The role of cardiac surgery in transvenous lead extraction (TLE) – experience from high volume center and 3207 procedures

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Tulecki ◽  
M Czajkowski ◽  
S Targonska ◽  
K Tomkow ◽  
D Nowosielecka ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Tricuspid Valve ◽  
Surgical Intervention ◽  
Clinical Success ◽  
Left Ventricular ◽  
Lead Extraction ◽  
Icd Leads ◽  
Ventricular Lead ◽  
Cardiac Surgeon

Abstract Background The guidelines suggest close co-operation between TLE operating team and cardiac surgery and its key role in the management of life-threatening complications remains unquestionable. But the role of cardiac surgeon seems to be much more extended. Purpose We have analysed the role of cardiac surgery in treatment of patients undergoing TLE procedures. Methods Using standard non-powered mechanical systems we have extracted ingrown PM/ICD leads from 3207 pts (38,7% female, average age 65,7-y) during the last 14 years. Non-infectious TLE indications were in 66,4% of patients. 46% had PM DDD system, 19% PM SSI, 22% ICD, 9% CRT, 4% other systems. In 12% of patients abandoned leads were found. 8% of patients had one lead, 54% - two, 15% - three and 4% - 4–6 leads in the heart. An average dwell time of all leads was 91,5 mth. The lead entry side was left in 96% of patients, right in 3% and both – 4%. Results Procedural success 96,1%, clinical success - 97,8%, procedure-related death 0,2%. Major complications appeared in 1,9% (cardiac tamponade 1,2%, haemothorax 0,2%, tricuspid valve damage 0,3%, stroke, pulmonary embolism <1%). Conclusions Rescue cardiac surgery (for severe haemorrhagic complications) is still the most frequent reason of surgical intervention (1,1%). The second area of co-operation includes supplementary cardiac surgery after (incomplete) TLE (0,8%). The third one is connected with reconstruction or replacement of tricuspid valve, which can be affected by ingrown lead or damaged during TLE procedure (0,5%). Implantation of the complete epicardial system during any surgical intervention (rescue or delayed) should be considered as a supplementation of the operation (0,65%). Some of patients after TLE need implantation of epicardial leads for permanent epicardial pacing (0,6%) and some only left ventricular lead to rebuild permanent cardiac resynchronisation (0,5%). The single experience of large TLE centre indicates the necessity of close co-operation with cardiac surgeon, whose role seems to be more comprehensive than a surgical stand-by itself. Table 1 Funding Acknowledgement Type of funding source: None

scholarly journals 655 The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Federico Migliore ◽  
Vincenzo Tarzia ◽  
Pietro Bernardo Dall’Aglio ◽  
Pasquale Valerio Falzone ◽  
Sabino Iliceto ◽  
...  
Keyword(s):  
Success Rate ◽  
Clinical Success ◽  
Hybrid Approach ◽  
Vena Cava ◽  
Clinical Success Rate ◽  
Left Ventricular ◽  
Lead Extraction ◽  
Lead Removal ◽  
Team Approach ◽  
Cardiac Surgeon

Abstract Aims Recent studies have shown that evolution RL bidirectional rotational mechanical sheath (Cook Medical, USA) is an effective and safe technique for transvenous lead extraction (TLE). We reported our experience with the bidirectional rotational mechanical tools using a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration. Methods and results The study population comprised 84 patients (77% male; mean age 65 ± 18 years) undergoing TLE. After multidisciplinary evaluation, a combined procedure was considered. The main indication for TLE was infection in 54 cases (64%).Overall, 152 leads were extracted with a mean implant duration of 94 ± 63 months (range: 6–421). Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6% (77/84), 97.6% (82/84), and 98.6% (150/152), respectively. Eighteen combined procedures were performed in 12 patients (14%), such as ‘hybrid approach’ (n = 2) or TLE concomitant to: (i) transcatheter aspiration procedure for large vegetation (n = 8); (ii) left ventricular assistance device implantation as bridge to cardiac transplantation (n = 1); (iii) permanent pacing with epicardial leads (n = 6); and (iv) tricuspid valve replacement (n = 1).One major complication (1.2%) and 11 (13%) minor complications were encountered. No injury to the superior vena cava occurred and no procedure-related deaths were reported. During a mean time follow-up of 21 ± 18 months, 17 patients (20%) died. They were more often diabetics (P = 0.02), and they underwent TLE more often for infection (P = 0.004). Conclusions Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators.

scholarly journals A Case of Neonatal Marfan Syndrome: A Management Conundrum and the Role of a Multidisciplinary Team

2017 ◽  
Vol 2017 ◽  
pp. 1-6 ◽  
Author(s):  
Elliott J. Carande ◽  
Samuel J. Bilton ◽  
Satish Adwani
Keyword(s):  
Marfan Syndrome ◽  
Surgical Intervention ◽  
Rare Condition ◽  
Mitral Valve Regurgitation ◽  
Left Ventricular ◽  
Cardiac Complications ◽  
Chromosome 15 ◽  
Fibrillin 1 ◽  
Neonatal Marfan Syndrome

Neonatal Marfan syndrome (nMFS) is a rare condition with a poor prognosis. It is genotypically and phenotypically distinct from the typical Marfan syndrome and carries a poorer prognosis. This case report describes the progression of a 14-month-old girl diagnosed with nMFS at 5 months of age. Her diagnosis followed the identification of a fibrillin-1 mutation (FBN1gene, exon 26, chromosome 15), which is a common locus of nMFS. This patient developed severe cardiac complications resulting in congestive cardiac failure in early life and required major cardiac surgery. Since surgical intervention, our patient is still reliant on a degree of ventilator support, but the patient has gained weight and echocardiography has demonstrated improved left ventricular function and improved tricuspid and mitral valve regurgitation. Therefore, we argue the importance of a cautious multidisciplinary approach to early surgical intervention in cases of nMFS.

Abstract 11945: Indications and Outcomes Following Transvenous Extraction of ICD versus Pacemaker Leads

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Eric W Black-Maier ◽  
Sean D Pokorney ◽  
Robert K Lewis ◽  
Alexander Christian ◽  
Ruth A Greenfield ◽  
...  
Keyword(s):  
Adverse Events ◽  
Dwell Time ◽  
Clinical Success ◽  
Lead Extraction ◽  
Index Hospitalization ◽  
Lead Failure ◽  
Icd Leads ◽  
Pacemaker Leads ◽  
Pacing Lead ◽  
Major Adverse Events

Introduction: Percutaneous transvenous lead extraction of cardiovascular implantable electronic devices (CIEDs) is increasingly common. Although ICD leads are widely considered to be more difficult to extract than pacemaker leads, there are few direct comparisons. Methods/Results: Using a cohort of 368 consecutive patients undergoing lead extraction (dwell time >1 year) between 2005-2012, we compared baseline characteristics/outcomes in extractions involving pacing versus ICD leads. We defined major adverse events (MAE) as any events/complications that required procedural intervention, transfusion, or that resulted in death or serious harm during index hospitalization. Median age was 60.6 yrs and 29.6% were women. There were 136 (37%) pacing lead extractions and 232 (63%) ICD lead extractions. Pacing leads had a longer dwell time (6.14 yrs [IQR 1.2-10.9 ] versus 4.4 yrs [IQR 1.1-6.4], p<0.001) and higher median LVEF (55% [IQR 35-55] vs. 30% [IQR 20-40], p<0.001) compared with ICD lead patients. Indications for pacing and ICD lead extractions included sepsis/endocarditis (21.3% vs. 24.6%, p=0.48), pocket infection (40.4% vs. 34.9%, p=0.29), and lead failure (15.4% vs. 38.8%, p<0.001). There were no significant differences between pacing and ICD lead extractions in median fluoroscopy time (5.5 vs. 8.5 minutes, p=0.86) or femoral bailout rate (4.4% vs. 5.2%, p=0.73). There were similar rates of all-cause MAE during index hospitalization (5.1% vs. 5.6%), death (2.2% vs 3.2%) and clinical success (97.0% vs. 97.0%, p=0.55) in pacemaker and ICD extractions, respectively. Conclusions: ICD leads are more commonly extracted relative to pacemaker leads, and this difference is driven by larger numbers of lead failure within ICD leads. Despite much longer dwell times, major adverse events were similar in pacing lead cases compared with ICD extractions.

Abstract 17362: A Multidisciplinary Heart Team Approach to High Risk Transvenous Pacemaker and Defibrillator Lead Extraction Improves Mortality

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Ryan G Aleong ◽  
Matthew Zipse ◽  
Christine Tompkins ◽  
Tamas Seres ◽  
David Fullerton ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
High Risk ◽  
Operating Room ◽  
Cardiac Electrophysiology ◽  
Lead Extraction ◽  
Team Approach ◽  
Heart Team ◽  
Hybrid Operating Room ◽  
Icd Leads ◽  
The Creation

Introduction: There is a risk of serious complications with high-risk lead extraction (LE) that may increase mortality. Current guidelines do not provide definitive guidance on collaborative involvement of cardiac surgery as compared to other procedures such as TAVR procedures. We report a single center experience of the benefits of a collaborative approach between cardiac surgery and cardiac electrophysiology (EP). Hypothesis: MDHT will improve outcomes in LE Methods: High risk lead extractions had dwell times of at least 4 years for pacemaker leads and 2 years for ICD leads. A multidisciplinary heart team (MDHT) was created based on the TAVR model that includes a combined lead management clinic and a monthly multidisciplinary conference. Prior to MDHT creation, high risk lead extractions were performed either in the hybrid operating room (OR) and cardiology procedure lab with a surgeon on call as needed. After the MDHT creation all cases were performed in the hybrid operating room by a cardiac surgeon, cardiac anesthesiologist and EP together with an interventional radiologist readily available. Results: Prior to MDHT, 169 patients underwent 344 leads extractions. There were six major procedural complications (3.6%) that included 2 procedural deaths (1.2%) during that period (SVC tear, Tricuspid valve avulsion). Following the creation of MDHT, there have been 47 cases performed with 85 leads extracted. There have been two complications requiring surgical repair (one SVC laceration, one RV laceration), which were surgically repaired. With the creation of a MDHT, the rate of major complications was unchanged (Pre vs. Post MDHT 3.6% vs. 4.3%) but there was a lower mortality rate (Pre vs. Post MDHT 1.2% vs. 0%). Conclusions: High risk lead extraction had a fixed complication rate at our institution however a MDHT decreased mortality. A structured multidisciplinary approach, involving EP and cardiac surgery, decreased mortality in a medium sized lead extraction center and should be considered at all centers.

Abstract 15655: Safety and Efficacy of Subclavian Fibroplasty in Patients With Prior Left Ventricular Lead Implant Failure

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
MALIK SHEHADEH ◽  
Nebu Alexander ◽  
Cyrus Hadadi ◽  
John Costello ◽  
Vijaywant Brar ◽  
...  
Keyword(s):  
Fibrous Tissue ◽  
Balloon Dilation ◽  
Vascular Complications ◽  
High Volume ◽  
Left Ventricular ◽  
Implant Failure ◽  
Distal Embolization ◽  
Interventional Techniques ◽  
Ventricular Lead

Introduction: Fibrous subclavian vein obstruction (SVO) is a common primary cause of left ventricular (LV) lead implant failure. Such obstruction might be apparent or unrecognized. Balloon dilation of the aggressive fibrosis that develops in response to chronic leads (fibroplasty) can be employed safely to achieve a successful implant. Hypothesis: To describe the experience of high-volume referral center with balloon dilation of fibrous tissue in patients with prior LV lead implant failure. Methods: We evaluated the role of balloon dilation in 187 patients referred to our institute because of prior LV lead implant failure between June 2017 and November 2019. Results: Of the 187 patients, 35 (19%) had apparent SVO as the primary explanation for implant failure. In 152 (81%), SVO was not recognized as contributing to implant failure. In 32 of 35 with apparent SVO (91.4%), it was possible to cross the obstruction and perform fibroplasty successfully. Three cases (8.6%) failed due to inability to advance a wire through the obstruction, none had existing leads to follow. In 33 of 152 (22%) cases without recognized SVO, fibroplasty of the subclavian was required, in addition to another interventional techniques, for successful implantation. There were no major or minor vascular complications related to fibroplasty. There was no distal embolization and no damage to the existing leads. Conclusions: In the setting of chronic leads, apparent SVO is commonly recognized as a cause of LV lead implant failure. However, 22% of prior LV lead implant failures without obvious obstruction also required fibroplasty (in addition to another interventional techniques) for success. In conclusion, subclavian fibroplasty is essential for successful implantation in patients with prior LV lead implant failure with and without obvious obstruction and can be safely performed by the implanting physician.

Predictors of success and complications in laser lead extraction

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
T Madej ◽  
K Matschke ◽  
M Knaut
Keyword(s):  
Adverse Events ◽  
Electronic Device ◽  
Clinical Success ◽  
Multivariable Analysis ◽  
Lead Extraction ◽  
Predictors Of Success ◽  
Funding Sources ◽  
Icd Leads ◽  
Short Term Mortality ◽  
Major Adverse Events

Abstract Funding Acknowledgements Type of funding sources: None. Background Extraction of cardiac implantable electronic device (CIED) leads using excimer laser is in use since &gt; 20 years, but the predictors of success, all-cause complications and mortality are not yet sufficiently statistically evaluated.  Method All consecutive laser extractions performed at our institution between September 2011 and March 2020 with lead age &gt; 12 months were included and retrospectively analysed. Results 792 leads (mean age 75 months) were extracted during 335 procedures. The indication for extraction was pocket infection in 59%, CIED endocarditis in 25%, lead dysfunction or upgrade in 14% and others in 2%. 94.6% of leads were extracted complete, 4.2% partial (&lt; 4 cm rest) and the extraction failed in 1.3% of the leads (retention of ≥ 4 cm rest). Multivariable analysis identified lead age &gt; 7.5 years (odds ratio [OR] 6.5; p = 0.0281), broken leads (OR 28.0; p = 0.0009) and implantable cardioverter-defibrillator (ICD) leads (OR 6.5; p = 0.0010) as independent predictors of failed extraction. CIED-endocarditis was independently associated with complete extraction (OR 3.3; p = 0.0218). Complete procedural success or clinical success was achieved in 330 of 335 procedures (98.6%). The lead extraction failed in five cases (1.5%). Major procedure-associated adverse events (injuries of the great vessels or heart) occurred in four cases (1.2%). Two patients died perioperatively (0.6%). Minor complications occurred in 13 cases (3.9%). Major adverse events (MAE) causally not related to the procedure occurred in 18 (5.4%) of the patients. The most frequent MAE was postoperative aggravation of the sepsis (10 patients; 3.0%).  Independent predictors of major adverse events were CIED-endocarditis (OR 6.0; p = 0.0175), preoperative C-reactive-protein (CRP) &gt; 35 mg/l (OR 3.8; p = 0.0412) and body mass index (BMI) ≥ 25 kg/m2 (OR 5.0; p = 0.0489). Ten patients (3%) died during the hospital stay.  CIED-endocarditis with preoperative CRP &gt; 35 mg/l was independently associated with hospital mortality in multivariable analysis (OR 10.7; p = 0.0020). The Kaplan-Meyer analysis of 30-day mortality showed a significantly worse survival of patients with endocarditis (Log-Rank p = 0.0102). Conclusion Leads &gt; 7.5 years, broken leads and ICD leads are independent predictors of failed extraction. CIED endocarditis, CRP &gt; 35 and BMI ≥ 25 are associated with MAE. CIED endocarditis is related to higher short-term mortality despite successful lead extraction. Abstract Figure. Predictors of major adverse events

P3139Transvenous lead extraction: lead age threshold to predict the success of the procedure

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Giannotti Santoro ◽  
L Segreti ◽  
F Fiorentini ◽  
G Bernini ◽  
V Barletta ◽  
...  
Keyword(s):  
Predictive Value ◽  
Dwell Time ◽  
Clinical Success ◽  
Effective Procedure ◽  
Lead Extraction ◽  
Youden Index ◽  
Operating Characteristics ◽  
Roc Curve Analysis ◽  
Dwelling Time ◽  
Icd Leads

Abstract Introduction Transvenous lead extraction is a safe and effective procedure. The dwell time of the leads, with other factors, is associated with poor outcome of the procedure. However, a precise estimation of the success of the procedure is not available. Purpose The aim of this study is to identify a lead's age threshold able to predict the success of the transvenous lead extraction (TLE) procedure. Methods All patients who underwent TLE in our center from January 2009 to December 2017 were retrospectively analyzed. The primary endpoint was the clinical success of the procedure. The optimal cut-off threshold was determined by the analysis of Receiver-Operating Characteristics (ROC) curves, using the Youden index. Results We analyzed 1210 consecutive patients that required transvenous removal of 2343 leads (686 ICD leads, 1657 pacemaker leads, 322 coronary sinus leads). Clinical success was achieved in 1168 patients (96.5%). Dwelling time median of the oldest lead for a patient was 66 months (interquartile range 27.0–115.0). The oldest lead completely removed was 32 years old. ROC curve analysis showed a dwell time threshold of 107 months – 8,92 years - for clinical success (Positive Predictive Value: 99.5%; Negative Predictive Value: 7.8%) and the area under the curve (AUC) was 0.879. Comparison of ROC for dwelling time and the 0.5 curve was assessed as statistically significative (p<0.0001). Conclusions Transvenous lead extraction is an effective procedure. The best cut-off threshold to predict a very high clinical success is 107 months.

scholarly journals Chest Pain Associated with Moderator Band Pacing

2014 ◽  
Vol 41 (5) ◽  
pp. 551-553 ◽  
Author(s):  
Anil K. Goli ◽  
Karoly Kaszala ◽  
Mohammed N. Osman ◽  
John Lucke ◽  
Roger Carrillo
Keyword(s):  
Chest Pain ◽  
Right Ventricular ◽  
Implantable Cardioverter Defibrillator ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Lead Extraction ◽  
Cardioverter Defibrillator ◽  
Moderator Band ◽  
Ventricular Lead ◽  
Defibrillator Lead

A 65-year-old man was evaluated for chronic chest pain that had been present for 8 years after placement of a dual-chamber implantable cardioverter-defibrillator to treat inducible ventricular tachycardia. Previous coronary angiography had revealed nonobstructive coronary artery disease and a left ventricular ejection fraction of 0.45 to 0.50, consistent with mild idiopathic nonischemic cardiomyopathy. Evaluation with chest radiography and transthoracic echocardiography showed the implantable cardioverter-defibrillator lead to be embedded within the right ventricle at the moderator band, which had mild calcification. Treatment included extraction of the dual-coil lead and placement of a new single-coil right ventricular lead at the mid septum. The patient had complete relief of symptoms after the procedure. This case shows that chest pain can be associated with the placement of a right ventricular implantable cardioverter-defibrillator lead in the moderator band and that symptomatic relief can occur after percutaneous lead extraction and the implantation of a new right ventricular lead to the mid septal region.

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