Laser-assisted lead extraction: the European experience

Removal of leads broken during extraction: A comparison of different approaches and tools

BACKGROUND

Extraction of a broken lead fragment (BLF) has received scant attention in the literature.

METHODS

Retrospective analysis was to compare the effectiveness of different approaches and tools used for BLF removal during 127 procedures.

RESULTS

A superior approach was the most popular (75.6%), femoral (15.7%) and combined (8.7%) approaches were the least common. Of 127 BLFs 78 (61.4%) were removed in their entirety and BLF length was significantly reduced to less than 4 cm in 21 (16.5%) or lead tip in 12 (9.4%) cases. The best results were achieved when BLFs were longer (>4 cm) (62/93 66.7% of longer BLFs), either in the case of BLFs free-floating in vascular bed including pulmonary circulation (68.4% of them) but not in cases of short BLFs (20.0% of short BLFs). Complete procedural success was achieved in 57.5% of procedures, the lead tip retained in the heart wall in 12 cases (9.4%) and short BLFs were found in 26.0%, whereas BLFs >4 cm were left in place in four cases (3.1%) of procedures only. There was no relationship between approach in lead remnant removal and long-term mortality.

CONCLUSIONS

(1) Effectiveness of fractured lead removal is satisfactory: entire BLFs were removed in 61.4% (total procedural success-57.5%, was lower because five major complications occurred) and BLF length was significantly reduced in 26.0%. (2) Among the broken leads, leads with a long stay in the patient (16.3 years on average), passive leads (97.6%) and pacemaker leads 92.1% are significantly more common, but not ICD leads (only 7.9% of lead fractures) compared to TLE without lead fractures. (3) Broken lead removal (superior approach) using a CS access sheath as a "subclavian workstation" for continuation of dilatation with conventional tools deserves attention. (4) Lead fracture management should become an integral part of training in transvenous lead extraction.

Outcome of transvenous lead extraction in nonagenarians: A single-center retrospective study

BACKGROUND

Transvenous lead extraction (TLE) for cardiovascular implantable electronic device (CIED)-related infections has increased. The incidence of TLE in nonagenarians is low, with limited reports outlining the outcomes of this procedure. Therefore, in this study, we aimed to clarify the outcomes of TLE in nonagenarians.

METHODS

Patients with TLE treated at our hospital between 2014 and 2023 were retrospectively examined; patient characteristics, device type, indications, procedures, complications, and clinical data of nonagenarians were analyzed.

RESULTS

Of 12 patients with 24 leads (active fixation lead, n = 11; passive fixation lead, n = 13) who underwent TLE, the indication for TLE was infection (pocket infection, n = 8; sepsis, n = 4). Methicillin-resistant Staphylococcus epidermidis was the most frequently identified causative agent (n = 4). The median patient age was 91 years; five patients were female. The median lead dwell time was 9 years. Excimer laser sheath (16 leads), mechanical sheath (five leads), Evolution RL (one lead), and manual traction (two leads) were employed in TLE. The procedure was successful in all patients, and only one had a minor complication. Six patients required CIED re-implantation, and leadless pacemakers were selected for five patients. The 30-day mortality after TLE was 0%.

CONCLUSION

TLE can be safely performed in nonagenarians. The decision to perform TLE should not be based on old age alone; the suitability of removing infected CIEDs should be determined based on each patient's condition.

Prevention and Risk Assessment of Cardiac Device Infections in Clinical Practice

The implantation of cardiac electronic devices (CIEDs), including pacemakers and defibrillators, has become increasingly prevalent in recent years and has been accompanied by a significant rise in cardiac device infections (CDIs), which pose a substantial clinical and economic burden. CDIs are associated with hospitalizations and prolonged antibiotic therapy and often necessitate device removal, leading to increased morbidity, mortality, and healthcare costs worldwide. Approximately 1-2% of CIED implants are associated with infections, making this a critical issue to address. In this contemporary review, we discuss the burden of CDIs with their risk factors, healthcare costs, prevention strategies, and clinical management.

Lead Break during Extraction: Predisposing Factors and Impact on Procedure Complexity and Outcome: Analysis of 3825 Procedures

Background: Currently, there are no reports describing lead break (LB) during transvenous lead extraction (TLE). Methods: This study conducted a retrospective analysis of 3825 consecutive TLEs using mechanical sheaths. Results: Fracture of the lead, defined as LB, with a long lead fragment (LF) occurred in 2.48%, LB with a short LF in 1.20%, LB with the tip of the lead in 1.78%, and LB with loss of a free-floating LF in 0.57% of cases. In total, extractions with LB occurred in 6.04% of the cases studied. In cases in which the lead remnant comprises more than the tip only, there was a 50.31% chance of removing the lead fragment in its entirety and an 18.41% chance of significantly reducing its length (to less than 4 cm). Risk factors for LB are similar to those for major complications and increased procedure complexity, including long lead dwell time [OR = 1.018], a higher LV ejection fraction, multiple previous CIED-related procedures, and the extraction of passive fixation leads. The LECOM and LED scores also exhibit a high predictive value. All forms of LB were associated with increased procedure complexity and major complications (9.96 vs. 1.53%). There was no incidence of procedure-related death among such patients, and LB did not affect the survival statistics after TLE. Conclusions: LB during TLE occurs in 6.04% of procedures, and this predictable difficulty increases procedure complexity and the risk of major complications. Thus, the possibility of LB should be taken into account when planning the lead extraction strategy and its associated training.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Laser lead extraction in octo- and nonagenarians. A subgroup analysis from the GALLERY registry

INTRODUCTION

In an aging population with cardiac implantable electronic devices, an increasing number of octo- and even nonagenarians present for lead extraction procedures. Those patients are considered at increased risk for surgical procedures including lead extraction. Here, we investigated safety and efficacy of transvenous lead extraction in a large patient cohort of octo- and nonagenarians.

METHODS AND RESULTS

A subgroup analysis of all patients aged ≥80 years (n = 499) in the German Laser Lead Extraction Registry (GALLERY) was performed. Outcomes were compared to the nonoctogenarians from the registry. Primary extraction method was Laser lead extraction, with additional use of mechanical rotational sheaths or femoral snares, if necessary. An analysis of patient- and device characteristics, as well as an assessment of predictors for adverse events via multivariate analyses was conducted. Mean patients age was 84.3 ± 3.7 years in the octogenarians group and 64.1 ± 12.4 years in the nonoctogenarians group. The median lead dwell time was 118.0 months (78; 167) and 92.0 months [60; 133], p < .001 in the octogenarians and nonoctogenarians group, respectively. Clinical procedural success rate was achieved in 97.6% of the cases in octogenarians and 97.9% in nonoctogenarians (p = .70). Overall complication rate was 4.4% in octogenarians and 4.3% in nonoctogenarians (0.91). In octogenarians procedure-related mortality was 0.8% and all-cause in-hospital mortality was 5.4%, while in nonoctogenarians, procedure related and all-cause in-hospital mortality were 0.5% and 3.1%, respectively. A body mass index (BMI) <20 kg/m2 , was the only statistically significant predictor for procedure-related complications in octogenarians, while systemic infection, BMI ≤20 kg/m2 , procedural complications and chronic kidney disease were predictors for in-hospital mortality.

CONCLUSIONS

Laser lead extraction in octo- and nonagenarians is safe and effective. BMI ≤20 kg/m2 was the only statistically significant predictor for procedural complications. According to our data, advanced age should not be considered as contraindication for laser lead extraction.

Transvenous Lead Extraction: Work in Progress

Cardiac implantable electronic devices are the cornerstone of cardiac rhythm management, with a significant number of implantations annually. A rising prevalence of cardiac implantable electronic devices coupled with widening indications for device removal has fuelled a demand for transvenous lead extraction (TLE). With advancement of tools and techniques, the safety and efficacy profile of TLE has significantly improved since its inception. Despite these advances, TLE continues to carry risk of significant complications, including a superior vena cava injury and mortality. However, innovative approaches to lead extraction, including the use of the jugular and femoral accesses, offers potential for further gains in safety and efficacy. In this review, the indications and risks of TLE are discussed while examining the evolution of this procedure from simple traction to advanced methodologies, which have contributed to a significant improvement in safety and efficacy.

Atrial Fibrillation and Transvenous Lead Extraction-A Comprehensive Subgroup Analysis of the GermAn Laser Lead Extraction RegistrY (GALLERY)

Background: Atrial fibrillation is the most common arrhythmia and has been described as driver of cardiovascular morbidity and risk factor for cardiac device-related complications, as well as in transvenous lead extraction (TLE). Objectives: Aim of this study was to characterize the procedural outcome and risk-factors of patients with atrial fibrillation (AF) undergoing TLE. Methods: We performed a subgroup analysis of all AF patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for all-cause mortality were assessed. Results: A total number of 510 patients with AF were identified with a mean age of 74.0 ± 10.3 years. Systemic infection (38.4%) was the leading cause for TLE, followed by local infection (37.5%) and lead dysfunction (20.4%). Most of the patients (45.9%) presented with pacemaker systems to be extracted. The total number of leads was 1181 with a 2.3 ± 0.96 leads/patient. Clinical procedural success was achieved in 97.1%. Occurrence of major complications was 1.8% with a procedure-related mortality of 1.0%. All-cause mortality was high with 5.9% and septic shock being the most common cause. Systemic device infection (OR: 49.73; 95% CI: 6.56−377.09, p < 0.001), chronic kidney disease (CKD; OR: 2.67; 95% CI: 1.01−7.03, p = 0.048) and a body mass index < 21 kg/m2 (OR: 6.6; 95% CI: 1.68−25.87, p = 0.007) were identified as independent predictors for all-cause mortality. Conclusions: TLE in AF patients is effective and safe, but in patients with systemic infection the mortality due to septic shock is high. Systemic infection, CKD and body mass index <21 kg/m2 are risk factors for death in patient with AF undergoing TLE.

The GermAn Laser Lead Extraction GallerY: GALLERY

AIMS

The GermAn Laser Lead Extraction GallerY (GALLERY) is a retrospective, national multicentre registry, investigating the safety and efficacy of laser lead extraction procedures in Germany.

METHODS AND RESULTS

Twenty-four German centres that are performing laser lead extraction have participated in the registry. All patients, treated with a laser lead extraction procedure between January 2013 and March 2017, were consecutively enrolled. Safety and efficacy of laser lead extraction were investigated. A total number of 2524 consecutive patients with 6117 leads were included into the registry. About 5499 leads with a median lead dwell time of 96 (62-141) months were treated. The mean number of treated leads per patient was 2.18 ± 1.02. The clinical procedural success rate was 97.86% and the complete lead removal was observed in 94.85%. Additional extraction tools were used in 6.65% of cases. The rate of procedural failure was 2.14% with lead age  ≥10 years being its only predictor. The overall complication rate was 4.32%, including 2.06% major and 2.26% minor complications. Procedure-related mortality was 0.55%. Female sex and the presence of abandoned leads were predictors for procedure-related complications. The all-cause in-hospital mortality was 3.56% with systemic infection being the strongest predictor, followed by age ≥75 years and chronic kidney disease.

CONCLUSION

In the GALLERY, a high success- and low procedure-related complication rates have been demonstrated. In multivariate analysis, female sex and the presence of abandoned leads were predictors for procedure-related complications, while the presence of systemic infection, age ≥75 years, and chronic kidney disease were independent predictors for all-cause mortality.

Efficacy and mortality of rotating sheaths versus laser sheaths for transvenous lead extraction: a meta-analysis

BACKGROUND

Rotating and laser sheaths are both routinely used in transvenous lead extraction (TLE) which can lead to catastrophic complications including death. The efficacy and risk of each approach are uncertain. To perform a meta-analysis to compare success and mortality rates associated with rotating and laser sheaths.

METHODS

We searched electronic academic databases for case series of consecutive patients and randomized controlled trials published 1998-2017 describing the use of rotating and laser sheaths for TLE. Among 48 studies identified, rotating sheaths included 1,094 patients with 1,955 leads in 14 studies, and laser sheaths included 7,775 patients with 12,339 leads in 34 studies. Patients receiving rotating sheaths were older (63 versus 60 years old) and were more often male (74% versus 72%); CRT-P/Ds were more commonly extracted using rotating sheaths (12% versus 7%), whereas ICDs were less common (37% versus 42%), p > 0.05 for all. Infection as an indication for lead extraction was higher in the rotating sheath group (59.8% versus 52.9%, p = 0.002). The mean time from initial lead implantation was 7.2 years for rotating sheaths and 6.3 years for laser sheaths (p > 0.05).

RESULTS

Success rates for complete removal of transvenous leads were 95.1% in rotating sheaths and 93.4% in laser sheaths (p < 0.05). There was one death among 1,094 patients (0.09%) in rotating sheaths and 66 deaths among 7,775 patients (0.85%) in laser sheaths, translating to a 9.3-fold higher risk of death with laser sheaths (95% CI 1.3 to 66.9, p = 0.01).

CONCLUSIONS

Laser sheaths were associated with lower complete lead removal rate and a 9.3-fold higher risk of death.

The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction

BACKGROUND

Recent studies have shown that Evolution RL bidirectional rotational mechanical sheath (Cook Medical,USA) is an effective and safe technique for transvenous lead extraction (TLE). We reported our experience with the bidirectional rotational mechanical tools using a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration.

METHODS

The study population comprised 84 patients (77%male;mean age 65±18 years) undergoing TLE.After multidisciplinary evaluation, a combined procedure was considered.

RESULTS

The main indication for TLE was infection in 54 cases (64%).Overall,152 leads were extracted with a mean implant duration of 94±63 months (range 12-421).Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6 % (77/84),97.6% (82/84), and 98.6%(150/152), respectively.Eighteen combined procedure were performed in 12 patients (14%), such as "hybrid approach" (n = 2) or TLE concomitant to:1) transcatheter aspiration procedure for large vegetation (n = 8); 2) left ventricular assistance device implantation as bridge to cardiac transplantation (n = 1); 3) permanent pacing with epicardial leads (n = 6); 4) tricuspid valve replacement (n = 1).One major complication (1.2%) and 11 (13%) minor complications were encountered.No injury to the superior vena cava occurred and no procedure-related deaths were reported. During a mean time follow-up of 21±18 months, 17 patients (20%) died.They were more often diabetics (P = 0.02), and they underwent TLE more often for infection (P = 0.004).

CONCLUSIONS

Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the Evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators. This article is protected by copyright. All rights reserved.

Safety and efficacy of transvenous lead extraction of very old leads

OBJECTIVES

Transvenous lead extraction using mechanical rotational- or laser sheaths is an established procedure. Lead dwell time has been recognized as a risk factor for extraction failure and procedure-related complications. We therefore investigated the safety and efficacy of transvenous extraction of leads with an implant duration of more than 10 years.

METHODS

Between January 2013 and March 2017, a total of 403 patients underwent lead extraction in 2 high-volume lead extraction centres. One hundred and fifty-four patients with extraction of at least 1 lead aged over 10 years were included in this analysis. Laser lead extraction was the primary extraction method, with additional use of mechanical rotational sheaths or femoral snares, if necessary. All procedural- and patient-based data were collected into a database and retrospectively analysed.

RESULTS

Mean patient's age was 65.8 ± 15.8 years, 68.2% were male. Three hundred and sixty-two leads had to be extracted. The mean lead dwell time of treated leads was 14.0 ± 6.1 years. Complete procedural success was achieved in 91.6% of cases, while clinical success was achieved in 96.8%. Failure of extraction occurred in 3.2%. Leads that could not be completely removed had a significantly longer lead dwell time (18.2 vs 13.2 years; P = 0.016). Additional mechanical rotational sheaths or femoral snares were used in 26 (16.9%) patients. Overall complication rate was 4.6%, including 5 (3.3%) major and 2 (1.3%) minor complications. There was no procedure-related mortality.

CONCLUSIONS

Transvenous lead extraction in leads aged over 10 years is safe and effective when performed in specialized centres and with use of multiple tools and techniques. Leads that could not be completely extracted had a statistically significant longer lead dwell time.

An expert spotlight on inferior vena cava filters

Introduction: Inferior vena cava (IVC) filters are mechanical filtration devices designed as an alternative to surgical ligation/plication of the IVC. Their use has been controversial, especially with the introduction of retrievable filters and expanded/prophylactic indications.Areas covered: Authors discuss the types of available IVC filters, indications for placement, evidence on their effectiveness in general and specific patient populations, procedural considerations, off-label use, complications, and filter retrieval. This review is based on manuscripts/abstracts published from 1960 to 2021 on venous thromboembolism and IVC filters.Expert opinion: Despite the limited data on their effectiveness and survival benefit, IVC filters continue to play an important role in the treatment of patients with venous thromboembolism (VTE) who cannot receive standard anticoagulation. There is no role of IVC filters in patients without VTE. While retrievable filters are desirable for short-term use, a dedicated team-based approach, and advanced training are required for their successful removal. Newer devices are promising in improving patient safety . The device manufacturers and regulatory agencies should consider specific approaches to track device-related adverse events. Population-based studies are required to establish optimal patient population who would benefit from these devices. .

Comparison between TightRail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction

BACKGROUND

There are limited data on the comparative analyses of TightRail rotating dilator sheath (Philips) and laser sheath for lead extraction.

OBJECTIVE

To evaluate the effectiveness and safety of the TightRail sheath as a primary or secondary tool for transvenous lead extraction (TLE).

METHODS

Retrospective cohort analysis of 202 consecutive patients who underwent TLE using either TightRail sheath and/or GlideLight laser sheath (Philips) in our hospital. The study population was divided into three groups: Group A underwent TLE with laser sheath only (N = 157), Group B with TightRail sheath only (N = 22), and Group C with both sheaths (N = 23).

RESULTS

During this period, 375 leads in 202 patients were extracted, including 297 leads extracted by laser sheath alone, 45 leads by TightRail sheath alone, and 33 by both TightRail sheath and laser sheaths. The most common indications included device infection (44.6%) and lead-related complications (44.1%). The median age of leads was 8.9 years. TightRail sheath (Group B) achieved similar efficacy as a primary extraction tool compared with laser sheath (Group A), with complete procedure success rate of 93.3% (vs. 96.6%, P = .263) and clinical success rate of 100.0% (vs. 98.1%, P = .513). Among 32 leads in which Tightrail was used after laser had failed (Group C), the complete procedure success rate was 75.8%. No significant difference in procedural adverse events was observed.

CONCLUSION

Our single-center experience confirms that the TightRail system is an effective first-line and second-line method for TLE. Further investigation is required to guide the selection of mechanical and laser sheaths in lead extraction cases.

Safety and efficacy of transvenous lead extraction in octogenarians using powered extraction sheaths

BACKGROUND

In the aging population equipped with cardiac implantable electronic devices, an increasing number of octogenarians require lead extractions. This patient population is often considered as a high-risk group for surgical procedures. We, therefore, investigated the safety and efficacy of transvenous lead extraction in octogenarians using powered extraction sheaths.

METHODS

Between January 2013 and March 2017, 403 patients underwent lead extraction at two high-volume lead extraction centers. A total of 71 octogenarians were treated with laser lead extraction and were included in this analysis. Primary extraction method was laser lead extraction, with additional use of mechanical rotational sheaths or femoral snares, if necessary. Patient-based and procedural data were collected and analyzed retrospectively.

RESULTS

Mean age was 83.5 ± 3.3 years, 64.7% were males. A total of 152 leads were extracted. The mean lead dwell time of treated leads was 10.2 ± 5.2 years. Complete procedural success rate was 92.9%, while clinical success was achieved in 98.6%. Failure of extraction occurred in one patient (1.4%). In six (7.7%) patients, additional mechanical rotational sheaths or femoral snares were used. Overall complication rate was 4.2%, including one (1.4%) major (RA perforation) and two (2.8%) minor complications. No procedure-related mortality was observed in any of the patients.

CONCLUSION

Transvenous lead extraction in octogenarians with old leads is safe and effective when performed in experienced centers. Patient's age should therefore not be considered as contraindication for lead extraction using powered extraction sheaths.

Benefits of routine prophylactic femoral access during transvenous lead extraction

BACKGROUND

The number of patients requiring lead extraction has been increasing in recent years. Despite significant advances in operator experience and technique, unexpected complications may occur. Prophylactic placement of femoral sheaths allows for immediate endovascular access for emergency procedures and may shorten response time in the event of complications.

OBJECTIVE

The purpose of this study was to assess the benefits of routine prophylactic femoral access in patients undergoing transvenous lead extraction (TLE) and to evaluate the methods, frequency, and efficacy of the emergency measures used in those patients.

METHODS

We conducted a retrospective analysis of patients who underwent TLE from January 2012 to February 2019. The data were analyzed with regard to procedural complications and deployment of emergency measures via femoral access.

RESULTS

Two hundred eighty-five patients (mean age 65.3 ± 15.5 years) were included in the study. Median lead dwell time was 84 months (interquartile range 58-144). Overall complication rate was 4.2% (n = 12), with 1.8% major complications (n = 5). Clinical success rate was 97.2%. Procedure-related mortality was 1.1% (n = 3). Femoral sheaths were actively engaged in 9.1% (n = 26) of cases. Deployment of snares was the most common intervention (n = 10), followed by prophylactic (n = 6) or emergency placement (n = 1) of occlusion balloons, temporary pacing (n = 3), venous angioplasty (n = 3), diagnostic venography (n = 3), and extracorporeal membrane oxygenation (n = 1). We did not observe any femoral vascular complications due to prophylactic sheath placement.

CONCLUSION

Routine prophylactic placement of femoral sheaths shortens response time and quickly establishes control in the event of various complications that may occur during TLE procedures.

Comparison of outcomes in infected cardiovascular implantable electronic devices between complete, partial, and failed lead removal: an ESC-EHRA-EORP ELECTRa (European Lead Extraction ConTrolled) registry

AIMS

The present study sought to determine predictors for success and outcomes of patients who underwent cardiac implantable electronic devices (CIED) extraction indicated for systemic or local CIED related infection in particular where complete lead removal could not be achieved.

METHODS AND RESULTS

ESC-EORP ELECTRa (European Lead Extraction ConTRolled Registry) is a European prospective lead extraction registry. Out of the total cohort, 1865/3510 (52.5%) patients underwent removal due to CIED related infection. Predictors and outcomes of failure were analysed. Complete removal was achieved in 1743 (93.5%) patients, partial (<4 cm of lead left) in 88 (4.7%), and failed (>4 cm of lead left) in 32 (1.8%) patients. Removal success was unrelated to type of CIED infection (pocket or systemic). Predictors for failure were older leads and older patients [odds ratio (OR) 1.14 (1.08-1.19), P < 0.0001 and OR 2.68 (1.22-5.91), P = 0.0146, respectively]. In analysis by lead, predictors for failure were: pacemaker vs. defibrillator removal and failure to engage the locking stylet all the way to the tip [OR 0.20 (0.04-0.95), P = 0.03 and OR 0.32 (0.13-0.74), P = 0.008, respectively]. Significantly higher complication rates were noted in the failure group (40.6% vs. 15.9 for partial and 8.7% for success groups, P < 0.0001). Failure to remove a lead was a strong predictor for in hospital mortality [hazard ratio of 2.05 (1.01-4.16), P = 0.046].

CONCLUSION

A total of 6.5% of infected CIED patients failed attempted extraction. Only were >4 cm of lead remained resulted in higher procedural complications and mortality rates.

Efficacy and safety of transvenous lead extraction using a liberal combined superior and femoral approach

Purpose

During transvenous lead extraction (TLE), the femoral snare has mainly been used as a bail-out procedure. The purpose of the present study is to evaluate the efficacy and safety of a TLE approach with a low threshold to use a combined superior and femoral approach.

Methods

This is a single-center observational study including all TLE procedures between 2012 till 2019.

Results

A total of 264 procedures (median age 63 (51–71) years, 67.0% male) were performed in the study period. The main indications for TLE were lead malfunction (67.0%), isolated pocket infection (17.0%) and systemic infection (11.7%). The median dwelling time of the oldest targeted lead was 6.8 (4.0–9.7) years. The techniques used to perform the procedure were the use of a femoral snare only (30%), combined rotational powered sheath and femoral snare (25%), manual traction only (20%), rotational powered sheath only (17%) and locking stylet only (8%). The complete and clinical procedural success rate was 90.2% and 97.7%, respectively, and complete lead removal rate was 94.1% of all targeted leads. The major and minor procedure-related complication rates were 1.1% and 10.2%, respectively. There was one case (0.4%) of emergent sternotomy for management of cardiac avulsion. Furthermore, there were 5 in-hospital non-procedure-related deaths (1.9%), of whom 4 were related to septic shock due to a Staphylococcus aureus endocarditis after an uncomplicated TLE with complete removal of all leads.

Conclusion

An effective and safe TLE procedure can be achieved by using the synergy between a superior and femoral approach.

Hybrid transvenous lead extraction during cardiac surgery for valvular endocarditis

INTRODUCTION

In patients with endocarditis and cardiac implantable electronic devices (CIED), lead extraction is recommended according to current guidelines. In patients with short lead implant duration, lead extraction by manual traction might be sufficient for intraoperative lead removal. However, in patients with long implant duration, specialized extraction tools like laser or mechanical rotational sheaths are necessary. We report our experience with transvenous lead extraction during concomitant cardiac surgery for valvular endocarditis using mechanical rotational sheaths.

METHODS AND RESULTS

Between December 2018 and April 2020, 12 patients were treated with transvenous lead extraction during open-heart surgery using mechanical rotational sheaths. Cardiac surgery was performed due to mitral, aortic, or tricuspid valve endocarditis. All patient-related and procedural data were collected, and in-hospital outcome was analyzed retrospectively. Mean patients' age was 65.2 ± 16.4 years, and 75.0% were male. Nine atrial, 15 ventricular, and 2 coronary sinus leads had to be extracted. The mean time from initial lead implantation was 94.3 ± 39.7 months. Complete procedural success was achieved in all patients with no major but one minor complication (pocket hematoma) occurring during lead extraction. Four patients with pacemaker dependency received epicardial leads, seven patients were treated in a two-step approach with endocardial leads, whereas one patient had no further CIED indication. No procedure-related mortality was seen. In-hospital survival was 91.7%.

CONCLUSIONS

Valvular endocarditis surgery in combination with lead extraction using mechanical rotational sheaths is safe and feasible. It results in a high procedural success rate with prompt infection control by immediate removal of all infected lead materials.

Use of the new rotating dilator sheath TightRail™ for lead extraction: A bicentric experience

AIM

The aim of this study is to assess the safety and efficacy of the new bidirectional rotational mechanical sheath TightRail™ (Spectranetics) for lead extraction.

METHODS AND RESULTS

This is a bicentric prospective study that included patients who underwent a transvenous lead extraction (TLE) in two Italian centers (San Raffaele Hospital and Humanitas Gavazzeni Hospital). From November 2016 to December 2018, 26 patients underwent a TLE procedure in which the TightRail™ was used. The new TightRail Sub-C was used in 20 (76%) patients to overcome the fibrosis between the vessel and the first rib. Median age was 69 (IQR 60.7-79.5) years. The indication for TLE were infection (57.7%) or lead dysfunction (42.3%). A total of 57 leads (range 1-4), 40 of which using the TightRail (range 1-4), were extracted. Overall mean implant duration was 98.2.0 ± 66.5 months. Mean age of the lead extracted with the TightRail sheath was 99.1 ± 70.2 months and was higher compared to that of the leads extracted manually (84.4 ± 60.3 months, P = .001). The overall clinical success was 100% and complete procedural success without the use of a snare was achieved in 98.3%. There were no cases of death or major complications and only two minor complications occurred. All patients were event-free at 6-month follow-up.

CONCLUSION

This initial experience using the TightRail™ suggests a high safety and efficacy profile for extractions in a wide range of lead age.

Reported mortality with rotating sheaths vs. laser sheaths for transvenous lead extraction

Aims

Rotating sheaths and laser sheaths are commonly used for transvenous lead extraction. This study aims to compare observed mortality between both approaches.

Methods and results

The Manufacturer and User Facility Device Experience database was searched from 2011 to 2016 to determine number of deaths associated with each sheath. An independent analytics firm provided estimates for number of cases done, allowing calculation of market share. A sensitivity analysis was performed to determine relative risk (RR) of mortality at the calculated market share (36% rotating/64% laser) and two others. Additional sensitivity analyses assumed underreporting of deaths associated with rotating sheaths. An estimated 50 545 extractions were performed. Thirteen deaths were associated with rotating sheaths compared to 167 with laser sheaths. Of these, 92% (rotating) and 95% (laser) were due to cardiovascular injury. At the calculated market share, the RR of death was 7.2 times greater with laser sheaths [95% confidence interval (CI) 4.1–12.7, P < 0.0001]. At market share estimates of 25% rotating/75% laser and 45% rotating/55% laser, the RR of death with laser sheaths was 4.3 (95% CI 2.4–7.5, P < 0.0001) and 10.5 times greater (95% CI 6.0–18.5, P < 0.0001), respectively. The RR of death remained significant when assuming deaths with rotating sheaths were underreported and when deaths using both sheaths were attributed to the rotating sheath.

Conclusions

Lead extraction with laser sheaths appears to be associated with a higher risk of mortality compared to rotating sheaths. Further studies are warranted to confirm this finding.

Prognosis associated with redo cardiac resynchronization therapy following complete device and lead extraction due to device-related infection

Aims

An increase in the number of cardiac resynchronization therapy (CRT) device implantations worldwide has led to a consequent increase in the number of infections associated with the device, making extraction of the CRT device inevitable. Redo CRT implantation after treatment and recovery following device extraction is challenging. This study aimed to evaluate the success rate, complications, and long-term prognosis of redo CRT implantation, including the rates of subclavian, cava, and coronary sinus (CS) vein thrombosis as well as re-infection.

Methods and results

Between 2007 and 2014, 1712 lead extractions were performed in 537 patients with device-related infection at Heart Center Brandenburg. Of the 537 patients, 125 (23%) underwent CRT device and lead extraction, including extraction of the left ventricular lead from the coronary sinus. Of these 125, 62 (50%) patients underwent redo CRT implantation (mean age, 68 ± 10 years); 34 patients had coronary artery disease (CAD) while 28 had dilated cardiomyopathy (DCM). The mean left ventricular ejection fraction was 27% ± 7%. The mean QRS duration of the left bundle branch block was 158 (range, 147-162) ms, and 25 patients had atrial fibrillation (AF). All these patients were followed up for a median duration of 29.6 (range, 15-43) months. In 53 of the 62 patients (85%), the CRT system was successfully re-implanted; however, the original CS vein could be used again only in 28 (45%) patients. The all-cause mortality rate was 7.1% after 1 year, and it was significantly higher in patients whose N-terminal pro B-type natriuretic peptide level was  ≥3,000 pg/mL (P < 0.001), those who were aged  ≥64 years (P = 0.028), those who had CAD (P = 0.042) or chronic kidney insufficiency (P = 0.001), those with AF (P = 0.001) and those whose blood cultures were positive for Staphylococcus aureus (P = 0.014).

Conclusion

Redo CRT implantation after device extraction owing to device-related infection has a low success rate and shows a higher rate of re-infection than that observed in patients who undergo CRT implantation for the first time. Further, patients whose blood cultures are positive for S. aureus show a particularly poor outcome.

Cardiac and Vascular Injuries Sustained During Transvenous Lead Extraction

The rise in indications for cardiac implantable electronic devices has necessitated the development of tools for removal of the electrodes that connect the heart to these externally located pacemakers and defibrillators. After implant of a cardiac electrode, variable but progressive fibrous adhesion occurs. Removal of these adhesions can cause devastating complications with high risk of mortality if not treated surgically in a highly expeditious and appropriate manner. This article describes the incidence, risk factors, and diagnosis of these injuries followed by discussion of recent evidence for use of superior vena cava balloon occlusion, and conventional surgical repair of these injuries.

Safety of Transvenous Lead Removal in Patients ≥70 Years of Age in the United States from 2005 to 2012

Cardiac devices are increasingly an element of treatment for the elderly, leading to more frequent transvenous lead removal (TLR) procedures in this population. Data on TLR in very elderly patients, especially nonagenarians, is scarce. We used Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify a total of 36,099 patients ≥70 years who underwent TLR from 2005 to 2012, with outcomes including in-hospital mortality and complications. The in-hospital mortality rate was significantly higher in nonagenarians without device infection (0.9% in age 70 to 79 vs 0.7% in age 80 to 89 vs 2.6% in age ≥90, p = 0.012), but overall complication rates were not different in age groups regardless of infection status and co-morbidity index (all p >0.05). Among patients with device infection, octogenarians, and nonagenarians were not associated with increased risk of in-hospital mortality relative to septuagenarians after controlling for all other confounders. However, in patients without device infection, logistic regression showed significantly higher mortality in patients age ≥90 years (odd ratio 4.22, 95% confidence interval 1.66 to 10.75, p = 0.003), but not in patients age 80 to 89 years (odd ratio 1.05, 95% confidence interval 0.48 to 2.30, p = 0.907), compared with patients age 70 to 79 years. In conclusion, in nonagenarians with infection, mortality is driven more by the patient's other conditions than by age. For patients without infection, however, nonagenarians experienced higher mortality than younger patients.

Comparative study about the tensile strength and yielding mechanism of pacing lead among major manufacturers

BACKGROUND

With extraction of cardiovascular implantable electronic devices (CIED) increasingly necessitated, various studies have contemplated to investigate clinical predictors for its success and complications. Intrinsic parameters of CIED leads have been studied less extensively and are the foci of this study.

METHODS

Three major pacemaker manufacturers accepted invitation. Leads then underwent tensile test in vitro with their composite tensile strength (TS) compared. Mechanism of yielding, under tensile stress, was also observed among them.

RESULTS

All pacing leads, participated in this study, surpassed requirement of European Standard EN 45502-2-1. Boston Scientific's FINELINE II STEROX 4456/52 cm (Boston Scientific Corp., St. Paul, MN, USA) and Medtronic's CAPSURE SENSE 4074/52 cm (Medtronic, Minneapolis, MN, USA) showed similar composite TS and both were stronger compared with St. Jude Medical's ISOFLEX OPTIM 1948/52 cm (P <0.001; St. Jude Medical, Sylmar, CA, USA). Despite a difference in the exact site, the Medtronic 4074 and St. Jude Medical 1948 yielded similarly in that their distal tip electrode remained connected with a flimsy inner coil to proximal portion of the lead after their composite TS was exceeded. Boston Scientific 4456's insulation tubing and coil wire broke almost simultaneously and separated completely from the tip electrode when it yielded.

CONCLUSIONS

FINELINE II STEROX 4456/52 cm and CAPSURE SENSE 4074/52 cm showed stronger composite tensile strength than ISOFLEX OPTIM 1948/52 cm. FINELINE II STEROX 4456 was found more prone to complete severance. Limitations and precautions to translate these differences directly into real-life scenario are discussed.

Endobronchial Forceps-Assisted and Excimer Laser-Assisted Inferior Vena Cava Filter Removal: The Data, Where We Are, and How It Is Done

The recognition of inferior vena cava filter related complications has motivated increased attentiveness in clinical follow-up of patients with inferior vena cava filters and has led to development of multiple approaches for retrieving filters that are challenging or impossible to remove using conventional techniques. Endobronchial forceps and excimer lasers are tools for designed to aid in complex inferior vena cava filter removals. This article discusses endobronchial forceps-assisted and excimer laser-assisted inferior vena cava filter retrievals.

ICD lead extraction: Not a benign procedure. External chest compression: Not a benign manoeuvre

This is the case of a 45-year-old man who was electively admitted to our hospital for revision and extraction of his faulty implantable cardioverter–defibrillator lead and box. The procedure was complicated by cardiac tamponade requiring pericardiocentisis (unsuccessful) and cardiopulmonary resuscitation. The patient was then rushed to theatre for emergency sternotomy and institution of cardiopulmonary bypass. A tear in the superior vena cava was identified and repaired. Unfortunately, the patient suffered of a liver laceration, due to chest compression, which required emergency laparotomy. The aim of this report is to highlight the combination and management of two rare life-threatening complications that occurred in a single case.

Anesthetic Management of Laser Lead Extraction for Cardiovascular Implantable Electronic Devices

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

Lead extraction with high frequency laser sheaths: a single-centre experience

OBJECTIVES

Extraction of chronically implanted cardiac implantable electrophysiological devices leads can be difficult. Excimer laser-assisted extraction with 40 Hz sheaths has shown good results in challenging cases. In 2012, a new 80 Hz high-frequency laser sheath became available that delivers twice as many pulses per second. Here, we report our clinical experience with the new GlideLight 80 Hz laser sheath.

METHODS

Between January 2012 and August 2016, 292 leads were treated in 151 patients using 80 Hz GlideLight laser sheath. Lead extraction indications included systemic infection or lead endocarditis n =  35 (23.2%), local infection n =  73 (48.3%), lead dysfunction n =  32 (21.2%), system upgrade n =  5 (3.3%), tricuspid regurgitation n =  3 (2.0%) and other indications n =  3 (2.0). All patient-related and procedural data were collected into a database and analysed.

RESULTS

Mean patient's age was 66.2 ± 14.4 years, 73.5% were male. Ninety-one (31.2%) atrial, 159 (54.4%) ventricular and 42 (14.4%) coronary sinus leads had to be extracted. The mean time from initial lead implantation was 98.0 ± 65.2 months. Mean laser treatment time was 67.5 ± 71.3 s, mean laser pulses delivered were 5130 ± 6592. Clinical success was achieved in 99.3% of the cases, while complete procedural success was observed in 96.7%. A failure of extraction was seen in 2 (1.3%) patients. An overall complication rate of 2.0%, including two major (1.3%) and one minor (0.7%) complications, was observed. No periprocedural mortality was seen.

CONCLUSIONS

The new GlideLight high-frequency laser sheath allows for a high safety and efficacy in extraction of chronically implanted pacemaker- and implantable cardioverter-defibrillator leads.

Chronic lead malposition diagnosis and management: discussion of two cases and literature review

Management of lead malposition is crucial to avoid complications and is carried out on case-by-case bases. The 12-lead ECG during pacing and chest X-ray are essential during initial workup and recommended for new patients to the device clinic. Echocardiography and CT scan are important to confirm the location and plan appropriate therapy.

Hybrid Minimally Invasive Approach for Transvenous Lead Extraction: A Feasible Technique in High-Risk Patients

INTRODUCTION

Despite the overall safety, transvenous lead extraction (TLE) remains a challenging procedure with inherent risks, where surgery can still be required in elective cases. In this study, we report our experience with a minimally invasive "hybrid" approach, defined as a procedure performed by an electrophysiologist with the support of a cardiac surgeon in the same operative session.

METHODS AND RESULTS

We reported 12 cases of planned hybrid lead extraction; minithoracotomy and thoracoscopy were performed on 10 (83%) and 2 (17%) patients, respectively. A total of 25 leads out of 27 (median lead age 19 years) were successfully extracted with laser, mechanical or combined transvenous sheath. In 3 patients, the direct monitoring of vascular and myocardial integrity allowed for prompt treatment of potential vascular injury during the lead extraction maneuvers. Mean in-hospital stay was 4 ± 2 days. There were no major intraoperative complications and no deaths occurred after 30 days' follow-up.

CONCLUSION

The hybrid approach, with minithoracotomy or thoracoscopy, is feasible and it might increase the safety in the most challenging TLE procedures: the minimally invasive surgical intervention allows for continuous monitoring of the critical cardiac structures and prompt treatment of potential complications.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Creation of the sole regional laser lead extraction program serving Atlantic Canada: initial experience

BACKGROUND

An increasing need for laser lead extraction has grown in parallel with the increase of implantation of pacing and defibrillating devices. We reviewed the initial experience of a regional laser-assisted lead extraction program serving Atlantic Canada.

METHODS

We retrospectively reviewed the cases of all consecutive patients who underwent laser lead extraction at the Maritime Heart Centre in Halifax, NS, between 2006 and 2015. We conducted univariate and Kaplan-Meier survivorship analyses.

RESULTS

During the 9-year study period, 108 consecutive patients underwent laser lead extractions (218 leads extracted). The most common indication for extraction was infection (84.3%). Most patients were older than 60 years (73.1%) and had leads chronically implanted; the explanted leads were an average of 7.5 ± 6.8 years old. Procedural and clinical success (resolution of preoperative symptoms) rates and mortality were 96.8%, 97.2%, and 0.9%, respectively. Sternotomy procedures were performed in 3 instances: once for vascular repair due to perforation and twice to ensure that all infected lead material was removed. No minor complications required surgical intervention. Survival after discharge was 98.4% at 30 days and 94% at 12 months.

CONCLUSION

Atlantic Canada's sole surgical extraction centre achieved high extraction success with a low complication rate. Lead extraction in an operative setting provides for immediate surgical intervention and is essential for the survival of patients with complicated cases. Surgeons must weigh the risks versus benefits in patients older than 60 years who have chronically implanted leads (> 1 yr) and infection.

A novel use of EP catheter in extraction of trapped intracardiac devices: Two case reports

The decision to retrieve chronically implanted abandoned leads and trapped intracardiac devices percutaneously has been difficult and highly controversial. We present two case reports in which electrophysiological ablation catheter was used to retrieve infected abandoned pacemaker lead and trapped permacatheter (permacath) in right ventricle. We could avert major cardiovascular surgeries in both the patients by simply modifying the traditionally used techniques for extraction of intracardiac devices.

Management of Cardiac Electronic Device Infections: Challenges and Outcomes

Cardiac implantable electronic device (CIED) infection is an increasing problem. Reasons for this are uncertain, but likely relate to an increasing proportion of implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices implanted, as well as implantations in 'higher risk' candidates, i.e. patients with heart failure, diabetes and renal failure. Challenges within the field of CIED infections are multiple with prevention being the most important challenge. Careful prescription of CIED treatment and careful patient preparation before implantation is important. Diagnosis is often difficult and delayed by subtle signs of infection. Treatment of CIED infection includes complete system removal in centres experienced in CIED extraction and prolonged antibiotic therapy. Meticulous planning and preparation before system extraction and later CIED re-implantation is essential for better patient outcome. Future strategies for reducing CIED infection should be tested in sufficiently powered, multicentre, randomised controlled trials.