Major cardiac and vascular complications after transvenous lead extraction: acute outcome and predictive factors from the ESC-EHRA ELECTRa (European Lead Extraction ConTRolled) registry

Sex differences in long-term outcomes following transvenous lead extraction

INTRODUCTION

Transvenous lead extraction (TLE) is generally considered a safe procedure, albeit not without risks. While gender-based disparities have been noted in short-term outcomes following TLE, a notable gap exists in understanding the long-term consequences of this procedure. The objective of this analysis was to investigate sex differences in both acute and long-term outcomes among patients who underwent TLE at a tertiary referral center.

METHODS

In this retrospective cohort study, consecutive patients who underwent TLE between January 2014 and January 2016 were enrolled. The primary outcome comprised a composite of all-cause mortality and need for repeated TLE procedures. Secondary outcomes included fluoroscopy time, lead extraction techniques, success rates, and major and minor complications. Results were compared between female and male cohorts.

RESULTS

The study population comprised 191 patients (median age, 70 years), 29 (15.2%) being women and 162 men (84.8%). Study groups had similar baseline characteristics. Complete procedural success was achieved in 189 out of 191 patients (99.0%), with no significant difference observed between the two groups (p = .17). No major complications were reported in the total cohort. However, there was a significantly higher incidence of minor complications in women compared to men (17.2% vs. 2.5%, p < .01). Following a median follow-up of 6.5 years, the incidence of the primary composite outcome occurred similarly between the study groups (log-rank p = .68).

CONCLUSION

Women who underwent TLE exhibited a significantly higher incidence of minor acute intra- and peri-procedural complications than men. However, no differences in long-term outcomes between genders were observed.

Computed tomography predictors of increased transvenous lead extraction difficulty

BACKGROUND

The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject.

OBJECTIVE

To identify CT characteristics associated with increased TLE difficulty.

METHODS

All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac-gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead-removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty.

RESULTS

A total of 343 patients were analyzed. The mean age of the study population was 63.8 ± 15.4 years; 71% were male. The mean lead dwell-in duration was 8.6 ± 5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead-removal fluoroscopy time (p = 0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p < 0.001, 95% CI: 2.54-10.46) and (odds ratio:3.72, p < 0.001, 95% CI: 1.89-7.35), respectively.

CONCLUSION

In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead-associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath.

Case Series and Review of Literature for Superior Vena Cava Injury During Laser Lead Extraction

Transvenous laser lead extraction poses a risk of major complications (0.19%-1.8%), notably injury to the superior vena cava (SVC) in 0.19% to 0.96% of cases. Various factors contribute to SVC injury, which can be categorized as patient-related (such as female gender, low body mass index, diabetes, renal problems, anemia, and reduced ejection fraction), device-related (including the number, dwell time, and type of leads), or procedural-related (such as reason for extraction, venous obstructions, and bilateral lead placements).

Infections of cardiac implantable electronic devices and how to improve transvenous lead extraction by the virtual reality

Introduction

Infections in cardiac implantable electronic devices (CIED) are increasing over time and associated with substantially mortality and healthcare costs. The best approach is the complete removal of the system by transvenous lead extraction (TLE). However, when leads are more than 10 years old, this technique requires considerable expertise and failures with the result of abandoned leads or serious complications may occur. The aim of this study is to describe our experience using virtual and mixed reality in the preoperative planning of complex cases.

Patients and methods

Consecutive patients from a referral centre with CIED infections in which TLE was judged difficult. Synchronized computed tomography (CT) scan images were processed and transferred to a fully immersive virtual reality room and also to the operative room (mixed reality) for better guidance during the extracting procedure.

Results

Ten patients (seven with local and three with systemic infections) were preoperative evaluated. Processed images and virtual reality showed intense adherences of the leads to the veins, right ventricle, and right atrium endocardium and between them that preclude a difficult extraction and required a carefully planning and sometimes a different technical approach. The anticipated difficulty was confirmed by the higher times of fluoroscopy. All leads were extracted and no complications were registered.

Conclusions

Preoperative planning is essential for evaluation of TLE difficulty and prevention of unexpected situations. Virtual reality seems an estimable aid for operators in planning difficult cases and also an excellent tool for teaching.

Supplementary information

The online version contains supplementary material available at 10.1007/s12055-023-01663-9.

VDD Lead Extraction-Differences with Other Leads and Practical Tips in Management

Background: VDD (atrial sensing, ventricular sensing/pacing) leads are relatively rarely implanted; therefore, experience in their extraction is very limited. We aimed to investigate whether VDD lead removal may be a risk factor for the increased complexity of transvenous lead extraction (TLE) or major complications. Methods: We retrospectively analyzed 3808 TLE procedures (including 103 patients with VDD leads). Results: If TLE included VDD lead removal, procedure duration (lead dilation time) was prolonged, complicated extractions were slightly more common, and more advanced tools were required. This is partly due to longer implant duration (in patients with VDD systems-135.2 months; systems without VDD leads-109.3 months; p < 0.001), more frequent presence of abandoned leads (all systems containing VDD leads-22.33% and all systems without VDD leads-10.77%), and partly to the younger age of patients with VDD leads (51.74 vs. 57.72 years; p < 0.001, in the remaining patients) at the time of system implantation. VDD lead extraction does not increase the risk of major complications (1.94 vs. 2.34%; p = 0.905). Conclusions: The extraction of VDD leads may be considered a risk factor for increased procedure complexity, but not for major complications. However, this is not a direct result of VDD lead extraction but specific characteristics of the patients with VDD leads. Operator skill and team experience combined with special custom maneuvers can enable favorable results to be achieved despite the specific design of VDD leads, even with older VDD lead models.

Associated factors and outcomes of crossover from a laser sheath to a bidirectional rotational mechanical sheath during transvenous lead extraction

Background

During transvenous lead extraction (TLE), a GlideLight laser sheath (Philips) cannot always be advanced over the lead, and crossover to the Evolution system (i.e., an Evolution RL sheath or Evolution Shortie RL sheath [Cook Medical]) is required. We aimed to determine the associated factors and outcomes of such device crossover.

Methods

This observational study included 112 patients who underwent TLE. The patients were divided into crossover and non-crossover groups. Outcomes and associated factors of crossover were evaluated.

Results

Overall, 57 (50.9%) patients required crossover to the Evolution system (crossover group), whereas 55 (49.1%) patients did not require crossover (non-crossover group). Clinical success rate was similar between the two groups (98.3% vs. 100%; p = 1.00). No major intraprocedural complications related to powered sheaths occurred. Multivariate logistic regression analysis results showed that dwell time of the oldest extracted lead (per year) (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02-1.36; p = .026), number of leads extracted per procedure (OR: 7.23, 95% CI: 1.74-29.99; p = .007), and use of a femoral approach (OR: 21.09, 95% CI: 2.33-190.67; p = .007) were associated factors of crossover. The cutoff for crossover was 7.7 years from the implant (sensitivity 90.5%, specificity 64.9%, area under the curve 0.80).

Conclusions

Both groups showed a high rate of clinical success. Switching to the Evolution system may facilitate a safe and effective TLE when a laser sheath does not advance despite laser activation.

[Lead extraction in cardiac implantable electronic devices]

Lead extraction due to infection or lead dysfunction has become more important in recent years. Patients with high risk of severe and life-threatening complications should only undergo surgery in experienced centers where appropriate personnel and equipment are available. In this review, different techniques and methods to safely and successfully perform transvenous lead extraction are summarized.

Safety of same-day discharge after lead extraction procedures

BACKGROUND

Same-day discharge (SDD) after cardiovascular procedures is rapidly gaining ground.

OBJECTIVE

We sought to evaluate the safety of SDD after transvenous lead extraction (TLE).

METHODS

We performed a retrospective chart review of patients who underwent elective TLE between January 2020 and October 2021 at our institution. The primary outcome was SDD, and major procedural complications and readmissions within 30 days of the procedure were secondary outcomes.

RESULTS

In this analysis of 111 patients who underwent elective TLE, 80 patients (72%) were discharged on the same day (SDD group) while 31 patients (28%) stayed overnight (overnight group). Lead malfunction was the most common indication for TLE in both groups. Patients in the overnight group were more likely to have a lead dwell time of ≤10 years than those in the SDD group (38.7% vs 20% of all leads in each group; P = .042), have laser sheaths used for extraction and a higher number of leads extracted. No major complications were reported in both groups. In a multivariate analysis, lower body mass index and the use of laser sheath during TLE were predictors of overnight stay. Patients who underwent a procedure using advanced extraction techniques were 3.5 times more likely to stay overnight (95% confidence interval 1.27-9.78; P = .016).

CONCLUSION

In appropriately selected patients undergoing elective lead extraction, SDD is feasible and safe. Higher body mass index, fewer extracted leads, shorter lead dwell times (<10 years), and less frequent use of laser-powered extraction sheaths were associated with an increased likelihood of SDD.

Transvenous lead extraction: Efficacy and safety of the procedure in female patients

Background

Existing data on the impact of sex differences on transvenous lead extraction (TLE) outcomes in cardiac device patients are limited.

Objective

The purpose of this study was to evaluate the safety and efficacy of mechanical TLE in female patients.

Methods

A retrospective evaluation was performed on 3051 TLE patients (group 1: female; group 2: male) from a single tertiary referral center. All individuals received treatment using single sheath mechanical dilation and various venous approaches as required.

Results

Our analysis included 3051 patients (group 1: 750; group 2: 2301), with a total of 5515 leads handled with removal. Female patients were younger, had a higher left ventricular ejection fraction, and lower prevalences of coronary artery disease and diabetes mellitus. Infection was more common in male patients, whereas lead malfunction or abandonment were more frequent in female patients. Radiologic success was lower in female patients (95.8% vs 97.5%; P = .003), but there was no significant difference in clinical success between groups (97.2% vs 97.5%; P = .872). However, major complications (1.33% vs 0.60%; P <.001) and procedural mortality (0.4% vs 0.1%; P <.001) were higher in females compared to male patients. After multivariate analysis, female sex emerged as the only predictor of major complications, including deaths (odds ratio 3.96; 95% confidence interval 1.39-11.24).

Conclusion

TLE using unpowered simple mechanical sheaths in female patients is safe and effective, but is associated with lower radiologic success and higher complication rates and mortality than in males. This finding underscores the importance of recognizing sex differences in TLE outcomes.

Discussing the Prognosis and Complications of Transvenous Lead Extraction in Patients With Cardiac Implantable Electronic Devices (CIED): A Systematic Review

An increase in cardiovascular implantable electronic devices (CIEDs) and undoubtedly the complications brought on by these devices coincide with an increase in cardiovascular disorders, particularly heart rhythm abnormalities. The safest procedure to extract these devices is transvenous lead extraction (TLE). Thus, this systematic review aimed to summarize the possibility of success rates and the common complications that could arise during the surgery. Full-text publications in PubMed, MEDLINE, PubMed Central (PMC), and ScienceDirect were used in this study, which was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventeen studies were reviewed for this systematic review after being screened by title, abstract, full-text availability, and quality appraisal assessment. Heart and vascular tears, along with tricuspid regurgitation (TR), are common adverse events. Pulmonary embolism, hemothorax, hemopericardium, and ghost appearance in echo are less common consequences. In addition, the longer the dwelling time of the leads, the greater the chance of infection due to an increase in lead adhesions and fibrous tissue that has made the procedure unsafe as time passes. However, we concluded that TLE is a successful method across all age groups with an excellent probability of clinical and procedural success in a majority of studies.

Long-term survival following transvenous lead extraction: unpicking differences according to sex

AIMS

Female sex is a recognized risk factor for procedure-related major complications including in-hospital mortality following transvenous lead extraction (TLE). Long-term outcomes following TLE stratified by sex are unclear. The purpose of this study was to evaluate factors influencing long-term survival in patients undergoing TLE according to sex.

METHODS AND RESULTS

Clinical data from consecutive patients undergoing TLE in the reference centre between 2000 and 2019 were prospectively collected. The total cohort was divided into groups based on sex. We evaluated the association of demographic, clinical, device-related, and procedure-related factors on long-term mortality. A total of 1151 patients were included, with mean 66-month follow-up and mortality of 34.2% (n = 392). The majority of patients were male (n = 834, 72.4%) and 312 (37.4%) died. Males were more likely to die on follow-up [hazard ratio (HR) = 1.58 (1.23-2.02), P < 0.001]. Males had a higher mean age at explant (66.2 ± 13.9 vs. 61.3 ± 16.3 years, P < 0.001), greater mean co-morbidity burden (2.14 vs. 1.27, P < 0.001), and lower mean left ventricular ejection fraction (LVEF) (43.4 ± 14.0 vs. 50.8 ± 12.7, P = 0.001). For the female cohort, age > 75 years [HR = 3.45 (1.99-5.96), P < 0.001], estimated glomerular filtration rate < 60 [HR = 1.80 (1.03-3.11), P = 0.037], increasing co-morbidities (HR = 1.29 (1.06-1.56), P = 0.011), and LVEF per percentage increase [HR = 0.97 (0.95-0.99), P = 0.005] were all significant factors predicting mortality. The same factors influenced mortality in the male cohort; however, the HRs were lower.

CONCLUSION

Female patients undergoing TLE have more favourable long-term outcomes than males with lower long-term mortality. Similar factors influenced mortality in both groups.

Outcomes of transvenous lead extraction in octogenarians using bidirectional rotational mechanical sheaths

BACKGROUND

Outcomes of transvenous lead extraction (TLE) are well reported in the general population, However, data on safety, efficacy of TLE in octogenarians with a long lead dwell time, using powered extraction tools are limited. The aim of this multicenter study was to evaluate the safety, effectiveness of TLE in octogenarians using the bidirectional rotational mechanical sheaths and mid-term outcome after TLE.

METHODS

The study population comprised 83 patients (78.3% male; mean age 85 ± 3 years; [range 80-94 years]) with 181 target leads. All the leads (mean implant duration 112 ± 77 months [range 12-377]) were extracted exclusively using the Evolution RL sheaths (Cook Medical, Bloomington, IN, USA).

RESULTS

The main indication for TLE was infection in 84.3% of cases. Complete procedural success rate, clinical success rate, per lead were 93.9% and 98.3%, respectively. Failure of lead extraction was seen in 1.7% of leads. The additional use of a snare was required in 8.4% of patients. Major complications occurred in one patient (1.2%). Thirty-day mortality after TLE was 6%. During a mean time follow-up of 22 ± 21 months, 24 patients (29%) died. No procedure-related mortality occurred. Predictors of mortality included ischemic cardiomyopathy (HR 4.35; 95% CI 1.87-10.13; p = .001), left ventricularejection fraction ≤35% (HR 7.89; 95% CI 3.20-19.48; p < .001), and TLE for systemic infection (HR 4.24; 95% CI 1.69-10.66; p = .002).

CONCLUSIONS

At experienced centers bidirectional rotational mechanical sheaths combined with different mechanical tools and femoral approach allowreasonable success and safety in octogenarian with long lead dwell time. Patient's age should not influence the decision to extract or not the leads, although the 30-day and mid-term mortality are significant, especially in the present of specific comorbidities.

Incomplete Lead Removal During the Extraction Procedure: Predisposing Factors and Impact on Long-Term Survival in Infectious and Non-Infectious Cases: Analysis of 3741 Procedures

BACKGROUND

The long-term significance of lead remnants (LR) following transvenous lead extraction (TLE) remains disputable, especially in infectious patients.

METHODS

Retrospective analysis of 3741 TLEs focused on the relationship between LR and procedure complexity, complications and long-term survival.

RESULTS

The study group consisted of 156 individuals with LR (4.17%), and the control group consisted of 3585 patients with completely removed lead(s). In a multivariable model, a younger patient age at CIED implantation, more CIED procedures and procedure complexity were independent risk factors for retention of non-removable LR. Although patients with LR showed better survival outcomes following TLE (log rank p = 0.041 for non-infectious group and p = 0.017 for infectious group), multivariable Cox regression analysis did not confirm the prognostic significance of LR either in non-infectious [HR = 0.777; p = 0.262], infectious [HR = 0.983; p = 0.934] or the entire group of patients [HR = 0.858; p = 0.321].

CONCLUSIONS

1. Non-removable LRs are encountered in 4.17% of patients. 2. CIED infection has no influence on retention of LRs, but younger patient age, multiple CIED-related procedures and higher levels of procedure complexity are independent risk factors for the presence of LR. 3. Better survival outcomes following TLE in patients with LRs are not the effects of their presence but younger patient and better health status.

Unexpected Procedure Difficulties Increasing the Complexity of Transvenous Lead Extraction: The Single Centre Experience with 3721 Procedures

BACKGROUND

Transvenous lead extraction (TLE) should be completed, even when facing difficulties which have yet to be described. The aim was to explore unexpected TLE obstacles (the circumstances of the occurrence and influence on TLE outcome).

METHODS

The retrospective analysis of a single centre database containing 3721 TLEs.

RESULTS

Unexpected procedure difficulties (UPDs) occurred in 18.43% of cases (singles in 12.20% of cases and multiples in 6.26% of cases). These included blockages in the lead venous approach in3.28% of cases, functional lead dislodgement in 0.91% of cases, and loss of broken lead fragment in 0.60% of cases. All of them, including implant vein-in 7.98% of cases, lead fracture during extraction-in 3.84% of cases, and lead-to-lead adherence-in 6.59% of cases, Byrd dilator collapse-in 3.41% of cases, including the use of an alternative prolonged the procedure but had no influence on long-term mortality. Most of the occurrences were associated with lead dwell time, younger patient age, lead burden, and poorer procedure effectiveness and complications (common cause). However, some of the problems seemed to be related to cardiac implantable electronic devices (CIED) implantation and the subsequent lead management strategy. A more complete list of all tips and tricks is still required.

CONCLUSIONS

(1) The complexity of the lead extraction procedure combines both prolonged procedure duration and the occurrence of lesser-known UPDs. (2) UPDs are present in nearly one fifth of the TLE procedures, and can occur simultaneously. (3) UPDs, which usually force the extractor to expand the range of techniques and tools, should become part of the training in transvenous lead extraction.

Outcomes of transvenous lead extraction of very old leads using bidirectional rotational mechanical sheaths: Results of a multicentre study

INTRODUCTION

Lead dwell time >10 years is a recognized predictor for transvenous lead extraction (TLE) failure and complications. Data on the efficacy and safety of TLE using the bidirectional rotational mechanical sheaths in patients with very old leads are lacking. In this multicenter study, we reported the outcomes of transvenous rotational mechanical lead extraction in patients with leads implanted for ≥10 years.

METHODS

A total of 441 leads (median: 159 months [135-197]; range: 120-487) in 189 consecutive patients were removed with the Evolution RL sheaths (Cook Medical, Bloomingtom, IN, USA) and mechanical ancillary tools supporting the procedures.

RESULTS

The main indication for TLE was infection in 74% of cases. Complete procedural success rate, clinical success rate, per lead were 94.8% and 98.2%, respectively. Failure of lead extraction was seen in 1.8% of leads. The additional use of a snare via the femoral approach was required in 9% of patients. Lead dwell time was the only predictor of incomplete led removal (odds ratio: 1.009; 95% confidence interval [CI]: 1.003-1.014; p = .002). Four major complication (2%) were encountered. During a mean time follow-up of 31 ± 27 months, 21 patients (11%) died. No procedure-related mortality occurred. Predictors of mortality included severe left ventricular systolic dysfunction (hazard ratio [HR]: 8.06; 95% CI: 2.99-21.73; p = .001), TLE for infection (HR: 8.0; 95% CI: 1.04-62.5; p = .045), diabetes (HR: 3.7; 95% CI: 1.48-9.5; p = .005), and previous systemic infection (HR: 3.1; 95% CI: 1.17-8.24; p = .022). Incomplete lead removal or failure lead extraction did not impact on survival during follow-up.

CONCLUSION

Our findings demonstrated that the use of bidirectional rotational TLE mechanical sheaths combined with different mechanical tools and femoral approach allows reasonable success and safety in patients with very old leads at experienced specialized centers.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Transvenous lead extractions in a single high-volume center over 24 years: High success rate and low complication rate

Background

Transvenous lead extraction (TLE) procedures can be complicated and are associated with a small but significant risk of cardiovascular complications. However, methods and tools vary among centers.

Objective

The purpose of this study was to the present the methods and results of pacemaker and implantable cardioverter-defibrillator TLE procedures in our center over a 24-year period.

Methods

From April 1997 through 2020, we attempted to extract 2964 leads in 1780 procedures and 1642 patients. We mainly utilized single sheath technique using snaring or mechanical rotational sheaths and steel sheaths when necessary. Difficult procedures were performed by an experienced cardiologist, and close supervision was emphasized. Most of the extractions were performed using local anesthesia with sedation.

Results

Median age of patients was 65.0 [interquartile range 20.00] years, and median dwelling time of leads was 5.0 [7.0] years. Clinical success was achieved in 1739 procedures (97.7%) and complete technical success in 2841 leads (95.8%). Clinical success (leaving <4 cm of the lead in the body and achieving the clinical goal for the patient) was achieved for 79 leads (2.7%). TLE failed in 44 leads (1.1%) and 41 procedures (2.3%) among 36 patients (2.2%). There were 23 cases (1.3%) of major complications, with only 1 death directly related to the procedure (<0.1%). In addition, 2 patients with sepsis died within the first 24 hours after the procedure. No caval tears occurred.

Conclusion

Single sheath lead extractions utilizing snaring or mechanical rotational sheaths were effective and safe in our high-volume center as performed by experienced operators.

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

KEY OUTCOME MEASURE

Effectiveness and safety of TLE depending on organisational model.

RESULTS

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

CONCLUSIONS

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

Cardiac tamponade as an inherent but potentially nonfatal complication of transvenous lead extraction: Experience with 1126 procedures performed using mechanical tools

INTRODUCTION

Cardiac tamponade (CT) is one of the most common and dangerous complications of transvenous lead extraction (TLE). So far, however, there has been little discussion about the problem.

METHODS

We analyzed the occurrence of CT in a group of 1226 patients undergoing TLE at a single reference center between June, 2015 and February, 2021. Using standard mechanical devices as first-line tools, a total of 2092 leads had been extracted.

RESULTS

CT occurred in 18 patients (1.47%): due to injury to the wall of the right atrium in 14 patients (1.14%) and other cardiac walls in four patients (0.33%). Younger patient age at first implantation, female gender, high left ventricular ejection fraction (LVEF), lower New York Heart Association class, low Charlson comorbidity index, longer implant duration, and the number of previous procedures related to cardiac implantable electronic devices (CIED) are important patient-related risk factors for CT. Significant procedure-related risk factors include the number of extracted leads, extraction of atrial leads and longer dwell time of extracted leads. Intraoperative transoesophageal echocardiography (TEE) provides a lot of information about pulling on various cardiac structures and is able to detect a very early phase of bleeding to the pericardial sac. As a result of implementing best practices guidance in performing extraction procedures and close collaboration with cardiac surgeons that allowed immediate rescue intervention in our series of 18 CT cases, there were no procedure-related deaths (mortality 0%).

CONCLUSIONS

The need for rescue surgery due to CT has no influence on clinical and procedural success. Early diagnosed (TEE monitoring) and properly managed CT does not generate any additional risk in short- and long-term follow-up after TLE.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Tricuspid Valve Damage Related to Transvenous Lead Extraction

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Disparities in transvenous lead extraction in young adults

Adults with cardiac implantable electronic devices (CIEDs) implanted at an early age constitute a specific group of patients undergoing transvenous lead extraction (TLE). The aim of this study is to assess safety and effectiveness of TLE in young adults. A comparative analysis of two groups of patients undergoing transvenous lead extraction was performed: 126 adults who were 19–29 years old at their first CIED implantation (early adulthood) and 2659 adults who were > 40 years of age at first CIED implantation and < 80 years of age at the time of TLE (middle-age/older adulthood). CIED-dependent risk factors were more common in young adults, especially longer implant duration (169.7 vs. 94.0 months). Moreover younger age of patients at first implantation, regardless of the dwell lead time, is a factor contributing to the greater development of connective tissue proliferation on the leads (OR 2.587; p < 0.001) and adhesions of the leads with the heart structures (OR 3.322; p < 0.001), which translates into worse TLE results in this group of patients. The complexity of procedures and major complications were more common in younger group (7.1 vs. 2.0%; p < 0.001), including hemopericardium (4.8 vs 1.3; p = 0.006) and TLE-induced tricuspid valve damage (3.2 vs.0.3%; p < 0.001). Among middle-aged/older adults, there were 7 periprocedural deaths: 6 related to the TLE procedure and one associated with indications for lead removal. No fatal complications of TLE were reported in young adults despite the above-mentioned differences (periprocedural mortality rate was comparable in study groups 0.3% vs 0.0%; p = 0.739). Predictors of TLE-associated major complications and procedure complexity were more likely in young adults compared with patients aged > 40 to < 80 years. In younger aged patients prolonged extraction duration and higher procedure complexity were combined with a greater need for second line tools. Both major and minor complications were more frequent in young adults, with hemopericardium and tricuspid valve damage being predominant.

The role of cardiac surgeon in transvenous lead extraction: experience from 3462 procedures

INTRODUCTION

The professional society guidelines recommend that transvenous lead extraction (TLE) operating teams collaborate closely with cardiac surgeons in the management of life-threatening complications.

METHODS AND RESULTS

We assessed the role of cardiac surgeons participating in 3462 TLE procedures at a high-volume center between 2006 and 2021. The roles for cardiac surgery in TLE can be categorized into five areas: emergency surgical interventions for the management of cardiac laceration and severe bleeding (1.184%), cardiac surgery complementing partially successful TLE or vegetation removal (0.693%), delayed surgical treatment of TLE-related tricuspid valve dysfunction (0.751%), epicardial pacemaker implantation through sternotomy during emergency, complementing or delayed surgical interventions (0.607%) and delayed epicardial lead implantation (0.491%). Isolated damage to the wall of the right atrium was the most common cause of cardiac tamponade (53.66% of emergency surgeries) followed by injury to the right ventricle and vena cava (both 7.317%).

CONCLUSIONS

Emergency cardiac surgery for the management of severe hemorrhagic complications is still the most common treatment option. The remaining areas include surgery complementing partially successful TLE: repair of tricuspid valve or epicardial ventricular lead placement to achieve permanent cardiac resynchronization. The experience at a single high-volume TLE center indicates the necessity of close collaboration with the cardiac surgeons whose roles appear broader than the mere surgical standby. Mortality in patients who survived cardiac surgery during transvenous lead extraction does not differ from the survival of other patients after TLE without complications requiring surgical intervention. This article is protected by copyright. All rights reserved.

Looking for Lead Adhesions While Planning for Transvenous Lead Extraction

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

Transvenous lead extraction using the TightRail mechanical rotating dilator sheath for Asian patients

The need for transvenous lead extraction (TLE) is increasing worldwide including in Asia–Pacific regions. However, supporting evidence for TightRail, a relatively new rotating mechanical dilator sheath, is still lacking in Asian patients. The efficacy and safety of TLE using TightRail performed between March 2018 and June 2021 were evaluated in 86 consecutive patients with 131 leads. The mean lead age was 11.7 ± 7.3 (range, 1.0–41.4) years. Clinical and complete procedural success using TightRail were achieved in 93.0% and 89.5% of 86 patients, respectively, with 6 min of median fluoroscopic time and 9.3% of major complication rate: death (1.2%), cardiac tamponade (3.5%), severe tricuspid regurgitation (3.5%), and stroke (1.2%). However, in 46 patients with longest lead age ≤ 10 years, clinical/complete success and major cardiac complication rates turned out better as 97.8%, 95.7%, and 2.2%, respectively. Additionally, when patients were divided into 3 groups: the first 28, second 29, and the last 29 patients, there was a clear trend toward better efficacy and safety outcomes with more experience with TightRail (P_trend < 0.05). Longest lead age > 10 years was closely associated with TLE-related major cardiac complication (P = 0.046) with 85.7% sensitivity, 57.0% specificity, 15.0% positive predictive value, and 97.8% negative predictive values. In conclusion, TLE using TightRail may be effectively and safely performed by experienced operators for Asian patients with the longest lead age ≤ 10 years. However, as TightRail is a potentially aggressive tool, special attention should be paid to patients with longer lead dwelling times (e.g., > 10 years).

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.

Predictors of perforation during lead extraction: Results of the Canadian Lead ExtrAction Risk (CLEAR) study

BACKGROUND

Transvenous lead extraction can have serious adverse events, such as cardiac or vascular perforation. Risk factors have not been well characterized.

OBJECTIVE

The purpose of this study was to identify factors associated with perforation and death, and to characterize lead extraction in a large contemporary population.

METHODS

We performed a retrospective multicenter study examining patients undergoing lead extraction at 8 Canadian institutions from 1996 through 2016. Demographic and clinical data were used to identify variables associated with perforation and mortality using logistic regression modeling.

RESULTS

A total of 2325 consecutive patients (age 61.9 ±16.5 years) underwent extraction of 4527 leads. Perforation rate was 2.7% (63/2325) and 30-day mortality was 1.6% (38/2325), with mortality of 0.4% due to perforation (10/2325). Variables associated with perforation included no previous cardiac surgery (odds ratio [OR] 3.33; 95% confidence interval [CI] 1.54-7.19; P = .002), female sex (OR 3.27; 95% CI 1.91-5.60; P <.001); left ventricular ejection fraction ≥40% (OR 2.81; 95% CI 1.28-6.14; P = .010); lead age >8 years (OR 2.64; 95% CI 1.52-4.60; P <.001); ≥2 leads extracted (OR 2.49; 95% CI 1.23-5.04; P = .011); and diabetes (OR 2.12; 95% CI 1.16-3.86; P = .014). Variables associated with death included infection as indication for extraction (OR 3.85; 95% CI 1.38-10.73; P = .010); anemia (OR 3.14; 95% CI 1.38-6.61; P = .003), and patient age (OR 1.04; 95% CI 1.01-1.07; P = .012).

CONCLUSION

Risk factors associated with perforation in lead extraction include no history of cardiac surgery, female sex, preserved left ventricular ejection fraction, lead age >8 years, ≥2 leads extracted, and diabetes.

The Use of Transvenous Lead Extraction of Non-Infected Leads to Prevent Long-Term Lead-Related Complications

The aim of the investigation was to study the issue of making challenging decisions concerning abandonment or removal of non-infected superfluous leads during lead revisions or cardiac implantable electronic device upgrades.

Powered sheaths for lead extraction

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

Outcome of transvenous lead extraction of leads older than 20 years

BACKGROUND

In patients undergoing transvenous lead extraction (TLE), lead dwell time has been recognized as a risk factor for extraction failure and procedure-related complications.

OBJECTIVES

The aim of this study was to evaluate the safety and effectiveness of TLE in patients with pacemaker or ICD leads with a dwell time of ≥20 years.

METHODS

This is a single-center retrospective study of all patients who underwent TLE of at least 1 pacemaker or ICD leads a dwell time of ≥20 years.

RESULTS

During the study period, 124 patients were included in this analysis (50.8% female, mean age: 74.6 ± 10.7 years). Device-related infection was the most common (92.7%) indication for TLE. Extraction was attempted for a total 313 leads, of which 182 leads had dwell times ≥20 years (median: 276 months; interquartile range: 255-300 months). Complete procedural success was achieved in 112/124 patients (90.3%), and clinical success in 119/124 patients (96.0%). Complete removal was achieved for 294 leads (93.9%), partial removal in 10 leads, and failure in 9 leads. Clinical success (combined complete and partial success) rates were higher for leads with dwell times <20 years compared to older leads (99.2% vs. 95.6%, p = .017). Major procedural complications (including 1 death) occurred in 7/124 patients (5.6%). Minor complications were observed in 8 patients (6.5%).

CONCLUSIONS

TLE of very old (≥20 years) leads can be performed with reasonable success and safety when conducted at centers with expertise in lead management.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Efficacy and safety of transvenous lead extraction in the Chinese octogenarian patients

BACKGROUND

Managing elderly patients with infection or malfunction deriving from a cardiac implantable electronic device (CIED) may be challenging. We report the safety and effectiveness of transvenous lead extraction in Chinese octogenarian patients.

HYPOTHESIS

Transvenous lead extraction can be performed safely and successfully in the Chinese octogenarians.

METHODS

We retrospectively identified all patients who underwent TLE at our institution between March 2013 and January 2021. This population was divided into the following two groups based solely on age: octogenarians and non-octogenarians. These two groups were compared on the basis of several characteristics and clinical outcomes.

RESULTS

Consecutive 1106 patients were analyzed, including 184 (16.6%) octogenarians and 922(83.4%) non-octogenarians. The octogenarians presented more comorbidities. A total of 378 leads and 2004 leads were removed from the patients in the octogenarian group and non-octogenarian group, respectively. The mean lead implant duration was 6.1 ± 5.1 and 5.8 ± 4.6 years for octogenarians and non-octogenarians (p = 0.296). The majority of the patients in both groups underwent TLE through the femoral approach (67.5% vs 61.6%, p = 0.14). The complete procedure success rate was similar between the octogenarian and non-octogenarian group (96.7% vs.95.3%, p = 0.39). There were no differences with respect to the proportion of minor, major complications and deaths. Long-term mortality (median time 3.3 years) after TLE in octogenarians was significantly higher compared with younger individuals.

CONCLUSIONS

At experienced centers, transvenous lead extraction can be performed safely in Chinese octogenarians with procedural success rate and complication rate comparable to younger individuals.

Laser-assisted lead extraction of a retained lead remnant in the femoral and iliac veins

Herein, we present a case of laser-assisted extraction of a retained lead remnant following incomplete removal of an implantable cardiac defibrillator system implanted via a left femoral approach.

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

AIMS

Optimal management of redundant or malfunctioning leads is controversial. We aimed to assess safety and efficacy of mechanical transvenous lead extraction (TLE) in patients with abandoned leads.

METHODS AND RESULTS

Consecutive TLE procedures performed in our centre from January 2009 to December 2017 were considered. We evaluated the safety and efficacy of mechanical TLE in patients with abandoned (Group 1) compared to non-abandoned (Group 2) leads. We analysed 1210 consecutive patients that required transvenous removal of 2343 leads. Group 1 accounted for 250 patients (21%) with a total of 617 abandoned leads (26%). Group 2 comprised 960 patients (79%) with 1726 leads (74%). The total number of leads (3.0 vs. 2.0), dwelling time of the oldest lead (108.00 months vs. 60.00 months) and infectious indications for TLE were higher in Group 1. Clinical success was achieved in 1168 patients (96.5%) with a lower rate in Group 1 (90.4% vs. 98.1%; P < 0.001). Major complications occurred in only 9 patients (0.7%), without significant differences among the two groups. The presence of one or more abandoned leads [odds ratio (OR) 3.47; 95% confidence interval (CI) 1.07-11.19; P = 0.037] and dwelling time of the oldest lead (OR 1.01 for a month; 95% CI 1.01-1.02; P < 0.001) were associated with a higher risk of clinical failure.

CONCLUSION

Transvenous mechanical lead extraction is a safe procedure also in high-risk settings, as patients with abandoned leads. Success rate resulted a bit lower, especially in the presence of abandoned leads with long implantation time.

Percutaneous Removal of Cardiac Leads in a Single Center in South America

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.

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.

Comparison of acute and long-term outcomes of Evolution® and TightRail™ mechanical dilator sheaths during transvenous lead extraction

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.

Prognostic Value of Preoperative Echocardiographic Findings in Patients Undergoing Transvenous Lead Extraction

(1) Background: In patients referred for transvenous lead extraction (TLE) transesophageal echocardiography (TEE) often reveals abnormalities related to chronically indwelling endocardial leads. The purpose of this study was to determine whether the results of pre-operative TEE might influence the long-term prognosis. (2) Methods: We analyzed data from 936 TEE examinations performed at a high volume center in patients referred for TLE from 2015 to 2019. The follow-up was 566.2 ± 224.5 days. (3) Results: Multivariate analysis of TEE parameters showed that vegetations (HR = 2.631 [1.738–3.983]; p < 0.001) and tricuspid valve (TV) dysfunction unrelated to the endocardial lead (HR = 1.481 [1.261–1.740]; p < 0.001) were associated with increased risk for long-term mortality. Presence of fibrous tissue binding sites between the lead and the superior vena cava (SVC) and/or right atrium (RA) wall (HR = 0.285; p = 0.035), presence of penetration or perforation of the lead through the cardiac wall up to the epicardium (HR = 0.496; p = 0.035) and presence of excessive lead loops (HR = 0.528; p = 0.026) showed a better prognosis. After adjustment the statistical model with recognized poor prognosis factors only vegetations were confirmed as a risk factor (HR = 2.613; p = 0.039). A better prognosis was observed in patients with fibrous tissue binding sites between the lead and the superior vena cava (SVC) and/or right atrium (RA) wall (HR = 0.270; p = 0.040). (4) Conclusions: Non-modifiable factors may have a negative influence on long-term survival after TLE. Various forms of connective tissue overgrowth and abnormal course of the leads modifiable by TLE can be a factor of better prognosis after TLE.

Clinical impact of antithrombotic therapy in transvenous lead extraction complications: a sub-analysis from the ESC-EORP EHRA ELECTRa (European Lead Extraction ConTRolled) Registry

AIMS

A sub-analysis of the ESC-EHRA European Lead Extraction ConTRolled (ELECTRa) Registry to evaluate the clinical impact of antithrombotic (AT) on transvenous lead extraction (TLE) safety and efficacy.

METHODS AND RESULTS

ELECTRa outcomes were compared between patients without AT therapy (No AT Group) and with different pre-operative AT regimens, including antiplatelets (AP), anticoagulants (AC), or both (AP + AC). Out of 3510 pts, 2398 (68%) were under AT pre-operatively. AT patients were older with more comorbidities (P < 0.0001). AT subgroups, defined as AP, AC, or AP + AC, were 1096 (31.2%), 985 (28%), and 317 (9%), respectively. Regarding AP patients, 1413 (40%) were under AP, 1292 (91%) with a single AP, interrupted in 26% about 3.8 ± 3.7 days before TLE. In total, 1302 (37%) patients were under AC, 881 vitamin K antagonist (68%), 221 (17%) direct oral anticoagulants, 155 (12%) low weight molecular heparin, and 45 (3.5%) unfractionated heparin. AC was 'interrupted without bridging' in 696 (54%) and 'interrupted with bridging' in 504 (39%) about 3.3 ± 2.3 days before TLE, and 'continued' in 87 (7%). TLE success rate was high in all subgroups. Only overall in-hospital death (1.4%), but not the procedure-related one, was higher in the AT subgroups (P = 0.0500). Age >65 years and New York Heart Association Class III/IV, but not AT regimens, were independent predictors of death for any cause. Haematomas were more frequent in AT subgroups, especially in AC 'continued' (P = 0.025), whereas pulmonary embolism in the No-AT (P < 0.01).

CONCLUSIONS

AT minimization is safe in patients undergoing TLE. AT does not seem to predict death but identifies a subset of fragile patients with a worse in-hospital TLE outcome.

Transvenous lead extraction: Efficacy and safety of the procedure in octogenarian patients

BACKGROUND

Managing elderly patients with infection or malfunction deriving from a cardiac implantable electronic device (CIED) may be challenging. The aim of this study was to evaluate safety and efficacy of mechanical transvenous lead extraction (TLE) in elderly patients.

METHODS

Patients who had undergone TLE in single tertiary referral center were divided in two groups (group 1: ≥ 80 years; group 2: < 80 years) and their acute and chronic outcomes were compared. All patients were treated with manual traction or mechanical dilatation.

RESULTS

Our analysis included 1316 patients (group 1: 202; group 2: 1114 patients), with a total of 2513 leads extracted. Group 1 presented more comorbidities, more pacemakers than implantable cardioverter-defibrillators, whereas the dwelling time of the oldest lead and the number of leads were similar, irrespective of patient's age. In group 1, the radiological success rate for lead was higher (99.0% vs 95.9%; P < .001) and the fluoroscopy time lower (13.0 vs 15.0 min; P = .04) than in group 2. Clinical success was reached in 1273 patients (96.7%), without significant differences between groups (group 1: 98.0% vs group 2: 96.4%; P = .36). Major complications occurred in 10 patients (0.7%) without significative differences between patients with more or less than 80 years (group 1: 1.5% vs group 2: 0.6%; P = .24) and with no procedure-related deaths in elderly group.

CONCLUSIONS

Mechanical TLE in elderly patients is a safe and effective procedure. In the over-80s, a comparable incidence of major complications with younger patients was observed, with at least a similar efficacy of the procedure.

Transvenous Lead Extraction SAFeTY Score for Risk Stratification and Proper Patient Selection for Removal Procedures Using Mechanical Tools

Background: To ensure the safety and efficacy of the increasing number of transvenous lead extractions (TLEs), it is necessary to adequately assess the procedure-related risk. Methods: We analyzed potential clinical and procedural risk factors associated with 2049 TLE procedures. The TLEs were performed between 2006 and 2016 using only simple tools for lead extraction. Logistic regression analysis was used to develop a risk prediction scoring system for TLEs. Results: Multivariate analysis showed that the sum of lead dwell times, anemia, female gender, the number of procedures preceding TLE, and removal of leads implanted in patients under the age of 30 had a significant influence on the occurrence of major complications during a TLE. This information served as a basis for developing a predictive SAFeTY TLE score, where: S = sum of lead dwell times, A = anemia, Fe = female, T = treatment (previous procedures), Y = young patients, and TLE = transvenous lead extraction. In order to facilitate the use of the SAFeTY TLE Score, a simple calculator was constructed. Conclusion: The SAFeTY TLE score is easy to calculate and predicts the potential occurrence of procedure-related major complications. High-risk patients (scoring more than 10 on the SAFeTY TLE scale) must be treated at high-volume centers with surgical backup.

Outcomes of transvenous lead extraction in patients with lead perforation: A single-center experience

Background

Management of cardiac perforation caused by the lead of a cardiac implantable electronic device (CIED) is currently unclear. This study evaluated the outcomes of transvenous lead extraction (TLE) in patients with cardiac perforation caused by a transvenous lead.

Hypothesis

Removal of perforated lead by transvenous approach is safe and effective.

Methods

The medical records of all patients diagnosed with cardiac perforation by a pacing or defibrillator lead in Peking University People's Hospital from January 2008 to January 2019 were reviewed. We included patients who were managed by TLE.

Results

A total of 53 patients (30 men; mean age: 67 ± 15 years) with lead perforation managed by TLE were included. Most of the perforated leads (94.9%) were pacemaker leads. Forty‐three leads (81.1%) were implanted within 1 year. Ten patients with a high risk of hemopericardium underwent percutaneous subxiphoid pericardial puncture prior to TLE. All 53 culprit leads were removed completely without major complications. Simple traction with or without a locking stylet was sufficient in 51 patients (96.2%). Forty‐eight patients (90.6%) had a new active‐fixation lead reimplanted. No patients showed evidence of new‐onset or worsening pericardial effusion during the procedure and hospital stay. During a median follow‐up time of 16 months, no recurrence of symptoms associated with lead perforation or CIED‐related infection were reported.

Conclusion

In most patients with lead perforation, TLE can be a safe and effective management approach.

Effectiveness and safety of transvenous extraction of single- versus dual-coil implantable cardioverter-defibrillator leads at single-center experience

The available literature lacks data concerning direct comparison of the effectiveness and safety of single- versus dual-coil implantable cardioverter-defibrillator (ICD) leads transvenous extraction. Certainly, additional shocking coil in superior vena cava adds to the amount of metal in the vascular system. Adhesions developing around the superior vena cava coil add to the difficulty of extraction of ICD lead if lead removal is required. The aim of the study was to assess the effectiveness and safety of single- and dual-coil ICD leads transvenous extraction using mechanical systems. We performed transvenous lead extraction (TLE) of 197 ICD leads in 196 patients. There were 46 (23.3%) dual-coil leads removed from 46 (23.5%) patients. Cardiovascular implantable electronic device-related infection was an indication for TLE in 25.0% of patients. The following extracting techniques were used: manual direct traction, mechanical telescopic sheaths, controlled-rotation mechanical sheaths, and femoral approach. Complete ICD lead removal and complete procedural success in both groups were similar (99.3% in single-coil vs 97.8% in dual-coil, P = .41 and 99.3% in single-coil vs 97.8% in dual-coil, P = 0.41, respectively). We did not find significant difference between major and minor complication rates in both groups (2.0% in single-coil vs 4.3% in dual-coil, and 0.7% in single-coil vs 0.0% in dual-coil, P = .58, respectively). There was 1 death associated with the TLE procedure of single-coil lead.This study shows that extraction of dual-coil leads seems to be comparably safe and effective to extraction of single-coil leads. On the other hand, it requires longer fluoroscopy time and frequent utilization of advanced tools.