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Vatterott P, Finley J, Savela J, De Kock A, Lewis R. Strategies to maximize lead tensile strength during extraction in three families of pacing leads. Heart Rhythm 2024; 21:929-938. [PMID: 38215809 DOI: 10.1016/j.hrthm.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND Traction force that can be applied to an extraction rail is based on lead tensile strength, a product of its construction. A strong rail allows safe advancement of the extraction sheath. This study expands previous work providing strategies to optimize INGEVITY rail strength. OBJECTIVE The purpose of this study was to measure forces that leads encounter in a simulated extraction procedure, determine lead response, and develop extraction recommendations for INGEVITY, INGEVITY+, and FINELINE II lead families. METHODS Leads were positioned in a simulated right atrial appendage implant. Subsequent traction forces enabled evaluation of lead tensile strength and effectiveness of preparation/extraction techniques. RESULTS Significant findings include (1) preserving the lead terminal pin did not decrease lead tensile strength and typically maximized it; (2) the weakest region is between the cathode and anode; (3) mid lead scar increases traction force tolerance until that scar is removed; and (4) optimal rail strength was observed using a multivenous approach with a femoral snare. Unique lead family findings include increased tensile strength of FINELINE II polyurethane vs silicone and INGEVITY active fixation vs passive fixation. CONCLUSION This study teaches the implanting clinician there are specific extraction techniques available to improve the removal of leads that may be the best option for a patient's clinical needs. Bench testing demonstrates that lead construction drives lead behavior during an extraction. Preserving the lead terminal pin provides consistent and, in most cases, optimal rail strength. If clinically indicated, a multivenous approach using a femoral snare significantly increases rail strength and protects the vulnerable lead tip.
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Affiliation(s)
- Pierce Vatterott
- Arrhythmia Science Center Minneapolis Heart Institute, Minneapolis, Minnesota.
| | | | | | | | - Robert Lewis
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
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Akhtar Z, Kontogiannis C, Elbatran AI, Leung LWM, Starck CT, Zuberi Z, Sohal M, Gallagher MM. Transvenous lead extraction: Experience of the Tandem approach. Europace 2023; 25:euad331. [PMID: 37936325 PMCID: PMC10903175 DOI: 10.1093/europace/euad331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/02/2023] [Indexed: 11/09/2023] Open
Abstract
AIMS Transvenous lead extraction (TLE) is important in the management of cardiac implantable electronic devices but carries risk. It is most commonly completed from the superior access, often with 'bail-out' support via the femoral approach. Superior and inferior access may be used in tandem, which has been proposed as an advance in safety and efficacy. The aim of this study is to evaluate the safety and efficacy of the Tandem approach. METHOD The 'Tandem' procedure entailed grasping of the targeted lead in the right atrium to provide countertraction as a rotational dissecting sheath was advanced over the lead from the subclavian access. Consecutive 'Tandem' procedures performed by a single operator between December 2020 and March 2023 in a single large-volume TLE centre were included and compared with the conventional superior approach (control) using 1:1 propensity score matching; patients were statistically matched for demographics. RESULTS The Tandem in comparison with the conventional approach extracted leads of much greater dwell time (148.9 ± 79 vs. 108.6 ± 77 months, P < 0.01) in a shorter procedure duration (96 ± 36 vs. 127 ± 67 min, P < 0.01) but requiring more fluoroscopy (16.4 ± 10.9 vs. 10.8 ± 14.9 min, P < 0.01). The Tandem and control groups had similar clinical (100% vs. 94.7%, P = 0.07) and complete (94.8% vs. 92.8%, P = 0.42) success, with comparable minor (4% vs. 6.7%, P = 0.72) and major (0% vs. 4%, P = 0.25) complications; procedural (0% vs. 1.3%, P = 1) and 30-day (1.3% vs. 4%, P = 0.62) mortality were also similar. CONCLUSION The Tandem procedure is as safe and effective as the conventional TLE. It can be applied to leads of a long dwell time with a potentially shorter procedure duration.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Christos Kontogiannis
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Ahmed I Elbatran
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
- Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Lisa W M Leung
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Christoph T Starck
- Department of Cardiothoracic Surgery, German Heart Centre, Berlin, Germany
| | - Zia Zuberi
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
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Kasai Y, Haraguchi T, Morita J, Kitai T, Okada T, Tamura T, Munakata Y, Tsujimoto M, Kasai J, Fujita T. Wire ThRoUgh Snare Twice (Wire TRUST) technique: A novel method to grasp a lead with inaccessible ends as a supportive femoral approach for transvenous lead extraction. J Cardiovasc Electrophysiol 2023; 34:1990-1995. [PMID: 37579218 DOI: 10.1111/jce.16041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/18/2023] [Accepted: 08/07/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Transvenous lead extraction (TLE) is a crucial procedure for managing cardiac implantable electronic devices. The use of a combined superior and femoral approach has been found to enhance the success rate of TLE. This report introduces a novel technique, named "Wire ThRoUgh Snare Twice" (Wire TRUST), for effectively grasping a lead without a free end during TLE. METHOD The Wire TRUST technique was applied in a case involving a 49-year-old male patient requiring TLE due to electrical artifact on the right ventricular (RV) lead, replacement of the RV lead, and pacemaker generator exchange. The Wire TRUST technique involved the insertion of a 4-Fr pigtail catheter and a 6-Fr snare catheter through the 14-Fr sheath inserted from the right common femoral vein. The 4-Fr pigtail catheter was hooked to the RV lead under multidirectional fluoroscopic guidance in the right atrium. The 0.014-in. guidewire was advanced through the pigtail catheter, crossing the RV lead until reaching the inferior vena cava. Subsequently, the distal end of the 0.014-in. guidewire was captured using a snare and pulled, facilitating externalization of the guidewire. After externalization, both ends of the 0.014-in. guidewire were passed through the snare outside the body and reinserted into the 14-Fr sheath. By simultaneously advancing and closing the snare while applying tension to the 0.014-in. guidewire, a secure grip on the lead without free ends was achieved. RESULTS The Wire TRUST technique enabled successful lead extraction and replacement without any complications. The technique facilitated the co-axial alignment of the powered sheath with the RV lead, ensuring safe and efficient extraction. CONCLUSION The Wire TRUST technique presents a novel and effective approach for grasping leads with inaccessible ends during TLE.
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Affiliation(s)
- Yuhei Kasai
- Asia Medical Group, Department of Cardiology, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
| | - Takuya Haraguchi
- Asia Medical Group, Department of Cardiology, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
| | - Junji Morita
- Asia Medical Group, Department of Cardiology, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
| | - Takayuki Kitai
- Asia Medical Group, Department of Cardiology, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
| | - Takuya Okada
- Asia Medical Group, Department of Clinical Engineering, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
| | - Takashi Tamura
- Asia Medical Group, Department of Clinical Engineering, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
| | - Yumetsugu Munakata
- Asia Medical Group, Department of Clinical Engineering, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
| | - Masanaga Tsujimoto
- Asia Medical Group, Department of Cardiology, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
| | - Jungo Kasai
- Paul G. Allen School of Computer Science and Engineering, University of Washington, Seattle, Washington, USA
| | - Tsutomu Fujita
- Asia Medical Group, Department of Cardiology, Sapporo CardioVascular Clinic, Sapporo Heart Center, Sapporo, Japan
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Akhtar Z, Sohal M, Sheppard MN, Gallagher MM. Transvenous Lead Extraction: Work in Progress. Eur Cardiol 2023; 18:e44. [PMID: 37456768 PMCID: PMC10345938 DOI: 10.15420/ecr.2023.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/10/2023] [Indexed: 07/18/2023] Open
Abstract
Cardiac implantable electronic devices are the cornerstone of cardiac rhythm management, with a significant number of implantations annually. A rising prevalence of cardiac implantable electronic devices coupled with widening indications for device removal has fuelled a demand for transvenous lead extraction (TLE). With advancement of tools and techniques, the safety and efficacy profile of TLE has significantly improved since its inception. Despite these advances, TLE continues to carry risk of significant complications, including a superior vena cava injury and mortality. However, innovative approaches to lead extraction, including the use of the jugular and femoral accesses, offers potential for further gains in safety and efficacy. In this review, the indications and risks of TLE are discussed while examining the evolution of this procedure from simple traction to advanced methodologies, which have contributed to a significant improvement in safety and efficacy.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
| | - Mary N Sheppard
- Cardiac Risk in the Young, Cardiovascular Pathology Unit, St George's University of LondonLondon, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
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Vatterott PJ, Mondesert B, Marshall M, Lulic T, Wilkoff BL. Mechanics of lumenless pacing lead strength during extraction procedures based on laboratory bench testing. Heart Rhythm 2023; 20:902-909. [PMID: 36868544 DOI: 10.1016/j.hrthm.2023.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND With the advent of conduction system pacing, use of the Medtronic SelectSecure Model 3830 lead has increased substantially. However, with this increased use, the potential need for lead extraction also will increase. Lumenless lead construction requires an understanding of both applicable tensile forces as well as lead preparation techniques that can influence consistent extraction. OBJECTIVE The purpose of this study was to use bench testing methodologies to characterize the physical properties of lumenless leads and to describe related lead preparation methods that support known extraction techniques. METHODS Multiple 3830 lead preparation techniques, commonly used in extraction practices, were compared on the bench to assess rail strength (RS) in simple traction and use conditions with simulated scar. Retention of the IS1 connector vs severing the lead body preparation techniques were compared. Distal snare and rotational extraction tools were evaluated. RESULTS The retained connector method provided higher RS compared to the modified cut lead method: mean 11.42 lbf (9.85-12.73 lbf) vs 8.51 lbf (1.66-14.32 lbf), respectively. Snare use distally did not significantly affect RS: mean 11.05 lbf (8.58-13.95 lbf). Lead damage occurred with the TightRail extraction tool at angles ≥90°, which could occur with right-sided implants. CONCLUSIONS When extracting SelectSecure leads, the retained connector method to maintain cable engagement benefits preservation of the extraction RS. Limiting traction force to <10 lbf (4.5 kgf) and avoiding poor lead preparation methods are critical to consistent extraction. Femoral snaring does not change RS when needed and offers a method to regain lead rail in cases of distal cable fracture.
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Affiliation(s)
- Pierce J Vatterott
- Heart Rhythm Science Center, Minneapolis Heart Institute, Minneapolis, Minnesota
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Akhtar Z, Gallagher MM. Transvenous lead extraction: the Subclavian to Jugular pull-through technique. HeartRhythm Case Rep 2022; 9:160-164. [PMID: 36970377 PMCID: PMC10030300 DOI: 10.1016/j.hrcr.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Zaki Akhtar
- Address reprint requests and correspondence: Dr Zaki Akhtar, St George’s University Hospital, Blackshaw Rd, Tooting, London SW17 0RE, UK.
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Bonner M, Hilpisch K, Wika K, Mesich ML, Harris M, White T. Visual observation of extraction of a Micra leadless pacemaker from a human cadaver. Pacing Clin Electrophysiol 2022; 45:1056-1061. [PMID: 35766651 PMCID: PMC9796770 DOI: 10.1111/pace.14559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/03/2022] [Accepted: 06/17/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION In this article we present the extraction of a Micra from a human cadaver implanted 3 years previously with both visual and X-ray imaging taken during the removal. METHODS A Micra pacemaker was extracted from a human cadaver with endoscopy and fluoroscopy using a Micra delivery tool. Histological analysis was performed on slices from the tissue surrounding the Micra. RESULTS The fully encapsulated Micra was easily retrieved with a maximum force of 1.9 pounds. CONCLUSIONS Even though the Micra was implanted almost 3 years previously, the snaring and extraction of the Micra was performed relatively easily and with minimal force required.
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Affiliation(s)
- Matthew Bonner
- Medtronic Cardiac Rhythm ManagementMinneapolisMinnesotaUSA
| | | | - Kent Wika
- Medtronic Physiological Research LaboratoriesMinneapolisMinnesotaUSA
| | | | - Megan Harris
- Medtronic Cardiac Rhythm ManagementMinneapolisMinnesotaUSA
| | - Troy White
- Medtronic Cardiac Rhythm ManagementMinneapolisMinnesotaUSA
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