(1) Background: Prescribing apixaban for stroke prevention has significantly increased in patients with non-valvular atrial fibrillation (NVAF). The ABCB₁ genotype can influence apixaban absorption and bioavailability. The aim of the present study was to assess the factors that influence apixaban’s plasma level and to establish if a certain relationship has clinical relevance. (2) Methods: Fifty-three NVAF patients were treated with 5 mg apixaban twice/day (70.0 years, range: 65–77, 60.4% men). Trough and peak plasma concentrations of apixaban were determined by liquid chromatography-tandem mass-spectrometry (LC-MS/MS), and ABCB₁ genotyping was performed. (3) Results: Apixaban plasma concentrations varied considerably. They were higher in women than in men (311.2 ng/dL vs. 252.2 ng/dL; p = 0.05) and were lower in patients with heart failure (149.4 ng/dL vs. 304.5 ng/dL; p < 0.01). Creatinine clearance was inversely correlated with the apixaban plasma level (Spearman correlation: r = −0.365; p = 0.007 for trough concentrations). No statistically significant differences between the genotypic groups of ABCB₁ rs1045642 and ABCB₁ rs4148738 were found in the trough or peak apixaban plasma concentrations. (4) Conclusions: Pharmacokinetic parameters are influenced by several clinical factors of which renal function is the major determinant. Plasma concentrations measured in women had higher values than those measured in men, and heart failure was associated with decreased plasma levels of apixaban.

Transvenous lead extraction (TLE) is a complex and technically challenging procedure useful in the management strategy for many complications related to the presence of cardiac implantable electronic devices (CIEDs). The decision to perform lead extraction should take into consideration the clinical indication for the procedure, risks versus benefits, extractor and team experience, and also patient preference for the procedure. A variety of techniques can be used when performing TLE procedures, such as simple traction, traction devices, and various types of sheaths or snares. TLE is a procedure with a potentially high risk of complications that can be divided into major complications, which require rapid intervention, and minor complications, which are more frequent but are not life-threatening. The present review aims to highlight the indications, contraindications, methods, and complications of transvenous lead extraction procedures.

(1) Background: The approach of bleeding complications in patients treated with non-vitamin K oral anticoagulants (NOACs) represents an important issue in clinical practice. Both dabigatran and apixaban are substrates for P-glycoprotein and, therefore, ABCB₁ gene variations may be useful in individualizing NOACs treatment, especially in high-risk patients. (2) Methods: ABCB₁ rs1045642 and rs4148738 were determined in 218 atrial fibrillation patients treated with dabigatran or apixaban (70.94 ± 9.04 years; 51.83% men). (3) Results: Non-major bleeding appeared in 7.34% NOACs–treated patients. The logistic tested models based on the four genetic models revealed no significant association between the variant genotype of two ABCB₁ SNPs and the risk of bleeding (p > 0.05). Among the four two-locus haplotypes, TA and CA haplotypes had the highest frequency in NOACs-treated patients with bleeding, involving a possible positive association with the susceptibility of bleeding complications (OR = 1.04 and OR = 1.91, respectively). The logistic model found no significant association of estimated haplotypes with bleeding (p > 0.05) except for the TG haplotype which had a trend toward statistical significance (p = 0.092). Among the risk factors for bleeding, only age > 70 years and stroke/TIA showed a tendency toward statistical significance. (4) Conclusions: We found no significant associations between the studied ABCB₁ variant genotypes with non-major bleeding risk in NOACs-treated patients. A trend of association between TG haplotype with bleeding risk was observed, implying a protective role of this haplotype against bleeding in patients treated with dabigatran or apixaban.

Transvenous lead extraction (TLE) is regarded as the first-line strategy for the management of complications associated with cardiac implantable electronic devices (CIEDs), when lead removal is mandatory. The decision to perform a lead extraction should take into consideration not only the strength of the clinical indication for the procedure but also many other factors such as risks versus benefits, extractor and team experience, and even patient preference. TLE is a procedure with a possible high risk of complications. In this paper, we present three clinical cases of patients who presented different indications of TLE and explain how the procedures were successfully performed. In the first clinical case, TLE was necessary because of device extravasation and suspicion of CIED pocket infection. In the second clinical case, TLE was necessary because occlusion of the left subclavian vein was found when an upgrade to cardiac resynchronization therapy was performed. In the last clinical case, TLE was necessary in order to remove magnetic resonance (MR) non-conditional leads, so the patient could undergo an MRI examination for the management of a brain tumor.

Background and Clinical Significance: The widespread use of cardiac implantable electronic devices (CIEDs) has led to an increasing number of pocket-related complications. While early hematoma and infection are common, late-onset non-infective cystic pocket collections are rare and may closely mimic infectious processes, creating significant diagnostic and therapeutic dilemmas. Case summary: We report the case of an 81-year-old woman with a complex medical history (including a previous device-related infection requiring complete pacing system extraction), with a gradually enlarging, painless elastic mass at the secondary pacemaker pocket site, without local inflammatory signs, with normal inflammatory markers, and repeated negative blood cultures. Imaging demonstrated a large cystic collection surrounding the pacemaker. Surgical exploration was performed and a large volume of odourless, thick, yellowish fluid was evacuated from a fibrous capsule. Complete extraction of the pacing system was undertaken. Fluid microbiological cultures were negative and histopathological analysis revealed a chronic, nonspecific fibro-inflammatory granulomatous process. A leadless transcatheter pacemaker was implanted with favourable clinical and procedural outcomes. Conclusions: This case highlights the complexity of decision-making in a late-onset large fluid accumulation within the device pocket when clinical and microbiological evidence of infection is lacking, and the etiology remains uncertain. The local tissue findings, after the pocket has been opened and drained, along with the distinct clinical characteristics of each case, must ultimately define the therapeutic strategy. In high-risk patients with diagnostic uncertainty, leadless pacing systems provide an effective strategy for definitive rhythm management while minimising the risk of future infection.