Safety and efficacy of transvenous mechanical lead extraction in patients with abandoned leads

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

The 2017 Heart Rhythm Society 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 (hereafter referred to as redundant leads). However, no randomized or even nonrandomized trials 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. According to the literature, however, not all abandoned leads need to be extracted as >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 the 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.

Long-term outcomes of abandoned leads of cardiac implantable electronic devices

BACKGROUND

Evidence of the long-term outcomes of abandoned leads (ALs) in patients with cardiac implantable electronic devices (CIEDs) is scarce.

OBJECTIVE

This study aimed to investigate the long-term outcomes of ALs.

METHODS

This retrospective cohort study reviewed a single-center CIED registry of 2962 procedures performed from 1984-2018 and identified 130 patients with AL (AL group). We matched 2 controls without AL (by age, sex, device type, and device revision/removal date) to each patient with AL (n = 260) and compared CIED-related infection, venous thrombosis/stenosis, and all-cause mortality between groups using a Cox proportional hazard model analysis.

RESULTS

For a mean follow-up period of 11.2 ± 8.2 years, 14 (3.6%), 7 (1.8%), and 143 (36.7%) patients had a CIED-related infection, venous thrombosis/stenosis, or experienced all-cause mortality, respectively. The AL group had more comorbidities than the control group. Lead malfunction was the most common cause of abandonment (64.6%). After adjustment for covariates, no significant intergroup differences were noted in the risks of infection, venous thrombosis/stenosis, or all-cause mortality (adjusted hazard ratio [aHR] 2.52; 95% confidence interval [CI] 0.77-8.25; aHR 1.18; 95% CI 0.25-5.64; aHR 1.26; 95% CI 0.89-1.80, respectively). Patients with multiple ALs had increased risks of infection and all-cause mortality vs controls (aHR 8.61; 95% CI 2.13-34.84; aHR 2.42; 95% CI 1.17-5.00, respectively).

CONCLUSION

Patients with a single AL showed similar risks of CIED-related infections, venous thrombosis/stenosis, and all-cause mortality as those without ALs, whereas those with multiple ALs showed increased risks of infection and all-cause mortality.

Transvenous Lead Extraction in Pediatric Patients - Is It the Same Procedure in Children as in Adults?

BACKGROUND

Cardiac implantable electronic devices (CIED) are very rare in the pediatric population. In children with CIED, transvenous lead extraction (TLE) is often necessary. The course and effects of TLE in children are different than in adults. Thus, this study determined the differences and specific characteristics of TLE in children vs. adults.

METHODS AND RESULTS

A post hoc analysis of TLE data in 63 children (age ≤18 years) and 2,659 adults (age ≥40 years) was performed. The 2 groups were compared with respect to risk factors, procedure complexity, and effectiveness. In children, the predominant pacing mode was a single chamber ventricular system and lead dysfunction was the main indication for lead extraction. The mean implant duration before TLE was longer in children (P=0.03), but the dwell time of the oldest extracted lead did not differ significantly between adults and children. The duration (P=0.006) and mean extraction time per lead (P<0.001) were longer in children, with more technical difficulties during TLE in the pediatric group (P<0.001). Major complications were more common, albeit not significantly, in children. Complete radiographic and procedural success were significantly lower in children (P<0.001).

CONCLUSIONS

TLE in children is frequently more complex, time consuming, and arduous, and procedural success is more often lower. This is related to the formation of strong fibrous tissue surrounding the leads in pediatric patients.

Efficacy and safety of the extraction of cardiostimulation leads using a mechanical dissection tool. A single center experience

BACKGROUND

The percutaneous extraction of endovascular cardiostimulation and defibrillation leads is the most frequent technique nowadays. The tools used today must guarantee the success of the procedure, with the minimum of complications. Our objective was to analyze the safety and efficacy of lead extraction using the Evolution mechanical dissection tool (Cook Medical, USA).

METHODS

A retrospective study was carried out in a total of 826 consecutive patients from October 2009 to December 2018 who underwent the procedure with the Evolution mechanical dissection tool. Preoperative study included complete blood tests, echocardiogram, and chest X-ray. The procedures were performed in the operating room, under general anesthesia and echocardiographic control.

RESULTS

A total of 1227 leads were extracted with a mean chronicity of 10.3 ± 5.1 years. Clinical success (CS) rate was 99.7%. A total of 16 (1.9%) complications occurred, 2 (0.24%) were major complications and 14 (1.7%) were minor complications. There was no operative mortality. There was no statistically significant relationship between implant chamber and complete efficacy. The complete extraction was achieved in all left ventricular leads, in 762 of 774 (98.45%) of right ventricular lead removal, and in 330 of 334 (98.8%) of right atrial leads (p = .31).

CONCLUSION

In our experience, percutaneous extraction of intravenous leads via the use of the Evolution tool (Cook Medical, USA), is a very effective and safe technique that offers low morbidity and mortality.

Mechanical extraction of implantable cardioverter-defibrillator leads with a dwell time of more than 10 years: insights from a single high-volume centre

AIMS

To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) of implantable cardioverter-defibrillator (ICD) leads with a dwell time of >10 years (Group A) vs. younger leads (Group B) using mechanical extraction systems.

METHODS AND RESULTS

Between October 2011 and July 2022, we performed TLE in 318 patients. Forty-six (14.4%) extracted ICD leads in 46 (14.5%) patients that had been implanted for >10 years. The median dwell time of all extracted ICD leads was 5.9 years. Cardiovascular implantable electronic device-related infection was an indication for TLE in 31.8% of patients. Complete ICD leads removal and complete procedural success in both groups were similar (95.7% in Group A vs. 99.6% in Group B, P = 0.056% and 95.6% in Group A vs. 99.6% in Group B, P = 0.056, respectively). We did not find a significant difference between major and minor complication rates in both groups (6.5% in Group A vs. 1.5% in Group B and 2.2% in Group A vs. 1.8% in Group B, P = 0.082, respectively). One death associated with the TLE procedure was recorded in Group B.

CONCLUSION

The TLE procedures involving the extraction of old ICD leads were effective and safe. The outcomes of ICD lead removal with a dwell time of >10 years did not differ significantly compared with younger ICD leads. However, extraction of older ICD leads required more frequent necessity for utilizing multiple extraction tools, more experience and versatility of the operator, and increased surgery costs.

Assessment of the impact of organisational model of transvenous lead extraction on the effectiveness and safety of procedure: an observational study

OBJECTIVES

To estimate the impact of the organisational model of transvenous lead extraction (TLE) on effectiveness and safety of procedures.

DESIGN

Post hoc analysis of patient data entered prospectively into a computer database.

SETTING

Data of all patients undergoing TLE in three centres in Poland between 2006 and 2021 were analysed.

PARTICIPANTS

3462 patients including: 985 patients undergoing TLE in a hybrid room (HR), with cardiac surgeon (CS) as co-operator, under general anaesthesia (GA), with arterial line (AL) and with transoesophageal echocardiography (TEE) monitoring (group 1), 68 patients-TLE in HR with CS, under GA, without TEE (group 2), 406 patients-TLE in operating theatre (OT) using 'arm-C' X-ray machine with CS under GA and with TEE (group 3), 154 patients-TLE in OT with CS under GA, without TEE (group 4), 113 patients-TLE in OT with anaesthesia team, using the 'arm-C' X-ray machine, without CS (group 5), 122 patients-TLE in electrophysiology lab (EPL), with CS under intravenous analgesia without TEE and AL (group 6), 1614 patients-TLE in EPL, without CS, under intravenous analgesia without TEE and AL (group 7).

KEY OUTCOME MEASURE

Effectiveness and safety of TLE depending on organisational model.

RESULTS

The rate of major complications (MC) was higher in OT/HR than in EPL (2.66% vs 1.38%), but all MCs were treated successfully and there was no MC-related death. The use of TEE during TLE increased probability of complete procedural succemss achieving about 1.5 times (OR=1.482; p<0.034) and were connected with reduction of minor complications occurrence (OR=0.751; p=0.046).

CONCLUSIONS

The most important condition to avoid death due to MC is close co-operation with cardiac surgery team, which permits for urgent rescue cardiac surgery. Continuous TEE monitoring plays predominant role in immediate decision on rescue sternotomy and improves the effectiveness of procedure.

Efficacy and Safety of Transvenous Lead Extraction at the Time of Upgrade from Pacemakers to Cardioverter-Defibrillators and Cardiac Resynchronization Therapy

BACKGROUND

Upgrading from pacemakers to ICDs and CRTs is a difficult procedure, and often, transvenous lead extraction (TLE) is necessary for venous access. TLE is considered riskier in patients with multiple diseases. We aimed to assess the complexity, risk, and outcome of TLE among CRT and ICD candidates.

METHODS

We analyzed clinical data from 2408 patients undergoing TLE between 2006 and 2021. There were 138 patients upgraded to CRT-D, 33 patients upgraded to CRT-P and 89 individuals upgraded to ICD versus 2148 patients undergoing TLE for other non-infectious indications.

RESULTS

The need for an upgrade was the leading indication for TLE in only 36-66% of patients. In 42.0-57.6% of patients, the upgrade procedure could be successfully done only after reestablishing access to the occluded vein. All leads were extracted in 68.1-76.4% of patients, functional leads were retained in 20.2-31.9%, non-functional leads were left in place in 0.0-1.1%, and non-functional superfluous leads were extracted in 3.6-8.4%. The long-term survival rate of patients in the CRT-upgrade group was lower (63.8%) than in the non-upgrade group (75.2%).

CONCLUSIONS

Upgrading a patient from an existing pacemaker to an ICD/CRT is feasible in 100% of cases, provided that TLE is performed for venous access. Major complications of TLE at the time of device upgrade are rare and, if present do not result in death.

Repeat Transvenous Lead Extraction-Predictors, Effectiveness, Complications and Long-Term Prognostic Significance

BACKGROUND

Data regarding repeat transvenous lead extraction (TLE) are scarce. The aim of study was to explore the frequency of repeat TLE, its safety, predisposing factors, as well as effectiveness of repeat procedures.

METHODS

Retrospective analysis of a large single-center database of 3654 TLEs.

RESULTS

Repeat TLE was a rare occurrence (193, i.e., 5,28% among 3654 TLEs). Subsequent re-extractions occurred in 12.21% of the patients. Lead failure was the most common cause of re-extraction (51.16%). Cox regression analysis showed that patients who were older at first implantation [HR = 0.987; p = 0.003], had infection-related TLE [HR = 0.392; p < 0.001] and complete procedural success [HR = 0.544; p = 0.034] were less likely to undergo repeat TLE. Functional leads left in place for continuous use [HR = 1.405; p = 0.012] or superfluous leads left in place (abandoned) [HR = 2.370; p = 0.011] were associated with an increased risk of undergoing a repeat procedure. Overall mortality in patients with repeat TLE and subsequent re-extraction in the entire FU period was similar to that in patients without a history of re-extraction [HR = 0.949; p = 0.480].

CONCLUSIONS

Repeat TLE was a rare occurrence (5.28%) among TLEs. Left of both active and nonactive leads during TLE increased the risk of re-extraction. Re-extraction has no effect on the long-term mortality.

A head-to-head comparison of laser vs. powered mechanical sheaths as first choice and second line extraction tools

AIMS

During transvenous lead extraction (TLE) longer dwelling time often requires the use of powered sheaths. This study aimed to compare outcomes with the laser and powered mechanical tools.

METHODS AND RESULTS

Single-centre data from consecutive patients undergoing TLE between 2012 and 2021 were retrospectively analysed. Efficacy and safety of the primary extraction tool were compared. Procedures requiring crossover between powered sheaths were also analysed. Moreover, we examined the efficacy of each level of the stepwise approach. Out of 166 patients, 142 (age 65.4 ± 13.7 years) underwent TLE requiring advanced techniques with 245 leads (dwelling time 9.4 ± 6.3 years). Laser sheaths were used in 64.9%, powered mechanical sheaths in 35.1% of the procedures as primary extraction tools. Procedural success rate was 85.5% with laser and 82.5% with mechanical sheaths (P = 0.552). Minor and major complications were observed in similar rate. Procedural mortality occurred only in the laser group in the case of three patients. Crossover was needed in 19.5% after laser and in 12.8% after mechanical extractions (P = 0.187). Among crossover procedures, only clinical success favoured the secondary mechanical arm (87.1 vs. 54.5%, aOR: 0.09, 95% CI: 0.01-0.79, P = 0.030). After step-by-step efficacy analysis, procedural success was 64.9% with the first-line extraction tool, 75.1% after crossover, 84.5% with bailout femoral snare, and 91.8% by non-emergency surgery.

CONCLUSION

The efficacy and safety of laser and mechanical sheaths were similar, however in the subgroup of crossover procedures mechanical tools had better performance regarding clinical success. Device diversity seems to help improving outcomes, especially in the most complicated cases.

Transvenous Lead Extraction in Adult Patient with Leads Implanted in Childhood-Is That the Same Procedure as in Other Adult Patients?

BACKGROUND

Lead management in children and young adults is still a matter of debate.

METHODS

To assess the course of transvenous lead extraction (TLE) in adults with pacemakers implanted in childhood (CIP) we compared 98 CIP patients with a control group consisting of adults with pacemakers implanted in adulthood (AIP).

RESULTS

CIP patients differed from AIP patients with respect to indications for TLE and pacing history. CIP patients were four-eight times more likely to require second-line or advanced tools. Furthermore, CIP patients more often than AIP were prone to developing complications: major complications (MC) (any) 2.6 times; hemopericardium 3.2 times; severe tricuspid valve damage 4.4 times; need for rescue cardiac surgery 3.7 times. The rate of procedural success was 11% lower because of 4.8 times more common lead remnants and 3.1 times more frequent permanently disabling complications.

CONCLUSIONS

Due to system-related risk factors TLE in CIP patients is more difficult and complex. TLE in CIP is associated with an increased risk of MC and incomplete lead removal. A conservative strategy of lead management, acceptable in very old patients seems to be less suitable in CIP because it creates a subpopulation of patients at high risk of major complications during TLE in the future.

Outcomes of Transvenous Extraction of Leads Older Than 20 and 30 Years-A Large Cohort Study

BACKGROUND

There is limited knowledge on outcome of transvenous lead extraction (TLE) of leads being 20 and 30 years old.

METHODS

Retrospective single center large database analysis containing 3673 TLE procedures performed from 2006 to 2020 was analysed. We aimed to compare procedure complexity and the incidence of the TLE major complications (MC) in groups where extracted leads were under 10 years, 10-20 years, 20-30 years (old) and over 30 years (very old).

RESULTS

Rate of removal of old and very old leads almost doubles with successive five-year periods (3-6-10%). In patients with old and very old leads there is an accumulation of risk factors for major complications of TLE (young age, female, multiple and/or abandoned leads, multiple previous procedures). The removal of old and very old leads was more labour-consuming, more difficult, and much more often required second-line (advanced) tools and complex techniques. Incidence of all MC grew parallel to age of removed leads from 0.6 to 18.2%; haemopericardium-from 0.3 to 12.1%, severe tricuspid valve damage-from 0.2 to 2.1%, need for rescue cardiac surgery-from 0.4 to 9.1%. Notably, there was no procedure-related death when old or very old lead was extracted. The percentages of clinical and procedural success decreased with increasing age of the removed leads from 99.2 and 97.8% to 90.9 and 81.8%. The risk of MC during extraction of leads aged 10-20 years increases 6.7 times, aged 20-30 years-14.3 times (amounting to 8.4%), and aged 30 and more years-20.4 times, amounting to 18.2%. Removal of ventricular leads is associated with a greater complexity of the procedure but not with more frequent MC. Removal of the atrial leads is associated with a higher incidence of MC, especially haemopericardium, regardless of the age of the leads, although the tendency becomes less pronounced with the oldest leads.

CONCLUSIONS

1. Extraction of old and very old leads is a rising challenge, since the rate of removal of leads aged 20-and-more years almost doubles with successive five-year periods. 2. Procedure difficulty, complexity and the risk of major complications increases along with the age of extracted lead. TLE is more time-consuming, difficult and much more often requires advanced tools and complex techniques. 3. TLE of old (≥20 years) or very old (≥30 years) leads can be performed with satisfactory success rate and safety profile when conducted at high-volume centre by an experienced operator under optimal safety conditions.

Reducing CIED-Related Morbidity: “LESS Is More”

In recent years, the rate of pacemaker implantations has continued to rise throughout Europe [...]

Looking for Lead Adhesions While Planning for Transvenous Lead Extraction

The first implantable pacemaker was placed in the 1958, ushering in a new frontier of cardiovascular medicine. This article is protected by copyright. All rights reserved.

Powered sheaths for lead extraction

Transvenous lead extraction (TLE) has seen a rapid expansion in the past 20 years. The procedure has changed from early techniques involving simple manual traction that frequently proved themselves ineffective for chronically implanted leads, and carried significant periprocedural risks including death, to the availability of a wide range of more efficacious techniques and tools, providing the skilled extractor with a well-equipped armamentarium. The reduction in morbidity and mortality associated with these new extraction techniques has widened indications to TLE from prevalent use in life-threatening situations, such as infection and sepsis, to a more widespread use even in noninfectious situations such as malfunctioning leads. Powered sheaths have been a remarkable step forward in this improvement in TLE procedures and recent registries at high-volume centers report high success rates with exceedingly low complication rates. This review is aimed at describing technical features of powered sheaths as well as reported performance during TLE procedures.

Transvenous Lead Extraction without Procedure-Related Deaths in 1000 Consecutive Patients: A Single-Center Experience

Background

Transvenous lead extraction (TLE) is now a first-line technique for the treatment of complications related to cardiac implantable electronic devices. The aim of the study was to demonstrate that it is possible to safely perform difficult TLE procedures with a maximum reduction of peri-procedural major complications.

Methods

A total of 1000 consecutive patients undergoing TLE in a single high-volume center from 2016 to 2019 were studied. All procedures were performed in a hybrid room or operating room by a specialized TLE team. TLE was performed under general anesthesia and monitored by transesophageal echocardiography, and the operating room was suitably equipped for immediate surgical intervention. The effectiveness and safety of the procedures were assessed, with particular emphasis on major complications.

Results

In all, 1952 leads with the mean implant duration of 111.7 ± 77.6 months had been extracted. Complete procedural success of patients was achieved in 95.9% and clinical success in 99.1%. Major complications, predominantly cardiac tamponade (63.3%), occurred in 22 patients (2.2%). Rapid diagnosis and immediate intervention were the key to a 100% survival in patients with this complication.

Conclusion

Performing procedures in a hybrid operating room under general anesthesia in the presence of a cardiac surgeon and with the use of transesophageal echocardiography significantly improves the safety of transvenous lead extraction.

Current practice in transvenous lead extraction in Latin America: Latin American Heart Rhythm Association survey

BACKGROUND

Transvenous lead extraction (TLE) is standard of care for the management of patients with cardiac implantable electronic device infection or lead-related complications. Currently, objective data on TLE in Latin America is lacking.

OBJECTIVE

To describe the current practice standards in Latin American centers performing TLE.

METHODS

An online survey was sent through the mailing list of the Latin American Heart Rhythm Society. Online reminders were sent through the mailing list; duplicate answers were discarded. The survey was available for 1 month, after which no more answers were accepted.

RESULTS

A total of 48 answers were received, from 44 different institutions (39.6% from Colombia, 27.1% from Brazil), with most respondents (82%) being electrophysiologists. Twenty-nine institutions (66%) performed <10 lead extractions/year, with 7 (16%) institutions not performing lead extraction. Although most institutions in which lead extraction is performed reported using several tools, mechanical rotating sheaths were cited as the main tool (66%) and only 13% reported the use of laser sheaths. Management of infected leads was performed according to current guidelines.

CONCLUSION

This survey is the first attempt to provide information on TLE procedures in Latin America and could provide useful information for future prospective registries. According to our results, the number of centers performing high volume lead extraction in Latin America is smaller than that reported in other continents, with most interventions performed using mechanical tools. Future prospective registries assessing acute and long-term success are needed.