Active versus passive fixation leads in cardiac implantable devices: a meta-analysis of post-discharge cardiac perforation and lead dislodgement risk.

backgroundActive and passive fixation leads are both commonly used in transvenous cardiac implantable electronic device procedures. Although active fixation leads (AFLs) are often selected over passive fixation leads (PFLs) for more precise positioning and the possibility of a potentially simpler future lead extraction, current evidence remains inconclusive regarding the delayed, post-discharge complications of lead dislodgement and cardiac perforation. This systematic review and meta-analysis aimed to compare these complications between AFLs and PFLs.

methodsObservational studies enrolling consecutive adult patients undergoing transvenous cardiac device implantation with either AFLs or PFLs were systematically identified. Studies reporting post-discharge lead dislodgement and/or cardiac perforation for both AFLs and PFLs were included. Pooled event rates were calculated using random-effects models, with sensitivity, cumulative and bootstrap analyses performed to assess robustness. Meta-regression and subgroup analyses for key variables were conducted to assess heterogeneity and possible effect modifications.

resultsEighteen studies were included, encompassing 69,198 patients (77,248 leads: 38,250 AFL and 38,998 PFL) who were followed up for at least 1-month post-implantation. Post-discharge lead dislodgement was significantly less frequent with AFLs than with PFLs [Odds Ratio (OR) 0.71; 95% Confidence Interval (CI), 0.54-0.94, p = 0.015], driven by a marginally significant lower risk involving atrial leads (OR: 0.70; 95% CI, 0.49-1.00, p = 0.052). Additionally, AFLs were associated with a significantly higher risk of post-discharge cardiac perforation compared to PFLs (OR 1.78; 95% CI, 1.09-2.90, p = 0.02), driven by a marginally significant higher risk of ventricular leads (OR 1.94; 95% CI, 0.97-3.86, p = 0.06). Subgroup analyses revealed that, in implantable cardioverter-defibrillator implantation, AFLs were associated with a lower risk of dislodgement, but a higher risk of perforation compared with PFLs.

conclusionsCompared with PFLs, AFLs are associated with a higher risk of post-discharge cardiac perforation, mainly ventricular, but with a lower risk of post-discharge dislodgement, mainly atrial. A pragmatic approach might favour the use of AFLs in atrial positions and PFLs in apical or trabeculated ventricular positions. Fixation strategy should be individualized rather than routine preference, and integrated into a broader lead lifecycle perspective, encompassing complications, revisions, and potential future extraction.