title: Cardiac implantable electronic device lead-based masses and atrial fibrillation ablation: a case-based illustration of periprocedural anticoagulation management strategies.
abstract: BACKGROUND
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.|Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Lenz
authors.affiliation: Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA.|Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
authors.forename: Christopher V
authors.initials: CV
authors.lastname: DeSimone
authors.affiliation: Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA.|Division of Hospital Internal Medicine, Mayo Clinic Health System, Austin, MN, USA.
authors.forename: Shiva P
authors.initials: SP
authors.lastname: Ponamgi
authors.affiliation: Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.|Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Alan
authors.initials: A
authors.lastname: Sugrue
authors.affiliation: Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA.|Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
authors.forename: Lawrence J
authors.initials: LJ
authors.lastname: Sinak
authors.affiliation: Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA.|Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
authors.forename: Krishnaswamy
authors.initials: K
authors.lastname: Chandrasekaran
authors.affiliation: Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA.|Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Packer
authors.affiliation: Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA. asirvatham.samuel@mayo.edu.|Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA. asirvatham.samuel@mayo.edu.|Division of Cardiovascular Diseases and Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. asirvatham.samuel@mayo.edu.
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Asirvatham
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy / Q000601:surgery*; D016022:Case-Control Studies; D017115:Catheter Ablation / Q000009:adverse effects*; D017147:Defibrillators, Implantable / Q000009:adverse effects; D004567:Electrodes, Implanted / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000009:adverse effects; D019990:Perioperative Care / Q000379:methods; D011292:Premedication / Q000379:methods; D013927:Thrombosis / Q000209:etiology* / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants
keywords: Anticoagulation; Cardiac implantable electronic device; Catheter ablation; Lead thrombus; Lead-based masses