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Patient Characteristics, Procedural Characteristics, and Outcomes in Patients Having Lead Extraction in a High-Volume Center. Am J Cardiol 2022; 176:51-57. [PMID: 35613955 DOI: 10.1016/j.amjcard.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 11/22/2022]
Abstract
The rate of transvenous lead extraction (TLE) is increasing, with an increasing rate of complex devices being implanted. TLE is now a routine part of cardiac device management and up-to-date data on the safety and efficacy of TLE with modern tools and techniques is essential to management decisions regarding noninfectious indications for lead extraction. We present a contemporary, prospective review of TLE at our high-volume cardiac center. All patients who underwent TLE from June 2016 to June 2019 were enrolled in our local database, and baseline clinical data, procedural information, and outcome data were collected. In total, 561 leads were explanted (n = 153) or extracted (n = 408) from 341 patients over the study period. Patients were predominantly male (71%), with a mean age of 65 ± 17 years. The most common indication for lead removal was lead failure (45.2%, n = 154), followed by infection of the pocket or device (29.3%, n = 100). In total, complete success was achieved in 96.4% (n = 541) leads, clinical success in a further 2.1% (n = 12), and failure only in 1.4% (n = 8). There was an overall complication rate of 0.9% (3/341) for major complications and 1.5% (5/341) for minor complications. There were no deaths. In conclusion, our data suggest that there are ongoing improvements in the safety profile and success rates of lead extraction undertaken by experienced operators. The major complication rate now is <1%.
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Akhtar Z, Gallagher MM, Elbatran AI, Starck CT, Gonzalez E, Al-Razzo O, Mazzone P, Delnoy PP, Breitenstein A, Steffel J, Eulert-Grehn J, Lanmüller P, Melillo F, Marzi A, Leung LW, Domenichini G, Sohal M. Patient Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: A comparison of two professions. Pacing Clin Electrophysiol 2022; 45:658-665. [PMID: 35417049 DOI: 10.1111/pace.14501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/09/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND With an increasing number of cardiac implantable electronic devices, there has been a paralleled increase in demand for transvenous lead extraction (TLE). Cardiac surgeons (CS) and cardiologists perform TLE; however, data comparing the two groups of operators is scarce. OBJECTIVE We compared the outcomes of TLE performed by cardiologists and CS from six European lead extraction units. METHOD Data was collected retrospectively of 2205 patients who had 3849 leads extracted (PROMET) between 2005-2018. Patient demographics and procedural outcomes were compared between the CS and cardiologist groups, using propensity score matching. A multivariate regression analysis was also performed for variables associated with 30-day mortality. RESULTS Cardiac surgeons performed the majority of extractions (59.8%), of leads with longer dwell times (90 [57-129 interquartile range (IQR)] vs 62 [31-102 IQR] months, CS vs cardiologists, p < 0.001) and with pre-dominantly non-infectious indications (57.4% vs 50.2%, CS vs cardiologists, p < 0.001). Cardiac surgeons achieved a higher complete success per lead than the cardiologists (98.1% vs 95.7%, respectively, p < 0.01), with a higher number of minor complications (5.51% vs 2.1%, p < 0.01) and similar number of major complications (0.47% vs 1.3%, p = 0.12). Thirty-day mortality was similarly low in the CS and cardiologist groups (1.76% vs 0.94%,p = 0.21). Unmatched data multivariate analysis revealed infection indication (OR 6.12 [1.9-20.3], p < 0.01), procedure duration (OR 1.01 [1.01-1.02], p < 0.01) and CS operator (OR 2.67, [1.12-6.37], p = 0.027) were associated with 30-day mortality. CONCLUSION Transvenous lead extraction by CS was performed with similar safety and higher efficacy compared to cardiologists in high and medium-volume lead extraction centres. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Zaki Akhtar
- St. George's University Hospitals NHS Foundation Trust, London
| | | | - Ahmed I Elbatran
- St. George's University Hospitals NHS Foundation Trust, London.,Ain Shams University, Cairo, Egypt
| | - Christoph T Starck
- German Heart Center Berlin, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany.,German Center of Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Steinbeis University Berlin, Institute (STI) of Cardiovascular Perfusion, Berlin, Germany
| | | | | | | | | | | | | | - Jürgen Eulert-Grehn
- German Heart Center Berlin, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany.,German Center of Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Pia Lanmüller
- German Heart Center Berlin, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany
| | | | | | - Lisa Wm Leung
- St. George's University Hospitals NHS Foundation Trust, London
| | | | - Manav Sohal
- St. George's University Hospitals NHS Foundation Trust, London
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Efficacy and mortality of rotating sheaths versus laser sheaths for transvenous lead extraction: a meta-analysis. J Interv Card Electrophysiol 2021:10.1007/s10840-021-01076-x. [PMID: 34839431 DOI: 10.1007/s10840-021-01076-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/22/2021] [Indexed: 10/19/2022]
Abstract
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.
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Ksela J, Prevolnik J, Racman M. Transvenous lead extraction outcomes using a novel hand-powered bidirectional rotational sheath as a first-line extraction tool in a low-volume centre. Interact Cardiovasc Thorac Surg 2021; 32:395-401. [PMID: 33249479 DOI: 10.1093/icvts/ivaa286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/23/2020] [Accepted: 10/04/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Extraction of cardiovascular implantable electronic devices in low-volume medical centres with limited clinical experience and an evolving lead extraction programme may be challenging. We aimed to evaluate the safety and efficacy of stepwise transvenous lead extraction (TLE) using a novel type of hand-powered rotational sheath as a first-line tool for extraction of chronically implanted devices in a single, low-volume centre. METHODS Sixty-seven consecutive patients undergoing a TLE procedure using the novel Evolution® RL rotational sheath as the first-line extraction tool between 2015 and 2019 at our institution were enrolled in the study. Their short-term and 30-day outcomes were observed. RESULTS Sixty-nine devices and 131 leads were explanted. Procedural and clinical success rates were 92.4% and 98.5%, respectively. Two procedures were classified as failures due to lead remnants >4 cm remaining in patients' vascular systems. One major (1.5%) and 3 minor (4.4%) adverse events and no deaths were observed. CONCLUSIONS TLE procedures, performed in a stepwise manner, using the Evolution RL sheath as a first-line extraction device and conducted by an experienced, surgically well-trained operator, offer excellent results with clinical and procedural success rates comparable to those, achieved in dedicated, high-volume institutions. Opting for optimal lead extraction approach in low-volume centres or institutions with evolving TLE programmes, a stepwise extraction strategy using the Evolution RL sheath by skilled operator may provide the optimal scheme with an excellent ratio between clinical and/or procedural success and complications.
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Affiliation(s)
- Jus Ksela
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia.,Department of Surgery, Faculty of Medicine, Ljubljana, Slovenia
| | - Jan Prevolnik
- Department of Surgery, Faculty of Medicine, Ljubljana, Slovenia
| | - Mark Racman
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
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Starck CT, Gonzalez E, Al-Razzo O, Mazzone P, Delnoy PP, Breitenstein A, Steffel J, Eulert-Grehn J, Lanmüller P, Melillo F, Marzi A, Sohal M, Domenichini G, Gallagher MM. Results of the Patient-Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: a multicentre retrospective study on advanced mechanical lead extraction techniques. Europace 2021; 22:1103-1110. [PMID: 32447388 PMCID: PMC7336182 DOI: 10.1093/europace/euaa103] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 04/08/2020] [Indexed: 01/10/2023] Open
Abstract
AIMS Several large studies have documented the outcome of transvenous lead extraction (TLE), focusing on laser and mechanical methods. To date there has been no large series addressing the results obtained with rotational lead extraction tools. This retrospective multicentre study was designed to investigate the outcomes of mechanical and rotational techniques. METHODS AND RESULTS Data were collected on a total of 2205 patients (age 66.0 ± 15.7 years) with 3849 leads targeted for extraction in six European lead extraction centres. The commonest indication was infection (46%). The targeted leads included 2879 pacemaker leads (74.8%), 949 implantable cardioverter-defibrillator leads (24.6%), and 21 leads for which details were unknown; 46.6% of leads were passive fixation leads. The median lead dwell time was 74 months [interquartile range (IQR) 41-112]. Clinical success was obtained in 97.0% of procedures, and complete extraction was achieved for 96.5% of leads. Major complications occurred in 22/2205 procedures (1%), with a peri-operative or procedure-related mortality rate of 4/2205 (0.18%). Minor complications occurred in 3.1% of procedures. A total of 1552 leads (in 992 patients) with a median dwell time of 106 months (IQR 66-145) were extracted using the Evolution rotational TLE tool. In this subgroup, complete success was obtained for 95.2% of leads with a procedural mortality rate of 0.4%. CONCLUSION Patient outcomes in the PROMET study compare favourably with other large TLE trials, underlining the capability of rotational TLE tools and techniques to match laser methods in efficacy and surpass them in safety.
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Affiliation(s)
- Christoph T Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Steinbeis University Berlin, Institute (STI) of Cardiovascular Perfusion, Berlin, Germany
| | | | | | | | | | | | - Jan Steffel
- University Hospital Zurich, Zurich, Switzerland
| | - Jürgen Eulert-Grehn
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Pia Lanmüller
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | | | | | - Manav Sohal
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Giulia Domenichini
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, London, UK
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Nubila BCLSD, Lacerda GDC, Rey HCV, Barbosa RM. Percutaneous Removal of Cardiac Leads in a Single Center in South America. Arq Bras Cardiol 2021; 116:908-916. [PMID: 34008813 PMCID: PMC8121483 DOI: 10.36660/abc.20190726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/29/2020] [Accepted: 04/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the last decade, the number of cardiac electronic devices has risen considerably and consequently the occasional need for their removal. Concurrently, the transvenous lead removal became a safe procedure that could prevent open-heart surgery. OBJECTIVE The primary objective of this study was to describe the successful performance and the complication rates of pacemaker removals in a Brazilian public hospital. Our secondary aim was to describe the variables associated to successes and complications. METHODS A retrospective case series was conducted in patients submitted to pacemaker removal in a Brazilian public hospital from January 2013 to June 2018. Removal, explant, extraction, success and complication rates were defined by the 2017 Heart Rhythm Society Guideline. Categorical variables were compared using x2 or Fisher's tests, while continuous variables were compared by unpaired tests. A p-value of 0.05 was considered statistically significant. RESULTS Cardiac device removals were performed in 61 patients, of which 51 were submitted to lead extractions and 10 to lead explants. In total, 128 leads were removed. Our clinical success rate was 100% in the explant group and 90.2% in the extraction one (p=0.58). Major complications were observed in 6.6% patients. Procedure failure was associated to older right ventricle (p=0.05) and atrial leads (p=0,04). Procedure duration (p=0.003) and need for blood transfusion (p<0,001) were associated to more complications. CONCLUSION Complications and clinical success were observed in 11.5% and 91.8% of the population, respectively. Removal of older atrial and ventricular leads were associated with lower success rates. Longer procedures and blood transfusions were associated with complications.
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Affiliation(s)
- Bruna Costa Lemos Silva Di Nubila
- Instituto Nacional de CardiologiaRio de JaneiroRJBrasilInstituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brasil
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
| | - Gustavo de Castro Lacerda
- Instituto Nacional de CardiologiaRio de JaneiroRJBrasilInstituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brasil
| | - Helena Cramer Veiga Rey
- Instituto Nacional de CardiologiaRio de JaneiroRJBrasilInstituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brasil
| | - Rodrigo Minati Barbosa
- Instituto Nacional de CardiologiaRio de JaneiroRJBrasilInstituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brasil
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7
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Qin D, Chokshi M, Sabeh MK, Maan A, Bapat A, Bode WD, Hanley A, Hucker WJ, Ng CY, Funamoto M, Barrett CD, Mela T. Comparison between TightRail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:895-902. [PMID: 33675073 DOI: 10.1111/pace.14206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 02/09/2021] [Accepted: 02/21/2021] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Dingxin Qin
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Moulin Chokshi
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mohamad Khaled Sabeh
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Abhishek Maan
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aneesh Bapat
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Weeranun D Bode
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alan Hanley
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William J Hucker
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Chee Yuan Ng
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Masaki Funamoto
- Cardiac Surgery Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Conor D Barrett
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Theofanie Mela
- Cardiac Arrhythmia Service, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
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Bahadır N, Canpolat U, Kaya EB, Sahiner ML, Ateş AH, Yorgun H, Aytemir K. Comparison of acute and long-term outcomes of Evolution ® and TightRail™ mechanical dilator sheaths during transvenous lead extraction. J Cardiovasc Electrophysiol 2021; 32:1395-1404. [PMID: 33724617 DOI: 10.1111/jce.15006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Powered transvenous lead extraction (TLE) tools are commonly required to remove the leads with long implant duration due to fibrotic adhesions. However, comparative data are lacking among different types of TLE tools. AIM To compare the efficacy and safety of two different rotational mechanical dilator sheaths in retrospectively analyzed patients who underwent TLE. METHODS AND RESULTS A total of 566 lead extractions from 302 patients using TightRail™ (333 lead extractions from 169 patients) and Evolution® (233 lead extractions from 133 patients) mechanical dilator sheaths were performed between July 2009 and June 2018. Acute and long-term outcomes of study groups were compared. There is no statistically significant difference between Evolution® and TightRail™ groups in procedural success (93.9% vs. 94%), clinical success (99.2% vs. 98%), and major complications (3.8% vs. 1.2%), respectively (p > .05). In multivariate regression analysis, lead dwell time, the number of extracted leads, and baseline leukocyte count were found as independent predictors of procedural success (p < .05). During the median follow-up of 36.6 (0.2-118) months, all-cause mortality was observed in 73 patients (25.6% in the Evolution® vs. 23.1 in the TightRail™ group, p > .05). Chronic renal disease, heart failure, and coagulopathy were shown as independent predictors of all-cause mortality in multivariate regression analysis (p < .05). CONCLUSION TLE using TightRail™ or Evoluation® mechanical dilator sheaths was a safe and effective therapeutic option. Both mechanical dilator sheaths showed similar efficacy, safety, and all-cause mortality at acute and long-term follow-up of patients who underwent TLE.
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Affiliation(s)
- Nihan Bahadır
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ugur Canpolat
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ergun B Kaya
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehmet L Sahiner
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ahmet H Ateş
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Hikmet Yorgun
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Kudret Aytemir
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
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9
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Elbatran AI, Akhtar Z, Bajpai A, Leung LWM, Li A, Pearse S, Zuberi Z, Kaba R, Saba MM, Norman M, Grimster A, Gallagher MM, Sohal M. Percutaneous management of lead-related cardiac perforation with limited use of computed tomography and cardiac surgery. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:614-624. [PMID: 33624296 DOI: 10.1111/pace.14204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/28/2021] [Accepted: 02/21/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiac implantable electronic device (CIED)-related perforation is uncommon but potentially lethal. Management typically includes the use of computed tomography (CT) scanning and often involves cardiac surgery. METHODS Patients presenting to a single referral centre with CIED-related cardiac perforation between 2013 and 2019 were identified. Demographics, diagnostic modalities, the method of lead revision, and 30-day complications were examined. RESULTS A total of 46 cases were identified; median time from implantation to diagnosis was 14 days (interquartile range = 4-50). Most were females (29/46, 63%), 9/46 (20%) had cancer, 18 patients (39%) used oral anticoagulants, and no patients had prior cardiac surgery. Active fixation was involved in 98% of cases; 9% involved an implantable cardioverter defibrillator lead. Thirty-seven leads perforated the right ventricle (apex: 24) and 9 punctured the right atrium (lateral wall: 5). Abnormal electrical parameters were noted in 95% of interrogated cases. Perforation was visualized in 41% and 6% of cases with chest X-ray (CXR) and transthoracic echocardiography, respectively. CXR revealed a perforation, gross lead displacement, or left-sided pleural effusion in 74% of cases. Pericardial effusion occurred in 26 patients (57%) of whom 11 (24%) developed tamponade, successfully drained percutaneously. Pre-extraction CT scan was performed in 19 patients but was essential in four cases. Transvenous lead revision (TLR) was successfully performed in all cases with original leads repositioned in six patients, without recourse to surgery. Thirty-day mortality and complications were low (0% and 26%, respectively). CONCLUSION CT scanning provides incremental diagnostic value in a minority of CIED-related perforations. TLR is a safe and effective strategy.
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Affiliation(s)
- Ahmed I Elbatran
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK.,Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Zaki Akhtar
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Abhay Bajpai
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Lisa W M Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Anthony Li
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Simon Pearse
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Zia Zuberi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Riyaz Kaba
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Magdi M Saba
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Mark Norman
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Alexander Grimster
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Manav Sohal
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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10
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Performance and outcomes of transvenous rotational lead extraction: Results from a prospective, monitored, international clinical study. Heart Rhythm O2 2021; 2:113-121. [PMID: 34113913 PMCID: PMC8183877 DOI: 10.1016/j.hroo.2021.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Transvenous lead extraction (TLE) plays a critical role in managing patients with cardiovascular implantable electronic devices. Mechanical TLE tools, including rotational sheaths, are used to overcome fibrosis and calcification surrounding leads. Prospective clinical data are limited regarding the safety and effectiveness of use of mechanical TLE devices, especially rotational tools. Objective To prospectively investigate the safety and effectiveness of mechanical TLE in real-world usage. Methods Patients were enrolled at 10 sites in the United States and Europe to evaluate the use of mechanical TLE devices. Clinical success, complete procedural success, and complications were evaluated through follow-up (median, 29 days). Patient data were source verified and complications were adjudicated by an independent clinical events committee (CEC). Results Between October 2018 and January 2020, mechanical TLE tools, including rotational sheaths, were used to extract 460 leads with a median indwell time of 7.4 years from 230 patients (mean age 64.3 ± 14.4 years). Noninfectious indications for TLE were more common than infectious indications (61.5% vs 38.5%, respectively). The extracted leads included 305 pacemaker leads (66.3%) and 155 implantable cardioverter-defibrillator leads (33.7%), including 85 leads with passive fixation (18.5%). A bidirectional rotational sheath was needed for 368 leads (88.0%). Clinical success was obtained in 98.7% of procedures; complete procedural success was achieved for 96.3% of leads. CEC-adjudicated device-related major complications occurred in 6 of 230 (2.6%) procedures. No isolated superior vena cava injury or procedural death occurred. Conclusion This prospective clinical study demonstrates that use of mechanical TLE tools, especially bidirectional rotational sheaths, are effective and safe.
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Migliore F, Testolina M, Sagone A, Carretta D, Agricola T, Rovaris G, Piazzi E, Facchin D, Lazzari M, Zorzi A, Melillo F, Cataldi C, Marzi A, Bottio T, Tarzia V, Gerosa G, Iliceto S, Bertaglia E, Mazzone P. Multicenter experience with the Evolution RL mechanical sheath for lead extraction using a stepwise approach: Safety, effectiveness, and outcome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:989-997. [DOI: 10.1111/pace.13700] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/18/2019] [Accepted: 04/15/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Federico Migliore
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Martina Testolina
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Antonio Sagone
- Policlinico IRCCS Multimedica Sesto San Giovanni Milano Italy
| | - Domenico Carretta
- Unit of Cardiovascular Diseases, Azienda Ospedaliera UniversitariaOspedale Policlinico Consorziale Bari Italy
| | - Tullio Agricola
- Electrophysiology Unit“Spirito Santo” Hospital Pescara Italy
| | - Giovanni Rovaris
- Interventional Electrophysiology UnitSan Gerardo Hospital Monza Italy
| | - Elena Piazzi
- Interventional Electrophysiology UnitSan Gerardo Hospital Monza Italy
| | | | - Manuel Lazzari
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Francesco Melillo
- Department of Cardiology and Cardiothoracic Surgery, Arrhythmia Unit and Electrophysiology LaboratoriesOspedale San Raffaele Milan Italy
| | - Claudia Cataldi
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Alessandra Marzi
- Department of Cardiology and Cardiothoracic Surgery, Arrhythmia Unit and Electrophysiology LaboratoriesOspedale San Raffaele Milan Italy
| | - Tomaso Bottio
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Vincenzo Tarzia
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Gino Gerosa
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Emanuele Bertaglia
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padova Padova Italy
| | - Patrizio Mazzone
- Department of Cardiology and Cardiothoracic Surgery, Arrhythmia Unit and Electrophysiology LaboratoriesOspedale San Raffaele Milan Italy
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Transvenous lead extraction with laser reduces need for femoral approach during the procedure. PLoS One 2019; 14:e0215589. [PMID: 31034499 PMCID: PMC6488060 DOI: 10.1371/journal.pone.0215589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/04/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction Cardiac implantable electronic device (CIED) trans venous lead extraction (TLE) is technically challenging. Whether the use of a laser sheath reduces complications and improves outcomes is still in debate. We therefore aimed at comparing our experience with and without laser in a large referral center. Methods Information of all patients undergoing TLE was collected prospectively. We retrospectively compared procedural outcomes prior to the introduction of the laser sheath lead extraction technique to use of laser sheath. Results During the years 2007–2017, there were 850 attempted lead removals in 407 pts. Of them, 339 (83%) were extracted due to infection, device upgrade/lead malfunction in 42 (10%) cases, and other (7%). Complete removal (radiological success) of all leads was achieved in (88%). Partial removal was achieved in another 6% of the patients. Comparison of cases prior to and after laser technique introduction, showed that with laser, a significantly smaller proportion of cases required conversion to femoral approach [31/275 (6%) laser vs. 40/132 (15%) non-laser; p<0.001]. However, success rates of removal [259/275 (94%) vs. 124/132 (94%) respectively; p = 0.83] and total complication rates [35 (13%) vs. 19 (14%) respectively; p = 0.86] did not differ prior to and after laser use. In multivariate analysis, laser-assisted extraction was an independent predictor for no need for femoral extraction (OR = 0.39; 95% CI 0.23–0.69; p = 0.01). Conclusion Introduction of laser lead removal resulted in decreased need to convert to femoral approach, albeit without improving success rates or preventing major complications.
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Corazza I, Diemberger I, Martignani C, Ziacchi M, Rossi PL, Lombi A, Zannoli R, Biffi M. Wireless Endocardial Atrial (and Ventricular) Sensing with no Implanted Power Source: a Proposal. J Med Syst 2019; 43:159. [DOI: 10.1007/s10916-019-1277-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/05/2019] [Indexed: 12/15/2022]
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Leung LWM, Gomes J, Domenichini G, Gallagher MM. Oesophageal perforation: an unexpected complication during extraction of a pacing lead. A case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 3:ytz008. [PMID: 31020253 PMCID: PMC6439371 DOI: 10.1093/ehjcr/ytz008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 01/20/2019] [Indexed: 12/03/2022]
Abstract
Background Peri-procedural transoesophageal echocardiography (TOE) is important in monitoring and minimizing major complications during pacing lead extraction. It is a widely accepted precautionary measure, especially in extractions considered to be higher risk. Pacing lead extraction may be challenging, and it is associated with significant risk of major bleeding from vascular trauma. Case summary We present a case of an 87-year-old woman who had an extraction of a ventricular pacing lead that had perforated to an extra-cardiac location, most likely to the left pleural space. Peri-procedural TOE was used as a precaution. The entire pacing lead was successfully extracted with gentle traction using standard equipment (mechanical technique). Extraction was followed by development of pneumomediastinum and a left pleural effusion, initially attributed to pulmonary injury from the pacing lead but which proved to be related to oesophageal injury from the TOE. Discussion Transoesophageal echocardiography-related complications are uncommon but should be considered in cases of unexpected post-procedural deterioration. Clinical deterioration after a seemingly uneventful procedure should prompt a thorough case review. A systematic approach should be applied to identify the offending cause and enable corrective measures to be undertaken. This case report is an important reminder to all operators utilizing TOE for peri-procedural purposes that this precautionary measure itself also independently exposes the patient to additional risk.
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Affiliation(s)
- Lisa W M Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Blackshaw Road, London, UK
| | - John Gomes
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Blackshaw Road, London, UK
| | - Giulia Domenichini
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Blackshaw Road, London, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Blackshaw Road, London, UK
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Perez AA, Woo FW, Tsang DC, Carrillo RG. Transvenous Lead Extractions: Current Approaches and Future Trends. Arrhythm Electrophysiol Rev 2018; 7:210-217. [PMID: 30416735 PMCID: PMC6141917 DOI: 10.15420/aer.2018.33.2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/16/2018] [Indexed: 12/11/2022] Open
Abstract
The use of cardiac implantable electronic devices (CIEDs) has continued to rise along with indications for their removal. When confronted with challenging clinical scenarios such as device infection, malfunction or vessel occlusion, patients often require the prompt removal of CIED hardware, including associated leads. Recent advancements in percutaneous methods have enabled physicians to face a myriad of complex lead extractions with efficiency and safety. Looking ahead, emerging technologies hold great promise in making extractions safer and more accessible for patients worldwide. This review will provide the most up-to-date indications and procedural approaches for lead extractions and insight on the future trends in this novel field.
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Affiliation(s)
- Adryan A Perez
- University of Miami Miller School of Medicine Miami, FL, USA
| | - Frank W Woo
- University of Miami Miller School of Medicine Miami, FL, USA
| | - Darren C Tsang
- University of Miami Miller School of Medicine Miami, FL, USA
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Cardiac implantable electronic device lead extraction using the lead-locking device system: keeping it simple, safe, and inexpensive with mechanical tools and local anesthesia. Anatol J Cardiol 2017; 18:289-295. [PMID: 28811391 PMCID: PMC5731525 DOI: 10.14744/anatoljcardiol.2017.7821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective: We have previously reported our successful approach for percutaneous cardiac implantable electronic device (CIED) lead extraction using inexpensive tools, which we have continued over the years. Herein we report the results of the systematic use of a unique stylet, the lead-locking device (LLD), which securely locks the entire lead lumen, aided with non-powered telescoping sheaths in 54 patients to extract 98 CIED leads. Methods: This prospective observational clinical study included 38 men and 16 women aged 68.9±13.1 years undergoing lead extraction for device infection (n=46), lead malfunction (n=5), or prior to defibrillator implant (n=3). Leads were in place for 6.7±4.3 years. Infections were more commonly due to Staphylococcus species (n=40). There were 78 pacing (31 ventricular, 37 atrial, 4 VDD, and 6 coronary sinus leads) and 20 defibrillating leads. Results: Using simple traction (6 leads) and the LLD stylets (92 leads) aided with telescoping sheaths (15 patients), 96 (98%) leads in 52 (96.3%) patients were successfully removed, with all but one leads removed using a subclavian approach; in 1 patient, the right femoral approach was also required. In 2 patients, distal fragments from one ventricular pacing and one defibrillating lead could not be removed. Finally, lead removal was completely (52/54) (96.3%) or partially (2/54) (3.7%) successful in 54 patients for 96 of 98 leads (98%) without major complications. Conclusion: Percutaneous lead extraction can be successful with mechanical tools using the LLD locking stylet aided with non-powered telescoping sheaths through a simplified, safe, and inexpensive procedure using local anesthesia alone.
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