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Khurana S, Das S, Frishman WH, Aronow WS, Frenkel D. Lead Extraction-Indications, Procedure, and Future Directions. Cardiol Rev 2023:00045415-990000000-00152. [PMID: 37729602 DOI: 10.1097/crd.0000000000000610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.
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Affiliation(s)
- Sumit Khurana
- From the Department of Internal medicine, MedStar Union Memorial hospital, Baltimore, MD
| | - Subrat Das
- Department of Cardiology, New York Medical College, Westchester Medical Center, Valhalla, NY
| | - William H Frishman
- Department of Medicine, Westchester Medical Center and New York Medical College, NY
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College, Westchester Medical Center, Valhalla, NY
| | - Daniel Frenkel
- Department of Cardiology, New York Medical College, Westchester Medical Center, Valhalla, NY
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Polewczyk A, Jacheć W, Nowosielecka D, Tomaszewski A, Brzozowski W, Szczęśniak-Stańczyk D, Duda K, Kutarski A. Tricuspid Valve Damage Related to Transvenous Lead Extraction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912279. [PMID: 36231579 PMCID: PMC9566121 DOI: 10.3390/ijerph191912279] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 05/29/2023]
Abstract
BACKGROUND Damage to the tricuspid valve (TVD) is now considered either a major or minor complication of the transvenous lead extraction procedure (TLE). As yet, the risk factors and long-term survival after TLE in patients with TVD have not been analyzed in detail. METHODS This post hoc analysis used clinical data of 2631 patients (mean age 66.86 years, 39.64% females) who underwent TLE procedures performed in three high-volume centers. The risk factors and long-term survival of patients with worsening tricuspid valve (TV) function after TLE were analyzed. RESULTS In most procedures (90.31%), TLE had no negative influence on TV function, but in 9.69% of patients, a worsening of tricuspid regurgitation (TR) to varying degrees was noted, including significant dysfunction in 2.54% of patients. Risk factors of TLE relating to severe TVD were: TLE of pacing leads (5.264; p = 0.029), dwell time of the oldest extracted lead (OR = 1.076; p = 0.032), strong connective scar tissue connecting a lead with tricuspid apparatus (OR = 5.720; p < 0.001), and strong connective scar tissue connecting a lead with the right ventricle wall (OR = 8.312; p < 0.001). Long-term survival (1650 ± 1201 [1-5519] days) of patients with severe TR was comparable to patients without tricuspid damage related to TLE. CONCLUSIONS Severe tricuspid valve damage related to TLE is relatively rare (2.5%). The main risk factors for the worsening of TV function are associated with a longer lead dwell time (more often the pacing lead), causing stronger connective tissue scars connecting the lead to the tricuspid apparatus and right ventricle. TVD is unlikely to affect long-term survival after TLE.
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Affiliation(s)
- Anna Polewczyk
- Institute of Medical Sciences, Jan Kochanowski University, 25-369 Kielce, Poland
- Department of Cardiac Surgery, Świętokrzyskie Center of Cardiology, 25-736 Kielce, Poland
| | - Wojciech Jacheć
- 2nd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, 41-800 Zabrze, Poland
| | - Dorota Nowosielecka
- Department of Cardiology, The Pope John Paul II Province Hospital, 22-400 Zamość, Poland
| | - Andrzej Tomaszewski
- Department of Cardiology, Medical University of Lublin Poland, 20-059 Lublin, Poland
| | - Wojciech Brzozowski
- Department of Cardiology, Medical University of Lublin Poland, 20-059 Lublin, Poland
| | | | - Krzysztof Duda
- Department of Cardiac Surgery, Masovian Specialistic Hospital, 26-617 Radom, Poland
| | - Andrzej Kutarski
- Department of Cardiology, Medical University of Lublin Poland, 20-059 Lublin, Poland
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A Study of Major and Minor Complications of 1500 Transvenous Lead Extraction Procedures Performed with Optimal Safety at Two High-Volume Referral Centers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910416. [PMID: 34639716 PMCID: PMC8508178 DOI: 10.3390/ijerph181910416] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/22/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
Background: Transvenous lead extraction (TLE) is the preferred management strategy for complications related to cardiac implantable electronic devices. TLE sometimes can cause serious complications. Methods: Outcomes of TLE procedures using non-powered mechanical sheaths were analyzed in 1500 patients (mean age 68.11 years; 39.86% females) admitted to two high-volume centers. Results: Complete procedural success was achieved in 96.13% of patients; clinical success in 98.93%, no periprocedural death occurred. Mean lead dwell time in the study population was 112.1 months. Minor complications developed in 115 (7.65%), major complications in 33 (2.20%) patients. The most frequent minor complications were tricuspid valve damage (TVD) (3.20%) and pericardial effusion that did not necessitate immediate intervention (1.33%). The most common major complication was cardiac laceration/vascular tear (1.40%) followed by an increase in TVD by two or three grades to grade 4 (0.80%). Conclusions: Despite the long implant duration (112.1 months) satisfying results without procedure-related death can be obtained using mechanical tools. Lead remnants or severe tricuspid regurgitation was the principal cause of lack of clinical and procedural success. Worsening TR(Tricuspid regurgitation) (due to its long-term consequences), but not cardiac/vascular wall damage; is still the biggest TLE-related problem; when non-powered mechanical sheaths are used as first-line tools.
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Wang L, Hai T, Feng Y, Han Q, Li Y, Ju H, Jiang Y, Li X, Ze F, Liu G, Jiang L. The clinical role of transesophageal echocardiography during transvenous lead extraction. Echocardiography 2021; 38:1552-1557. [PMID: 34510520 DOI: 10.1111/echo.15171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/19/2021] [Accepted: 07/20/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is commonly used during cardiothoracic procedures. TEE has also become standard during transvenous lead extraction (TLE) procedures, but its effect and role have not been optimally defined. The goal of this study is to identify how TEE was used during TLE at our institute and review its utility. METHODS We retrospectively reviewed high-risk patients undergoing TLE, for whom more complications during extraction procedures, from June 2012 to September 2020. The patients were divided into TEE group and non-TEE group according to real-time TEE monitoring. We compared the rate of procedural success, complications between two groups and concluded the clinical utility of TEE during TLE. RESULTS A total of 195 patients were included (105 in TEE group vs 90 in non-TEE group), the rate of procedure success (97.8% vs 96.5%, p = 0.41) and complications during extraction (8.6% vs 12.2%, p = 0.40, major complication 5.7% vs 12.2%, p = 0.11, minor complication 2.9% vs 0%, p = 0.30) were comparable. In TEE group, 12 patients (11.4%) received following benefits: altering surgical plans, guiding subsequent therapy strategies, and rapidly diagnosing complications, moreover no complications occurred from TEE. CONCLUSIONS This study demonstrates that real-time monitoring by TEE cannot change the rate of procedural success and complication during TLE; however, TEE provides valuable information to instruct clinical therapy and improves the safety of TLE.
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Affiliation(s)
- Lu Wang
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Ting Hai
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Yi Feng
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - QiaoYu Han
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - YaRu Li
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Hui Ju
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Yan Jiang
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - XueBin Li
- Department of Cardiac Electrophysiology, Peking University People's Hospital, Beijing, China
| | - Feng Ze
- Department of Cardiac Electrophysiology, Peking University People's Hospital, Beijing, China
| | - Gang Liu
- Department of Cardiac Surgery, Peking University People's Hospital, Beijing, China
| | - LuYang Jiang
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
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Tułecki Ł, Polewczyk A, Jacheć W, Nowosielecka D, Tomków K, Stefańczyk P, Kosior J, Duda K, Polewczyk M, Kutarski A. Analysis of Risk Factors for Major Complications of 1500 Transvenous Lead Extraction Procedures with Especial Attention to Tricuspid Valve Damage. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179100. [PMID: 34501689 PMCID: PMC8431163 DOI: 10.3390/ijerph18179100] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/22/2021] [Accepted: 08/25/2021] [Indexed: 01/28/2023]
Abstract
Background: Transvenous lead extraction (TLE) is a relatively safe procedure, but it may cause severe complications such as cardiac/vascular wall tear (CVWT) and tricuspid valve damage (TVD). Methods: The risk factors for CVWT and TVD were examined based on an analysis of data of 1500 extraction procedures performed in two high-volume centers. Results: The total number of major complications was 33 (2.2%) and included 22 (1.5%) CVWT and 12 (0.8%) TVD (with one case of combined complication). Patients with hemorrhagic complications were younger, more often women, less often presenting low left ventricular ejection fraction (LVEF) and those who received their first cardiac implantable electronic device (CIED) earlier than the control group. A typical patient with CVWT was a pacemaker carrier, having more leads (including abandoned leads and excessive loops) with long implant duration and a history of multiple CIED-related procedures. The risk factors for TVD were similar to those for CVWT, but the patients were older and received their CIED about nine years earlier. Any form of tissue scar and technical problems were much more common in the two groups of patients with major complications. Conclusions: The risk factors for CVWT and TVD are similar, and the most important ones are related to long lead dwell time and its consequences for the heart (various forms of fibrotic scarring). The occurrence of procedural complications does not affect long-term survival in patients undergoing lead extraction.
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Affiliation(s)
- Łukasz Tułecki
- Department of Cardiac Surgery, The Pope John Paul II Province Hospital of Zamość, 22-400 Zamość, Poland; (Ł.T.); (K.T.)
| | - Anna Polewczyk
- Department of Physiology, Pathophysiology and Clinical Immunology Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland
- Department of Cardiac Surgery, Świętokrzyskie Cardiology Center, 25-369 Kielce, Poland
- Correspondence:
| | - Wojciech Jacheć
- 2nd Department of Cardiology, Silesian Medical University, 41-808 Zabrze, Poland;
| | - Dorota Nowosielecka
- Department of Cardiology, The Pope John Paul II Province Hospital of Zamość, 22-400 Zamość, Poland; (D.N.); (P.S.)
| | - Konrad Tomków
- Department of Cardiac Surgery, The Pope John Paul II Province Hospital of Zamość, 22-400 Zamość, Poland; (Ł.T.); (K.T.)
| | - Paweł Stefańczyk
- Department of Cardiology, The Pope John Paul II Province Hospital of Zamość, 22-400 Zamość, Poland; (D.N.); (P.S.)
| | - Jarosław Kosior
- Department of Cardiology, Masovian Specialist Hospital of Radom, 26-617 Radom, Poland;
| | - Krzysztof Duda
- Department of Cardiac Surgery,
Masovian Specialist Hospital of Radom, 26-617 Radom, Poland;
| | - Maciej Polewczyk
- Faculty of Medicine and Health Studies, Jan Kochanowski University, 25-369 Kielce, Poland;
| | - Andrzej Kutarski
- Department of Cardiology, Medical University of Lublin, 20-509 Lublin, Poland;
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Nowosielecka D, Jacheć W, Polewczyk A, Kleinrok A, Tułecki Ł, Kutarski A. The prognostic value of transesophageal echocardiography after transvenous lead extraction: landscape after battle. Cardiovasc Diagn Ther 2021; 11:394-410. [PMID: 33968618 DOI: 10.21037/cdt-20-871] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background In patients undergoing transvenous lead extraction (TLE) transesophageal echocardiography (TEE) provide valuable information after procedure. Methods We analyzed data from 936 TEE performed in patients undergoing TLE between 2015 and 2019 (mean follow-up 566.23±224.47 days) and assessed the role of echocardiographic phenomena after procedure. Results Increment in tricuspid regurgitation (TR) was observed in 9% of patients after TLE. Factors increasing the risk of TR were: binding sites between lead and right ventricle (RV) (OR: 5.429), tricuspid valve (TV) (OR: 3.42), superior vena cava (SVC) (OR: 3.30) and lead-to-lead adhesions (OR: 2.88). Predisposing factors of residual structures after TLE were: asymptomatic masses on the leads (AMEL) (OR: 1.68), binding sites between SVC and cardiac structures (OR: 1.72), and multiple leads (OR: 1.30). Probability of vegetation remnants increased in the presence of abandoned leads (OR: 7.91). The risk factors of tamponade were: dwell time of the oldest lead (OR: 1.17), lead-to-lead adhesion (OR: 22.47), binding sites between lead and TV (OR: 6.08), RA (OR: 11.50), SVC (OR: 4.47), higher LVEF (OR: 2.35; P=0.006), female gender (OR: 5.43), multiple leads (OR: 2.11), looped leads (OR: 4.90) and AMEL (OR: 6.42). The risk of lead fracture was increased by: lead-to-lead adhesion (OR: 5.69), fibrosis binding the lead to RV (OR: 5.16), RA (OR: 2.39) and dwell time of the oldest lead (OR: 1.068). The mortality rate was 11.97% during follow-up. The risk of death was increased by: severe TR and vegetation remnants. Conclusions The most important phenomena evaluated after TLE are: tricuspid valve function, residual fibrosis and vegetation remnants, progression of pericardial effusion and retained lead fragments. Postoperative TEE provides information about the results of TLE and helps establish further management.
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Affiliation(s)
- Dorota Nowosielecka
- Department of Cardiology, The Pope John Paul II Province Hospital of Zamość Poland
| | - Wojciech Jacheć
- 2nd Department of Cardiology, Faculty of Medical Sciences, Medical University of Silesia, Zabrze, Poland
| | - Anna Polewczyk
- Collegium Medicum, The Jan Kochanowski University, Kielce, Poland.,Department of Cardiac Surgery, Świętokrzyskie Cardiology Center, Kielce, Poland
| | - Andrzej Kleinrok
- Department of Cardiology, The Pope John Paul II Province Hospital of Zamość Poland.,Medical College, Department of Physiotherapy, University of Information Technology and Management, Rzeszów, Poland
| | - Łukasz Tułecki
- Department of Cardiac Surgery, The Pope John Paul II Province Hospital of Zamość Poland
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7
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Issa ZF, Issa TZ. Utility of fluoroscopy alone for monitoring of intrathoracic bleeding complications during transvenous lead extraction. J Cardiovasc Electrophysiol 2021; 32:1724-1732. [PMID: 33709412 DOI: 10.1111/jce.14995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/28/2021] [Accepted: 02/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Transvenous lead extraction (TLE) carries a significant risk of major complications, namely bleeding into the pericardial sac or thoracic cavity. While echocardiographic imaging has been recommended for intraprocedural monitoring for those complications, no studies had examined the potential benefits of fluoroscopy alone as an alternative to echocardiography. The aim of this study was to evaluate the utility of fluoroscopy for monitoring intrathoracic bleeding complications during TLE. METHODS This is a single-center retrospective study of consecutive patients who underwent TLE of a pacemaker or ICD lead with fluoroscopy-only monitoring. At the beginning of each TLE procedure, baseline fluoroscopic images were obtained for both lung fields and the cardiac silhouette. Similar images were acquired again when hypotension develops during the procedure. RESULTS Fluoroscopy alone (without echocardiographic imaging) was used in 783 consecutive patients (54% women; average age, 71.5 ± 12.9 years) who underwent TLE. There were 93 patients (11.9%) who experienced significant hypotension. Fluoroscopy showed no obvious cause for hypotension in 63 patients. Right ventricular inversion was implied by fluoroscopy in 27 patients. Fluoroscopy detected new pericardial effusion in two patients and new right pleural effusion in one patient, which prompted halting the extraction procedure and therapeutic intervention. Additionally, routine fluoroscopic images revealed the development of an unsuspected new small left pleural effusion in one patient and a pericardial effusion in another. In-hospital mortality rate was 0%. CONCLUSIONS In selected patients undergoing TLE, fluoroscopy can provide valuable information for identifying or excluding cardiovascular causes during periods of intraprocedural hemodynamic instability.
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Affiliation(s)
- Ziad F Issa
- Prairie Heart Institute, Cardiac Electrophysiology, HSHS St. John's Hospital, Springfield, Illinois, USA
| | - Tariq Z Issa
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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8
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Burkett DA, Runciman M, Jone PN, Collins KK. Transesophageal three-dimensional echocardiographic guidance for pacemaker lead extraction. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:641-650. [PMID: 33565632 DOI: 10.1111/pace.14191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/25/2021] [Accepted: 02/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The ability of transesophageal three-dimensional echocardiography (3DE) to aid in pacemaker lead extraction has not yet been evaluated. 3DE provides real-time evaluation of intracardiac anatomy and the location of pacemaker leads in greater detail than either fluoroscopy or -two-dimensional echocardiography (2DE), aiding in the extraction of such leads, which can be potentially dangerous. We sought to investigate the feasibility and utility of 3DE to visualize intracardiac anatomy and pacemaker leads, and to assist in lead extraction procedures. METHODS We utilized 3DE in nine encounters for eight different patients, to visualize intracardiac anatomy and leads before, during, and after extraction to evaluate the feasibility and utility to aid in the procedure and evaluate for potential sequelae. RESULTS 3DE was able to identify pertinent intracardiac anatomy and leads in all cases. 3DE detected procedural complications or altered management in five of nine encounters (five of eight patients); this included detection of an avulsed papillary muscle, tricuspid valve leaflet damage, and cast/thrombus after lead removal, as well as adjustment of excess lead slack to avoid future valve damage, or risk stratification of lead removal. CONCLUSION 3DE is feasible and adds utility to lead extraction cases by visualizing intracardiac anatomy and leads beyond fluoroscopy or 2DE, providing real-time information during extraction, and identifying potential complications.
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Affiliation(s)
- Dale A Burkett
- Department of Pediatric Cardiology, Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Martin Runciman
- Department of Pediatric Cardiology, Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Pei-Ni Jone
- Department of Pediatric Cardiology, Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kathryn K Collins
- Department of Pediatric Cardiology, Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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Nowosielecka D, Polewczyk A, Jacheć W, Tułecki Ł, Kleinrok A, Kutarski A. Echocardiographic findings in patients with cardiac implantable electronic devices-analysis of factors predisposing to lead-associated changes. Clin Physiol Funct Imaging 2020; 41:25-41. [PMID: 32949059 DOI: 10.1111/cpf.12662] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/27/2020] [Accepted: 09/09/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The constant interaction between intracardiac leads and the heart and veins results in excessive accumulation of fibrous connective tissue around the leads. The extent of this pathological phenomenon, which is visible on transesophageal echocardiography (TEE), and predisposing factors are not well defined. METHODS We examined 936 transesophageal echocardiograms prior to transvenous lead extraction (TLE) performed at a high-volume centre between 2015 and 2019. RESULTS The most important echocardiographic findings were fibrous binding sites between leads and cardiovascular structures, lead-to-lead adhesions, excessive lead loops, lead-dependent tricuspid dysfunction (LDTD), asymptomatic masses on endocardial leads (AMEL) and vegetations. Fibrotic reaction within the walls of the heart and veins correlated with the presence of lead loops (OR = 1.771; p < .01) and lead dwell time (OR = 1.111; p < .001). Women were more likely to have excessive lead loops (OR = 1.639; p < .01), and the occurrence of loops increase with the number of implanted leads (OR = 2.557; p < .001). Heart failure (OR = 4.016; p < .001), lead looping (OR = 2.603; p < .01) and longer cumulative lead dwell time (OR = 1.017; p < .05) increased the likelihood of LDTD. A variety of AMEL were identified in this study, most commonly in patients with older leads (OR = 1.043; p < .001). CONCLUSIONS Lead dwell time is the main factor predisposing to the occurrence of most lead-associated phenomena visualized by TEE in patients with cardiac implantable electronic devices (CIED). Excessive looping of the lead is an important cause of fibrous binding sites and LDTD. AMEL are frequently detected in CIED patients, and their various forms concurrent with vegetations could represent an evolutionary stage of lead-associated masses.
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Affiliation(s)
- Dorota Nowosielecka
- Department of Cardiology, The Pope John Paul II Province Hospital, Zamosc, Poland
| | - Anna Polewczyk
- Department of Physiology and Patophysiology, Collegium Medicum The Jan Kochanowski University, Kielce, Poland.,Department of Cardiac Surgery, Swietokrzyskie Cardiology Center, Kielce, Poland
| | - Wojciech Jacheć
- 2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Łukasz Tułecki
- Department of Cardiac Surgery, The Pope John Paul II Province Hospital, Zamosc, Poland
| | - Andrzej Kleinrok
- Department of Cardiology, The Pope John Paul II Province Hospital, Zamosc, Poland.,University of Information Technology and Management, Rzeszow, Poland
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Transesophageal Echocardiography As a Monitoring Tool During Transvenous Lead Extraction-Does It Improve Procedure Effectiveness? J Clin Med 2020; 9:jcm9051382. [PMID: 32397115 PMCID: PMC7290980 DOI: 10.3390/jcm9051382] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/15/2020] [Accepted: 05/02/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Transesophageal echocardiography (TEE) is a valuable tool for monitoring the patient during transvenous lead extraction (TLE), but the direct impact of TEE on the effectiveness and safety of TLE has not yet been documented. Methods: The effectiveness of TLE and short-term survival were compared between two groups of patients: 2106 patients in whom TEE was performed before and after TLE and 1079 individuals in whom continuous TEE monitoring was used. The procedure-related risk of major complications was assessed using a predictive SAFeTY TLE score. Results: The patients monitored by TEE were characterized by older age, more comorbidities and higher SAFeTY TLE scores (6.143 ± 4.395 vs. 5.593 ± 4.127; p = 0.004). Complete procedural success was significantly higher in the TEE-guided group (97.683% vs. 95.442%, p < 0.01). The rate of serious complications in the TEE-guided group was lower than the predictive SAFeTY TLE score—a reduction of 28.75% (p < 0.05). Periprocedural mortality in the TEE-guided and non-TEE-guided groups was zero vs. six deaths (p = 0.186). Short-term survival was comparable between the groups. Conclusions: Transesophageal echocardiography as a monitoring tool during transvenous lead extraction provides valuable results—higher rates of complete procedural success and a reduced risk of the most severe complications, thus preventing periprocedural deaths.
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Nowosielecka D, Polewczyk A, Jacheć W, Tułecki Ł, Tomków K, Stefańczyk P, Kleinrok A, Kutarski A. A new approach to the continuous monitoring of transvenous lead extraction using transesophageal echocardiography—Analysis of 936 procedures. Echocardiography 2020; 37:601-611. [DOI: 10.1111/echo.14628] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 12/12/2019] [Accepted: 02/18/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Dorota Nowosielecka
- Department of Cardiology The Pope John Paul II Province Hospital of Zamosc Zamosc Poland
| | - Anna Polewczyk
- Collegium Medicum The Jan Kochanowski University Kielce Poland
- Department of Cardiac Surgery Swietokrzyskie Cardiology Center Kielce Poland
| | - Wojciech Jacheć
- 2nd Department of Cardiology Silesian Medical University Zabrze Poland
| | - Łukasz Tułecki
- Department of Cardiac Surgery The Pope John Paul II Province Hospital of Zamosc Zamosc Poland
| | - Konrad Tomków
- Department of Cardiac Surgery The Pope John Paul II Province Hospital of Zamosc Zamosc Poland
| | - Paweł Stefańczyk
- Department of Cardiology The Pope John Paul II Province Hospital of Zamosc Zamosc Poland
| | - Andrzej Kleinrok
- Department of Cardiology The Pope John Paul II Province Hospital of Zamosc Zamosc Poland
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12
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Strachinaru M, Kievit CM, Yap SC, Hirsch A, Geleijnse ML, Szili-Torok T. Multiplane/3D transesophageal echocardiography monitoring to improve the safety and outcome of complex transvenous lead extractions. Echocardiography 2019; 36:980-986. [PMID: 30905087 PMCID: PMC6593712 DOI: 10.1111/echo.14318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/11/2019] [Accepted: 02/22/2019] [Indexed: 02/02/2023] Open
Abstract
Both transesophageal echocardiography (TEE) and intracardiac echocardiography have been used to assist transvenous lead extractions. The clinical utility of continuous echocardiographic monitoring during the procedure is still debated, with different reports supporting opposite findings. In cases where the procedure is expected to be difficult, we propose adding a continuous TEE monitoring using a static 3D/multiplane probe in mid-esophageal position, with digital remote manipulation of the field of view. This approach may improve the chances of a successful extraction, increase safety, or even guide the entire intervention. We present here a short case series where continuous monitoring by TEE played an important role.
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Affiliation(s)
| | | | - Sing C Yap
- Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Alexander Hirsch
- Cardiology, Erasmus MC, Rotterdam, The Netherlands.,Radiology, Erasmus MC, Rotterdam, The Netherlands
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Abstract
Lead extraction procedures have a low but real risk of major complications, such as superior vena cava tear and cardiac tamponade. Complications during lead removal are commonly related to lead binding sites, lead malposition, and lead perforation. Lead extraction imaging may indicate lead vascular binding sites, lead position, and perforation. Several imaging modalities are available, including chest radiograph, cardiac computed tomography, and echocardiography. The information provided by various imaging modalities will help assess the challenges of each lead extraction procedure and allows for better preprocedure planning.
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Affiliation(s)
- Pierce J Vatterott
- United Heart & Vascular Clinic, Allina Health System, 225 North Smith Avenue, Suite 400, St Paul, MN 55102, USA.
| | - Imran S Syed
- United Heart & Vascular Clinic, Allina Health System, 225 North Smith Avenue, Suite 400, St Paul, MN 55102, USA
| | - Akbar H Khan
- United Heart & Vascular Clinic, Allina Health System, 225 North Smith Avenue, Suite 400, St Paul, MN 55102, USA
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Leung LWM, Gomes J, Domenichini G, Gallagher MM. Oesophageal perforation: an unexpected complication during extraction of a pacing lead. A case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 3:ytz008. [PMID: 31020253 PMCID: PMC6439371 DOI: 10.1093/ehjcr/ytz008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 01/20/2019] [Indexed: 12/03/2022]
Abstract
Background Peri-procedural transoesophageal echocardiography (TOE) is important in monitoring and minimizing major complications during pacing lead extraction. It is a widely accepted precautionary measure, especially in extractions considered to be higher risk. Pacing lead extraction may be challenging, and it is associated with significant risk of major bleeding from vascular trauma. Case summary We present a case of an 87-year-old woman who had an extraction of a ventricular pacing lead that had perforated to an extra-cardiac location, most likely to the left pleural space. Peri-procedural TOE was used as a precaution. The entire pacing lead was successfully extracted with gentle traction using standard equipment (mechanical technique). Extraction was followed by development of pneumomediastinum and a left pleural effusion, initially attributed to pulmonary injury from the pacing lead but which proved to be related to oesophageal injury from the TOE. Discussion Transoesophageal echocardiography-related complications are uncommon but should be considered in cases of unexpected post-procedural deterioration. Clinical deterioration after a seemingly uneventful procedure should prompt a thorough case review. A systematic approach should be applied to identify the offending cause and enable corrective measures to be undertaken. This case report is an important reminder to all operators utilizing TOE for peri-procedural purposes that this precautionary measure itself also independently exposes the patient to additional risk.
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Affiliation(s)
- Lisa W M Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Blackshaw Road, London, UK
| | - John Gomes
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Blackshaw Road, London, UK
| | - Giulia Domenichini
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Blackshaw Road, London, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Blackshaw Road, London, UK
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15
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Abstract
The role of the anesthesiologist in lead extraction procedures is multifaceted and highlights the collaborative, multidisciplinary teamwork needed to ensure patient safety and procedural success in these complex cases. Thorough preoperative evaluation and identification of high-risk characteristics enable the anesthesiologist to tailor a comprehensive intraoperative and postoperative care plan for each case. Institutional practices may vary but anesthetic management typically includes general anesthesia with an endotracheal tube, invasive measurement of arterial blood pressure, vascular access for rapid volume expansion, echocardiographic monitoring, preparation for blood transfusion, and initiation of cardiopulmonary bypass in the event of an emergency.
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16
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Özkartal T, Regoli F, Conte G, Caputo ML, Klersy C, Moccetti T, Auricchio A. New onset of phrenic nerve palsy after laser-assisted transvenous lead extraction: a single-centre experience. Europace 2018; 20:1827-1832. [PMID: 29672695 DOI: 10.1093/europace/euy044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/20/2018] [Indexed: 11/12/2022] Open
Abstract
Aims Phrenic nerve palsy (PNP) after mechanical transvenous lead extraction (TLE) was recently described for the first time. We aimed to analyse our TLE database for the presence of PNP. Methods and results All consecutive patients referred to our institution were included in this study. Every available post-procedural chest X-ray was compared to the routinely performed pre-procedural radiographs. A newly elevated hemidiaphragm ipsilateral to TLE was considered indicative of PNP. Altogether 255 TLE procedures with extraction of 364 leads were performed. Most common TLE indication was lead malfunction (63%). Complete radiographic success rate was 97.3% with an in-hospital procedure-related major complication rate of 2.4%, including one intra-procedural death (0.4%). We identified five cases with PNP (2%), all occurring after laser-assisted TLE. Clinical presentation varied from subtle and aspecific chest pain/discomfort to severe and acute dyspnoea, with time to diagnosis varying from immediate to several weeks after the procedure. In 80% of cases, the explanted lead was a defibrillator electrode and the median lead dwelling time was 70.2 months (29.3; 1084.9). In four cases, the extraction was performed using high-energy laser (pulse repetition rate 80 Hz). Conclusion The present study reports the incidence of PNP after laser-assisted TLE. We postulate that the thermal energy generated by laser is not dissipated quickly enough in occluded or heavily calcified lesions, injuring the ipsilateral phrenic nerve. Our findings advise to carefully consider to increase pulse repetition rate at the subclavian level. Larger, possibly prospective studies are needed to evaluate the real incidence through systematic radiological assessment after TLE.
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Affiliation(s)
- Tardu Özkartal
- Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - François Regoli
- Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Giulio Conte
- Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Maria Luce Caputo
- Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Catherine Klersy
- Service of Clinical Epidemiology & Biometry, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Tiziano Moccetti
- Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Angelo Auricchio
- Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
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Simultaneous lead traction from above and below: A novel technique to reduce the risk of superior vena cava injury during transvenous lead extraction. Heart Rhythm 2018; 15:1655-1663. [PMID: 29803849 DOI: 10.1016/j.hrthm.2018.05.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Superior vena cava (SVC) injury is a rare but dreaded complication during percutaneous transvenous lead extraction (TLE) that carries high morbidity and mortality. Despite technological advances and improved efficacy, complication rates remain unchanged. OBJECTIVE We sought to develop and test a novel technique that could reduce the risk of SVC injury during TLE. METHODS Fifteen patients referred for TLE of an implantable cardioverter-defibrillator lead were included. Patients underwent fluoroscopic and intracardiac echocardiographic (ICE) imaging of the lead-SVC interface with traction from above, below, and simultaneously. Clinical characteristics, fluoroscopic and ICE findings, and procedural outcomes were collected and analyzed. RESULTS Fourteen of 15 patients were men (93%) with a mean age of 58 years. The mean lead dwell time was 8.09 ± 3.97 years (range 1.08-16.25 years), and 12 of 15 leads (80%) were dual-coil. Acceptable ICE imaging was not possible in 3 of 15 patients (20%). Simultaneous traction showed greater leftward fluoroscopic shift compared with traction from above (24.96 ± 8.82 mm vs 13.68 ± 6.86 mm; P < .01), created greater separation between the lead and the SVC wall upon ICE imaging (2.0 ± 0.52 mm vs 1.24 ± 0.38 mm; P < .01), and maintained a more parallel relationship of the lead with the SVC wall (24.41° ± 4.14° vs 27.91° ± 4.92°; P < .05). CONCLUSION In patients presenting for TLE, simultaneous traction results in increased separation and a more parallel alignment of the lead and SVC wall, allowing the sheath to be better oriented in the desired cleavage plane. This improved sheath alignment is particularly critical when powered sheaths are to be used.
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New-onset pericardial effusion during transvenous lead extraction: incidence, causative mechanisms, and associated factors. J Interv Card Electrophysiol 2018; 51:253-261. [DOI: 10.1007/s10840-018-0327-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 02/06/2018] [Indexed: 12/22/2022]
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Sadek MM, Cooper JM, Frankel DS, Santangeli P, Epstein AE, Marchlinski FE, Schaller RD. Utility of intracardiac echocardiography during transvenous lead extraction. Heart Rhythm 2017; 14:1779-1785. [DOI: 10.1016/j.hrthm.2017.08.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 11/25/2022]
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20
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Fermin L, Gebhard RE, Azarrafiy R, Carrillo R. Pearls of Wisdom for High-Risk Laser Lead Extractions: A Focused Review. Anesth Analg 2017; 126:406-412. [PMID: 28991113 DOI: 10.1213/ane.0000000000002540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Due to new indications and improved technology, the incidence of laser lead extraction (LLE) has significantly increased over the past years. While LLE has been well studied and proven to be safe and effective, only few studies are geared toward the anesthesiologist's role during high-risk LLEs. This article utilized both a focused review and authors' experience to investigate anesthetic protocols during LLEs. Through this review, we recommend best practices for the anesthesiologist including appropriate procedure location, onsite availability of a cardiac surgeon, availability of a cardiopulmonary bypass machine, and intraoperative use of echocardiography to detect and address potential complications during high-risk LLEs.
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Affiliation(s)
- Lilibeth Fermin
- From the Department of Anesthesiology, Cleveland Clinic Florida, Weston, Florida
| | - Ralf E Gebhard
- Department of Anesthesiology, Perioperative Medicine and Pain Management
| | - Ryan Azarrafiy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Roger Carrillo
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Abou-Leila A, Voronov G. The Journey of Harmless Bullet: The Perioperative Care of Penetrating Cardiac Injury. Anesth Essays Res 2017; 11:790-793. [PMID: 28928592 PMCID: PMC5594811 DOI: 10.4103/0259-1162.194578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Traumatic injuries to the heart contribute significantly to trauma are associated with high mortality. Cardiac gunshot wounds (GSW) are considered more lethal compared to other injuries and present several unique challenges to the anesthesia management and perioperative care. We are reporting a rare case of a trauma victim who survived a GSW to the heart. We will discuss the perioperative care of penetrating cardiac injuries, the role of the anesthesia team in resuscitation, safe anesthesia induction, cardiopulmonary bypass management, and the essential role of intraoperative transesophageal echocardiogram imaging.
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Affiliation(s)
- Ahmad Abou-Leila
- Department of Anesthesiology and Pain Management, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Gennadiy Voronov
- Department of Anesthesiology and Pain Management, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
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2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm 2017; 14:e503-e551. [PMID: 28919379 DOI: 10.1016/j.hrthm.2017.09.001] [Citation(s) in RCA: 710] [Impact Index Per Article: 101.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 02/06/2023]
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23
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Regoli F, Bongiorni MG, Rordorf R, Santamaria M, Klersy C, Segreti L, De Regibus V, Moccetti T, Conte G, Caputo ML, Auricchio A. High recurrence of device-related adverse events following transvenous lead extraction procedure in patients with cardiac resynchronization devices. Eur J Heart Fail 2016; 18:1270-1277. [DOI: 10.1002/ejhf.558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/16/2016] [Accepted: 04/03/2016] [Indexed: 11/07/2022] Open
Affiliation(s)
- François Regoli
- Fondazione Cardiocentro Ticino, Department of Cardiology; Lugano Switzerland
| | - Maria Grazia Bongiorni
- Second Division of Cardiology, Cardiothoracic and Vascular Department; University Hospital of Pisa; Italy
| | - Roberto Rordorf
- Department of Cardiology, IRCCS, Fondazione Policlinico San Matteo; Pavia Italy
| | - Matteo Santamaria
- Cardiovascular Department; Catholic University of the Sacred Heart; Campobasso Italy
| | - Caterine Klersy
- Service of Biometry and Statistics, IRCCS, Fondazione Policlinico San Matteo; Pavia Italy
| | - Luca Segreti
- Second Division of Cardiology, Cardiothoracic and Vascular Department; University Hospital of Pisa; Italy
| | | | - Tiziano Moccetti
- Fondazione Cardiocentro Ticino, Department of Cardiology; Lugano Switzerland
| | - Giulio Conte
- Fondazione Cardiocentro Ticino, Department of Cardiology; Lugano Switzerland
| | - Maria Luce Caputo
- Fondazione Cardiocentro Ticino, Department of Cardiology; Lugano Switzerland
| | - Angelo Auricchio
- Fondazione Cardiocentro Ticino, Department of Cardiology; Lugano Switzerland
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Oestreich BA, Ahlgren B, Seres T, Zipse MM, Tompkins C, Varosy PD, Aleong RG. Use of Transesophageal Echocardiography to Improve the Safety of Transvenous Lead Extraction. JACC Clin Electrophysiol 2015; 1:442-448. [DOI: 10.1016/j.jacep.2015.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 06/30/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
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