When pacing or defibrillator leads become redundant: extract or abandon?

The 2017 HRS expert consensus paper on lead management and extraction did not express a preference for either extracting or abandoning pacing or defibrillator leads that are dysfunctional or superfluous after an upgrade (further referred to as redundant leads) 1. However, there are no randomized or even non-randomized trials that show a better patient outcome with extraction. Many experienced centers currently advise patients to have redundant leads removed to prevent more complicated procedures after years of abandonment. But according to the literature not all abandoned leads need to be extracted as more than 90% will have an uneventful follow-up. As immediate extraction of redundant leads has a small but significant risk this will generate more adverse events at population level than when extraction is limited to the patients with future lead complications, even considering a higher extraction risk at that time. Lead extraction is also limited to specialized centers and often necessitates expensive tools, in contrast to abandoning leads which can be safely performed by any experienced device specialist without additional cost.

Cardiac implantable electronic device-induced tricuspid regurgitation: Implications and management

Tricuspid regurgitation (TR) secondary to cardiac implantable electronic devices (CIEDs) has been well documented and is associated with worse cardiovascular outcomes. A variety of mechanisms have been proposed including lead-induced mechanical disruption of the tricuspid valvular or subvalvular apparatus and pacing-induced electrical dyssynchrony. Patient characteristics such as age, sex, baseline atrial fibrillation, and pre-existing TR have not been consistent predictors of CIED-induced TR. While two-dimensional echocardiography is helpful in assessing the severity of TR, three-dimensional echocardiography has significantly improved accuracy in identifying the etiology of TR and whether lead position contributes to TR. Three-dimensional echocardiography may therefore play a future role in optimizing lead positioning during implant to reduce the risk of CIED-induced TR. Optimal lead management strategies in addition to percutaneous interventions and surgery in alleviating TR are very important.

Minimally invasive epicardial left-ventricular lead implantation and simultaneous left atrial appendage closure

Background

Atrial fibrillation (AF) is common in patients with heart failure resulting in a high prevalence of AF in patients receiving Cardiac Resynchronization Therapy (CRT) implantation. In patients, unsuitable for transvenous left ventricular (LV)-lead implantation, epicardial LV-lead implantation represents a valuable alternative. Epicardial LV-lead placement can be achieved totally thoracoscopical or via minimally invasive left lateral thoracotomy. In patients with atrial fibrillation, concomitant left atrial appendage (LAA) clipping is feasible via the same access. Therefore, the aim of our study was the analysis of safety and efficacy of epicardial LV lead implantation and concomitant LAA clipping via minimally invasive left-lateral thoracotomy.

Methods

Between December 2019 and March 2022, 8 patients received minimally invasive left atrial LV-lead implantation with concomitant LAA closure using the AtriClip. Transesophageal echocardiography (TEE) was performed to intraoperatively guide and control LAA closure.

Results

Mean patients age was 64 ± 11.2 years, 67% were male patients. Minimally invasive left-lateral thoracotomy was used in 6 patients while a totally thoracoscopic approach was performed in 2 cases. Epicardial lead implantation was successfully performed in all patients with good pacing threshold (mean 0.8 ± 0.2 V) and sensing values (10.1 ± 2.3 mV). Posterolateral position of the LV lead was achieved in all patients. Furthermore, successful LAA closure was confirmed during TEE in all patients. No procedure-related complications occurred in any of the patients. Two patients additionally received simultaneous laser lead extraction during the same procedure. Complete lead extraction was achieved in both patients. All patients were extubated in the OR and had an uneventful postoperative course.

Conclusion

Our study highlights a novel treatment approach for patients with atrial fibrillation and the necessity of epicardial LV leads. Placement of a posterolateral LV lead position with concomitant occlusion of the left atrial appendage via a minimally-invasive left-lateral thoracotomy or even a totally thoracoscopic approach is safe and feasible with superior cosmetic result and complete occlusion of the left atrial appendage.

Tricuspid Valve Damage Related to Transvenous Lead Extraction

BACKGROUND

Damage to the tricuspid valve (TVD) is now considered either a major or minor complication of the transvenous lead extraction procedure (TLE). As yet, the risk factors and long-term survival after TLE in patients with TVD have not been analyzed in detail.

METHODS

This post hoc analysis used clinical data of 2631 patients (mean age 66.86 years, 39.64% females) who underwent TLE procedures performed in three high-volume centers. The risk factors and long-term survival of patients with worsening tricuspid valve (TV) function after TLE were analyzed.

RESULTS

In most procedures (90.31%), TLE had no negative influence on TV function, but in 9.69% of patients, a worsening of tricuspid regurgitation (TR) to varying degrees was noted, including significant dysfunction in 2.54% of patients. Risk factors of TLE relating to severe TVD were: TLE of pacing leads (5.264; p = 0.029), dwell time of the oldest extracted lead (OR = 1.076; p = 0.032), strong connective scar tissue connecting a lead with tricuspid apparatus (OR = 5.720; p < 0.001), and strong connective scar tissue connecting a lead with the right ventricle wall (OR = 8.312; p < 0.001). Long-term survival (1650 ± 1201 [1-5519] days) of patients with severe TR was comparable to patients without tricuspid damage related to TLE.

CONCLUSIONS

Severe tricuspid valve damage related to TLE is relatively rare (2.5%). The main risk factors for the worsening of TV function are associated with a longer lead dwell time (more often the pacing lead), causing stronger connective tissue scars connecting the lead to the tricuspid apparatus and right ventricle. TVD is unlikely to affect long-term survival after TLE.

Monitoring excimer laser-guided cardiac lead extractions by uniportal video-assisted thoracoscopy: A single center experience

BACKGROUND

Though laser guided extractions of cardiac implantable electronic devices leads have become a routine procedure, the severe complications are associated with a high mortality. Here, we report our single center experience using uniportal video-assisted thoracoscopy for laser lead extraction and compare it to stand-alone laser lead extraction.

METHODS

The intraoperative data and postoperative clinical outcomes of patients undergoing laser lead extraction with concomitant thoracoscopy (N = 28) or without (N = 43) in our institution were analyzed retrospectively.

RESULTS

Neither the median x-ray time (612.0 s for the thoracoscopy group vs. 495.5 s for the non-thoracoscopy group, p = 0.962), length of the operation (112.5 vs. 100.0 min, p = 0.676) or the median length of hospital stay (9.0 vs. 10.0 days, p = 0.990) differed significantly. The mean intensive care unit stay was longer for patients in the non-thoracoscopy group (0.8 vs. 2.5 days, p = 0.005). The 30-day-mortality in the thoracoscopy group was zero, whereas five patients died in the non-thoracoscopy group. Furthermore, four patients in the non-thoracoscopy group had encountered haemothorax, while none were observed in the thoracoscopy group (p = 0.148).

CONCLUSIONS

The adoption of uniportal video-assisted thoracoscopy during laser-guided lead extraction of cardiac implantable electronic devices can be considered safe and does not lengthen the operating time or hospital stay. It might be useful in the detection of severe complications and, in experienced hands, possibly allow direct bleeding control.

A Study of Major and Minor Complications of 1500 Transvenous Lead Extraction Procedures Performed with Optimal Safety at Two High-Volume Referral Centers

Background: Transvenous lead extraction (TLE) is the preferred management strategy for complications related to cardiac implantable electronic devices. TLE sometimes can cause serious complications. Methods: Outcomes of TLE procedures using non-powered mechanical sheaths were analyzed in 1500 patients (mean age 68.11 years; 39.86% females) admitted to two high-volume centers. Results: Complete procedural success was achieved in 96.13% of patients; clinical success in 98.93%, no periprocedural death occurred. Mean lead dwell time in the study population was 112.1 months. Minor complications developed in 115 (7.65%), major complications in 33 (2.20%) patients. The most frequent minor complications were tricuspid valve damage (TVD) (3.20%) and pericardial effusion that did not necessitate immediate intervention (1.33%). The most common major complication was cardiac laceration/vascular tear (1.40%) followed by an increase in TVD by two or three grades to grade 4 (0.80%). Conclusions: Despite the long implant duration (112.1 months) satisfying results without procedure-related death can be obtained using mechanical tools. Lead remnants or severe tricuspid regurgitation was the principal cause of lack of clinical and procedural success. Worsening TR(Tricuspid regurgitation) (due to its long-term consequences), but not cardiac/vascular wall damage; is still the biggest TLE-related problem; when non-powered mechanical sheaths are used as first-line tools.

Analysis of Risk Factors for Major Complications of 1500 Transvenous Lead Extraction Procedures with Especial Attention to Tricuspid Valve Damage

Background: Transvenous lead extraction (TLE) is a relatively safe procedure, but it may cause severe complications such as cardiac/vascular wall tear (CVWT) and tricuspid valve damage (TVD). Methods: The risk factors for CVWT and TVD were examined based on an analysis of data of 1500 extraction procedures performed in two high-volume centers. Results: The total number of major complications was 33 (2.2%) and included 22 (1.5%) CVWT and 12 (0.8%) TVD (with one case of combined complication). Patients with hemorrhagic complications were younger, more often women, less often presenting low left ventricular ejection fraction (LVEF) and those who received their first cardiac implantable electronic device (CIED) earlier than the control group. A typical patient with CVWT was a pacemaker carrier, having more leads (including abandoned leads and excessive loops) with long implant duration and a history of multiple CIED-related procedures. The risk factors for TVD were similar to those for CVWT, but the patients were older and received their CIED about nine years earlier. Any form of tissue scar and technical problems were much more common in the two groups of patients with major complications. Conclusions: The risk factors for CVWT and TVD are similar, and the most important ones are related to long lead dwell time and its consequences for the heart (various forms of fibrotic scarring). The occurrence of procedural complications does not affect long-term survival in patients undergoing lead extraction.

Transvenous extraction of pacemaker leads via femoral approach using a gooseneck snare

BACKGROUND

The growing problem of endocardial lead infections and lead malfunctions has increased interest in percutaneous lead-removal technology. Transvenous lead extraction (TLE) via simple manual traction (SMT) is the first-line therapy. When SMT is not successful, TLE from the femoral vein using a gooseneck snare (GS) with a radiofrequency ablation catheter (RFAC) may be an alternative option. The aim of our study was to evaluate the success rate of transvenous extraction of chronically implanted leads via the femoral approach using a GS with RFCA in cases of failure with SMT.

METHODS

The study included 94 consecutive patients who were referred for lead extraction due to pocket erosion and infection (71 patients) and to lead malfunction (23 patients). Initially, SMT was attempted for all patients. If SMT was not successful, patients underwent TLE using a GS with RFAC.

RESULTS

Leads were extracted successfully with SMT in 34 patients (54 leads), while 60 patients (83 leads) underwent TLE using a GS with RFAC. The mean indwelling time of the leads was longer in the femoral approach with GS (87.5 ± 37.9 vs. 31.3 ± 25.8 months; p < 0.001). The procedural success rate was 96.7% in the femoral approach with GS. A preceding implantation lead duration of >51 months predicted an unsuccessful SMT necessitating alternative TLE using a GS with RFAC with 86% sensitivity and 78% specificity (p < 0.001).

CONCLUSION

Transvenous lead extraction via the femoral approach using GS with RFAC may be an alternative approach to SMT with a high success rate, especially when the indwelling time of the leads is long.

Laser Lead Extraction Complicated by Avulsed Tricuspid Subvalvular Apparatus with Severe Tricuspid Regurgitation

The use of laser lead extraction (LLE) to remove pacemaker or implantable cardioverter-defibrillator leads has become increasingly prevalent. This advanced technique has been shown to be highly effective and safe. We report a rare case of severe traumatic tricuspid regurgitation after LLE that led to death.

The role of transvenous lead extraction in the management of redundant or malfunctioning pacemaker and defibrillator leads post ELECTRa

Cardiac implantable electronic devices implantation rates have increased over the past decade due to broader indications and an ageing population. Similarly, device and lead complications have also risen. The management of pacemaker/defibrillator leads that are no longer required (redundant) or malfunctioning, can be contentious. There is a need to balance the risk of transvenous lead extraction (TLE) against those of lead abandonment. The recently published European Lead Extraction ConTRolled Registry (ELECTRa) study provides contemporary outcomes for TLE across Europe with important implications for the management of redundant and/or malfunctioning leads. This review article discusses the potential complications for each interventional approach when managing redundant or malfunctioning pacemaker leads.

Misplaced Ventricular Lead via an Atrial Septal Defect-Percutaneous Extraction

Background  Necessity for lead removal in this case was after 12 years due to mitral valve regurgitation caused by retraction of the posterior leaflet by the inadvertently misplaced lead.

Case Description  This history describes a 45-year-old woman with history of multiple cardiac operations at young age with an abandoned defibrillator lead via a patent atrial septal defect. Lead extraction was performed with first described use of rotational dilating sheaths to reduce emboli risk, hoping to avoid a fourth surgical procedure with high risk.

Conclusions  Percutaneous lead removal using rotational sheaths is possible even for misplaced leads after long-time intervals with acceptable operative risk.

Pearls of Wisdom for High-Risk Laser Lead Extractions: A Focused Review

Due to new indications and improved technology, the incidence of laser lead extraction (LLE) has significantly increased over the past years. While LLE has been well studied and proven to be safe and effective, only few studies are geared toward the anesthesiologist's role during high-risk LLEs. This article utilized both a focused review and authors' experience to investigate anesthetic protocols during LLEs. Through this review, we recommend best practices for the anesthesiologist including appropriate procedure location, onsite availability of a cardiac surgeon, availability of a cardiopulmonary bypass machine, and intraoperative use of echocardiography to detect and address potential complications during high-risk LLEs.