Usefulness of mechanical transvenous dilation and location of areas of adherence in patients undergoing coronary sinus lead extraction

Abstract Aims The rates of cardiac device-related infection have increased substantially over the past years. Transvenous lead extraction is the standard therapy for such cases. In some patients, however, the procedure cannot be completed through the transvenous route alone. A hybrid surgical and transvenous approach may provide the solution in such cases. Methods and results We present three cases who underwent hybird transvenous and surgical extraction for coronary sinus leads due to infection of CRT-D systems. One patient had an Attain Starfix lead implanted in the coronary sinus. The procedures were performed under local anaesthesia with continuous haemodynamic and transthoracic echocardiographic monitoring. We highlight the characteristics of the patients, the features of the devices, the technical difficulties, and the outcomes of the procedures. In all cases, the right atrial and right ventricular leads were extracted through the transvenous route. In one patient, they were extracted using regular stylets and manual traction, while in the other two patients, telescoping dilator sheaths (Cook), Tightrail hand-powered mechanical sheaths (Spectranetics), and/or Glidelight Excimer Laser sheaths (Spectranetics) were used. The coronary sinus lead could not be retrieved due to extensive fibrosis after utilizing locking stylets and mechanical dilator sheaths in all three cases, in addition to rotational mechanical sheaths and laser sheaths in one case, so the patients were referred to surgery. Two patients underwent left mini-thoracotomy and one patient underwent midline sternotomy to extract the remaining CS lead. The target vein was identified and ligated, then the fibrosis around the lead was dissected, this was followed by lead retrieval through the surgical incision. The patient who underwent sternotomy suffered from mediastinitis, which required reoperation and mediastinal lavage. There were no complications in the other two patients. All three patients were reimplanted with a new CRT-D device on the contralateral side after the resolution of infection. Conclusions A hybrid surgical and transvenous approach can be complementary in case the transvenous route alone fails to completely extract the coronary sinus lead. The transvenous approach can be used to free the proximal part of the lead, while the distal adhesions can be removed surgically, preferably though a limited thoracic incision.

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Primum atrial septal laceration following coronary sinus lead extraction

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez293 ◽

2019 ◽

Vol 21 (6) ◽

pp. 701-701

Author(s):

Mariateresa Librera ◽

Guido Carlomagno ◽

Claudia Calvanese ◽

Tommaso Lonobile ◽

Giuseppe De Martino

Keyword(s):

Coronary Sinus ◽

Lead Extraction ◽

Coronary Sinus Lead

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Abstract 11914: Coronary Sinus Lead Extraction_Laser Required

Circulation ◽

10.1161/circ.130.suppl_2.11914 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Erin A Fender ◽

Charles A Henrikson

Keyword(s):

Coronary Sinus ◽

Dwell Time ◽

Lead Extraction ◽

Success Rates ◽

Assisted Extraction ◽

Endovascular Approach ◽

Coronary Sinus Lead ◽

Average Lead ◽

Open Surgical Approach ◽

Manual Traction

Introduction: Studies of coronary sinus (CS) lead extraction have reported high success rates with manual traction, but largely included leads with dwell times less than 3 years. Our aim was to evaluate CS lead extractions of more chronic leads and establish if dwell time was correlated to complexity of extraction. Methods: This is a single center, retrospective review of 96 consecutive lead extraction procedures. A total of 14 CS leads were identified. Results: Of the 14 CS lead extractions, 13 were successful from an endovascular approach. Indications included 8 cases of endocarditis, 4 pocket infections, 1 dislodged lead and 1 malfunctioning lead. Six extractions were performed with manual traction, dwell time of these leads ranged from 5 months to 28 months, with an average implant time of 10.8 months. Eight extractions required use of a laser sheath (LS) to free the lead from adhesions. In no case was the LS used within the CS. The dwell time of these leads ranged from 45 months to 114 months, with an average lead age of 83.4 months. One LS case also required use of a rotating mechanical sheath. In one LS assisted extraction, the lead fragmented within the CS and could not be recovered endovascularly despite the use of multiple snares. This lead fragment was removed via an open surgical approach. Conclusion: CS leads require the use of advanced extraction tools in the majority of patients. All leads placed in the preceding 28 months were removed with simple manual traction, however all leads that were in place for more than 3 years required use of a LS. In contrast to prior reports, we found that coronary sinus leads posed the same procedural challenges as other cardiac leads and typically require advanced extraction tools.

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