A novel indication for transvenous lead extraction: upgrading implantable cardioverter defibrillator systems

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.

Central Venous Occlusion Is Not an Obstacle to Device Upgrade with the Assistance of Laser Extraction

OBJECTIVE

To assess the efficacy and safety of laser-assisted lead extraction for upgrade of existing pacemakers and defibrillators in patients with central venous obstruction.

BACKGROUND

Implantable cardiac defibrillators and biventricular pacing have become the accepted therapeutic measures for patients with congestive heart failure. Many patients who are candidates for device therapy, however, already have existing right ventricular leads and the presence of central venous obstruction. Upgrade of existing devices in these patients is a dilemma, which is increasingly encountered by device-implanting physicians. Laser-assisted extraction of existing leads can facilitate access for device upgrade and provide an alternative to lead abandonment and contralateral implant.

METHODS

We review our experience with laser-assisted lead extraction in patients, referred for upgrade of existing devices, who were found to have, or known to have, ipsilateral subclavian vein occlusion.

RESULTS

Over the past 3 years, 18 patients (13 men, 5 women; mean age 63.9 +/- 16 years) with subclavian vein occlusion underwent successful laser-assisted lead extraction (total 29 leads) and upgrade of existing leads to defibrillators and/or biventricular systems. Mean implant duration prior to extraction was 70.8 +/- 43.5 (11-192) months. Cannulation of the coronary sinus and placement of a transvenous left ventricular lead were achieved in all 13 patients in whom it was attempted. No complications occurred.

CONCLUSIONS

Laser-assisted lead extraction is a safe and effective approach, allowing for ipsilateral device upgrade in patients with existing devices and central venous obstruction.

Fracture of the Subcutaneous Patch Electrode in a Patient With an Implanted Cardioverter-Defibrillator

There are more than 20 years of experience with implantation of defibrillator devices in humans and the procedure is an important therapeutic option for patients at high risk of life-threatening ventricular arrhythmias. The incidence of new defibrillator implantation has gradually increased, being used even in children, (1) although pediatric use is associated with several complications, especially with epicardial systems,(2) including fracture of the subcutaneous patch,(3-5) mainly because of growth.(3) We present a case of subcutaneous patch electrode fracture in the left axillary pectoral region of a patient who needed the patch for effective defibrillation, and we discuss the methods of treatment.

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.

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.