What goes in may need to come out: Considerations in the extraction of a lumenless, fixed-screw permanent pacemaker lead

Cardiac Device Implantation: Techniques and Best Practices

Transvenous leads continue to be the standard means to deliver bradyarrhythmia and tachyarrhythmia device therapy. Risk factors for cardiac implantable electronic devices (CIED) infection or complications of transvenous lead extraction (TLE) and mortality represent a complex interplay between non-modifiable patient-related factors and actionable implant-related characteristics or adverse events. Careful attention to patient screening, infection mitigation, lead selection, and implant technique may enhance safety of the index procedure and subsequent clinical management.

Extraction of His Bundle Pacing Lead: More Difficult than Coronary Sinus Lead Extraction: An Analysis of 3897 Lead Extraction Procedures Including 27 His and 253 Coronary Sinus Lead Removals

BACKGROUND

Experience with the transvenous extraction of leads used for His bundle pacing (HBP) is limited.

METHODS

Analysis of 3897 extractions including 27 HBP and 253 LVP (left ventricular pacing) leads.

RESULTS

The main reason for HBP lead extraction was lead failure (59.26%). The age of HBP and LVP leads (54.52 vs. 50.20 months) was comparable, whereas procedure difficulties were related to the LVP lead dwell time. The extraction of HBP leads > 40 months old was longer than the removal of younger leads (8.57 vs. 3.87 min), procedure difficulties occurred in 14.29%, and advanced tools were required in 28.57%. There were no major complications. The extraction time of dysfunctional or infected leads was similar in the HBP and LVP groups (log-rank p = 0.868) but shorter when compared to groups with other leads. Survival after the procedure did not differ between HBP and LVP groups but was shorter than in the remaining patients.

CONCLUSIONS

1. HBP is used in CRT-D systems for resynchronisation of the failing heart in 33.33%. 2. Extraction of HBP leads is most frequently performed for non-infectious indications (59.26%) and most often because of lead dysfunction (33.33%). 3. The extraction of "old" (>40 months) HBP leads is longer (8.57 vs. 3.87 min) and more difficult than the removal of "young" leads due to unexpected procedure difficulties (14.29%) and the use of second line/advanced tools (28.57%), but it does not entail the risk of major complications and procedure-related death and is comparable to those encountered in the extraction of LVP leads of a similar age. 4. Survival after lead extraction was comparable between HBP and LVP groups but shorter compared to patients who underwent the removal of other leads.

Pitfalls and tips for lumenless lead extraction inserted deep within the ventricular septum

Key Clinical Message

This case highlights the pitfalls and provides tips for the extraction of deeply implanted lumenless leads, and encourages careful lead selection in the current era of widespread left bundle branch area pacing.

Abstract

The extraction of cardiovascular implantable electronic device leads is sometimes complicated. We describe a case with difficult but successful extraction of SelectSecure, a lumenless permanent pacemaker lead, implanted deep in the ventricular septum, highlighting its pitfalls and tips in the current era of left bundle branch area pacing.

Transvenous lead extraction of lumenless 3830 pacing lead in conduction system pacing: a single-center experience

BACKGROUND

The Medtronic SelectSecure Model 3830 lumenless lead (Medtronic, Inc., Minneapolis, MN) is commonly used for conduction system pacing (CSP). However, with this increased use, the potential need for transvenous lead extraction (TLE) also will increase. While extraction of endocardial 3830 leads is rather well described especially in pediatric and adult congenital heart disease population, there is very limited data on extraction of CSP leads. In the present study, we reported our preliminary experience on TLE of CSP leads and provided technical considerations.

METHODS

The study population comprised 6 consecutive patients (67% male; mean age 70 ± 22 years) with CSP leads (3830 leads), including left bundle branch pacing (LBBP) lead (n = 3) and His pacing lead (n = 3) undergoing TLE. Overall target leads were 17. The mean implant duration time of CSP leads was 97 ± 90 months [range 8-193).

RESULTS

Manual traction was successful in 2 cases and mechanical extraction tools were required in the remaining cases. Sixteen leads (94%) were completely extracted, whereas incomplete removal was observed in one lead (6%) among 1 patient. Of note, in the only lead incompletely removed, we observed retention of < 1-cm remnant of lead material consisting of the screw of 3830 LBBP lead into the interventricular septum. No failure of lead extraction was reported and no major complications occurred.

CONCLUSIONS

Our findings demonstrated that at an experienced center the success of TLE of chronically implanted CSP leads is high in the absence of major complications also when mechanical extraction tools are needed.

Rationale for and use of the lumenless 3830 pacing lead

Most currently available pacing and defibrillation leads utilize a stylet-based design that facilitates implantation. This has advantages, but also increases the lead diameter and adds the potential for metal fatigued-based conductor failure. A systematic literature search was conducted, and the authors add their twenty-year experience with this lead design. The global experience with lumenless leads was reviewed both for "standard" positioning and with conduction system pacing. Methods for both placement and system modification are reviewed. Lumenless leads have the potential to improve the durability of endocardial pacing and facilitate conduction system pacing.

Mechanics of lumenless pacing lead strength during extraction procedures based on laboratory bench testing

BACKGROUND

With the advent of conduction system pacing, use of the Medtronic SelectSecure Model 3830 lead has increased substantially. However, with this increased use, the potential need for lead extraction also will increase. Lumenless lead construction requires an understanding of both applicable tensile forces as well as lead preparation techniques that can influence consistent extraction.

OBJECTIVE

The purpose of this study was to use bench testing methodologies to characterize the physical properties of lumenless leads and to describe related lead preparation methods that support known extraction techniques.

METHODS

Multiple 3830 lead preparation techniques, commonly used in extraction practices, were compared on the bench to assess rail strength (RS) in simple traction and use conditions with simulated scar. Retention of the IS1 connector vs severing the lead body preparation techniques were compared. Distal snare and rotational extraction tools were evaluated.

RESULTS

The retained connector method provided higher RS compared to the modified cut lead method: mean 11.42 lbf (9.85-12.73 lbf) vs 8.51 lbf (1.66-14.32 lbf), respectively. Snare use distally did not significantly affect RS: mean 11.05 lbf (8.58-13.95 lbf). Lead damage occurred with the TightRail extraction tool at angles ≥90°, which could occur with right-sided implants.

CONCLUSIONS

When extracting SelectSecure leads, the retained connector method to maintain cable engagement benefits preservation of the extraction RS. Limiting traction force to <10 lbf (4.5 kgf) and avoiding poor lead preparation methods are critical to consistent extraction. Femoral snaring does not change RS when needed and offers a method to regain lead rail in cases of distal cable fracture.

Transvenous lead extraction in conduction system pacing

Conduction System Pacing (CSP) delivered by His Bundle Pacing (HBP) or Left Bundle Pacing (LBP) are exciting novel interventions in the field of Cardiac Resynchronization Therapy (CRT). As the evidence base for CSP grows, the volume of implants worldwide is projected to rise significantly in the coming years. As such, physicians will be confronted with increasingly prevalent and vital issues arising in long-term follow up, including the management of infected, malfunctioning, or redundant CSP leads. Transvenous lead extraction (TLE) is the first-line option for removal of pacing leads when indicated in these circumstances. The evidence base for TLE in the context of CSP is still in its infancy. In this article, we first provide a brief overview of TLE. We then examine the data on the long-term performance of HBP leads. Next, we describe the features of the Medtronic Select Secure 3,830 lead, and how experience of TLE of this lead in the paediatric population has informed our practice. Finally, we review the current evidence for TLE in HBP and LBP, and discuss how future studies can address gaps in our current knowledge.