High-Risk Lead Removal by Laser Extraction and Thoracotomy
High-Risk Lead Removal by Laser Extraction and Thoracotomy
Hybrid Lead Extraction for High-Risk Leads. Introduction: Transvenous pacemaker or implantable cardioverter defibrillator (ICD) lead extraction via mechanical or excimer laser sheath is typically safe and effective. Longer duration from implant, presence of large vegetations or thrombi, fractured leads, and prior failed extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Techniques developed for minimally invasive valve surgery were used in conjunction with laser extraction to refine a "hybrid" technique for lead extraction. We assessed the outcomes of high-risk lead extraction using this hybrid lead extraction technique.
Methods and Results: Retrospective assessment of clinical parameters and procedural outcomes in patients undergoing planned hybrid lead extraction from February 2008 to September 2012 was performed. We report 8 cases of hybrid lead extraction performed at our institution. We extracted 21 leads with average lead age of 13.8 years since implant. All leads were removed with complete clinical and radiographic success. There were no intraprocedure complications. One patient died of continued sepsis and 1 other had symptoms consistent with pulmonary embolism.
Conclusions: Hybrid lead extraction using this technique is a safe and effective approach for removal of high-risk chronic pacemaker or ICD leads. This method extends the range of approachable leads resulting in complete removal without median sternotomy. Hybrid lead extraction can be scheduled electively facilitating complete lead removal with a low complication rate and short postoperative recovery time, mitigating the risks inherent in midline sternotomy or emergent cardiac surgical rescue.
The number of implanted cardiac implanted electronic devices (CIEDs) has increased significantly over last 2 decades. Clinical trials showing evidence of improved survival with the use of CIEDs and new modality such as biventricular pacing have driven the increase in the number of implants. CIEDs may require extraction for a variety of indications, including infection, lead malfunction, or venous occlusion. There has been a disproportionate rise in the number of device infections compared to the increase in device implant rate. Since October 2007, Two major advisories on widely used implantable cardioverter defibrillator (ICD) leads have exposed a large patient population potentially requiring future ICD lead extraction. Transvenous lead extraction is the primary method of lead extraction and is successful in ~90–95% of patients.
Longer duration from implant (>10 years), presence of large vegetations or thrombi (>2 cm), fractured leads, and prior failed transvenous extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Surgical removal is often accomplished by midline sternotomy or the traditional "transatrial" approach pioneered by Byrd. We have adopted techniques commonly used for minimally invasive valve surgery, in conjunction with a transvenous laser sheath approach, to define a minimally invasive "hybrid" extraction approach for high-risk lead extraction. We describe our single-center experience with this novel approach.
Abstract and Introduction
Abstract
Hybrid Lead Extraction for High-Risk Leads. Introduction: Transvenous pacemaker or implantable cardioverter defibrillator (ICD) lead extraction via mechanical or excimer laser sheath is typically safe and effective. Longer duration from implant, presence of large vegetations or thrombi, fractured leads, and prior failed extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Techniques developed for minimally invasive valve surgery were used in conjunction with laser extraction to refine a "hybrid" technique for lead extraction. We assessed the outcomes of high-risk lead extraction using this hybrid lead extraction technique.
Methods and Results: Retrospective assessment of clinical parameters and procedural outcomes in patients undergoing planned hybrid lead extraction from February 2008 to September 2012 was performed. We report 8 cases of hybrid lead extraction performed at our institution. We extracted 21 leads with average lead age of 13.8 years since implant. All leads were removed with complete clinical and radiographic success. There were no intraprocedure complications. One patient died of continued sepsis and 1 other had symptoms consistent with pulmonary embolism.
Conclusions: Hybrid lead extraction using this technique is a safe and effective approach for removal of high-risk chronic pacemaker or ICD leads. This method extends the range of approachable leads resulting in complete removal without median sternotomy. Hybrid lead extraction can be scheduled electively facilitating complete lead removal with a low complication rate and short postoperative recovery time, mitigating the risks inherent in midline sternotomy or emergent cardiac surgical rescue.
Introduction
The number of implanted cardiac implanted electronic devices (CIEDs) has increased significantly over last 2 decades. Clinical trials showing evidence of improved survival with the use of CIEDs and new modality such as biventricular pacing have driven the increase in the number of implants. CIEDs may require extraction for a variety of indications, including infection, lead malfunction, or venous occlusion. There has been a disproportionate rise in the number of device infections compared to the increase in device implant rate. Since October 2007, Two major advisories on widely used implantable cardioverter defibrillator (ICD) leads have exposed a large patient population potentially requiring future ICD lead extraction. Transvenous lead extraction is the primary method of lead extraction and is successful in ~90–95% of patients.
Longer duration from implant (>10 years), presence of large vegetations or thrombi (>2 cm), fractured leads, and prior failed transvenous extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Surgical removal is often accomplished by midline sternotomy or the traditional "transatrial" approach pioneered by Byrd. We have adopted techniques commonly used for minimally invasive valve surgery, in conjunction with a transvenous laser sheath approach, to define a minimally invasive "hybrid" extraction approach for high-risk lead extraction. We describe our single-center experience with this novel approach.
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