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Volk L, Verghis N, Ikegami H, Takebe M, Russo MJ, Lee LY, Lemaire A. Is cardiopulmonary bypass standby still required for laser lead extractions? J Cardiothorac Surg 2022; 17:235. [PMID: 36109812 PMCID: PMC9476252 DOI: 10.1186/s13019-022-01987-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 08/24/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Over the last two decades there has been an increase in the number of cardiac implantable electronic devices and consequently, there has also been an increased need for lead extractions. Fibrotic attachments develop between the lead and the venous and cardiac structures that may require the use of a laser to mobilize the lead. Cardiothoracic surgeons (CTS) have traditionally provided backup for surgical emergencies for these extractions. This study evaluates the surgical outcomes of patients undergoing transvenous laser lead extractions (TLE) and determines if CTS are still needed for backup. Methods A retrospective review of consecutive patients undergoing laser lead extractions at a single academic center. Lead extractions using only laser sheaths were analyzed. The clinical characteristics, complications, and mortality of the patients were evaluated. Results One hundred and twenty-one patients underwent TLEs from January 1st, 2014 to December 31st, 2018. The majority were male (N = 80, 66.1%), and the average age was 66.48 ± 14 years. The indication for removal was either laser lead malfunction or infection. A total of 30 patients (24.8%) had complications postoperatively including wound hematomas, superficial infections, and arrhythmias. The average length of stay was 9 ± 12 for all the patients in the study. 2 patients (1.6%) had injuries that required emergency surgical repair with injuries to the posterior superior vena cava and right ventricle. Both patients survived the initial injury with one patient was discharged home on day 4 and the other succumbing to his injuries on postoperative day 20. Conclusion Although the incidence of surgical emergencies is rare the morbidity and mortality for TLE require that surgical backup be available.
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Migliore F, Tarzia V, Dall'Aglio PB, Falzone PV, De Lazzari M, Bottio T, D'Onofrio A, Padalino M, Vida V, Rosso J, Leoni L, Pittarello D, Bertaglia E, Iliceto S, Gerosa G. The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction. Pacing Clin Electrophysiol 2021; 45:92-102. [PMID: 34699079 DOI: 10.1111/pace.14396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/23/2021] [Accepted: 10/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent studies have shown that Evolution RL bidirectional rotational mechanical sheath (Cook Medical,USA) is an effective and safe technique for transvenous lead extraction (TLE). We reported our experience with the bidirectional rotational mechanical tools using a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration. METHODS The study population comprised 84 patients (77%male;mean age 65±18 years) undergoing TLE.After multidisciplinary evaluation, a combined procedure was considered. RESULTS The main indication for TLE was infection in 54 cases (64%).Overall,152 leads were extracted with a mean implant duration of 94±63 months (range 12-421).Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6 % (77/84),97.6% (82/84), and 98.6%(150/152), respectively.Eighteen combined procedure were performed in 12 patients (14%), such as "hybrid approach" (n = 2) or TLE concomitant to:1) transcatheter aspiration procedure for large vegetation (n = 8); 2) left ventricular assistance device implantation as bridge to cardiac transplantation (n = 1); 3) permanent pacing with epicardial leads (n = 6); 4) tricuspid valve replacement (n = 1).One major complication (1.2%) and 11 (13%) minor complications were encountered.No injury to the superior vena cava occurred and no procedure-related deaths were reported. During a mean time follow-up of 21±18 months, 17 patients (20%) died.They were more often diabetics (P = 0.02), and they underwent TLE more often for infection (P = 0.004). CONCLUSIONS Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the Evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Federico Migliore
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Vincenzo Tarzia
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | | | - Pasquale Valerio Falzone
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Manuel De Lazzari
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Tomaso Bottio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Augusto D'Onofrio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Massimo Padalino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Vladimiro Vida
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Jacopo Rosso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Loira Leoni
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Demetrio Pittarello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Emanuele Bertaglia
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - Gino Gerosa
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
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Marinheiro R, Neves JP, Morgado F, Madeira M, Magro P, Carmo P, Adragão P. Analysis of a 10-year period of lead removal in a referral centre. Interact Cardiovasc Thorac Surg 2020; 31:166-173. [PMID: 32464643 DOI: 10.1093/icvts/ivaa078] [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: 02/06/2020] [Revised: 03/23/2020] [Accepted: 04/09/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Our goal was to analyse all lead extraction procedures (transvenous or open surgery) performed in our centre and the short- and long-term follow-up data from these patients. METHODS All lead extractions performed from 2008 to 2017 were retrospectively reviewed for patient characteristics and indications for device implantation; indications for lead extraction; techniques used; peri- and postprocedural complications and short- and long-term follow-up data. RESULTS A total of 159 patients (282 leads) were included [age 70 (62-78) years; 72% men]. The median follow-up time was 57 (25-90) months. Patients with lead explants were excluded. The most common indication for lead removal was infection (77%). A surgical approach was necessary in 14 patients (9%) owing to unsuccessful transvenous removal (n = 3), large vegetation in the lead (n = 4), concomitant valvular endocarditis (n = 2), other indications for open surgery (n = 4) and complicated transvenous removal (n = 1). Removal was tried for 282 leads. Of those, 256 were completely removed. Clinical success was achieved in 155 individual patients (98%). Complications occurred in 6 patients: 3 persistent infections, 1 stroke and 2 blood vessel ruptures. The procedure-related mortality rate was 2% (n = 3). CONCLUSIONS Lead removal was associated with a high success rate and low all-cause complication and mortality rates. Emergency surgery because of acute complications was rare, and open-heart surgery was most frequently elective and not associated with a worse outcome.
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Affiliation(s)
- Rita Marinheiro
- Cardiology Department, Centro Hospitalar de Setubal, Setubal, Portugal
| | - José Pedro Neves
- Cardio-Thoracic Department, Centro Hospitalar de Lisboa Ocidental-Hospital de Santa Cruz, Lisboa, Portugal
| | - Francisco Morgado
- Cardiology Department, Centro Hospitalar de Lisboa Ocidental-Hospital de Santa Cruz, Lisboa, Portugal
| | - Márcio Madeira
- Cardio-Thoracic Department, Centro Hospitalar de Lisboa Ocidental-Hospital de Santa Cruz, Lisboa, Portugal
| | - Pedro Magro
- Cardio-Thoracic Department, Centro Hospitalar de Lisboa Ocidental-Hospital de Santa Cruz, Lisboa, Portugal
| | - Pedro Carmo
- Cardiology Department, Centro Hospitalar de Lisboa Ocidental-Hospital de Santa Cruz, Lisboa, Portugal
| | - Pedro Adragão
- Cardiology Department, Centro Hospitalar de Lisboa Ocidental-Hospital de Santa Cruz, Lisboa, Portugal
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Afzal MR, Daoud EG, Matre N, Shoben A, Burnside M, Gilliam C, Pinkhas D, Okabe T, Tyler J, Houmsse M, Kalbfleisch SS, Crestanello JA, Turner K, Weiss R, Hummel JD, Love CJ, Augostini RS. RIsk Stratification prior to lead Extraction and impact on major intraprocedural complications (RISE protocol). J Cardiovasc Electrophysiol 2019; 30:2453-2459. [DOI: 10.1111/jce.14151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Muhammad R. Afzal
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Emile G. Daoud
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Nancy Matre
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Abigail Shoben
- Department of Public Health, Division of Biostatistics, College of Public Health The Ohio State University Columbus Ohio
| | - Melissa Burnside
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Courtney Gilliam
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Daniel Pinkhas
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Toshimasa Okabe
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Jaret Tyler
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Mahmoud Houmsse
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Steven S. Kalbfleisch
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | | | - Katja Turner
- Department of Internal Medicine, Electrophysiology Section, Division of Anesthesiology Ross Heart Hospital at the Ohio State University Medical Center Columbus Ohio
| | - Raul Weiss
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - John D. Hummel
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
| | - Charles J. Love
- Department of Internal Medicine, Division of Cardiovascular Medicine Johns Hopkins Hospital Baltimore Maryland
| | - Ralph S. Augostini
- Department of Internal Medicine, Division of Cardiovascular Medicine Wexner Medical Center at the Ohio State University Medical Center Columbus Ohio
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Azarrafiy R, Carrillo RG. Minimally Invasive Techniques to Avoid Sternotomy in Complex Lead Extraction Cases. J Innov Card Rhythm Manag 2019; 10:3515-3521. [PMID: 32494411 PMCID: PMC7252869 DOI: 10.19102/icrm.2019.100201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/17/2018] [Indexed: 11/06/2022] Open
Abstract
Cardiac device lead extractions have increased in frequency over the past several years. Although most of these procedures are successfully performed through a percutaneous approach, certain cases may be unmanageable using conventional methods. The traditional approach for such complex cases has been median sternotomy. However, four surgical techniques offer a less-invasive alternative. These include the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy. In the present study, we reviewed data from patients who underwent minimally invasive, surgical lead extraction at our institution from January 2003 to October 2017 using an ongoing, prospective registry. Summary statistics were generated for age, sex, device extracted, lead dwell time (years), procedure indication, major/minor complications and procedural success as defined by the 2017 Heart Rhythm Society consensus statement, and survival at discharge. Between January 2003 and October 2017, 14 cases at our center were managed via a transatrial approach, whereas 11 involved the subxiphoid approach, 19 involved a left minithoracotomy or thoracoscopy, and one involved a ministernotomy. For the transatrial approach, all cases were classified as procedural successes and all patients were discharged alive. Additionally, for the subxiphoid approach, all cases were deemed procedural successes, whereas survival at discharge was 90.9%. For the left minithoracotomy/thoracoscopy, all cases were procedural successes and survival at discharge was 94.7%. Lastly, the ministernotomy was successfully used to remove an infected, retained lead fragment from the innominate vein. In conclusion, at our institution, the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy were used as minimally invasive, surgical approaches that represent fairly safe and effective alternatives to median sternotomy in complex cases unamenable to management via conventional, percutaneous approaches to lead extraction.
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Affiliation(s)
- Ryan Azarrafiy
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Roger G Carrillo
- The Heart Institute at Palmetto General Hospital, Hialeah, FL, USA
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Boyle NG, Wilkoff BL. Overview of Lead Management. Card Electrophysiol Clin 2018; 10:549-559. [PMID: 30396571 DOI: 10.1016/j.ccep.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Lead management describes a comprehensive approach to cardiac implantable electronic device lead utilization, encompassing lead and device selection, vascular access, implant techniques, handling lead failures and recalls, managing infectious and other complications, and performing device and lead extraction. Device and lead selection should be based on the latest guidelines and the available data to choose the optimal device system for each patient. Lead extraction is a highly specialized procedure and should be carried out by a team of personnel extensively trained in the procedure at centers with cardiac surgical support.
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Affiliation(s)
- Noel G Boyle
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA.
| | - Bruce L Wilkoff
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic Lerner College of Medicine of CWRU, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Abstract
The role of the anesthesiologist in lead extraction procedures is multifaceted and highlights the collaborative, multidisciplinary teamwork needed to ensure patient safety and procedural success in these complex cases. Thorough preoperative evaluation and identification of high-risk characteristics enable the anesthesiologist to tailor a comprehensive intraoperative and postoperative care plan for each case. Institutional practices may vary but anesthetic management typically includes general anesthesia with an endotracheal tube, invasive measurement of arterial blood pressure, vascular access for rapid volume expansion, echocardiographic monitoring, preparation for blood transfusion, and initiation of cardiopulmonary bypass in the event of an emergency.
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Abstract
Surgical and hybrid lead extraction has developed considerably over the past several decades. Although transvenous lead extraction is the standard approach to remove infected or malfunctioning cardiac implantable electronic device leads, surgical approaches may be necessary in complex cases not amenable to transvenous lead extraction or in cases that involve concomitant pathologies, such as tricuspid valve regurgitation. We describe our experience with 4 minimally invasive surgical approaches to lead extraction as well as our experience with hybrid open heart surgery and transvenous lead extraction as an option for patients who present with concomitant conditions.
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Affiliation(s)
- Ryan Azarrafiy
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Roger G Carrillo
- The Heart Institute at Palmetto General Hospital, 7150 West 20th Avenue, Suite 615, Hialeah, FL 33016, USA.
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Fermin L, Gebhard RE, Azarrafiy R, Carrillo R. Pearls of Wisdom for High-Risk Laser Lead Extractions: A Focused Review. Anesth Analg 2017; 126:406-412. [PMID: 28991113 DOI: 10.1213/ane.0000000000002540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Due to new indications and improved technology, the incidence of laser lead extraction (LLE) has significantly increased over the past years. While LLE has been well studied and proven to be safe and effective, only few studies are geared toward the anesthesiologist's role during high-risk LLEs. This article utilized both a focused review and authors' experience to investigate anesthetic protocols during LLEs. Through this review, we recommend best practices for the anesthesiologist including appropriate procedure location, onsite availability of a cardiac surgeon, availability of a cardiopulmonary bypass machine, and intraoperative use of echocardiography to detect and address potential complications during high-risk LLEs.
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Affiliation(s)
- Lilibeth Fermin
- From the Department of Anesthesiology, Cleveland Clinic Florida, Weston, Florida
| | - Ralf E Gebhard
- Department of Anesthesiology, Perioperative Medicine and Pain Management
| | - Ryan Azarrafiy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Roger Carrillo
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
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