Lead Extraction

Percutaneous Lead Extraction in Patients with Large Vegetations: Limiting our Aspirations

Transvenous lead extraction (TLE) in the 1960's involved orthopedic-style pulley systems that joined the exposed portion of the lead to progressively heavier weights hanging from the bed This article is protected by copyright. All rights reserved.

Re-implantation after extraction of a cardiac implantable electronic device

Background: With increasing cardiovascular implantable electronic device (CIED) implantations, growing number of extractions of leads and devices are noted, mainly for complications such as infection and lead dysfunction. The optimal timing for re-implantation remains uncertain. We  investigated the time to eventual re-implantation of CIEDs in the University Hospitals Leuven, Belgium.Methods: All consecutive patients, referred for extraction between January 2005 and December 2016, were analysed for the timing of eventual re-implantation.Results: Two-hundred and forty-three patients were included. Mean follow-up was 77 ± 37 months. Global re-implantation rate was 89.3%: 100% for lead dysfunctions versus 80.7% following infections. Median time to re-implantation (TTR) was 0 [0-111] days and 8.5 [0-3025] days, respectively (p < .001). Globally 0 [0-3025] days. Re-implantation was performed in 83.2% of pacemaker patients, compared to 95.8% of defibrillator patients (p < .001). Median TTR was 4 [0-3025] days and 0 [0-345] days, respectively (p < .001). In AV-block related pacemaker indications, 90% were re-implanted, compared to 78% for symptomatic indications (p = .09). Median TTR was 2 [0-3025] and 6 [0-2047] days, respectively (p = .02). Re-implantation was performed in 96.7% of defibrillator patients with a secondary prevention indication, compared to 94.7% with primary prevention indication (p = .59). Median TTR was 0 [0-164] and 0 [0-345] days, respectively (p = .472).Conclusions: Ten percent of CIEDs is not re-implanted after extraction. CIEDs are re-implanted more often and earlier after extraction for lead dysfunction than after extraction for infectious reasons. Pacemakers are re-implanted less and later than defibrillators. Re-implantation is performed faster in stronger clinical CIED indications.

Transesophageal Echocardiography As a Monitoring Tool During Transvenous Lead Extraction-Does It Improve Procedure Effectiveness?

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.

Transvenous Lead Extraction SAFeTY Score for Risk Stratification and Proper Patient Selection for Removal Procedures Using Mechanical Tools

Background: To ensure the safety and efficacy of the increasing number of transvenous lead extractions (TLEs), it is necessary to adequately assess the procedure-related risk. Methods: We analyzed potential clinical and procedural risk factors associated with 2049 TLE procedures. The TLEs were performed between 2006 and 2016 using only simple tools for lead extraction. Logistic regression analysis was used to develop a risk prediction scoring system for TLEs. Results: Multivariate analysis showed that the sum of lead dwell times, anemia, female gender, the number of procedures preceding TLE, and removal of leads implanted in patients under the age of 30 had a significant influence on the occurrence of major complications during a TLE. This information served as a basis for developing a predictive SAFeTY TLE score, where: S = sum of lead dwell times, A = anemia, Fe = female, T = treatment (previous procedures), Y = young patients, and TLE = transvenous lead extraction. In order to facilitate the use of the SAFeTY TLE Score, a simple calculator was constructed. Conclusion: The SAFeTY TLE score is easy to calculate and predicts the potential occurrence of procedure-related major complications. High-risk patients (scoring more than 10 on the SAFeTY TLE scale) must be treated at high-volume centers with surgical backup.

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.

Innominate vein-right atrial bypass for relief of superior vena cava syndrome due to pacemaker lead thrombosis

We present a patient with superior vena cava (SVC) obstruction due to multiple intraluminal pacemaker leads. Previous attempts at balloon dilatation of the SVC and surgical angioplasty did not provide a long-term solution. A Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ, USA) conduit interposed between the innominate vein and right atrial appendage has resulted in symptomatic relief at a follow-up of 6 months.

Successful management of multiple permanent pacemaker complications--infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis

A 59 year old man underwent mechanical tricuspid valve replacement and removal of pacemaker generator along with 4 pacemaker leads for pacemaker endocarditis and superior vena cava obstruction after an earlier percutaneous extraction had to be abandoned, 13 years ago, due to cardiac arrest, accompanied by silent, unsuspected right atrial perforation and exteriorisation of lead. Postoperative course was complicated by tricuspid valve thrombosis and secondary pulmonary embolism requiring TPA thrombolysis which was instantly successful. A review of literature of pacemaker endocarditis and tricuspid thrombosis along with the relevant management strategies is presented. We believe this case report is unusual on account of non operative management of right atrial lead perforation following an unsuccessful attempt at percutaneous removal of right sided infected pacemaker leads and the incidental discovery of the perforated lead 13 years later at sternotomy, presentation of pacemaker endocarditis with a massive load of vegetations along the entire pacemaker lead tract in superior vena cava, right atrial endocardium, tricuspid valve and right ventricular endocardium, leading to a functional and structural SVC obstruction, requirement of an unusually large dose of warfarin postoperatively occasioned, in all probability, by antibiotic drug interactions, presentation of tricuspid prosthetic valve thrombosis uniquely as vasovagal syncope and isolated hypoxia and near instantaneous resolution of tricuspid prosthetic valve thrombosis with Alteplase thrombolysis.

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.

Problems with implantable cardiac device therapy

Implantable cardioverter-defibrillators (ICDs) improve survival in patients who have left ventricular dysfunction; however, they are associated with numerous problems at implant and during follow-up. The diagnosis and management of these problems is usually straightforward, but more difficult problems may include the management of patients who have elevated energy requirements to terminate ventricular fibrillation or of those who have postoperative device infections. Long-term issues in ICD patients include the occurrence of inappropriate or frequent appropriate shocks. ICD generators and leads are more prone to failures than are pacing systems alone; management of patients potentially dependent on "recalled" devices to deliver life-saving therapy is a particularly complex issue. The purpose of this article is to review the diagnosis and management of these more troublesome ICD problems.

Laser-assisted lead extraction: the European experience

AIMS

The aim of this study is to investigate the safety and effectiveness of Excimer laser-assisted lead extraction in Europe. The final European multi-centre study experience is presented.

METHOD AND RESULTS

The Excimer is a cool cutting laser (50 degrees C) with a wavelength of 308 nm. The energy is emitted from the tip of a flexible sheath and is absorbed by proteins and lipids, 64% of the energy is absorbed at a tissue depth of 0.06 mm. The sheath is positioned over the lead, and the fibrosis surrounding the lead is vaporized while advancing the sheath without damaging other leads. From August 1996 to March 2001, 383 leads (170 atrial, 213 ventricular) in 292 patients (mean age 61.6 years, range 13-96) were extracted at 14 European centres. Mean implantation time was 74 months (3-358). Most frequent indications were pocket infection (26%), non-functional leads (21%), patient morbidity (21%), septicaemia or endocarditis (14%), erosion (5%), and lead interference (8%). Median extraction time was 15 min (1-300). Complete extraction was achieved in 90.9% of the leads and partial extraction in 3.4%. Extraction failed in 5.7% of the leads. Major complications = perforations caused 10/22 (3.4/5.7%) of the failures. Most partially extracted patients were considered clinically successful, as only minor lead parts without clinical significance were left. Femoral non-laser technique was used to remove 8/12 of the non-complication failures. The total complication rate, including five minor complications (1.7%), was 5.1%. No in-hospital mortality occurred.

CONCLUSION

Pacing and implantable cardioverter-defibrillator leads can safely, effectively, and predictably be extracted. Open-heart extractions can be limited to special cases. The results indicate that the traditional policy of abandoning redundant leads, instead of removing them, may be obsolete in many patients.

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.

Laser Lead Extraction: Predictors of Success and Complications

BACKGROUND

Paralleling the rise in pacemaker and defibrillator implantations, lead extraction procedures are increasingly required. Concerns regarding failure and complications remain.

METHODS AND RESULTS

A total of 200 lead extraction procedures were performed at the Montreal Heart Institute between September 2000 and August 2005. In 23 patients, all leads were removed by traction with a locking stylet. A total of 270 leads were extracted using a laser sheath system (Spectranectics, Colorado Springs, CO, USA) in 177 procedures involving 175 patients (74% male), age 62+/-16 years. Procedural indications were: infection 88 (50%), dysfunction 54 (30%), upgrade 21 (12%), and other 14 (8%). Overall, 241 leads (89%) were successfully extracted, 7 (3%) were partially extracted (< or = 4 cm retained), and 22 (8%) were non-extractable. In multivariate analyses, predictors of failed extraction were longer time from implant (OR 1.16 per year, P=0.0001) and history of hypertension (OR 5.2, P=0.0023). Acute complications occurred in 14 of 177 procedures (7.9%): 8 (4.5%) minor and 6 (3.4%) major, with one death. In multivariate analyses, the only predictor of acute complications was laser lead extraction from both right and left sides during the same procedure (OR 9.4, P = 0.0119). In addition, 3 of 10 patients with failed or partially extracted infected systems eventually required open chest explantation because of endocarditis.

CONCLUSION

Most leads not amenable to manual traction may be successfully extracted by a percutaneous laser sheath system. While most complications are minor, major complications including death may occur. Older leads are at higher risk for failed extraction. Endocarditis may ensue if infected leads are incompletely removed.

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.

Implications and Outcome of Permanent Coronary Sinus Lead Extraction and Reimplantation

OBJECTIVE

We examined the implications and outcome of coronary sinus (CS) lead removal including the feasibility of laser use within the CS.

BACKGROUND

Cardiac anatomy and lead interactions are more complex with the advent of biventricular pacemakers and atrial cardioverters requiring permanent lead/shocking coil placement in the coronary sinus and its branches.

METHODS

Fifty-five permanent cardiac leads were extracted during 2003 in 28 consecutive patients. Our study population included a 10/55 (18%) subset (all males; age 73 +/- 6 years; EF = 0.24 +/- 0.09) that underwent CS (1/10) or vein branch (9/10) lead extraction. Leads were extracted with an excimer laser sheath (n = 4) or by direct traction (n = 6). Median times between implantation and lead removal were 9.5 months (range 5-59) in the laser group and 3 months (range 3-4) in the direct traction group. Indication for extraction was infection (n = 4), dislodgement (n = 3), diaphragm stimulation (n = 2), and elevated threshold (n = 1). The CS was divided into distal, mid, and proximal segments by venogram.

RESULTS

Entry of the laser sheath into the CS was necessary in three of four laser patients. The two distal CS laser cases (left lateral CS coil and anterior-lateral left ventricular (LV) lead) required both 14- and 12-Fr sheaths, separately. The proximal CS laser case (posterior-lateral LV lead) required a 12 Fr sheath. The remaining laser patient required a 12-Fr sheath to pass to the mid SVC. There were no procedural complications as a result of CS lead extraction. Reimplantation of a CS lead was attempted in 7/10 patients at a median of 4 days (range 1-300). CS venograms were available for review in patients before initial implantation (6/10) and after extraction (7/10). The postextraction venograms demonstrated complete occlusion of the vein from which the lead was extracted, and its distal branches, which were unusable in 5/10 (50%). The vein occlusions were present in patients with indwelling leads for greater than 3 months and were independent of extraction method.

CONCLUSIONS

Laser lead extraction in the coronary sinus appears feasible in carefully selected cases with mandatory indications. However, special intraoperative monitoring and echocardiographic imaging with surgical backup ready is strongly recommended. Target vein selection may be limited for the purpose of reimplantation when leads are indwelling for greater than 3 months.

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.

Endocardial pacemaker or defibrillator leads with infected vegetations: a single-center experience and consequences of transvenous extraction

BACKGROUND

Removal of infected endovascular leads if often required for cure of systemic infection, but the perceived risk of embolic events in the presence of large (>10 mm) vegetations has been considered a relative contraindication to transvenous removal. Surgical removal of pacemaker leads has been suggested in this situation to avoid occurrence of pulmonary embolization.

METHODS

Of 38 patients with infection of implanted pacemaker or cardioverter-defibrillator devices, those with evidence for systemic infection underwent transesophageal echocardiography to assess for the presence of vegetations.

RESULTS

Vegetations on endocardial leads or right-sided cardiac structures ranging in size from 10 mm to 38 mm in their largest dimension were detected in 9 patients. All patients underwent successful transvenous removal of endocardial leads. Five of 9 patients (55%) had evidence of pulmonary embolism. However, all 5 patients made a full recovery with antibiotic treatment and anticoagulation. Among patients with endocardial vegetations, there was no difference in hospitalization periods between those with or without pulmonary embolism (14.6 +/- 0.8 days vs 18.0 +/- 4.5 days, P =.7).

CONCLUSIONS

Transvenous removal of infected pacemaker leads is an alternative to open-thoracotomy removal of infected leads. Fifty-five percent of patients with vegetations on endocardial leads in our series experienced pulmonary embolism, but neither survival nor length of hospital stay were affected by this complication.

Venous occlusion of the access vein in patients referred for lead extraction: influence of patient and lead characteristics

The aim of this study was to determine the effect of patient and lead characteristics on occlusion of the access vein in pacemaker and ICD patients. Contrast venography of the access vein was obtained in 89 patients (17 patients with an ICD) scheduled for lead extraction. The indication for extraction was infection in 57 patients (systemic infection in 9) and lead malfunction in 32 patients. In 6 of the 89 patients, leads were introduced in both the right and left subpectoral area, resulting in a total of 95 venous entry sites. In 22 of these entry sites one lead was present, in 61 two leads, in 11 three, and in 1 four leads. The vessel patency was graded open or occluded. Occlusion of the subclavian vein occurred in four (13%) patients with lead malfunction versus 18 (32%) patients with infection (P = 0.07). In patients with systemic infection, 5 of 9 showed venous occlusion (P = 0.01 when compared to patients with malfunction, odds ratio 8.75, 95% confidence interval 1.21-64.11). Considered per entry site, the incidence of occlusion was 7 of 22 with one lead present, 17 of 61 with two leads, 0 of 11 with three leads, and 0 of 1 with four leads (P = 0.13). No patient had a superior vena caval occlusion. Patients with systemic infection have an increased risk of occlusion of the access vein. On the contrary, the study found no support for the concept that the risk of venous occlusion increases with a higher number of leads present.

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

BACKGROUND

Extraction of chronically implanted pacing and defibrillator leads has historically been difficult, occasionally requiring open surgical procedures. The purpose of this study was to evaluate the efficacy, safety, and potential need for percutaneous laser-assisted sheath techniques for extraction of chronically implanted leads.

METHODS

From January 1999 to August 2001, 128 consecutive patients underwent extraction of 229 leads (138 pacing, 91 defibrillator) in the operating room 61 +/- 44 (mean +/- standard deviation) months after implantation. Common indications included erosion or pocket infection (41%), lead dysfunction (30%), and sepsis (13%).

RESULTS

Laser techniques were used for 56% +/- 4% (104 of 186) of long-term (implanted for more than 1 year) leads, compared with only 16% +/- 6% (7 of 43) of short-term (implanted for less than 1 year) leads (p < 0.001). For infected leads, laser was used in 53% +/- 5% (49 of 92) with erosion or pocket infections, compared with only 3% +/- 4% (1 of 29) with sepsis (p < 0.001). Extraction was complete in 88%, near complete (retained tip) in 10%, and incomplete in 2%. Two patients required a later percutaneous femoral venous approach to remove mobile retained segments, but no patients required cardiac surgery for extraction. Complications included sternotomy for subclavian vein injury (1), chest tube for caval perforation (1), innominate vein thrombosis (1), and partial clavicle removal for subclavian vein repair (2). There were no procedure-related deaths.

CONCLUSIONS

Laser-assisted lead extraction is safe, but it is best performed in the operating room; it should be available for long-term leads, except when they are grossly infected, producing sepsis. Laser techniques have essentially eliminated the need for open surgical removal of retained leads.

Advances in device lead extraction

The removal of chronically implanted pacemaker and defibrillator leads has evolved over the past 20 years into an integral part of the medical and surgical practice of electrophysiology. It is the basis for management of device-related complications. Lead removal has progressed from just pulling, to a sophisticated procedure based on telescoping sheaths, counterpressure, and countertraction. Current telescoping sheaths have a powered tip (laser or electrosurgical) for more efficient extirpation of leads from encapsulating fibrous tissue. The management of a device infection exemplifies the spectrum of procedures ranging from debridement of inflammatory tissue to transvenous, transatrial, or epicardial lead reimplantation (care must be given to the consequences of chronic implant complications such as superior vein occlusion). The magnitude of these lead removal procedures ranges from a transvenous procedure to cardiopulmonary bypass removing a pannus of infected material. Current procedure related mortality is less than 0.2% at experienced centers.

Pacemaker leads: a simple atraumatic method for replacing pacemaker electrodes

Early dislodgment or malfunction of pacemaker leads can result in significant morbidity and therefore must be corrected promptly. We describe a method of changing pacemaker leads that is atraumatic, maintains central venous access, and eliminates the need for venipuncture. Our technique is simple, highly reproducible, and can be performed with standard operating room instruments.

Successful laser-assisted percutaneous extraction of four pacemaker leads associated with large vegetations

A man with four endocardial pacemaker leads and two vegetations (1.5 cm and 1 cm) underwent successful percutaneous laser-assisted lead extraction. Although this procedure was complicated by embolization to a left pulmonary arterial branch, the patient recovered without sequelae. This article reviews the literature on lead extraction associated with large vegetations.

Large laser sheaths for pacing and defibrillator lead removal

BACKGROUND AND OBJECTIVE

In a recent clinical trial, the 12-F laser sheath showed 95% success in completely explanting chronically implanted pacing leads smaller than 7.5-F diameter. For larger leads, two new sizes of laser sheath have been implemented, the 14-F and 16-F (outer diameter) devices, which accommodate leads up to 9.5- and 11.5-F, respectively. The object of this study was to determine the cutting ability of the larger devices compared to the 12-F design.

MATERIALS AND METHODS

The rate of device advancement through fresh porcine aorta was measured for three sizes of laser sheath as pulsed ultraviolet light from a 308-nm XeCl excimer laser was applied. Dependent variables were fluence (mJ/mm2), laser pulse repetition rate, and pressure applied between the device and the tissue.

RESULTS

At 60 mJ/mm2, 40 Hz repetition rate and 1.4 kg/cm2 pressure, all devices produced cutting rates in the range of 9-13 microns/pulse. Improvement in advancement per laser shot can be attained by increasing any independent variable studied.

CONCLUSIONS

Physicians must apply only slightly greater force to the larger laser sheaths, and maximum available repetition rate and fluence implies maximum cutting speed.

[Perforating epicardial lead: atypical evolution]

Endocarditis related to pacemaker lead is a rare complication of permanent transvenous pacing, of which the diagnosis is carried out with the presence of verrucae in echocardiography and positive blood cultures, its treatment being mixed -medical and surgical- because the isolated medical treatment is rarely successful and the lead should be extracted. We present the case of recurrent endocarditis of several years of evolution, in the which it was not possible to extract of the electrode due to the special characteristics of the patiente (epicardial lead perforating into right atrial).

Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, training. North American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty

The procedure of lead removal has recently matured into a definable, teachable art with its own specific tools and techniques. It is now time to recognize and formalize the practice of lead removal according to the current methods of medicine and the health care industry. In addition, since at this time the only prospective scientific study of lead extraction is the PLEXES trial, we suggest that studies relating to the techniques of and indications for lead extraction be designed. Recommendations for a common set of definitions, for a framework of training and reviewing physicians in the art, for general methods of reimbursement, and for consistency among clinical trials have been made. Implementation of these recommendations will require additional effort and cooperation from practicing physicians, medical societies, hospital administrations, and industry.

[Secondary infections after pacemaker implantation]

INTRODUCTION

Infectious complications following pacemaker implantation are not common but may be particularly severe. Localized wound infections at the site of implantation have been reported in 0.5% of the cases in the most recent series, with an average of about 2%. The incidence of septicemia and infectious endocarditis is lower, about 0.5% of the cases. The operator's experience, the duration of the procedure and repeat procedures are considered to be predisposing factors.

CURRENT KNOWLEDGE AND KEY POINTS

The main cause of these infections has been recently demonstrated to be local contamination during implantation. The commonest causal organism is Staphylococcus (75 to 92% of the cases), Staphylococcus aureus being the cause of acute infections (less than 6 weeks), whereas Staphylococcus epidermidis is associated with cases of secondary infection (more than 2 months). The usual clinical presentation is infection at the site of the pacemaker but other forms such as abscess, endocarditis, rejection of the implanted material, septic emboli or phlebitis have been described. The diagnosis is confirmed by local and systemic biological investigations and by echocardiography (especially transesophageal echocardiography) in cases of right heart endocarditis. There are two axes of treatment: bactericidal double antibiotherapy and surgical ablation of the infected material either percutaneously or by cardiotomy.

FUTURE PROSPECTS AND PROJECTS

A recent meta-analysis supported the role of systematic, preoperative, prophylactic antibiotic therapy in the prevention of these complications. These data should be confirmed by suitably powered clinical trials.

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

Previous studies of the removal of implantable cardioverter defibrillator (ICD) leads have been restricted to case reports or small series. In this report, we describe our experience in ICD lead extraction by intravascular countertraction method using Cook's extraction kit. A total of 47 high-voltage (HV) leads, 3 rate sensing (S) leads, and 2 subcutaneous arrays were removed from 42 patients (33 men, 9 women; mean age 59 years [range 14 to 81]). One HV superior vena cava (SVC) lead and 11 HV right ventricular (RV) leads were explanted by manual traction only and defined in the "lead removal" category. One S lead was removed using a femoral venous approach. The remaining 37 leads were explanted by SVC approach using extraction sheaths and defined in the "lead extraction" category. Twenty leads were extracted for "infectious" (group A) and 17 leads for "noninfectious" (group B) etiologies for which extraction times of 27.0+/-18.0 and 27.0+/-15.0 minutes (mean+/-SD), respectively, were not different. Although extraction time, 34.0+/-11.0 minutes, for leads implanted for >48 months was longer than 23.0+/-16.0, 28.0+/-18.0, and 24.0+/-14.0 minutes, for leads with implant durations of 12, 24, and 48 months, respectively, such differences were not statistically significant. The extraction time, however, was directly related to the degree of fibrosis around the lead, 39.0+/-15.0 minutes for leads with severe fibrosis compared with 13.0+/-6.0 minutes for the leads with mild fibrosis (p<0.001). Patient's age, sex, or history of coronary artery bypass graft surgery did not significantly affect extraction time. All except the initial 2 lead extractions were performed in the electrophysiology laboratory. No mortality or serious complications associated with the procedure using these methods were observed.

Current concepts in extraction of transvenous pacing and ICD leads

Extraction of chronically implanted pacing leads involves a thorough understanding of the pathophysiology of lead maturation and the problems that may occur. It also requires specific knowledge of lead construction and the idiosyncrasies of individual lead models. Though we have evolved to use a standardized approach to lead extraction, each patient and lead removal is unique. The operator must be ready to adapt the technique and tools used to the situation at hand. The more experience and the more tools available to the operator, the more likely that there will be a safe and successful outcome to the procedure. Preparation for disaster is mandatory, such that when a complication does occur, one may respond quickly and therefore salvage the patient.

Intravascular extraction of problematic or infected permanent pacemaker leads: 1994-1996. U.S. Extraction Database, MED Institute

Of the 400,000-500,000 permanent pacemaker leads implanted worldwide each year, around 10% may eventually fail or become infected, becoming potential candidates for removal. Intravascular techniques for removing problematic or infected leads evolved over a 5-year period (1989-1993). This article analyzes results from January 1994 through April 1996, a period during which techniques were fairly stable. Extraction of 3,540 leads from 2,338 patients was attempted at 226 centers. Indications were: infection (27%), nonfunctional or incompatible leads (25%), Accufix or Encore leads (46%), or other causes (2%). Patients were 64+/-17 years of age (range 5-96); 59% were men, 41% women. Leads were implanted 47+/-41 months (maximum 26 years), in the atrium (53%), ventricle (46%), or SVC (1%). Extraction was attempted via the implant vein using locking stylets and dilator sheaths, and/or transfemorally using snares, retrieval baskets, and sheaths. Complete removal was achieved for 93% of leads, partial for 5%, and 2% were not removed. Risk of incomplete or failed extraction increased with implant duration (P<0.0001), less experienced physicians (P<0.0001), ventricular leads (P<0.005), noninfected patients (P<0.0005), and younger patients (P<0.0001). Major complications were reported for 1.4% of patients (<1% at centers with >300 cases), minor for 1.7%. Risk of complications increased with number of leads removed (P<0.005) and with less experienced physicians (P<0.005); risk of major complications was higher for women (P<0.01). Given physician experience, appropriate precautions, and appropriate patient selection, contemporary lead removal techniques allow success with low complication rates.

Transesophageal echocardiographic visualization of left ventricular malpositioned pacemaker electrodes: implications for lead extraction procedures

Two cases of malpositioned LV electrodes are presented. Transesophageal echocardiography (TEE) allowed for a careful inspection of left-sided leads and for tracking their course. One LV and two right-sided leads were safely retrieved with TEE monitoring. One chronic LV lead was left in place as it was heavily fibrosed. TEE was helpful in the inspection and monitoring of the extraction and also in guided traction efforts. This is the first published report of echocardiographic visualization of the lead retrieval procedure.

Initial experience with larger laser sheaths for the removal of transvenous pacemaker and implantable defibrillator leads

BACKGROUND

In a previous randomized trial, the 12F laser sheath removed pacing leads via the implant vein more successfully than traditional mechanical tools alone. Two larger sizes of laser sheath, the 14F and 16F models, were developed to extract defibrillator leads and large-diameter pacing leads implanted for the chronic. These devices use pulsed ultraviolet laser light to core though fibrotic tissue grown over the lead body to free the lead from the vasculature. A mandatory prospective registry studied the safety and effectiveness profiles of the larger laser sheaths vis-à-vis the 12F laser sheath.

METHODS AND RESULTS

In this study, 863 patients underwent extraction of 1285 leads at 52 sites. Patients treated with the 14F device tended to have older leads than the 12F population; the 16F population, which comprised mostly defibrillator patients, were younger, had younger leads, and were more often male than the 12F population. Clinical success (extracting the entire lead or the lead body minus the distal electrode) was observed in 91% to 92% of cases for all device sizes. The overall complication rate was 3.6%, with 0.8% perioperative mortality. Incidence of complications was independent of laser sheath size.

CONCLUSIONS

The 14F and 16F laser sheaths offer an extraction option for larger long-term transvenous pacemaker and defibrillator leads that is as safe and effective as the 12F laser sheath.

Single center experience with femoral extraction of permanent endocardial pacing leads

Between March 1995 and June 1997, 128 leads were extracted from the hearts of 28 women and 50 men, 69 +/- 15 years of age (mean +/- SD, range 22-92 years). The indications for the procedure were: Accufix leads in 18 patients (14%), dysfunction or incompatibility with ICD in 16 (12%), endocarditis on the lead in 41 (32%), pulse generator pocket infection in 28 (22%), and pulse generator and/or lead erosion in 25 patients (19%). The extraction was performed with a snare (lasso), via a femoral vein as a first approach in 116 leads, and as an alternate approach, after extraction from the original site of implantation had failed, in 12 leads. The leads had been implanted for 62 +/- 48 months (range 1-205 months). A Cook sheath was used in 7, and a femoral approach traction in 20 instances. Of the 128 leads, 122 (95%) were completely extracted, and 2 (2%) were partially extracted (the distal electrode remaining attached to the myocardium), and 4 (3%) could not be removed. Four complications occurred: 2 tears of the tricuspid valve without clinical consequences, one separation of the lead's distal electrode which migrated into the hypogastric vein, and one hemorrhage at the femoral puncture site. There was no death or serious complication caused by lead extraction in this series.

Excimer laser assisted extraction of permanent pacemaker and ICD leads: present experiences of a European multi-centre study

OBJECTIVE

Excimer Laser technique can be used to extract leads. We present the European multi-centre experience.

METHOD

The Spectranetics Excimer Laser is a Xenon-Chloride laser with a wavelength of 308 nm, not visible to the human eye. This cool cutting laser (50 degrees C) has an absorption depth of 0.06 mm. The laser energy is emitted from the tip of flexible 12, 14 or 16 French (Fr) probes and is absorbed by proteins and lipids. The fibrotic sheaths usually surrounding leads can be cut without damaging the endothelial wall or the insulation of other leads.

RESULTS

From August 1996 to August 1998, 179 leads (104 atrial, 57 ventricular, one SVC, 17 ICD) in 149 patients (mean age 68.3 years, range 14-94) were extracted in 11 centres. Mean implantation time was 68.3 months (2.8-357.8). Most common indications were patient morbidity, non-function, pocket infection, septicaemia or endocarditis. Median extraction time was 10 min (1-189). Most procedures (78%) were performed in operating rooms. Complete extraction was achieved in 89.5% of the leads, 6% were partially extracted and 4.5% of the extractions failed. In the majority of the partial cases, only minor lead parts without clinical significance were left. Of the failures, 3/8 were completely removed by femoral non-laser approach, 1/8 with a right subclavian approach and 1/8 with thoracotomy. Complications were few but included one ventricular perforation that did not need surgery; two other perforations were related to the reimplantation of leads and required surgery. Mean hospital stay was 3 days and all patients were discharged well and alive.

CONCLUSIONS

Excimer Laser assisted lead extraction is a safe and efficacious procedure. Open-chest extractions are still necessary but can be limited to very selected cases. These initial results may widen indications from mandatory to include the extraction of many non-functional leads, previously abandoned.

Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the excimer sheath (PLEXES) trial

OBJECTIVES

The purpose of this study was to evaluate the safety and effectiveness of pacemaker lead extraction with the excimer sheath in comparison to nonlaser lead extraction.

BACKGROUND

Fibrotic attachments that develop between chronically implanted pacemaker leads and to the venous, valvular and cardiac structures are the major obstacles to safe and consistent lead extraction. Locking stylets and telescoping sheaths produce a technically demanding but effective technique of mechanically disrupting the fibrosis. However, ultraviolet excimer laser light dissolves instead of tearing the tissue attachments.

METHODS

A randomized trial of lead extraction was conducted in 301 patients with 465 chronically implanted pacemaker leads. The laser group patients had the leads removed with identical tools as the nonlaser group with the exception that the inner telescoping sheath was replaced with the 12-F excimer laser sheath. Success for both groups was defined as complete lead removal with the randomized therapy without complications.

RESULTS

Complete lead removal rate was 94% in the laser group and 64% in the nonlaser group (p = 0.001). Failed nonlaser extraction was completed with the laser tools 88% of the time. The mean time to achieve a successful lead extraction was significantly reduced for patients randomized to the laser tools, 10.1 +/- 11.5 min compared with 12.9 +/- 19.2 min for patients randomized to nonlaser techniques (p < 0.04). Potentially life-threatening complications occurred in none of the nonlaser and three of the laser patients, including one death (p = NS).

CONCLUSIONS

Laser-assisted pacemaker lead extraction has significant clinical advantages over extraction without laser tools and is associated with significant risks.

Reliability of coated wire defibrillation leads

A higher rate of complications and need for reoperation has been identified with epicardial and endocardial defibrillator systems. Improved reliability may be achieved with alternate designs that use coated wire and coated coil conductors. Six-year reliability in the 98% range is reported for one bipolar design, the Sulzer Intermedics Intervene lead.

Stent dilation of superior vena cava and innominate vein obstructions permits transvenous pacing lead implantation

The purpose of this study was to assess the feasibility of stent dilation of venous obstructions/occlusions to permit transvenous pacing lead implantation. Innominate vein or superior vena cava (SVG) obstruction may preclude the implantation of transvenous pacing leads. Patients with d-transposition of the great arteries, after a Mustard or Senning procedure, and children with previously placed transvenous pacing leads are at higher risk for this vascular complication. From May 1993 to January 1996, eight pediatric patients who underwent transvenous pacing lead implantation or replacement were found to have significant innominate vein or SVC obstruction or occlusion. Utilizing intravascular stents, a combined interventional and electrophysiological approach was used to relieve the venous obstruction and to permit implantation of a new transvenous pacing lead. Two patients had complete SVC occlusion requiring puncture through the obstruction with a transseptal needle. Vessel recanalization was achieved with balloon dilation and stent implantation. The remaining six patients had severe venous obstruction with a mean minimum diameter of 3.1 +/- 3.3 mm. The mean pressure gradient across the obstructed veins was 8.6 +/- 7.3 mmHg. Following implantation of 15 Palmaz P308 stents in eight vessels, the mean diameter increased to 14.2 +/- 1.9 mm and the mean pressure gradient across the stented vessels decreased to 1.0 +/- 2.0 mmHg. A transvenous pacing lead was implanted successfully through the stent(s) immediately or 6-8 weeks later. Innominate vein and SVC obstruction can be safely and effectively relieved with intravascular stents and permit immediate or subsequent transvenous pacing lead implantation.

Chronic atrial lead explantation using a staged percutaneous laser and open surgical approach

We report a staged approach to the explantation of a passive fixation atrial lead 4 years after implantation in a patient with extracardiac J wire protrusion. The body of the lead, from the venous entry site to the proximal electrode, was freed from extensive fibrous binding using an investigational Excimer laser lead extraction sheath. The distal end and J wire were freed and the lead was removed at thoracotomy. This staged approach offered a safe and effective method for the removal of a heavily fibrosed chronic endocardial lead.

Teletronics 330-801 atrial lead extraction via the subclavian approach

BACKGROUND

The Telectronics 330-801 atrial J (801) lead was recalled after reports implicated lead fracture/retention wire protrusion in patient mortality and morbidity. Recent reports suggest that 801 lead extraction may be associated with substantial morbidity and, possibly, excess mortality. We hypothesized that the 801 lead could be extracted using the subclavian approach with a high success rate and acceptable morbidity.

METHODS

We analyzed the clinical outcomes in 60 consecutive patients who underwent 801 lead extraction.

RESULTS

Sixty patients (34 women) with a mean age of 67 +/- 14.8 years had 18 class I, 13 class II, and 29 class III fractures. The lead age was 39 +/- 17 months. The subclavian approach was successful in 58 of 60 patients (96%). Complications, three major and eight minor, occurred in 10 of 60 patients (16%). All complications were successfully treated. There were no deaths. Only concurrent ventricular lead extraction was associated with complications (p = 0.008 by Fisher's exact test).

CONCLUSIONS

Telectronics 801 leads can be successfully extracted using the subclavian approach with acceptable short-term morbidity, low mortality, and excellent long-term results.

Pacemakers

Rapid advances in pacing technology will continue to affect the quality of life of many patients with cardiovascular disease. A truly "smart" device that seemed fanciful 30 years ago now seems to be a virtual certainty by early in the next century. The surgical contributions and expertise of individuals trained in cardiothoracic surgery in these bradypacing developments is highly desirable to minimize morbidity to the greatest possible degree, to optimize the outcome of the procedure for the individual patient, and to conserve health care costs as much as possible. To maintain this cardiothoracic presence in cardiac pacing, acquisition of knowledge and expertise in the basic electrophysiology and technology of cardiac pacing, to go along with surgical expertise, is necessary on the part of individuals with the interest and opportunity to do so.

Surgical management of infected permanent transvenous pacemaker systems: ten year experience

BACKGROUND

Between January 1985 and June 1995, more than 1800 consecutive patients underwent implantation of a new permanent cardiac pacemaker at our institution. Thirty-six patients (0.02%) had 45 reinterventions for infected pacemaker systems.

METHODS

in group A, 24 of 27 patients received simultaneous implantation of a new pacemaker. One had reimplantation of the same pacemaker in the same pocket, and two did not require reimplantation. The leads were retained in 19 (70%) of the patients. In group B, nine patients underwent cardiopulmonary bypass or "pursestring" surgery for removal of an infected pacemaker; a new epicardial pacemaker system was simultaneously implanted in seven patients.

RESULTS

Identification of an infectious agent failed in 17 patients (47%), and Staphylococci were found in 15 patients (42%). The time from pacemaker implantation to onset of infection ranged from 1 month to 11 years (mean 31 months; median 19 months) and the time from onset of infection to surgical treatment from 1 month to 7 years (mean 7 months; median 2 months). The mean follow-up time is 74 months (range, 1 month to 10 years; median 5 years). There were 9 reoperations in 3 patients (16%) of group A for recurrent infection of their retained leads ultimately necessitating the use of open cardiac surgery. There was no early death; six patients died late due to unrelated causes.

CONCLUSIONS

Complete removal of all pacemaker leads is recommended; open heart surgery with the use of cardiopulmonary bypass is indicated in selected cases and is effective and safe.