Lead extractions

Dr. RemesCardiac SurgeonBHCNovember 2013

Byrd classifcation: Mandatory, Necessary, Discretionary

2000 ACC: Guidelines for Indication

HRS Lead Extraction Consensus 2009

Class I, class IIa, class IIb, Class IIILevel of evidence A, B, C

Transvenous Lead Extraction: Heart Rhythm Society Expert Consensus on Facilities, Training, Indications, and Patient Management.This document was endorsed by the American Heart Association (AHA).Bruce L. Wilkoff, MD, FHRS,* Charles J. Love, MD, FHRS,† Charles L. Byrd, MD,‡Maria Grazia Bongiorni, MD, …

PM lead extraction: History

PM lead extraction: IndicationOverview

InfectionChronic pain

Thrombosis – venous stenosis

Non functional leadsFunctional leads

PM lead extraction: IndicationInfection: Class I (Level B)

• Device infection:Valve endocarditis, lead

infection, sepsis

• Pocket infection: Erosion, chronic drainage. Without clinical lead infection

• Valvular infection: Without lead or device infection

• Occult gram+ bacteremia

Removal is recommended

PM lead extraction: IndicationInfection: Bacteremia

• Class I (B): gram+ bacteremia• Class IIa (B): gram- bacteremia

PM lead extraction: IndicationInfection: Class III (Level C)

Removal is not indicated

Superficial incisional infection, without involvement of the device or leads

PM lead extraction: IndicationChronic pain: Class IIa (Level B)

Removal is reasonable:

If there is no acceptable surgical alternative.

PM lead extraction: IndicationThrombosis: Class I (Level c)

Removal is recommended:In patients with clinically significant

thromboembolic events associated with a thrombus on a lead.

PM lead extraction: IndicationVenous stenosis: Class IIa (Level c)

Removal is reasonable:

In patients with ipsilateral venous occlusion, requiring placement of an additional lead, when there is no contra indication for using the contralateral side.

PM lead extraction: IndicationFunctional lead: Class I (Level B)

Removal is recomended:• Live threatening arrhythmias• Immediate threat if left in

place• Leads that interfere with

operation of the device• Leads that interfere with a

treatment of malignancy

PM lead extraction: IndicationFunctional lead: Class IIb (Level B)

Removal may be considered:In patients with leads that are

functional but not being used. Ex: RV pacing lead after upgrade to ICD

PM lead extraction: IndicationNon Functional lead: Class I (Level B)

Removal is recomended:• Live threatening arrhythmias• Immediate threat if left in

place• Leads that interfere with

operation of the device• Leads that interfere with a

treatment of malignancy

PM lead extraction: IndicationMulti lead: Class IIa (B)

Removal is reasonable:If a new device needs 4 leads

on one side or 5 leads through the VCS.

PM lead extraction: IndicationNon Functional lead: Class IIb (C)

Removal may be considered:

At the time of CID, if contra-indications of removal are absent.

PM lead extraction:Contraindications

• Life expectancy less than one year. • Patient not suitable candidate for

sternotomy.• Presence of calcifications on RX in

de VCS or RA• If there is a anomalous placement of

leads through other structures than normal venous and cardiac structures (sublavian art, aorta, systemic atrium/ventricle).

Lead removal techniques

• Direct manual traction. With/Without locking stylet

• Telescoping sheaths (counterpressure)

• Rotational cutting blade sheath.

• Excimer laser sheaths• Surgical removal

Lead removal techniques

• Direct manual traction. With/Without locking stylet.

Direct manual traction:

Lead removal techniquesTelescoping sheaths: Counterpressure

Lead removal techniquesRotational cutting blade sheath:

Lead removal techniquesExcimer Laser:

Lead removal techniquesSurgical removal:

Patient management

• Preoperative management• Intra operative management• Postoperative management

Preoperative management

• Physical examination (infection & thrombosis)

• Previous indication for device implantation.

• Duration of implantation• Lead number – Lead location• Lead type – Lead fixation

machanism• Current medications

(ATB&anticoagulants)

• Cardiac rhythm: PM dependent?

Preoperative management

• Chest X ray (AP&LL)• Laboratory tests• Echocardiography• Venography

Intraoperative management

• General anesthesia• ECG monitoring• O2 monitoring• Arterial line• Large periferal infusion line• Draping: bilat fem&jug, bilat

groin.• Trans Oesophageal

Echocardiography• High quality fluoroscopy

Intraoperative management

• External defib pads• Temporary PM (Left fem vein)

• ICD mode switch off• Blood products availability• Pericardiocentesis tray• Surgical sternotomy

equipment.

Intraoperative managementTools

• Locking stylets.• Polypropylene Sheaths.• Evolution extraction• High quality fluoroscopy.• Additional material: (lasso

catheter, steerable material).

• Femoral working station

Postoperative management

• Temperature monitoring• ECG monitoring• Blood pressure monitoring• Blood exams & cultures• TTE evaluation• Adapted medical treatment

Procedure succes Complications:

• Pericardial effusion without pericardiocentesis

• Hemothorax not requiring drainage• Hematoma requiring revision• Arm swelling/thrombosis• Migrated lead fragments without sequelae• Blood transfusion

Minor complications

Procedure succes Complications:

• Vessel laceration• Cardiac lesion• Cardiac tamponade• Stroke• Infection of a previously non-infected area• Traumatic tricuspid regurgitation (6,7%)• Embolisation of thrombus or vegetation• Death (<1%)

Major complications

Procedure succes

Risk factor for a complication:

Complications:

• Younger age• Longer implantation time• Female sex• Presence of calcification• Multiple leads• ICD leads (Double > single coil)• Passive fixation

Procedure succes

Leads / pts Complete removalByrd 2002 2561 / 1684 90%LExlCon 2010 2405 / 1449 96,5%de Bie 2012 445 85%

Completeness of lead removal:

Procedure succes

Center Technique Pts Leads Clin Major Mortality success compl

Byrd 99 Mechanical 2338 3540 98% 1,4%Byrd 01 RF sheath 265 542 99,4% 2,6%Neuzil 07 RF sheath 60 84 99% 3,3%Wilkoff 07 Laser 1850 3238 99,4% 0,3%Bongiorni 08 Single sheath 1193 2062 99,7% 0,7% 0,3%Epstein 08 Laser 498 975 99,1% 0,4% 0Kennergren 09 Laser 647 1032 99,3% 0,9% 0Saba 08 Laser 212 456 98% 4,2% 0,4%LExlCon 09 Laser 1449 2405 97,7% 1,4% 1,8%Platou 09 Single sheath 420 692 97,6% 1,9% 0,4%

Literature overview:

Lead extractions

Dr. RemesCardiac SurgeonBHCNovember 2013