Extraction of defibrillator leads recalled for cable externalization and failure

Efficacy and mortality of rotating sheaths versus laser sheaths for transvenous lead extraction: a meta-analysis

BACKGROUND

Rotating and laser sheaths are both routinely used in transvenous lead extraction (TLE) which can lead to catastrophic complications including death. The efficacy and risk of each approach are uncertain. To perform a meta-analysis to compare success and mortality rates associated with rotating and laser sheaths.

METHODS

We searched electronic academic databases for case series of consecutive patients and randomized controlled trials published 1998-2017 describing the use of rotating and laser sheaths for TLE. Among 48 studies identified, rotating sheaths included 1,094 patients with 1,955 leads in 14 studies, and laser sheaths included 7,775 patients with 12,339 leads in 34 studies. Patients receiving rotating sheaths were older (63 versus 60 years old) and were more often male (74% versus 72%); CRT-P/Ds were more commonly extracted using rotating sheaths (12% versus 7%), whereas ICDs were less common (37% versus 42%), p > 0.05 for all. Infection as an indication for lead extraction was higher in the rotating sheath group (59.8% versus 52.9%, p = 0.002). The mean time from initial lead implantation was 7.2 years for rotating sheaths and 6.3 years for laser sheaths (p > 0.05).

RESULTS

Success rates for complete removal of transvenous leads were 95.1% in rotating sheaths and 93.4% in laser sheaths (p < 0.05). There was one death among 1,094 patients (0.09%) in rotating sheaths and 66 deaths among 7,775 patients (0.85%) in laser sheaths, translating to a 9.3-fold higher risk of death with laser sheaths (95% CI 1.3 to 66.9, p = 0.01).

CONCLUSIONS

Laser sheaths were associated with lower complete lead removal rate and a 9.3-fold higher risk of death.

Managing patients with advisory defibrillator leads: what can we learn from published data?

Defibrillator lead advisories stir a lot of emotions, both with patients and physicians, and this may influence lead management. We reviewed the literature for a more evidence-based approach to this issue.

From the complications of two of the current advisory leads, the Medtronic Sprint Fidelis and St. Jude Riata leads, and the consequences of possible interventions, we can conclude that a restrained approach to premature replacement is appropriate. It may be opportune to replace the leads during a scheduled generator replacement in case of a higher electrical failure rate, in order to prevent future premature interventions.

We found no support to extract non-functional advisory leads. In contrast, extraction is often more demanding than anticipated, and the risk substantially exceeds that of simply abandoning the leads.

Longitudinal follow-up of externalized Riata leads

Riata family of implantable cardioverter defibrillator leads have demonstrated in situ conductor externalization, prompting a class I recall and the Food and Drug Administration recommendation for fluoroscopic screening. The natural history of externalized Riata leads, however, remains unclear. In this study, we examined the rate of electrical failure in Riata leads with externalized cables. We reviewed medical and implantable cardioverter defibrillator records of all 329 patients with Riata leads who underwent fluoroscopic screening from December 2011 to March 2012 at the University of Pittsburgh Medical Center hospitals. Externalization was present in 76 patients (23%); of whom, 24 (32%) had the Riata lead replaced shortly after screening. The remaining 52 patients were followed for 7.9 ± 2.9 months, during which 5 patients were lost to follow-up and 2 patients exhibited electrical lead failure resulting in lead replacement, an electrical failure rate of 6.4% per year in externalized leads. In conclusion, prospective follow-up data on externalized Riata leads suggest an electrical failure rate in excess of 6% per year. This high failure rate warrants consideration of prophylactic replacement of externalized Riata leads. Further studies examining the natural history of Riata leads are warranted.