Contemporary Pacemaker and ICD Lead Management
Contemporary Pacemaker and ICD Lead Management
The status of lead extraction as part of a cardiac device management practice has dramatically changed over the last three decades. The major advances have involved the use of energy sources (laser or radiofrequency energy) to facilitate lead removal from the implant site (right or left subclavian venous systems). Major challenges, however, remain. They are discussed below.
At present, there are no clear data on how best to manage redundant leads. Thus, when a patient undergoes an upgrade from a pacing system to a defibrillator, should the existing ventricular pacing lead be removed electively? While there is consensus in certain situations (e.g., younger patients with multiple redundant leads) there is no clear knowledge to guide management of other situations such as in older patients and the presence of only one redundant lead.
Lead extraction, although safe in experienced hands, remains a high-risk procedure, especially with lower volume centers and operators. Should all procedures be performed in the surgical operating room? Should multiple operators or advanced imaging be needed in all extraction cases? Contemporary practice, especially for the new trainee starting in the field of extraction, remains daunting in terms of avoiding complications and a significant need for simulation tools and simplification of the procedure and nonsurgical techniques to manage complications (balloon occlusion, covered stents, and so on) remains an important need.
There have been major improvements that have positively affected present practice in educating operators on the best techniques for lead extraction. These include the written literature as well as a variety of symposia that target new operators, including ex vivo simulation, centers with direct supervision and guidance. A need, however, continues to exist for a reliable and useable model for teaching and practicing complex extraction techniques, including laser extraction, radiofrequency extraction and femoral extraction.
Expert Commentary
The status of lead extraction as part of a cardiac device management practice has dramatically changed over the last three decades. The major advances have involved the use of energy sources (laser or radiofrequency energy) to facilitate lead removal from the implant site (right or left subclavian venous systems). Major challenges, however, remain. They are discussed below.
At present, there are no clear data on how best to manage redundant leads. Thus, when a patient undergoes an upgrade from a pacing system to a defibrillator, should the existing ventricular pacing lead be removed electively? While there is consensus in certain situations (e.g., younger patients with multiple redundant leads) there is no clear knowledge to guide management of other situations such as in older patients and the presence of only one redundant lead.
Lead extraction, although safe in experienced hands, remains a high-risk procedure, especially with lower volume centers and operators. Should all procedures be performed in the surgical operating room? Should multiple operators or advanced imaging be needed in all extraction cases? Contemporary practice, especially for the new trainee starting in the field of extraction, remains daunting in terms of avoiding complications and a significant need for simulation tools and simplification of the procedure and nonsurgical techniques to manage complications (balloon occlusion, covered stents, and so on) remains an important need.
There have been major improvements that have positively affected present practice in educating operators on the best techniques for lead extraction. These include the written literature as well as a variety of symposia that target new operators, including ex vivo simulation, centers with direct supervision and guidance. A need, however, continues to exist for a reliable and useable model for teaching and practicing complex extraction techniques, including laser extraction, radiofrequency extraction and femoral extraction.
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