unrelated to the current manuscript.