Prophylactic Lead Extraction at Implantable Cardioverter-Defibrillator Generator Change

Safety and efficacy of combined dilation/stenting of venous abnormalities, including complete obstructions, during lead extractions in patients with congenital heart disease

INTRODUCTION

Management of transvenous leads in patients with congenital heart disease (CHD) can be complicated by venous obstructions and residual shunts. We present our experience performing concurrent lead extraction and dilation/stenting of venous pathways, including patients with complete venous obstruction.

METHODS

All cases of concurrent lead extraction and recanalization of vena cavae/baffles between 2017 and 2021 at Boston Children's Hospital were retrospectively included and reviewed for safety and efficacy.

RESULTS

Eight patients, 4 female, median 38.5 years of age (range 16.7-49 years) and 81.6 kg weight (range 41.3-97.8 kg) at time of procedure were included. All patients had CHD, a majority (n = 7) having transposition of the great arteries palliated via atrial switch. All leads were removed in their entirety, with most patients having two leads extracted (n = 7). Median lead dwell time was 13.8 years (range 3.6-35.3 years). Three patients had complete obstructions, three required stenting of their innominate veins and three required recanalization of their femoral vessels. Median procedure time was 9.8 h (range 5.4-12.8 h). Complications included blood transfusion (n = 2), arrhythmia (n = 3), pleural effusion (n = 1), and pressure ulcer (n = 1). There were no cardiac perforations, venous tears, or deaths.

CONCLUSION

Lead extraction along with dilation and stenting of venous anomalies, though long in duration, proved effective with minimal complications. This combined procedure can safely and effectively resolve complete obstructions secondary to transvenous leads.

Transvenous Lead Extraction in Adult Patient with Leads Implanted in Childhood-Is That the Same Procedure as in Other Adult Patients?

BACKGROUND

Lead management in children and young adults is still a matter of debate.

METHODS

To assess the course of transvenous lead extraction (TLE) in adults with pacemakers implanted in childhood (CIP) we compared 98 CIP patients with a control group consisting of adults with pacemakers implanted in adulthood (AIP).

RESULTS

CIP patients differed from AIP patients with respect to indications for TLE and pacing history. CIP patients were four-eight times more likely to require second-line or advanced tools. Furthermore, CIP patients more often than AIP were prone to developing complications: major complications (MC) (any) 2.6 times; hemopericardium 3.2 times; severe tricuspid valve damage 4.4 times; need for rescue cardiac surgery 3.7 times. The rate of procedural success was 11% lower because of 4.8 times more common lead remnants and 3.1 times more frequent permanently disabling complications.

CONCLUSIONS

Due to system-related risk factors TLE in CIP patients is more difficult and complex. TLE in CIP is associated with an increased risk of MC and incomplete lead removal. A conservative strategy of lead management, acceptable in very old patients seems to be less suitable in CIP because it creates a subpopulation of patients at high risk of major complications during TLE in the future.

Lead age as a predictor for failure in pediatrics and congenital heart disease

BACKGROUND

Pediatric and congenital heart disease (CHD) patients have a high rate of transvenous (TV) lead failure.

OBJECTIVE

To determine whether TV lead age can aid risk assessment for lead failure to guide the decision of whether a lead should be replaced or reused at the time of a generator change.

METHODS

Retrospective cohort study of patients <21 years old undergoing TV device implant from 2000 to 2014 at our institution. Patient, device, and lead variables were collected. Leads were compared in groups based on how many generator changes were completed.

RESULTS

A total of 393 leads in 257 patients met inclusion criteria, 60 leads failed (15%). Failed leads were more likely to have not yet undergone generator change (p = .048). CHD (p = .045), Tendril lead type (p = .02) and silicone insulation (p = .02) were associated with failure. In multivariate analysis, younger leads (p = .022), number of generator changes (p = .003), CHD (p = .005) and silicone insulation (p = .004) remained significant while Tendril lead type did not (p = .052). Survival curves show an early decline around 4 years.

CONCLUSIONS

Lead failure rate in pediatric and CHD patients is high. Leads that have not yet undergone a generator change were more likely to fail in this cohort. The strategy of serial replacement based on lead age needs further research to justify in this population.

Implantable Cardiac Defibrillator Lead Failure and Management

The implantable-cardioverter defibrillator (ICD) lead is the most vulnerable component of the ICD system. Despite advanced engineering design, sophisticated manufacturing techniques, and extensive bench, pre-clinical, and clinical testing, lead failure (LF) remains the Achilles' heel of the ICD system. ICD LF has a broad range of adverse outcomes, ranging from intermittent inappropriate pacing to proarrhythmia leading to patient mortality. ICD LF is often considered in the context of design or construction defects, but is more appropriately considered in the context of the finite service life of a mechanical component placed in chemically stressful environment and subjected to continuous mechanical stresses. This clinical review summarizes LF mechanisms, assessment, and differential diagnosis of LF, including lead diagnostics, recent prominent lead recalls, and management of LF and functioning, but recalled leads. Despite recent advances in lead technology, physicians will likely continue to need to understand how to manage patients with transvenous ICD leads.

Lead extraction technology and techniques: a surgeon's perspective

Transvenous lead extraction procedures have gained substantial clinical importance during the past decade. With current tools and techniques, high success rates in combination with low complication rates can be achieved by experienced centres. Even in experienced hands, life-threatening complications can occur, and every physician performing such procedures must be prepared for this scenario. This necessitates immediately available access to extracorporeal circulation, and if the operator is a cardiologist, cardiac surgical standby is mandatory.

To extract or retain a sterile, nonfunctional lead: the case for extraction

Decision-making regarding extracting or abandoning sterile but nonfunctioning ICD leads has to be individualized. Providing recommendations to patients and their families requires a careful weighing of pros and cons and understanding of the availability of local expertise. Decision models to help with these clinical scenarios have started to become available but remain in their infancy.

Extracting versus abandoning sterile pacemaker and defibrillator leads

Nonfunctional or recalled cardiac implantable electronic device leads can be revised with either lead extraction (LE) or lead capping (LC). Factors that influence this decision and comparative outcomes of these strategies are unclear. We reviewed data from our institution to identify patients who received LE (n = 296) or LC (n = 192) from 2006 to 2012. Patients with infectious indications for lead removal were excluded. We compared unanticipated device-related procedures, defined as cardiac implantable electronic device procedures not for device upgrade or battery depletion, using a proportional hazards model adjusted for differences in baseline characteristics. Secondary outcomes were procedural complications, hospitalizations, and all-cause mortality. Patients who received LE were younger and more likely to have an operator with extraction experience (76% vs 26%, p <0.001). Leads removed by experienced extractors versus nonextractors had longer dwell times (4.2 ± 3.6 vs 0.9 ± 1.1 years, p <0.001). Over a median follow-up of 3.0 (interquartile range = 3.2) years, the adjusted risk of unanticipated device-related procedures was similar for LE versus LC (hazard ratio 1.04, 95% confidence interval 0.62 to 1.75). Complications, hospitalization rates, and mortality rates were also similar between the 2 groups. In conclusion, lead revision strategy is influenced by operator extraction experience and dwell time of leads. In our analysis, we found no difference in outcomes between the 2 strategies.