Elsevier

Heart Rhythm

Volume 18, Issue 8, August 2021, Pages 1272-1278
Heart Rhythm

Clinical
Devices
Transvenous lead extraction in 1000 patients guided by intraprocedural risk stratification without surgical backup

https://doi.org/10.1016/j.hrthm.2021.03.031Get rights and content

Background

Transvenous lead extraction (TLE) carries a significant risk of morbidity and mortality. Reliable preprocedural risk predictors to guide resource allocation and optimize procedural safety are lacking.

Objective

The aim of this study was to evaluate an intraprocedural approach to risk stratification during elective TLE procedures.

Methods

This is a single-center retrospective study of consecutive patients who underwent elective TLE of a pacemaker or implantable cardioverter-defibrillator lead for noninfectious indications. The risk of TLE is judged intraprocedurally only after an attempt is made to extract the target lead as long as high-risk extraction techniques are avoided. TLE was performed in a well-equipped electrophysiology laboratory with rescue strategies in place but in the absence of surgical staff.

Results

During the study period, 1000 patients were included in this analysis (527 female (52.7%); mean age 61.5 ± 10.2 years). TLE was attempted for 1362 leads, with a mean lead dwell time of 73 ± 43 months (median 70 months; interquartile range 12–180 months). TLE was successful in 914 patients, partially successful in 10, and failed in 76 patients. A laser sheath was required for extraction of 926 leads (68%). Only 1 patient developed intraprocedural cardiac tamponade requiring emergency pericardiocentesis. None of the patients developed hemothorax or required surgical intervention.

Conclusion

At experienced centers, intraprocedural risk stratification for TLE that avoids high-risk extraction techniques achieved successful TLE in the majority of patients and can potentially help optimize the balance between efficacy, safety, and efficiency in lead extraction.

Introduction

Transvenous lead extraction (TLE) has become an integral part of the long-term management of patients with cardiovascular implantable electronic devices (CIEDs). The TLE procedure is complex and carries a significant risk of life-threatening intraprocedural complications, namely, vascular laceration and cardiac avulsion, which typically require emergent surgical intervention.1, 2, 3 Several approaches to risk stratification have been proposed to identify patients at exceedingly high risk of procedural complications in whom backup surgery is necessary. However, while some schemes were shown to help identify a subset of patients whose extractions might be more difficult and complex, correlation with procedural outcome has been lacking. Therefore, TLE procedures have been considered a category of high-risk interventions, mandating the recruitment of vast resources, including the immediate availability of cardiothoracic surgical services.4,5

In this study, we describe a large series of consecutive patients undergoing TLE for noninfectious indications using an intraprocedural risk stratification approach to avoid catastrophic complications during TLE and reduce the need for surgical backup availability. This approach, by design, prefers lead extraction over lead abandonment whenever the extraction procedure could be performed safely without exposing the patient to unacceptably high-risk extraction techniques.

Section snippets

Study group

This is a single-center, single-operator, retrospective study of all consecutive patients who underwent elective TLE of a pacemaker or implantable cardioverter-defibrillator (ICD) lead at the Prairie Heart Institute between January 2008 and June 2020 without the availability of a backup surgical team. This approach of TLE was used in patients with noninfectious indications for extraction of atrial, ventricular, or coronary sinus pacemaker leads or single-coil ICD leads with a dwell time of <15

Demographic characteristics and indications for lead extraction

During the study period, 1000 patients were included in this analysis (52.7% female; mean age 61.5 ± 10.2 years; range 29–83 years). Demographic characteristics are listed in Table 1.

As shown in Table 2, a total of 1362 leads were extracted for an average of 1.4 leads per patient. The maximum number of leads extracted in a single patient was 4. The mean length of time since lead implantation was 73 ± 43 months (median 70 months; interquartile range 36–94 months). The most common indications for

Main findings

The main findings of this study are as follows: (1) laser/mechanical dissection at the SVC-RA junction was not necessary for successful extraction of the majority of leads in our selected study cohort; (2) the complication rates of TLE for noninfectious indications were extremely low when laser/mechanical dissection at the SVC-RA junction was avoided; (3) intraprocedural risk stratification during TLE can potentially reduce the need for the immediate availability of backup surgery; and (4) TLE

Conclusion

In the absence of reliable preprocedural risk predictors, identifying the small group of patients at exceedingly high risk of TLE procedural complications in whom the immediate availability of backup surgery is necessary remains challenging. In this study, the risk of TLE is judged intraprocedurally only after an attempt is made to extract the target lead as long as high-risk extraction techniques are avoided. This approach achieved successful TLE in the majority of patients, and none required

Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosures: The authors have no conflicts of interest to disclose.

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