Feasibility, safety, and determinants of extraction time of percutaneous extraction of endocardial implantable cardioverter defibrillator leads by intravascular countertraction method

Characterization of Lead Adherence Using Intravascular Ultrasound to Assess Difficulty of Transvenous Lead Extraction

Background:

Clinical factors associated with development of intravascular lead adherence (ILA) are unreliable predictors. Because vascular injury in the superior vena cava-right atrium during transvenous lead extraction is more likely to occur in segments with higher degrees of ILA, reliable and accurate assessment of ILA is warranted. We hypothesized that intravascular ultrasound (IVUS) could accurately visualize and quantify ILA and degree of ILA correlates with transvenous lead extraction difficulty.

Methods:

Serial imaging of leads occurred before transvenous lead extraction using IVUS. ILA areas were classified as high or low grade. Degree of extraction difficulty was assessed using 2 metrics and correlated with ILA grade. Lead extraction difficulty was calculated for each patient and compared with IVUS findings.

Results:

One hundred fifty-eight vascular segments in 60 patients were analyzed: 141 (89%) low grade versus 17 (11%) high grade. Median extraction time (low=0 versus high grade=97 seconds, P <0.001) and median laser pulsations delivered (low=0 versus high grade=5852, P <0.001) were significantly higher in high-grade segments. Most patients with low lead extraction difficulty score had low ILA grades. Eighty-six percentage of patients with high lead extraction difficulty score had low IVUS grade, and the degree of transvenous lead extraction difficulty was similar to patients with low IVUS grades and lead extraction difficulty scores.

Conclusions:

IVUS is a feasible imaging modality that may be useful in characterizing ILA in the superior vena cava-right atrium region. An ILA grading system using imaging correlates with extraction difficulty. Most patients with clinical factors associated with higher extraction difficulty may exhibit lower ILA and extraction difficulty based on IVUS imaging.

Graphic Abstract:

A graphic abstract is available for this article.

Comparative study about the tensile strength and yielding mechanism of pacing lead among major manufacturers

BACKGROUND

With extraction of cardiovascular implantable electronic devices (CIED) increasingly necessitated, various studies have contemplated to investigate clinical predictors for its success and complications. Intrinsic parameters of CIED leads have been studied less extensively and are the foci of this study.

METHODS

Three major pacemaker manufacturers accepted invitation. Leads then underwent tensile test in vitro with their composite tensile strength (TS) compared. Mechanism of yielding, under tensile stress, was also observed among them.

RESULTS

All pacing leads, participated in this study, surpassed requirement of European Standard EN 45502-2-1. Boston Scientific's FINELINE II STEROX 4456/52 cm (Boston Scientific Corp., St. Paul, MN, USA) and Medtronic's CAPSURE SENSE 4074/52 cm (Medtronic, Minneapolis, MN, USA) showed similar composite TS and both were stronger compared with St. Jude Medical's ISOFLEX OPTIM 1948/52 cm (P <0.001; St. Jude Medical, Sylmar, CA, USA). Despite a difference in the exact site, the Medtronic 4074 and St. Jude Medical 1948 yielded similarly in that their distal tip electrode remained connected with a flimsy inner coil to proximal portion of the lead after their composite TS was exceeded. Boston Scientific 4456's insulation tubing and coil wire broke almost simultaneously and separated completely from the tip electrode when it yielded.

CONCLUSIONS

FINELINE II STEROX 4456/52 cm and CAPSURE SENSE 4074/52 cm showed stronger composite tensile strength than ISOFLEX OPTIM 1948/52 cm. FINELINE II STEROX 4456 was found more prone to complete severance. Limitations and precautions to translate these differences directly into real-life scenario are discussed.

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.

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.

From lead management to implanted patient management: systematic review and meta-analysis of the last 15 years of experience in lead extraction

Percutaneous lead extraction is considered a safe and effective procedure, although published results derive primarily from cohort studies. The authors performed a systematic review and meta-analysis of the last 15 years' experience in this field, to give an objective evaluation of the efficacy and safety of this procedure. Moreover, the subsequent metaregression analysis enabled the identification of the main factors influencing these results: patient age, presence of leads in situ for more than 1 year, presence of device infection and use of laser sheath. These findings are significant in order to improve our extraction approach, data reporting and future research.

[ICD lead defects: diagnosis and therapeutical options]

The number of cardioverter/defibrillator (ICD) implantations has been steadily increasing; thus, ICD lead-associated complications are an important issue. No clear recommendations for the diagnosis and management are available. This article gives an overview of how to diagnose and manage an ICD lead defect. Possible therapeutic options are discussed by reviewing the literature.

Do abandoned leads pose risk to implantable cardioverter-defibrillator patients?

BACKGROUND

With the increased number of implantable cardioverter-defibrillator (ICD) recipients and the frequent need for device upgrading, lead malfunction is a concern, but the optimal approach to managing nonfunctioning leads is unknown.

OBJECTIVE

The purpose of this study was to determine the rate and characteristics of complications related to abandoned ICD leads.

METHODS

Patients with abandoned leads were identified by retrospective review of the Mayo Clinic ICD database from August 1993 to May 2002. We reviewed the medical records to assess long-term follow-up for venous thromboembolic complications, device sensing malfunction, appropriateness of delivered shocks, defibrillation threshold (DFT) values before and after lead abandonment, and subsequent surgical procedures related to devices or leads.

RESULTS

We identified 78 ICD patients (81% males; mean age 63 +/- 14 years) with 101 abandoned leads (69 in the right ventricle, 31 in the right atrium or superior vena cava, 1 in the coronary sinus). During a mean follow-up of 3.1 +/- 2.0 years, neither sensing malfunction nor venous thromboembolic complications were detected. DFT values were high in 13 patients (17%), but there was no significant increase in mean DFT values before and after lead abandonment in 43 patients for whom both values were available (16.2 +/- 9.2 J before abandonment vs 14.1 +/- 5.5 J after; P = .24). Fourteen patients (18%) required further ICD-related surgery; none of these operations were attributed to abandoned leads. Five-year rates of appropriate and inappropriate shocks were 25.9% and 20.5%, respectively.

CONCLUSION

Abandoning a nonfunctioning lead appears to be safe and does not pose a clinically significant additional risk of future complications.

Two Different Therapeutic Strategies in ICD Lead Defects: Additional Combined LeadVersus Replacement of the Lead

OBJECTIVES

Implantation of an additional HV-P/S lead versus extraction of the defective HV-P/S lead and implantation of a new one is one possible therapeutic approach in cases of a defective high-voltage pace/sense lead (HV-P/S). No information is available on potential differences in clinical outcome in these different approaches.

METHODS

Between January 2000 and February 2006, 86 patients with HV-P/S lead defect received either an additional transvenous HV-P/S lead (n = 33, group 1) or the HV-P/S lead was replaced (n = 53, group 2). The duration of the initially implanted leads was significantly different in the two groups (7.4 +/- 2.9; group 1 and 4.1 +/- 3.4 years; group 2). The outcome of these two groups of patients was retrospectively analyzed.

RESULTS

Seventy-three patients [85%] survived until the end of follow-up of 29 +/- 15 (group 1) and 33 +/- 21 (group 2) months (P = ns), respectively. Thirteen patients died: six in group 1 and seven in group 2 (P = ns). Fourteen patients experienced perioperative complications (group 1: six; group 2: eight; P = ns). ICD system-related complications occurred in 22 patients (group 1: seven; group two: 15; P = ns). The event-free cumulative survival of patients with additional and replaced HV-P/S lead for postoperative events (including death) after 1, 2, and 3 years was 82%, 70%, 70%, and 86%, 81%, 66%, respectively (P = 0.93).

CONCLUSIONS

Implantation of an additional HV-P/S lead or replacement of the HV-P/S lead in case of HV-P/S lead failure is statistically not different concerning mortality and morbidity. There are no predictors for further lead defects. Implantation of an additional HV-P/S lead should not be recommended in young patients or patients with greater likelihood of living many years. Predictors for death were an age over 70 years and renal insufficiency.

Extracción de electrodos de marcapasos y desfibrilador mediante técnicas percutáneas

INTRODUCTION AND OBJECTIVES

There is an increasing need for endocardial pacing and defibrillators leads to be removed. However, the procedure can be complex and it is not risk-free. We reviewed our experience between April 1989 and June 2006 with the percutaneous extraction of leads.

METHODS

In total, 314 electrodes were extracted from 187 patients. The leads had been implanted over an average period of 69.16 months (range 0.11-234.6 months, median 60.25 months). Some 115 were atrial leads, 196 were ventricular, and three were in the coronary veins; of these, 78 had been abandoned in the vascular bed.

RESULTS

Indications for removal were infection (26.1%), dysfunction (22.9%), erosion (25%), endocarditis (20.7%), and bacteremia (2.7%). Overall, 58.8% of patients were referred from other departments. In 96.8%, the electrodes were completely removed. Simple traction was used in 23.4%, and countertraction techniques (with and without radiofrequency current support) were used in 60.7%. For abandoned leads, a biopsy clamp was used in combination with countertraction (4.3%) or a femoral approach with a snare (10.1%). A sternotomy was required in three of the 10 patients with remaining electrode fragments. The complication rate was 4.6% (with major complications in 2.5%). Complications were associated with age < 60 years (odds ratio [OR]=5.38, 95% confidence interval [CI] 1.07-27.23), the presence of endocarditis (OR=4.97: 95%CI, 1.04-23.70), and right side implantation (OR=17.09; 95% CI, 2.15-135.70).

CONCLUSIONS

In the majority of cases, pacing and defibrillator leads can be removed without difficulty using modern extraction techniques. However, because there is a risk of complications during extraction, even though it is low, the procedure should be carried out in specialized centers with surgical facilities.

Randomized Comparison of J-Shaped Atrial Leads with and without Active Fixation Mechanism

BACKGROUND

In this prospective, randomized, controlled study, we compared the performance of J-shaped active fixation (AF) atrial leads with J-shaped passive fixation (PF) leads, over a 1-year follow-up period.

METHODS

A total of 200 consecutive patients were prospectively randomized for implantation with a Medtronic 5568 AF lead model (n = 103; Minneapolis, MN, USA) versus a Medtronic 5592 PF model (n = 97), and all lead-related measurements and complications were recorded over one year.

RESULTS

All leads were successfully implanted with a nonsignificant difference in crossover rate to the alternative lead due to failed implantation (1 in the AF and 4 in the PF group, P = NS). Fluoroscopy time during implantation procedure was significantly shorter in the PF group (2.1 +/- 3.6 vs 3.3 +/- 4.5 minute, P < 0.05). Pacing thresholds during implantation were significantly lower in patients with PF leads (0.7 +/- 0.3 V vs 0.9 +/- 0.3 V, P < 0.001) and this difference persisted at 1-year follow-up (0.8 +/- 0.6 V vs 1.3 +/- 0.9 V in PF and AF leads respectively, P < 0.05). Lead-related complications occurred in PF and AF with similar frequency (4% and 9% respectively, P = 0.2). However, pericardial complications occurred only in the AF group (6 cases, P = 0.01). Lead dislodgement was observed in only two cases-both in the PF group (P = 0.3).

CONCLUSION

Both types of J-shaped atrial leads had reasonable performance. PF leads required shorter fluoroscopy time for implantation, demonstrated a better pacing threshold over a 1-year follow-up period and had no pericardial complications, while AF lead implantation was complicated by pericardial irritation and/or effusion in 6% cases (P = 0.01).

Covering sleeves can shield the high-voltage coils from lead chatter in an integrated bipolar ICD lead

AIMS

Integrated bipolar implantable cardioverter-defibrillator (ICD) leads use the distal high-voltage coil as both the ventricular sensing anode and the distal shocking electrode. Mechanical interactions between the distal ICD coil and other intracardiac leads have been reported to result in electrical oversensing and inappropriate ICD therapies. We sought to determine whether covering sleeves over the high-voltage coils of an integrated bipolar ICD lead could prevent sensed artefact from mechanical lead interactions.

METHODS AND RESULTS

Endotak Reliance 0157 and Endotak Reliance-G 0185 leads, the latter with expanded polytetrafluoroethylene (ePTFE) sleeves covering the high-voltage coils, were connected to ICD generators and the leads were submerged in saline. Device programmers were used to communicate with the ICD generators, providing real-time electrogram recording throughout testing. A series of mechanical interactions were performed with the ICD leads, including sliding and striking each distal coil against metal and non-metal components of other ICD and pacemaker leads. All direct metal-metal interactions resulted in sensed electrical artefact, including interactions between the bare ICD coil and another bare ICD coil or metal pacemaker ring. Identical mechanical interactions where metal-metal contact was prevented due to an interposed ePTFE covering sleeve were electrically silent with no sensed artefact.

CONCLUSIONS

A covering sleeve over the distal high-voltage coil of an integrated bipolar ICD lead can mechanically shield the lead from metal-metal interactions, which might otherwise result in sensed artefact and inappropriate ICD therapies or withholding of pacing output. This finding has implications for lead selection when a new ICD lead is to be implanted adjacent to abandoned intracardiac leads or lead fragments.

Incidence of Complications in Patients with Implantable Cardioverter/Defibrillator Who Receive Additional Transvenous Pace/Sense Leads

BACKGROUND

Implantation of an additional pace/sense (P/S) lead is commonly used in patients with implantable cardioverter/defibrillators (ICDs) to overcome P/S defects of integrated defibrillation leads (HV-P/S leads). No information is available about the clinical outcome and the incidence of complications in these patients.

METHODS

Retrospective analysis was performed in 151 patients (125 male, age 54.9 +/- 13.6 years, LVEF 48.1 +/- 17.8%, CAD in 86 [57%], DCM in 24 [16%], ARVCM in 11 [7%]) who received an additional P/S lead between 1990 and 2002 (54 patients with abdominal and 97 patients with pectoral ICD system). Statistical analysis was done using Kaplan-Meier survival curves.

RESULTS

The average follow-up (FU) after implantation of the additional P/S lead was 43 +/- 27 months. In total 117 patients [77.5%] remain implanted; 22 patients died due to cardiac-related reasons. After a FU of 23 +/- 23 months, 43 patients [28.5%] experienced lead-related problems after implantation of the additional P/S lead: oversensing in 23 [53.5%], insulation defect in 3 [7.0%], fracture in 1 [2.3%], system infection in 4 [9.3%], and defect of the HV-P/S lead in 6 [14.0%] patients. The event-free cumulative survival of the additional P/S lead after 1, 2, and 5 years was 87.0%, 79.8%, and 59.4%, respectively (for pectoral leads: 89.6%, 82.0%, and 60.0%, respectively).

CONCLUSIONS

Implantation of an additional P/S lead in case of failure of an HV-P/S lead is safe. However, it is associated with a substantial rate of complications during FU. Therefore, extraction of damaged defibrillation leads instead of implantation of P/S leads should be favored.

Pacemaker and defibrillator lead extraction

PURPOSE OF REVIEW

Continued growth in the elderly population and expanding indications have resulted in a progressive increase in the number of implants of pacemakers and defibrillators. Concomitant with these expanding numbers, more leads require removal, due especially to mechanical dysfunction, the need to upgrade to more complex devices, or local or systemic infection. Further, leads have become more complex, particularly for defibrillator systems, resulting in the development of powered extraction sheaths to expedite their removal. For these reasons, it is important to understand the expanding indications, procedural aspects, and limitations of arrhythmia device extraction.

RECENT FINDINGS

Expanded indications for lead extraction include upgrade to more complex systems, particularly pacemaker to defibrillator or biventricular device, extraction through occluded vasculature to produce a conduit for reimplantation, more frequent removal due to vascular overload with multiple leads, and a finite frequency of infection, occurring particularly with device replacement or revision. Powered sheaths now include laser and electrocautery systems, both improving the ease of lead explantation.

SUMMARY

Complication rates remain low but constant with extraction of larger numbers of leads using new technologies. Expansion of the use of biventricular systems, with implantation of coronary sinus electrodes, will continue to challenge lead extraction in terms of technology and safety. Design of leads that are easier to remove remains of paramount importance.

Nonthoracotomy Implantable Defibrillator Lead Extraction:. Results and Comparison with Extraction of Pacemaker Leads

Extraction of pacemaker leads has been demonstrated to be successful and safe in experienced hands using current tools. Whether application of such techniques and tools yield similar results among patients undergoing extraction of nonthoracotomy implantable defibrillator leads is unknown. This report describes a retrospective analysis of indications, techniques used, and outcome of patients who had a single ventricular nonthoracotomy implantable defibrillator lead extracted at The Cleveland Clinic Foundation. Results were compared to a matched population of patients undergoing extraction of ventricular pacemaker leads from a national registry and to the experience with pacemaker lead extraction at The Cleveland Clinic Foundation. Successful complete extraction of ventricular nonthoracotomy implantable defibrillator leads, in the absence of major complications, was achieved in 96.9% of attempts to extract leads from 161 patients. Clinical success was achieved in 98.1% of patients. Failure occurred in three patients. Two patients had major complications, including one death. The most common indication for extraction was infection (46.6%), followed by lead failure (34.2%). Procedure (140.8 vs 171.2 minutes, P<0.01) and fluoroscopy (9.9 vs 11.0 minutes, P<0.01) times compared favorably with those obtained from the pacemaker lead extraction database. Use of LASER did not influence the safety of the procedure or fluoroscopy times. Extraction of ventricular nonthoracotomy implantable defibrillator leads using currently available tools is a complex but effective procedure. In experienced hands, excellent success rates should be achieved with a low incidence of complications.

A randomized prospective study of single coil versus dual coil defibrillation in patients with ventricular arrhythmias undergoing implantable cardioverter defibrillator therapy

ICD implantation is standard therapy for malignant ventricular arrhythmias. The advantage of dual and single coil defibrillator leads in the successful conversion of arrhythmias is unclear. This study compared the effectiveness of dual versus single coil defibrillation leads. The study was a prospective, multicenter, randomized study comparing a dual with a single coil defibrillation system as part of an ICD using an active pectoral electrode. Seventy-six patients (64 men, 12 women; age 61 +/- 11 years) were implanted with a dual (group 1, n = 38) or single coil lead system (group 2,n = 38). The patients represented a typical ICD cohort: 60% presented with ischemic cardiomyopathy as their primary cardiac disease, the mean left ventricular ejection fraction was 0.406 +/- 0.158. The primary tachyarrhythmia was monomorphic ventricular tachyarrhythmia in 52.6% patients and ventricular fibrillation in 38.4%. There was no significant difference in terms of P and R wave amplitudes, pacing thresholds, and lead impedance at implantation and follow-up in the two groups. There was similarly no difference in terms of defibrillation thresholds (DFT) at implantation. Patients in group 1 had an average DFT of 10.2 +/- 5.2 J compared to 10.3 +/- 4.1 J in Group 2, P = NS. This study demonstrates no significant advantage of a dual coil lead system over a single coil system in terms of lead values and defibrillation thresholds. This may have important bearing on the choice of lead systems when implanting ICDs.

Implantable cardioverter defibrillator lead complications and laser extraction in children and young adults with congenital heart disease: implications for implantation and management

INTRODUCTION

Implantable cardioverter defibrillators (ICDs) are being implanted for primary and secondary prevention of sudden death in children and young adults with congenital heart disease. Over time, ICD leads adhere to venous endothelium and endocardium. Lead removal, when necessary, often requires disruption of this fibrous tissue.

METHODS AND RESULTS

We retrospectively reviewed and analyzed our experience with ICD lead extraction in children and young adults with congenital heart disease. From April 1999 through January 2002, 14 patients underwent 15 lead extraction procedures to remove 21 leads (17 ICD leads and 4 pacing or sensing leads). Seven patients had surgically corrected structural heart disease (5 transposition of the great arteries with atrial switch repair and 2 corrected tetralogy of Fallot). Mean patient age at extraction was 17.9 +/- 5.7 years (range 9-32), and mean duration of lead implantation was 42.0 +/- 18.9 months (range 15-75). Fourteen of 15 procedures were performed for lead fracture or failure. A laser sheath was used for 20 of 21 lead extractions. Twenty of 21 leads (95%) were completely extracted. There were three instances of blood loss requiring transfusion. There were no major complications or deaths.

CONCLUSION

Young congenital heart disease patients with an ICD are at risk for growth-related lead distortion. The use of a laser sheath is safe and effective for ICD lead extraction in congenital heart disease patients, despite coil adherence and altered anatomy. It may be advisable to avoid dual-coil leads in patients with the potential for future growth.