Large, single-center, single-operator experience with transvenous lead extraction: Outcomes and changing indications

Classification and Surgical Repair of Injuries Sustained During Transvenous Lead Extraction

Background—

Injuries to cardiac and venous structures during pacemaker and defibrillator lead extraction are serious complications that have been studied poorly. The incidence of these injuries is unknown but likely underestimated. No systematic multicenter review of these injuries or their management has been undertaken.

Methods and Results—

We interrogated our mandatory administrative database for all excimer laser extractions that sustained a cardiac or venous injury in the province of British Columbia. Injuries were classified according to presentation and compared with respect to nature of injury, type of repair, utilization of cardiopulmonary bypass, and outcome. Of 1082 excimer laser extractions over 19 years, 33 sustained an injury (3.0%). The majority of injuries occurred in women (21/33; 63.6%), and median age of oldest lead extracted was 10.8 (7.5, 12.2) years. A type 1 presentation, defined as circulatory collapse, was found in 12/33 patients (36.4%). A type 2 presentation, defined as progressive hypotension responsive to treatment, was found in 20/33 patients (60.6%). Over half the patients had a moderate or large injury, and cardiopulmonary bypass was required in 13 patients with extensive injury. Despite the presence of devastating injuries, the immediate availability of aggressive salvage measures resulted in a survival of 87.9% of patients at 30 days.

Conclusions—

The immediate availability of a cardiovascular surgeon, perfusionist, and cardiopulmonary bypass pump facilitates lifesaving repair of injuries sustained during laser lead extraction. The size and complexity of injury correlates closely with the presentation, blood loss, and need for cardiopulmonary bypass to facilitate repair.

Creation of the sole regional laser lead extraction program serving Atlantic Canada: initial experience

BACKGROUND

An increasing need for laser lead extraction has grown in parallel with the increase of implantation of pacing and defibrillating devices. We reviewed the initial experience of a regional laser-assisted lead extraction program serving Atlantic Canada.

METHODS

We retrospectively reviewed the cases of all consecutive patients who underwent laser lead extraction at the Maritime Heart Centre in Halifax, NS, between 2006 and 2015. We conducted univariate and Kaplan-Meier survivorship analyses.

RESULTS

During the 9-year study period, 108 consecutive patients underwent laser lead extractions (218 leads extracted). The most common indication for extraction was infection (84.3%). Most patients were older than 60 years (73.1%) and had leads chronically implanted; the explanted leads were an average of 7.5 ± 6.8 years old. Procedural and clinical success (resolution of preoperative symptoms) rates and mortality were 96.8%, 97.2%, and 0.9%, respectively. Sternotomy procedures were performed in 3 instances: once for vascular repair due to perforation and twice to ensure that all infected lead material was removed. No minor complications required surgical intervention. Survival after discharge was 98.4% at 30 days and 94% at 12 months.

CONCLUSION

Atlantic Canada's sole surgical extraction centre achieved high extraction success with a low complication rate. Lead extraction in an operative setting provides for immediate surgical intervention and is essential for the survival of patients with complicated cases. Surgeons must weigh the risks versus benefits in patients older than 60 years who have chronically implanted leads (> 1 yr) and infection.

Trends in Use and Adverse Outcomes Associated with Transvenous Lead Removal in the United States

Background—

Transvenous lead removal (TLR) has made significant progress with respect to innovation, efficacy, and safety. However, limited data exist regarding trends in use and adverse outcomes outside the centers of considerable experience for TLR. The aim of our study was to examine use patterns, frequency of adverse events, and influence of hospital volume on complications.

Methods and Results—

Using the Nationwide Inpatient Sample, we identified 91 890 TLR procedures. We investigated common complications including pericardial complications (hemopericardium, cardiac tamponade, or pericardiocentesis), pneumothorax, stroke, vascular complications (consisting of hemorrhage/hematoma, incidents requiring surgical repair, and accidental arterial puncture), and in-hospital deaths described with TLR, defining them by the validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. We specifically assessed in-hospital death (2.2%), hemorrhage requiring transfusion (2.6%), vascular complications (2.0%), pericardial complications (1.4%), open heart surgery (0.2%), and postoperative respiratory failure (2.4%). Independent predictors of complications were female sex and device infections. Hospital volume was not independently associated with higher complications. There was a significant rise in overall complication rates over the study period.

Conclusions—

The overall complication rate in patients undergoing TLR was higher than previously reported. Female sex and device infections are associated with higher complications. Hospital volume was not associated with higher complication rates. The number of adverse events in the literature likely underestimates the actual number of complications associated with TLR.

[Percutaneous lead extraction. Complications and their management]

BACKGROUND

Percutaneous lead extraction represents one of the most difficult and challenging interventions in the therapy with cardiac implantable electronic devices (CIEDs). Despite the progress in outcome and safety of these procedures in the last decade, the first published results of the ELECTRa registry point out that the risk of life-threatening complications should not be underestimated. Therefore, pre-operative screening for indications, present infections, pacemaker dependency, age and type of implanted leads, previous cardiac surgery and presence of anatomic variations are prerequisite to assess the individual operation risk.

RESULTS

Apart from the decision for any particular operative approach, the risk-adjusted settings should be selected in order to enable intraoperative escalation of extraction methods, if needed. A good theoretical knowledge of potential perioperative problems and complications as well as the intraoperative use of TEE enables early detection and management of complications. Furthermore, preoperative arrangements with other professionals and a team approach in emergency management enable fast and structured action when needed, thus, reducing mortality in case of life-threatening complications.

Outcomes and Complications of Lead Removal: Can We Establish a Risk Stratification Schema for a Collaborative and Effective Approach?

BACKGROUND

Removal of an entire cardiovascular implantable electronic device is associated with morbidity and mortality. We sought to establish a risk classification scheme according to the outcomes of transvenous lead removal in a single center, with the goal of using that scheme to guide electrophysiology lab versus operating room extraction.

METHODS

Consecutive patients undergoing transvenous lead removal from January 2001 to October 2012 at Mayo Clinic were retrospectively reviewed.

RESULTS

A total of 1,378 leads were removed from 652 (age 64 ± 17 years, M 68%) patients undergoing 702 procedures. Mean (standard deviation) lead age was 57.6 (58.8) months. Forty-four percent of leads required laser-assisted extraction. Lead duration (P < 0.001) and an implantable cardioverter defibrillator (ICD) lead (P < 0.001) were associated with the need for laser extraction and procedure failure (P < 0.0001 and P = 0.02). The major complication rate was 1.9% and was significantly associated with longer lead duration (odds ratio: 1.2, 95% confidence interval: 1.1-1.3; P < 0.001). High-risk patients (with a >10-year-old pacing or a >5-year-old ICD lead) had significantly higher major events than moderate-risk (with pacing lead 1-10 years old or ICD lead 1-5 years old) and low-risk (any lead ≤1-year-old) patients (5.3%, 1.2%, and 0%, respectively; P < 0.001).

CONCLUSIONS

Transvenous lead removal is highly successful, with few serious procedural complications. We propose a risk stratification scheme that may categorize patients as low, moderate, and high risk for lead extraction. Such a strategy may guide which extractions are best performed in the operating room.

A Questionable Indication For ICD Extraction After Successful VT Ablation

Sustained ventricular tachyarrhythmias represent a kind of complication shared by a number of clinical presentations of heart disease, sometimes leading to sudden cardiac death. Many efforts have been made in the fight against such a complication, mainly being represented by the implantable cardioverter defibrillator (ICD). In recent years, catheter ablation has grown as a means to effectively treat patients with sustained ventricular arrhythmias, in the contest of different cardiac substrates. Since carrying an ICD is associated with a potential risk deriving from its possible infective or malfunctioning complications, and given the current effectiveness of lead extraction procedures, it has been thought not to be unreasonable to ask ourselves about how to deal with ICD patients who have been successfully treated by means of ablation of their ventricular arrhythmias. To date, no control data have been published on transvenous lead extraction in the setting of VT ablation. In this paper we will review the current evidence about ICD therapy, catheter ablation of ventricular arrhythmias and lead extraction, trying to outline some considerations about how to face this new clinical issue.

Superior vena cava echocardiography as a screening tool to predict cardiovascular implantable electronic device lead fibrosis

BACKGROUND

Currently there is no noninvasive imaging modality used to risk stratify patients requiring lead extractions. We report the novel use of superior vena cava (SVC) echocardiography to identify lead fibrosis and complex cardiac implantable electronic device (CIED) lead extraction. With an aging population and expanding indications for cardiac device implantation, the ability to deal with the complications associated with chronically implanted device has also increased.

METHODS

This was a retrospective analysis of Doppler echocardiography recorded in our outpatient Electrophysiology/Device Clinic office over 6 months. Images from 109 consecutive patients were reviewed.

RESULTS

62% (68/109) did not have a CIED and 38% (41/109) had a CIED. In patients without a CIED, 6% (4/68) displayed turbulent color flow by Doppler in the SVC, while 22% (9/41) of patients with a CIED displayed turbulent flow. Fisher's exact test found a statistically significant difference between the two groups (p value < 0.05). The CIED group was subdivided into 2 groups based on device implant duration (< 2 years vs. ≥ 2 years). Of the CIED implanted for ≥ 2 years, 27% (9/33) had turbulent flow in the SVC by Doppler, while no patients (0/8) with implant durations < 2 years demonstrated turbulent flow. Nine patients underwent subsequent lead extraction. A turbulent color pattern successfully identified all 3 patients that had significant fibrosis in the SVC found during extraction.

CONCLUSION

Our data suggests that assessing turbulent flow using color Doppler in the SVC may be a valuable noninvasive screening tool prior to lead extraction in predicting complex procedures.

Safety of transvenous lead extraction according to centre volume: a systematic review and meta-analysis

BACKGROUND

Transvenous lead extraction (TLE) is a complex invasive procedure and the experience of the operator and the team is a major determinant of procedural outcomes.

AIM

Because of very limited data available on minimum procedural volumes to enable training and ongoing competency for TLEs, we performed a meta-analysis aimed at assessing the outcomes of TLE in the centres with low, medium, and high volume of procedures.

METHODS

Of the 280 papers initially retrieved until February 2013, 66 observational studies met inclusion criteria and were included in at least one stratified meta-analysis: 17 were prospective studies; 47 had a retrospective design; and 2 were defined 'experience studies'. We included only articles published after the introduction of laser technique (year 1999). We divided the studies in low, medium, and high volume centres utilizing either the European Heart Rhythm Association (EHRA) or Lexicon classification criteria.

RESULTS

When meta-analyses were carried out separately for the studies with larger and smaller sample sizes, either using EHRA or Lexicon classification criteria, no clear differences emerged in the combined rate of major complications or intraoperative deaths. In contrast, both minor complications and mortality at 30 days decreased as centre volume increased.

CONCLUSIONS

In our meta-analysis of observational studies, patients who have been treated in higher volume centres have a lower probability of minor complications and death at 30 days regardless of the infection rate, length of lead duration, type of device, and type of extraction.

Surgical management of cardiac implantable electronic device infections

PURPOSE

The infection of cardiac implantable electronic devices (CIED) is a serious and potentially lethal complication. The population at risk is growing, as the device implantation is increasing especially in older patients with associated comorbid conditions. Our purpose was to present the management of this complicated surgical condition and to extract the relevant conclusions.

METHODS

During a 3-year period 1,508 CIED were implanted in our hospital. We treated six cases of permanent pacemaker infection with localized pocket infection or endocarditis. In accordance to the recent AHA/ACC guidelines, complete device removal was decided in all cases. The devices were removed under general anaesthesia, with a midline sternotomy, under extracorporeal circulation on the beating heart. Epicardial permanent pacing electrodes were placed on the right atrium and ventricle before the end of the procedure.

RESULTS

The postoperative course of all patients was uncomplicated and after a follow up period of five years no relapse of infection occurred.

CONCLUSIONS

Management protocols that include complete device removal are the only effective measure for the eradication of CIED infections. Although newer technologies have emerged and specialized techniques of percutaneous device removal have been developed, the surgical alternative to these methods can be a safe solution in cases of infected devices.

Percutaneous extraction of transvenous permanent pacemaker/defibrillator leads

Background. Widespread use of cardiovascular implantable electronic devices has inevitably increased the need for lead revision/replacement. We report our experience in percutaneous extraction of transvenous permanent pacemaker/defibrillator leads. Methods. Thirty-six patients admitted to our centre from September 2005 through October 2012 for percutaneous lead extraction were included. Lead removal was attempted using Spectranetics traction-type system (Spectranetics Corp., Colorado, CO, USA) and VascoExtor countertraction-type system (Vascomed GmbH, Weil am Rhein, Germany). Results. Lead extraction was attempted in 59 leads from 36 patients (27 men), mean ± SD age 61 ± 5 years, with permanent pacemaker (n = 25), defibrillator (n = 8), or cardiac resynchronisation therapy (n = 3) with a mean ± SD implant duration of 50 ± 23 months. The indications for lead removal included pocket infection (n = 23), endocarditis (n = 2), and ventricular (n = 10) and atrial lead dysfunction (n = 1). Traction device was used for 33 leads and countertraction device for 26 leads. Mean ± SD fluoroscopy time was 4 ± 2 minutes/lead for leads implanted <48 months (n = 38) and 7 ± 3 minutes/lead for leads implanted >48 months (n = 21), P = 0.03. Complete procedural success rate was 91.7% and clinical procedural success rate was 100%, while lead procedural success rate was 95%. Conclusions. In conclusion, percutaneous extraction of transvenous permanent pacemaker/defibrillator leads using dedicated removal tools is both feasible and safe.

Forces applied during transvenous implantable cardioverter defibrillator lead removal

Methods. 17 physicians, experienced in transvenous lead removal, performed a lead extraction manoeuvre of an ICD lead on a torso phantom. They were advised to stop traction only when further traction would be considered as harmful to the patient or when—based on their experience—a change in the extraction strategy was indicated. Traction forces were recorded with a digital precision gauge. Results. Median traction forces on the endocardium were 10.9 N (range from 3.0 N to 24.7 N and interquartile range from 7.9 to 15.3). Forces applied to the proximal end were estimated to be 10% higher than those measured at the tip of the lead due to a friction loss. Conclusion. A traction force of around 11 N is typically exerted during standard transvenous extraction of ICD leads. A traction threshold for a safe procedure derived from a pool of experienced extractionists may be helpful for the development of required adequate simulator trainings.

Endocardial Lead Extraction in the Polish Registry - clinical practice versus current Heart Rhythm Society consensus

INTRODUCTION

Over the last 10 years, there has been an increasing number of patients with pacemaker (PM) and cardioverter-defibrillator (ICD). This study is a retrospective analysis of indications for endocardial pacemaker and ICD lead extractions between 2003 and 2009 based on the experience of three Polish Referral Lead Extraction Centers.

MATERIAL AND METHODS

Since 2003, the authors have consecutively retrospectively collected all cases and entered the information in the database. All patients which had indication for lead extraction according to Heart Rhythm Society Guidelines were included to final analyze. Between 2003 and 2005, the data were analyzed together. Since 2006, data have been collected and analyzed annually.

RESULTS

In each year, a significant increase in lead extraction was observed. The main indications for LE were infections in 52.4% of patients. Nonfunctioning lead extraction constituted the second group of indications for LE in 29.7% of patients. During the registry period, the percentage of class I indications decreased from 80% in 2006 to only 47% in 2009. On the other hand, increasingly more leads were removed because of class 2, especially class 2b. In 2009, 40% of leads were extracted due to class 2b.

CONCLUSIONS

Polish Registry of Endocardial Lead Extraction 2003-2009, shows an increasing frequency of lead extraction. The main indication for LE is infection: systemic and pocket. An increase in class 2, especially 2b, LE indication in every center during the study period was found.

Prophylactic Lead Extraction at Implantable Cardioverter-Defibrillator Generator Change

Background—

Current implantable cardiac devices have a finite battery life of ≈3 to 7 years for implantable cardioverter-defibrillators. It is current practice to reuse all properly functioning intravascular leads. We tested the hypothesis that a strategy of prophylactic lead removal at the time of device change would be superior under some conditions to the current practice of lead reuse.

Methods and Results—

Using currently available data and a Monte Carlo microsimulation trial, we calculated the risks of leaving an indwelling lead until extraction is indicated because of malfunction versus an aggressive management strategy of prophylactic serial extraction at time of generator change. With a serial lead exchange strategy of leads at generator change, there is reduced overall extraction-related mortality because of fewer late complications attributable to extraction of leads with high dwell time because of infection, recall, or subsequent lead failure. This finding is limited to young patients or those with high expected indwell time of lead. This trend reverses for leads with <40 years expected dwell time. Sensitivity analysis shows high dependence on extraction performance and device longevity. In all cases, serial extraction would be expected to lead to increased adverse events related to the more complex procedure.

Conclusions—

A strategy of serial lead extraction, given best available current parameters, yields a lower procedural mortality risk in the long-term management of indwelling implantable cardioverter-defibrillator leads in young patients (>40-year estimated dwell time) driven by high aggregate anticipated risk of lifetime lead complication.

Legal aspects in implantable defibrillator extraction

At the Institute of Legal Medicine in Chieti, a case of iatrogenic superior vena cava perforation was observed during laser extraction of an infected biventricular implantable cardiac defibrillator. The presentation of this particular case represented a starting point for studying the occurrence of similar complications in literature, since their knowledge and understanding should induce resolution of any organisation problems, aid in increasing physicians' training and impose the availability of cardiac surgeons during such operations.

[Device related infections. How to identify and how to treat]

Because of the enormous increase in pacemaker and implantable cardioverter-defibrillator (ICD) implants, the number of device-related infections has also increased considerably. In fact, this increase has been out of proportion due to the higher patient age at implant, the increased co-morbidity of patients and the higher complexity of the implanted devices. Apart from few exceptions the infection of a pacemaker or ICD requires complete explantation of the whole system with adjunctive antibiotic therapy. The diagnosis of device infection, the indication and different options for therapy are thoroughly discussed in this article according to the current status of knowledge.

Cardiac resynchronization therapy in pacemaker-dependent patients with left ventricular dysfunction

AIMS

Heart failure and left ventricular (LV) systolic dysfunction (LVSD) are common in patients with permanent pacemakers. The aim was to determine if cardiac resynchronization therapy (CRT) at the time of pulse generator replacement (PGR) is of benefit in patients with unavoidable RV pacing and LVSD.

METHODS AND RESULTS

Fifty patients with unavoidable RV pacing, LVSD, and mild or no symptoms of heart failure, listed for PGR were randomized 1 : 1 to either standard RV-PGR (comparator) or CRT. The primary endpoint was the difference in change in LV ejection fraction (LVEF) between RV-PGR and CRT groups from baseline to 6 months. Secondary endpoints included peak oxygen consumption, quality of life, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. At 6 months there was a difference in change in median (interquartile range) LVEF [9 (6-12) vs. -1.5 (-4.5 to -0.8)%; P < 0.0001] between the CRT and RV-PGR arms. There were also improvements in exercise capacity (P = 0.007), quality of life (P = 0.03), and NT-proBNP (P = 0.007) in those randomized to CRT. After 809 (729-880) days, 17 patients had died or been hospitalized (6 in CRT group and 11 in the comparator RV-PGR group) and two patients in the RV-PGR arm had required CRT for deteriorating heart failure. Patients with standard RV-PGR had more days in hospital during follow-up than those in the CRT group [4 (2-7) vs. 11 (6-16) days; P = 0.047].

CONCLUSION

Performing CRT in pacemaker patients with unavoidable RV pacing and LVSD but without severe symptoms of heart failure, at the time of PGR, improves cardiac function, exercise capacity, quality of life, and NT-pro-BNP levels.

Determining the risks of clinically indicated nonthoracic magnetic resonance imaging at 1.5 T for patients with pacemakers and implantable cardioverter-defibrillators: rationale and design of the MagnaSafe Registry

BACKGROUND

Until recently, the presence of a permanent pacemaker or an implantable cardioverter-defibrillator has been a relative contraindication for the performance of magnetic resonance imaging (MRI). A number of small studies have shown that MRI can be performed with minimal risk when patients are properly monitored and device programming is modified appropriately for the procedure. However, the risk of performing MRI for patients with implanted cardiac devices has not been sufficiently evaluated to advocate routine clinical use. The aim of the present protocol is to prospectively determine the rate of adverse clinical events and device parameter changes in patients with implanted non-MRI-conditional cardiac devices undergoing clinically indicated nonthoracic MRI at 1.5 T.

METHODS

The MagnaSafe Registry is a multicenter, prospective cohort study of up to 1500 MRI examinations in patients with pacemakers or implantable cardioverter-defibrillators implanted after 2001 who undergo clinically indicated nonthoracic MRI following a specific protocol to ensure that preventable potential adverse events are mitigated. Adverse events and changes in device parameter measurements that may be associated with the imaging procedure will be documented.

RESULTS

Through August 2012, 701 MRI studies have been performed, representing 47% of the total target enrollment.

CONCLUSIONS

The results of this registry will provide additional documentation of the risk of MRI and will further validate a clinical protocol for screening and the performance of clinically indicated MRI for patients with implanted cardiac devices.

Implantation and follow-up of totally subcutaneous versus conventional implantable cardioverter-defibrillators: a multicenter case-control study

BACKGROUND

The approval of an entirely subcutaneous implantable-cardioverter defibrillator (ICD) system (S-ICD) has raised attention about this promising technology. It was developed to overcome lead failure and infection problems of conventional transvenous ICD systems. Nevertheless, lead migration of the initial design and inappropriate shock rates have raised concerns regarding its reliability and safety.

OBJECTIVE

The purpose of this study was to report the largest multicenter series to date of patients with the new device in comparison with a matched conventional transvenous ICD collective with focus on perioperative complications, conversion of induced ventricular fibrillation (VF), and short-term follow-up.

METHODS/RESULTS

Sixty-nine patients (50 male and 19 female; mean age 45.7 ± 15.7 years) received an S-ICD in three German centers and were randomly assigned to 69 sex- and age-matched conventional ICD patients. The indication was primary prevention in 41 patients (59.4%) without difference between groups (34 control patients; P = .268). The predominant underlying heart disease was ischemic cardiomyopathy in 11 (15.9%), dilated cardiomyopathy in 25 (36.2%), and hypertrophic cardiomyopathy in 10 (14.5%) in the S-ICD group. Mean implantation time was 70.8 ± 27.9 minutes (P = .398). Conversion rates of induced VF were 89.5% for 65 J (15-J safety margin) and 95.5% including reversed shock polarity (15-J safety margin) in the study group. Termination of induced VF was successful in 90.8% (10-J safety margin, device dependent) of the control patients (P = .815). Procedural complications were similar between the 2 groups. Mean follow-up was 217 ± 138 days. During follow-up, 3 patients with S-ICD were appropriately treated for ventricular arrhythmias. Three inappropriate episodes (5.2%) occurred in 3 S-ICD patients due to T-wave oversensing, whereas atrial fibrillation with rapid conduction was the predominant reason for inappropriate therapy in conventional devices (P = .745).

CONCLUSION

The novel S-ICD system can be implanted safely with similar perioperative adverse events compared with standard transvenous devices. Our case-control study demonstrates a 10.4% failure of conversion of induced VF with the S-ICD set to standard polarity and 15-J safety margin and comparable inappropriate shock rates during short-term follow-up.

Extraction of Sterile Leads: Is it Beneficial?

Extraction of sterile leads remains a controversial area. The risks and benefits of abandoning a lead are largely unknown, whereas the risks of lead extraction are better studied. Lead management decisions need to be made on a patient-by-patient basis, with important input from the patient and family. This article presents several representative cases and reviews the major considerations in making the decision of whether or not to extract a sterile lead that has become either no longer needed or no longer functional.