Laser-assist during extraction of chronically implanted pacemaker and defibrillator leads

Comparison of non-laser and laser transvenous lead extraction: a systematic review and meta-analysis

AIMS

Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature. We sought to compare non-laser and laser TLE in a meta-analysis.

METHODS AND RESULTS

We searched Medline, Embase, Scopus, ClinicalTrials.gov, and CENTRAL databases for TLE studies published between 1991 and 2021. From the included 68 studies, safety and efficacy data were carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR), and pooled rates were synthesized from eligible studies to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed. Non-laser in comparison with laser had lower procedural mortality (pooled rate 0% vs. 0.1%, P < 0.01), major complications (pooled rate 0.7% vs. 1.7%, P < 0.01), and superior vena cava (SVC) injury (pooled rate 0% vs. 0.5%, P < 0.001), with higher complete success (pooled rate 96.5% vs. 93.8%, P < 0.01). Non-laser comparatively to laser was more likely to achieve clinical [OR 2.16 (1.77-2.63), P < 0.01] and complete [OR 1.87 (1.69-2.08), P < 0.01] success, with a lower procedural mortality risk [OR 1.6 (1.02-2.5), P < 0.05]. In the subgroup analysis, rotational tool compared with laser achieved greater complete success (pooled rate 97.4% vs. 95%, P < 0.01) with lower SVC injury (pooled rate 0% vs. 0.7%, P < 0.01).

CONCLUSION

Non-laser TLE is associated with a better safety and efficacy profile when compared with laser methods. There is a greater risk of SVC injury associated with laser sheath extraction.

Anesthetic Management of Laser Lead Extraction for Cardiovascular Implantable Electronic Devices

Cardiovascular implantable electronic devices (CIEDs) play a significant role in the modern management of cardiovascular disease. CIEDs include implantable pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. These devices improve the quality of life of their recipients and help reduce the incidence of sudden cardiac death. Traditionally, CIEDs have been reliant on the use of transvenous endocardial leads to directly connect with the heart. Over time, these endovascular leads may become endothelialized rendering removal extremely difficult. As the indications for CIEDs expands and with the continuing evolution of these devices, the number of patients requiring explantation for device recall, malfunction, and infection continues to increase. In this manuscript, we review the most common CIEDs, the indications and process of lead removal/device explantation, potential complications associated with the procedure and the anesthetic management of these patients.

A Novel Video-Assisted Approach to Excimer Laser-Guided Cardiac Implantable Electronic Devices Lead Extraction

OBJECTIVE

Even though roughly 90% of all implanted cardiac implantable electronic devices leads can be removed through conventional techniques, presence of large vegetations or thrombi, fractured leads, previous failed extraction, or long duration from implantation often impede classical transvenous extraction. In these cases, laser-assisted procedures represent a highly successful alternative and have a low procedural complication rate with major adverse events in less than 2% of cases. Unfortunately, most encountered complications are potentially fatal, which prompted us to develop a novel approach that adds additional safety measures by allowing for real-time intrathoracic visualization and intervention.

METHODS

Five consecutive patients classified as high-risk patients received concomitant laser sheet extraction and right-sided uniportal video-assisted thoracic surgery for real-time intrathoracic visualization.

RESULTS

Complete extraction was achieved in all cases without observing major intraoperative events, and on-table extubation was feasible in all cases. No chest tube-associated or incision-related complications were encountered.

CONCLUSIONS

Concomitant laser sheet extraction and video-assisted thoracoscopy are feasible and may offer benefits in high-risk patients. Further studies to document the actual safety and clinical value of our procedure are warranted.

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.

Comparison of standard and modified transvenous techniques for complex pacemaker lead extractions in the context of cardiac implantable electronic device-related infections: a 10-year experience

AIMS

Complete lead extraction of cardiac implantable electronic devices (CIED) for device-related infections remains a complex procedure for chronically implantated leads. We present data from a single-centre registry of consecutive patients with extractions over 10 years.

METHOD AND RESULTS

Patients were identified from the centre's electronic database with CIED-related infections who underwent lead extraction using either the standard technique and equipment or a modified innovative transvenous lead technique extraction using an ablation catheter. Of 151 patients with CIED-related infections, not responding to simple manual traction to effect lead extraction, average age 65 ± 8 years (range 45-82), 64% being male, 75 underwent standard (S) extraction, and 76 underwent modified (M) extraction. Procedural, lead extraction, and fluoroscopy exposure times with S and M methods, respectively, were 65 ± 14 vs. 52 ± 6 min (P < 0.01), 56 ± 12 vs. 36 ± 8 min (P < 0.001), and 48 ± 12 vs. 31 ± 7 min (P < 0.001). Retrieval rates were numerically lower with the standard technique at 92 vs. 96% but did not achieve significance, with respective complication rates of 6.7 and 5.3%.

CONCLUSION

In our single-centre study, a modified extraction technique to retrieve leads for infections of CIEDs using a steerable ablation catheter has improved procedural parameters over the standard technique, without compromising clinical lead extraction success rates. This may be a promising approach for a future, prospective trial.

[Laser sheath extraction of an infected pacemaker lead]

A case of pacemaker electrode infection with Staphylococcus aureus is presented. In order to avoid sternotomy, the right ventricular pacemaker lead, which had been implanted for 15 years, was successfully extracted using a laser sheath despite large endocarditic vegetations on the pacemaker lead. After completion of a 6-week course of antibiotics, the patient was discharged without any further evidence of infection.

Single surgical procedure combining epicardial pacemaker implantation and subsequent extraction of the infected pacing system for pacemaker-dependent patients

OBJECTIVES

Management of pacemaker infection in pacing-dependent patients is often challenging. Typically, temporary pacing is used while antibiotic therapy is given for a number of days before reimplantation of a new endocardial system. This results in a prolonged hospital stay and complications associated with temporary pacing. In this study, we examine the feasibility of performing a single combined procedure of epicardial pacemaker implantation followed by system extraction.

METHODS

One hundred consecutive infected pacemaker-dependent patients underwent implantation of 2 epicardial ventricular leads and were converted to a ventricular demand pacing system. The infected pacing system was then extracted during the same procedure. Patients were followed up for 12 months.

RESULTS

Significant pericardial bleeding developed during the procedure in 3 patients. The presence of the pericardial drain positioned during the implantation of the epicardial pacing system meant that cardiac tamponade did not occur, allowing surgical repair with sternotomy to be carried out under stable hemodynamic conditions. Two of these 100 patients died in the 30-day postoperative period; 1 death was due to septic shock and 1 to pulmonary distress. Median 1-year epicardial pacing thresholds were stable and excellent (1.4 ± 0.9 volts). However, 1 of the 2 leads developed increased thresholds in 6 patients, which led to the exclusive use of other ventricular lead.

CONCLUSIONS

A single combined procedure of surgical epicardial pacemaker implantation and pacemaker system extraction appears to be a safe and effective method for managing pacemaker-dependent patients with infected pacemakers.

Complex lead extraction via subclavian approach using laser technique

Removal of fully intravascular pacing leads may be cumbersome. Herein, we report a technique that may be used to remove intravascular leads using laser technology through a subclavian approach, and discuss the process of lead removal as well as management of potential bleeding from the surgical site. We also address the advantages and pitfalls of this technique as compared to other surgical options.

Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads

AIMS

The aim of the present study was to describe a 10 years single-centre experience in pacing and defibrillating leads removal using an effective and safe modified mechanical dilatation technique.

METHODS AND RESULTS

We developed a single mechanical dilating sheath extraction technique with multiple venous entry site approaches. We performed a venous entry site approach (VEA) in cases of exposed leads and an alternative transvenous femoral approach (TFA) combined with an internal transjugular approach (ITA) in the presence of very tight binding sites causing failure of VEA extraction or in cases of free-floating leads. We attempted to remove 2062 leads [1825 pacing and 237 implantable cardiac defibrillating (ICD) leads; 1989 exposed at the venous entry site and 73 free-floating] in 1193 consecutive patients. The VEA was effective in 1799 leads, the TFA in 28, and the ITA in 205; in the overall population, we completely removed 2032 leads (98.4%), partially removed 18 (0.9%), and failed to remove 12 leads (0.6%). Major complications were observed in eight patients (0.7%), causing three deaths (0.3%).

CONCLUSION

Mechanical single sheath extraction technique with multiple venous entry site approaches is effective, safe, and with a good cost effective profile for pacing and ICD leads removal.

Laser Assistance for Extraction of Chronically Implanted Endocardial Leads: Infectious versus Noninfectious Indications

BACKGROUND

Powered sheaths, including Excimer laser sheaths, were introduced for the removal of transvenous pacing and defibrillator leads. The purpose of this study was to develop an algorithm to better predict which patients are likely to benefit from these devices.

METHODS

We reviewed 283 consecutive patients in whom a total of 500 leads (302 pacing and 198 defibrillator leads) were extracted over a 5-year period at our operative facilities. Laser assist was utilized whenever moderate traction failed.

RESULTS

In 128 patients, 203 leads were removed for noninfectious indication. In 155 patients, 297 leads for infectious indications, including sepsis 22% (111), pocket infection 23% (115), and erosion 14% (71). Laser assistance was required for 6%+/- 5% (+/- 95% confidence interval) of septic leads, 51%+/- 7% of leads associated with erosion or pocket infection and 60%+/- 7% of noninfected leads (P = 0.001). Laser assistance was necessary more often for leads implanted >12 months (53%+/- 5%) than 12 months or less (6%+/- 5%) (P = 0.001) and for ventricular (52%+/- 6%) compared to atrial (35%+/- 7%) leads (P = 0.001).

CONCLUSIONS

Chronically implanted leads (>12 months), especially noninfected leads and leads associated with erosion or pocket infection, should be referred for extraction with powered sheaths to ensure successful removal. However, leads that are associated with systemic sepsis can generally be removed without powered sheaths.

Management of Arterial Injuries Caused by Laser Extraction of Indwelling Venous Pacemaker and Defibrillator Leads

The use of laser technology for the removal of pacemaker and defibrillator leads has decreased the lead extraction time and improved the success rate for complete lead removal when compared to traditional techniques. However, this extraction method may be associated with significant complications. This report documents two cases of iatrogenic arteriovenous fistula created by laser lead extraction. Endovascular repair of these fistulas provides an effective and less invasive alternative to open repair.

Effectiveness of Excimer Laser-Assisted Pacing and ICD Lead Extraction in Children and Young Adults

BACKGROUND

High capture thresholds, decreased electrical sensing, and lead fractures continue to be a problem in children undergoing transvenous pacing. The clinician must therefore decide at the time of pacing system revision to either abandon chronically implanted transvenous pacing leads or extract them.

METHODS

We report our experience using an excimer laser-assisted (LA) strategy for removing chronically implanted pacing (36) and implantable cardioverter/defibrillator (ICD) (7) leads in children and young adults. The study population consisted of 25 patients, in whom 29 procedures were performed. The patients ranged in age from 8.4 to 39.9 years, median age was 13.9 years, at the time of the extraction procedure. In all procedures, a Spectranectics locking stylet and excimer laser sheath were used to assist in lead extraction.

RESULTS

Lead removal was complete for 39 (91%) leads, and partial for four leads. In two patients, the pacing lead tip was retained and in two, the ring electrode from a bipolar pacing lead was left in situ. All ICD leads were removed completely. Two major complications occurred--cardiac perforation and tamponade (1), and thrombosis of the left subclavian/innominate vein (1). LA extraction facilitated the implantation of new pacing or ICD leads in three patients with obstructed venous access.

CONCLUSIONS

Removal of pacing and ICD leads using an excimer LA technique was highly successful. Lead removal was complete in 91%. The most common indication for lead removal in our study was lead fracture. Complications were few, but may be significant.

Transvenous pacemaker lead removal is safe and effective even in large vegetations: an analysis of 53 cases of pacemaker lead endocarditis

BACKGROUND

The aim of this study was to investigate whether transvenous lead removal is safe and effective in patients with lead vegetations greater than 1 cm in size.

METHODS

From 1991 to 2005, a total of 53 patients underwent pacemaker or ICD lead removal for vegetations. Transvenous lead removal using locking stylets and sheaths was performed in 30 patients (56.6%) and was found to be effective in 29 of those patients. In 1 patient, due to rupture of the lead, open heart removal of the ventricular lead remnant and tricuspid valve repair had to be performed due to persistent infection. In 23 of these patients, transesophageal echocardiography (TEE) verified vegetations greater than 1 cm in size. The remaining patients underwent primary lead removal using sternotomy and extracorporeal circulation (ECC). Pacemaker pocket infection was found in 16 patients (55.2%) of the transvenous study group and in 11 patients (45.8%) of the ECC group (P = 0.72).

RESULTS

Perioperative mortality was 5.7% (3 patients); all of them underwent primary ECC removal and had severe endocarditis of the tricuspid valve. None of the patients who underwent transvenous lead removal died and there were no further complications such as pericardial tamponade or major pulmonary embolism requiring further interventions, even in patients demonstrating large vegetations.

CONCLUSIONS

This study demonstrates that transvenous lead removal is a safe and highly effective procedure for the removal of infected pacemaker and ICD leads, even in patients with large vegetations. Embolism to the lung proceeds mainly without further complications; however, patients with vegetations that might obstruct a main stem of the pulmonary artery should undergo ECC removal.

Septic shock induced from an implantable cardioverter-defibrillator lead-associated Candida albicans vegetation

In recent years, the use of implantable cardioverter-defibrillators has made a significant impact in the treatment of cardiac disease. With the advent of this therapy, infection has become a growing concern, with a reported incidence of 1-11%. Although device-related infections are most frequently caused by bacterial pathogens, fungal etiologies are uncommon and carry an exceedingly high mortality rate. To date, there is only one published report of an implantable cardioverter-defibrillator lead-associated infection secondary to Candida albicans. This case report presents the second such case. A review of the literature regarding fungal endocarditis as well as diagnosis and therapy of this rare and dangerous disease is discussed.

Less-Invasive Surgical Extraction of Problematic or Infected Permanent Transvenous Pacemaker System

BACKGROUND

The best management of problematic or infected transvenous permanent pacemaker system is complete surgical or percutaneous intravascular extraction of the pacemaker leads and removal of the generator. We present our experiences in 13 such patients in whom the leads were removed with the less-invasive technique.

METHODS

From 1996 to 2003, 13 patients, from 31 to 83 years of age (mean, 66.9 +/- 14.0 years), with problematic or infected transvenous permanent pacemaker systems were referred to our department for surgical treatment. In 6 patients, the original pacemakers were dual-chamber. A subxiphoid pericardiotomy was used as the monitoring port during the ventricular lead extraction. In addition, a right parasternal pericardiotomy through the third intercostal space was used as the monitoring port during the atrial lead extraction.

RESULTS

Pacemaker systems were completely removed in all patients. Three bleeding episodes (23%), including two right atrial tears and one right ventricular rupture, were successfully circumvented through these monitoring ports. Concomitantly, a new epicardial single-chamber device was implanted through the subxiphoid pericardiotomy whenever indicated in 9 patients. All patients recovered and were discharged uneventfully. At a mean follow-up of 24.8 months (range, 1 to 90 months), no recurrent infections were observed.

CONCLUSIONS

A less-invasive technique for explantation of the complete pacemaker system is feasible. This is a reliable method to eradicate infection. Neither cardiopulmonary bypass nor specific intravascular lead extraction devices, such as locking stylets or laser-assisted sheath, are needed.

Laser Lead Extraction: Is There a Learning Curve?

Laser extraction of device leads offers an attractive alternative to countertraction and electrosurgical dissection sheath, potentially increasing efficacy and reducing complications. Wider adoption of this technology depends on relative ease of use. We report the experience of a new center to define the "learning curve." We performed 76 laser lead extractions in 75 patients (age 63 +/- 17 years, 59 male) from July 2001 to January 2004. Two experienced device implanters who were novice extractors underwent a 2-day site visit to a high volume extraction center for training. Lead extractions were performed in the operating room with immediate surgical backup. The indication for extraction was infection in 39 (systemic in 15), erosion or pain in 11, and lead related or debulking in 25. Complete removal was achieved in 139 of 145 leads (14 ICD, 131 pacemaker). Partial removal (<4 cm retained) was achieved in five leads (4%), and one lead could not be extracted. Complete success was 95% in the first third of patients, 94% in the second third, and 100% in the latter third. Fluoroscopy time fell from 19 +/- 22 minute in the first third of patients to 11 +/- 8 minute in the second third to 8 +/- 4 minute in the latter third (ANOVA P = 0.02). No major complications occurred. Local bleeding required minor left subclavian vein repair in two individuals. Symptomatic venous thrombosis occurred in 3 of the first 11 cases 1-21 days after extraction, but did not occur in the next 64 consecutive patients who received a 1-month anticoagulation regimen (27% vs 0%, P < 0.001). One patient developed venous thrombosis 3 weeks following cessation of warfarin therapy. Practice guidelines reasonably recommend appropriate training prior to independent performance of lead extraction. The current study suggests that experienced device implanters with appropriate operative backup taking a limited, but intensive training program can be safe and effective at lead extraction in a short time, in part a reflection of the improved technology.

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.