Pacemaker lead complications: when is extraction appropriate and what can we learn from published data?

Tricuspid valve surgery in implantable cardiac electronic device-related endocarditis: Repair or replace?

Background

The aim of this study was to investigate lead endocarditis-related tricuspid valve regurgitation, to identify underlying causes, and to report our surgical approaches to tricuspid valve endocarditis.

Methods

Between March 2010 and August 2016, medical records of a total of 43 patients (23 males, 20 females; mean age: 63.2±13.6 years; range 48 to 72 years) who underwent tricuspid valve surgery for severe tricuspid regurgitation caused by lead endocarditis, which was previously placed as an implantable cardiac electronic device were reviewed. We removed all systems including infected leads and generators, revised infected wounds and tissues, performed tricuspid valve surgery for lead endocarditis, and applied long-term intravenous antibiotic regimen for the culprit agent, as confirmed by the culture.

Results

Of 43 patients, 18 underwent tricuspid valve repair and 25 underwent tricuspid valve replacement for lead endocarditisrelated severe tricuspid valve regurgitation. During followup (range, 2 to 62 months), two patients required temporary mechanical support due to postoperative acute right heart failure, while eight patients died due to sepsis (n=6; 14%) and stroke (n=2; 4.6%) in the early postoperative period. The remaining patients showed significant improvement in signs and symptoms of heart failure.

Conclusion

Our study results suggest that incompetent experience and inaccurate decision for valve repair may result in delayed valve replacement and prolonged operation time.

Clinical features, follow-up, and reprogramming of patients with pacemaker in a secondary care center

INTRODUCTION

During recent years, several recommendations and guidelines regarding cardiac pacing have been published in the literature. However, only a few studies have examined the implementation of these guidelines in clinical practice. The current study aimed to record and evaluate the effects of the mainstream studies, and the experience gathered by all patients who have been followed-up at the pacemaker Unit of Veroia Hospital, which is a secondary care center.

METHODS AND RESULTS

Epidemiological, clinical, and electrocardiographic data were collected and studied for patients with a permanent pacemaker that have been followed-up in our hospital from 2002 to 2017. The total number of patients of the study was 3,902 (2,164 men; 55.45 %) with a mean age of 73.4 ± 12.6 years. Third degree atrioventricular (AV) block was the most common cause of pacing. Dysfunction of the sinus node involved the majority of cases with bradycardia-tachycardia syndrome. At 18 patients, the cause of permanent pacemaker implantation was carotid sinus syndrome and at 13 of them, cardio-vascular type of neurocardiogenic syncope. Dizziness and syncope were the most common symptoms. Dual-chamber pacing was the most common type of pacing, which has been increasing in recent years. In follow-up visits, the most frequent examinations concerned battery condition, as the stimulation and sensing threshold. Reprogramming of the device was required in 1,434 patients (36.75 %), especially during the first year after implantation.

CONCLUSION

Pacing indications have been unchanged during all the years of the study and have been based on confirmed bradycardia and major symptoms. Reprogramming of the device was needed in an increased number of patients. HIPPOKRATIA 2018, 22(2): 75-79.

Superior Vena Cava Thrombosis after Intravascular AICD Lead Extraction: A Case Report

Pacemaker lead extraction has been shown to be an effective and safe treatment in the case of infected permanent pacemaker leads. However, it can lead to potentially serious complications, usually occurring during the extraction procedure. This report describes a case of a 74-year-old male with a persistent superior vena cava thrombosis related to an infected permanent pacemaker lead transvenous extraction. Clinical and surgical management are discussed.

Neointimal fibrotic lead encapsulation - Clinical challenges and demands for implantable cardiac electronic devices

Every tenth patient with a cardiac pacemaker or implantable cardioverter-defibrillator implanted is expected to have at least one lead problem in his lifetime. However, transvenous leads are often difficult to remove due to thrombotic obstruction or extensive neointimal fibrotic ingrowth. Despite its clinical significance, knowledge on lead-induced vascular fibrosis and neointimal lead encapsulation is sparse. Although leadless pacemakers are already available, their clinical operating range is limited. Therefore, lead/tissue interactions must be further improved in order to improve lead removals in particular. The published data on the coherences and issues related to lead associated vascular fibrosis and neointimal lead encapsulation are reviewed and discussed in this paper.

Characterization of a previously unrecognized clinical phenomenon: Delayed shock after cardiac implantable electronic device extraction

BACKGROUND

Transvenous lead extraction remains a challenging procedure with inherent risk and associated complications.

OBJECTIVE

We sought to characterize and evaluate predictors of delayed shock after transvenous lead extraction with no intraprocedural complications.

METHODS

We retrospectively analyzed data of 217 consecutive patients who underwent extraction between 2010 and 2015. The primary end point was sudden onset of shock more than 4 hours after the completion of the procedure. Shock was defined as at least 30 minutes of persistent hypotension, necessitating vasopressors. Patients with mechanical or hemorrhagic shock were excluded.

RESULTS

Seventeen patients (9%) developed delayed shock during the first 24 hours. Reasons for shock were sepsis (47%) or no apparent cause (53%). In multivariate analysis, patients with delayed shock had significantly lower glomerular filtration rate (median estimated glomerular filtration rate 53 mL/min vs 73 mL/min; P = .001), had more signs of systemic infection before extraction (fever, bacteremia, and leukocytosis; P < .05), and had more lead/tip remnants (29% vs 3%; P < .001). Patients presenting with delayed shock had significantly higher mortality rates at 1-year follow-up (10 [59%] vs 40 [23%], respectively; P < .01). Multivariate analysis adjusted for 1-year mortality risk was 114% higher (hazard ratio 2.14; 95% confidence interval 1.02-4.47; P < .05) in patients presenting with delayed shock.

CONCLUSION

We describe a previously unrecognized clinical phenomenon of delayed shock developing after extraction. Patients with predictors of this condition at baseline should be identified and followed up closely. Even with prompt treatment, long-term mortality rates remain high.

Dermatologic surgery on the chest wall in patients with a cardiac surgery history: a review of material that may be encountered intraoperatively, including potential complications and suggestions for proceeding safely

Background

Thoracic surgical procedures and the use of cardiac devices such as pacemakers are becoming increasingly prevalent in the population. As such, dermatologists may have a greater likelihood of encountering previously implanted or abandoned surgical material in the course of dermatologic surgery on the chest wall. A basic understanding of the wire types and the tunneling paths utilized in such procedures is important in accurately anticipating the presence of these wires to effectively manage any chance encounters.

Objective

We present a review on temporary epicardial pacing wires, temporary transvenous pacing wires, pacemaker leads, and surgical steel sutures in the context of dermatologic surgery.

Methods

A literature review was performed on frequently used wire material in patients with a history of cardiac surgery as well as related dermatologic complications from these materials.

Results & Conclusion

Dermatologic surgeons should particularly be aware that temporary epicardial pacing wires and pacemaker leads are not uncommonly abandoned in the chest wall of many patients. All patients with a cardiac surgery history should be questioned about possible retained wires. If wire material is encountered intraoperatively, immediately stop the procedure and do not attempt further manipulation of the wire until suggested steps are taken to ascertain the wire type.

Conservative therapy for the management of cardiac implantable electronic device infection

Along with the increased frequency of implantation, the incidence of cardiac implantable electronic device (CIED) infection, which can have serious or fatal complications, has also increased. Although several successful conservative therapies for CIED infection have been reported, retained infected devices remain a source of relapse, which is closely related to a higher mortality rate. Presently, complete hardware removal is initially recommended for infected CIED patients, and indications for conservative therapy, including continuous administration of antibiotics, require careful consideration.

On the other hand, complete removal is not required for superficial or incisional infection at the device pocket if an infection does not involve the device, but the patient should be closely followed for progression to deeper infection, which would require extraction.

Unusual cause of hypoxemia after automatic implantable cardioverter-defibrillatorleads extraction

The indication of pacemaker/AICD removal are numerous. Serious complication can occur during their removal, severe tricuspid regurgitation is one of the complication. The occurrence of PFO is not uncommon among adult population. Shunting across PFO in most circumstance is negligible, but in some necessitates closure due to hypoxemia. We report a case of 62 year old man, while undergoing AICD removal, had an emergency sternotomy for cardiac tamponade. Postoperatively, he experienced profound hypoxemia refractory to oxygen therapy. Transthoracic Echocardiogram was performed to rule out intracardiac shunts at an early stage, but it was difficult to obtain an good imaging windows poststernotomy. A small pulmonary emboli was noted on CTPA, but was not sufficient to account for the level of hypoxemia and did not resolve with anticoagulation. Transesophageal echocardiogram showed flail septal tricuspid valve with severe TR and bidirectional shunt through large PFO. Patient was posted for surgery, tricuspid valve was replaced and PFO surgically closed. Subsequently, patient recovered well ad was discharged to home. Cause of hypoxemia might be due to respiratory or cardiac dysfunction. But for hypoxemia refractory to oxygen therapy, transoesophageal echocardiogram should be always considered and performed early as an diagnostic tool in post cardiac surgical patients.

Surgical management of cardiac implantable electronic device infections

PURPOSE

The infection of cardiac implantable electronic devices (CIED) is a serious and potentially lethal complication. The population at risk is growing, as the device implantation is increasing especially in older patients with associated comorbid conditions. Our purpose was to present the management of this complicated surgical condition and to extract the relevant conclusions.

METHODS

During a 3-year period 1,508 CIED were implanted in our hospital. We treated six cases of permanent pacemaker infection with localized pocket infection or endocarditis. In accordance to the recent AHA/ACC guidelines, complete device removal was decided in all cases. The devices were removed under general anaesthesia, with a midline sternotomy, under extracorporeal circulation on the beating heart. Epicardial permanent pacing electrodes were placed on the right atrium and ventricle before the end of the procedure.

RESULTS

The postoperative course of all patients was uncomplicated and after a follow up period of five years no relapse of infection occurred.

CONCLUSIONS

Management protocols that include complete device removal are the only effective measure for the eradication of CIED infections. Although newer technologies have emerged and specialized techniques of percutaneous device removal have been developed, the surgical alternative to these methods can be a safe solution in cases of infected devices.

Femoral approach: an exceptional alternative for permanent pacemaker implantation

The classic transvenous implantation of a permanent pacemaker in a pectoral location may be precluded by obstruction of venous access through the superior vena cava or recent infection at the implant site. When these barriers to the procedure are bilateral and there are also contraindications or technical difficulties to performing a thoracotomy for an epicardial approach, the femoral vein, although rarely used, can be a viable alternative. We describe the case of a patient with occlusion of both subclavian veins and a high risk for mini-thoracotomy or videothoracoscopy, who underwent implantation of a permanent single-chamber pacemaker via the right femoral vein.

The Promise of Leadless Pacing: Based on Presentations at Nanostim Sponsored Symposium Held at the European Society of Cardiology Congress 2013, Amsterdam, The Netherlands, 2 September 2013

Pacemaker technologies have advanced dramatically over the decades since they were first introduced, and every year many thousands of new implants are performed worldwide. However, there continues to be a high incidence of acute and chronic complications, most of which are linked to the lead or the surgical pocket created to hold the device. A leadless pacemaker offers the possibility of bypassing these complications, but requires a catheter-based delivery system and a means of retrieval at the end of the device's life, as well as a way of repositioning to achieve satisfactory pacing thresholds and R waves, a communication system and low peak energy requirements. A completely self-contained leadless pacemaker has recently been developed, and its key characteristics are discussed, along with the results of an efficacy and safety trial in an animal model. The results of the LEADLESS study, the first human trial to look at safety and feasibility of the leadless device, are discussed and the possible implications for future clinical practice examined.

Relationship between changes in selected thrombotic and inflammatory factors, echocardiographic parameters and the incidence of venous thrombosis after pacemaker implantation based on our own observations

INTRODUCTION

Thrombosis (VTh) is a rare dangerous complication of pacemaker implantation (PM). The aim of the study was to determine the dynamics of change in selected thrombotic and inflammatory factors after PM.

MATERIAL AND METHODS

The study involved 81 patients (30 female, mean age: 71.1 years) with PM, divided into two groups. Group A (71 patients) consisted of patients without VTh, whereas group B (10 patients) comprised the patients with VTh. A transthoracic echocardiogram (TTE) and a venous ultrasound (VU) examination were performed. The levels of D-dimers, fibrinogen, tissue factor (TF), factor VII, plasminogen activator inhibitor-1 (PAI-1), interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) were determined in the venous blood. After PM, the TTE and VU examinations were repeated at 6 and 12 months, and blood analyses were performed within 7 days after PM, and subsequently at 6 and 12 months.

RESULTS

In 10 patients of group B, symptomatic VTh occurred at a mean time of 13.06 months after PM. Initially, the levels of IL-6, hsCRP, D-dimers, fibrinogen, TF, VII factor and PAI-1 were considerably higher in group B than in group A. In all patients the levels of these factors kept on increasing for up to 7 days after the procedure. In group A they subsequently decreased, whereas in group B they continued to rise.

CONCLUSIONS

Increased levels of inflammatory and thrombotic factors were observed in patients with VTh before and after PM. The factors of highest risk of VTh occurrence were D-dimers, fibrinogen and TF.

The prevalence of methicillin resistant organisms among pacemaker and defibrillator implant recipients

INTRODUCTION

Pacemaker and defibrillator infections are an uncommon, but catastrophic complication of device implantation. The present study examined the prevalence of device-related infections, the patterns of antibiotic resistance, and the presence of methicillin resistant staphylococcus aureus (MRSA) nares colonization in device implant recipients.

METHODS

Two protocols were employed using a retrospective and a prospective analysis. A retrospective chart review of 218 patients with suspected device infection from 1/2000 to 1/2011 was performed. Demographics, infection rates, and patterns of antibiotic resistance were compared. The prospective analysis enrolled one hundred eighty two patients undergoing device implantations or generator replacements. The nares were swabbed and analyzed for the presence of staphylococcus aureus, and tested for methicillin sensitivity.

RESULTS

Over a period of ten years, 12,771 device implants/generator changes/system revisions were performed, with an infection rate of 1.2%. Methicillin resistance (MR) was identified in 98/218 (44.9%) of patients. Those with MR infection had more diabetes and cardiomyopathy. There was no significant increase in methicillin resistance over time (p=0.30). Our prospective analysis included 110 men. A total of 32 patients (17.6%) had positive cultures for SA: 6.6% with MRSA. Patients positive for MRSA nares colonization had a statistically significant greater length of hospital stay 8.5 days (mean) versus 4.4 days (P=0.049).

CONCLUSIONS

Methicillin resistant organisms appear to be emerging and persistent pathogens in device implants. The screening of MRSA colonization may identify new populations at risk. Further studies and analysis are needed to determine the cost effectiveness of a screening protocol.

Permanent pacemaker and implantable cardioverter defibrillator infections: seven years of diagnostic and therapeutic experience of a single center

BACKGROUND

Increasing evidence-based indications for the implantation of permanent pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) have led to an increase in the rate of device infections. The aim of the present study was to evaluate infection frequency, clinical characteristics, risk factors, and microbiologic and therapeutic features in patients with PM/ICD infections.

HYPOTHESIS

Clinical and demographic characteristics of the patients can affect the PM/ICD infections.

METHODS

The PM/ICD infection group consisted of 57 patients diagnosed and treated with PM/ICD infections in our hospital. The control group in this case-control study consisted of 833 patients in whom a PM or ICD had been implanted and no infections were noted.

RESULTS

Patients with PM/ICD infections (median age 65 years; range, 18-104 years) were older than those without PM/ICD infections (median age 58 years; range, 18-86 years; P = 0.005). The percentage of generator replacement was higher in the PM/ICD infection group compared with the control group (16% vs 8%, P = 0.003). Independent predictors of PM/ICD infections were advanced age (>60 years; odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.2-4.0, P = 0.021) and device revision (OR: 3.8, 95% CI: 1.5-5.5, P = 0.002). Primary antibiotic prophylaxis during the procedure reduced the risk for PM/ICD infection (OR: 0.5, 95% CI: 0.4-0.8, P = 0.011).

CONCLUSIONS

PM/ICD infections occur in a significant number of patients. It is important to be aware of the risk factors for PM/ICD infections so that patients with an increased risk can be identified and preventive measures can be implemented.

Innominate vein-right atrial bypass for relief of superior vena cava syndrome due to pacemaker lead thrombosis

We present a patient with superior vena cava (SVC) obstruction due to multiple intraluminal pacemaker leads. Previous attempts at balloon dilatation of the SVC and surgical angioplasty did not provide a long-term solution. A Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ, USA) conduit interposed between the innominate vein and right atrial appendage has resulted in symptomatic relief at a follow-up of 6 months.

The femoral route revisited: an alternative for pectoral pacing lead implantation

We describe the implantation via the femoral vein of a dual-chamber pacing system with lumenless, catheter-delivered pacing leads in a patient in whom subclavian access on both sides was obstructed. (Neth Heart J 2010;18:42-4.).

A case of pacing lead induced clinical superior vena cava syndrome: a case report

Introduction

Transvenous pacing is a relatively safe treatment with a low complication rate, but serious thromboembolic complications have been reported to occur in 0.6% to 3.5% of cases. Superior vena cava obstruction syndrome is generally an uncommon but serious complication occurring in <0.1% of patients. However, when it occurs it carries with it significant morbidity and mortality.

Case presentation

A 51-year-old lady with long history of DDD permanent pacemaker presented following a mechanical fall. She had no obvious injuries, and was hemodynamically stable. General examination revealed features suggestive of Superior vena caval obstruction which was later confirmed by imaging. She was treated with long term oral anticoagulation with good clinical improvement.

Conclusion

Superior vena cava obstruction in patients with transvenous pacing leads, although rare, is a well recognized complication. With growing elderly population and increasing number of procedures performed, more and more people with permanent pacemaker are likely to be encountered in clinical practice. One should carefully look for thromboembolic complications during follow-up in patients with transvenous pacemaker leads, as it has implications for future management and carries significant morbidity and mortality.

New perspectives of infections in cardiovascular disease

Infections have been recognized as significant causes of cardiac diseases for many decades. Various microorganisms have been implicated in the etiology of these diseases involving all classes of microbial agents. All components of the heart structure can be affected by infectious agents, i.e. pericardium, myocardium, endocardium, valves, autonomic nervous system, and some evidence of coronary arteries. A new breed of infections have evolved over the past three decades involving cardiac implants and this group of cardiac infectious complications will likely continue to increase in the future, as more mechanical devices are implanted in the growing ageing population. This article will review the progress made in the past decade on understanding the pathobiology of these infectious complications of the heart, through advances in genomics and proteomics, as well as potential novel approach for therapy.An up-to-date, state-of-the-art review and controversies will be outlined for the following conditions: (i) perimyocarditis; (ii) infective endocarditis; (iii) cardiac device infections; (iv) coronary artery disease and potential role of infections.

Complications and lead extraction in cardiac pacing and defibrillation

The only indications for which lead extraction may be really necessary are infected pacing or defibrillation systems. Superfluous non-functional leads can on the whole be more safely abandoned than extracted. Improvements in lead extraction will be more helped by designing and implanting leads that can be more easily removed than current models, than with better extraction tools. Still, as infection and hence lead extraction usually follows surgical interventions of a pacing or defibrillation system, avoiding the latter - or postponing it if possible - is of great importance (Neth Heart J 2008;16(Suppl1):S28-S31.).

A case of permanent pacemaker lead infection

BACKGROUND

A 70-year-old man with diabetes mellitus, fever of unknown origin and oliguria was admitted to hospital. Blood cultures were positive for a Staphylococcus aureus infection and antibiotic therapy was started. A year previously the patient had received a DDD pacemaker to treat sick sinus syndrome with intermittent atrioventricular block. Transthoracic echocardiography showed severe tricuspid regurgitation and a mass attached to the ventricular pacemaker lead; transesophageal echocardiography showed the same finding but additionally showed a vegetation on the tricuspid septal leaflet and a mass attached to the atrial pacemaker lead. Coronary angiography revealed a lesion that occluded 70% of the proximal left anterior descending artery and occlusion of the proximal right coronary artery.

INVESTIGATIONS

Electrocardiography, transthoracic echocardiography, transesophageal echocardiography, multidetector thoracic CT, coronary angiography, blood cultures and laboratory testing.

DIAGNOSIS

Pacemaker lead infection and tricuspid valve endocarditis.

MANAGEMENT

The patient was surgically treated under cardiopulmonary bypass during which the pacemaker system was removed and an accurate debridement of the tricuspid tissue was performed.

[Non-valvular cardiac devices endocarditis]

The risk of infective endocarditis on pacemaker or ICD is not negligible and has increased in recent years. Several host-related, procedure-related, or device-related risk factors have been recognized. Owing to its potential severity, the possibility of infective endocarditis should be envisaged in patients with repeated pulmonary infections or documented bacteremia and transesophageal echocardiography should then be used. The most common germs causing pacemaker endocarditis are staphylococci. Treatment requires prolonged antibiotic therapy and retrieval of the pacemaker and leads.

Pacemaker Endocarditis in Patients with Prosthetic Valve Replacements: Case Trilogy and Literature Review

Infective endocarditis is not uncommon in patients with both a permanent pacemaker system and a prosthetic valve. No guidelines exist to aid management. The recommendations for pacemaker infective endocarditis alone are limited and contradictory. We present a case trilogy and literature review that highlights these shortcomings and the challenges facing physicians. Complete extraction of the infected pacemaker system is essential. The timing of extraction, duration of antibiotic therapy, and timing of reimplantation are all controversial. The presence of a concomitant prosthetic valve exacerbates these dilemmas further.

Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections

OBJECTIVES

We describe the management and outcome of permanent pacemaker (PPM) and implantable cardioverter-defibrillator (ICD) infections in a large cohort of patients seen at a tertiary care facility with expertise in device lead extraction.

BACKGROUND

Infection is a serious complication of PPM and ICD implantation. Optimal care of patients with these cardiac device infections (CDI) is not well defined.

METHODS

A retrospective review of all patients with CDI admitted to Mayo Clinic Rochester between January 1, 1991, and December 31, 2003, was conducted. Demographic and clinical data were collected, and descriptive analysis was performed.

RESULTS

A total of 189 patients met the criteria for CDI (138 PPM, 51 ICD). The median age of the patients was 71.2 years. Generator pocket infection (69%) and device-related endocarditis (23%) were the most common clinical presentations. Coagulase-negative staphylococci and Staphylococcus aureus, in 42% and 29% of cases, respectively, were the leading pathogens for CDI. Most patients (98%) underwent complete device removal. Duration of antibiotic therapy after device removal was based on clinical presentation and causative organism (median duration of 18 days for pocket infection vs. 28 days for endocarditis; 28 days for S. aureus infection vs. 14 days for coagulase-negative staphylococci infection [p < 0.001]). Median follow-up after hospital discharge was 175 days. Ninety-six percent of patients were cured with both complete device removal and antibiotic administration.

CONCLUSIONS

Cure of CDI is achievable in the large majority of patients treated with an aggressive approach of combined antimicrobial treatment and complete device removal. Based on findings of our large retrospective institutional survey and previously published data, we submit proposed management guidelines of CDI.

Pacemaker and ICD lead extraction with electrosurgical dissection sheaths and standard transvenous extraction systems: results of a randomized trial

AIMS

The purpose of this prospective randomized study was to evaluate the safety and efficacy of transvenous pacemaker and implantable cardioverter-defibrillator (ICD) lead extraction with an electrosurgical dissection sheath (EDS) system in a single-centre experience. Methods Over 10 years, 462 patients have undergone transvenous lead extraction in our institution. From these, 120 consecutive patients (with 161 leads) were randomized to either radiofrequency (RF) current supported extraction or standard countertraction lead removal (60 patients in each arm, 96 men and 24 women). The mean age of randomized patients was 62.7 +/- 9.6 years. In 16 patients, we explanted 17 ICD leads. The average time from the date of implantation to the extraction procedure was 73.4 +/- 15.7 months. The most common reason for lead extraction was infection (95.6%). Results The complete extraction of 78 leads (93%) was achieved in the RF group and 56 leads (73%) with the standard transvenous lead extraction system by counter-traction (P < 0.01). Among these leads, we successfully removed nine of 10 ICD leads (90%) in the RF group and only four of seven ICD leads (57%) in the standard group. We also observed a significant reduction in the time taken for the successful removal of pacemaker and ICD leads using the RF system (9.6 +/- 6.2 min versus 21 +/- 9 min, P < 0.01). Partial success was achieved in six patients with the RF system and in 11 with standard sheaths. In those cases where we failed to remove the lead from the body we sent all but one patient to cardiac surgery. Serious complications were associated with the standard system in two patients, both of whom developed septic pulmonary embolization. Serious bleeding occurred in three patients, one with standard and two with the EDS lead extraction system.

CONCLUSION

The EDS extraction system is significantly more effective and quicker. However, the standard counter-traction method is still an effective alternative when used in a highly experienced centre.

Laser Lead Extraction: Predictors of Success and Complications

BACKGROUND

Paralleling the rise in pacemaker and defibrillator implantations, lead extraction procedures are increasingly required. Concerns regarding failure and complications remain.

METHODS AND RESULTS

A total of 200 lead extraction procedures were performed at the Montreal Heart Institute between September 2000 and August 2005. In 23 patients, all leads were removed by traction with a locking stylet. A total of 270 leads were extracted using a laser sheath system (Spectranectics, Colorado Springs, CO, USA) in 177 procedures involving 175 patients (74% male), age 62+/-16 years. Procedural indications were: infection 88 (50%), dysfunction 54 (30%), upgrade 21 (12%), and other 14 (8%). Overall, 241 leads (89%) were successfully extracted, 7 (3%) were partially extracted (< or = 4 cm retained), and 22 (8%) were non-extractable. In multivariate analyses, predictors of failed extraction were longer time from implant (OR 1.16 per year, P=0.0001) and history of hypertension (OR 5.2, P=0.0023). Acute complications occurred in 14 of 177 procedures (7.9%): 8 (4.5%) minor and 6 (3.4%) major, with one death. In multivariate analyses, the only predictor of acute complications was laser lead extraction from both right and left sides during the same procedure (OR 9.4, P = 0.0119). In addition, 3 of 10 patients with failed or partially extracted infected systems eventually required open chest explantation because of endocarditis.

CONCLUSION

Most leads not amenable to manual traction may be successfully extracted by a percutaneous laser sheath system. While most complications are minor, major complications including death may occur. Older leads are at higher risk for failed extraction. Endocarditis may ensue if infected leads are incompletely removed.