Application of Intravascular Dissection Devices for Closed Chest Coronary Sinus Lead Extraction: An Interdisciplinary Approach

Clinical Predictors of Incomplete CS Lead Removal during Transvenous Lead Extraction in the Patients with Cardiac Resynchronization Therapy

BACKGROUND

Reports of coronary sinus (CS) lead removal include small studies with short implant durations. Procedural outcomes for mature CS leads removed with long duration implantation are unavailable.

OBJECTIVE

To examine the safety, efficacy, and clinical predictors for incomplete CS lead removal by Transvenous Lead Extraction (TLE) in a large, long implant duration cardiac resynchronization therapy (CRT) patient cohort.

METHODS

Consecutive patients with CRT devices in the Cleveland Clinic Prospective TLE Registry who had TLE between 2013 and 2022.

RESULTS

CS leads, n=231, implant duration = 6.1±4.0 years, removed from 226 patients were included, employing powered sheaths for 137 leads (59.3%). Complete CS lead success was achieved in 95.2% of leads (n=220) and in 95.6% of patients (n=216). Major complications occurred in 5 patients (2.2%). Patients who had the CS lead extracted 1st had significantly higher incomplete removal rates than when the other leads were 1st removed. Multivariable analysis showed that older CS lead age (OR 1.35, 95% CI 1.01-1.82; P = 0.03), and removing the CS lead 1st (OR 7.48, 95% CI 1.02-54.95; P = 0.045) were independent predictors of incomplete CS lead removal.

CONCLUSION

Complete and safe lead removal rate of long implant duration CS leads by TLE was 95%. However, CS lead age and the order that leads were extracted were the independent predictors of incomplete CS lead removal. Therefore, before the CS lead is extracted, physicians should first extract the leads from the other chambers and employ powered sheaths.

Hybrid transvenous and surgical approach for the extraction of coronary sinus leads: A case series

Background

Transvenous lead extraction is the standard therapy for cardiac device‐related infection. In some patients, however, a hybrid surgical and transvenous approach may be necessary.

Methods and Results

We present three cases who underwent transvenous lead extraction for an infected CRT‐D system. In all cases the CS lead could not be retrieved transvenously due to extensive fibrosis. The lead was successfully extracted through left minithoracotomy in two patients and midline sternotomy in one patient.

Conclusion

In cases where the coronary sinus lead shows severe fibrosis, a transvenous approach can be used to free the proximal part of the lead, while the distal adhesions can be removed surgically through a limited thoracic incision.

Transvenous extraction of permanent pacemaker and defibrillator leads: Reduced procedural complexity and higher procedural success rates in patients with infective versus noninfective indications

INTRODUCTION

Transvenous lead extraction (TLE) is critical in the long-term management of patients with cardiac implanted electronic devices (CIEDs). The aim of the study is to evaluate the outcomes of TLE and to investigate the impact of infection.

METHODS AND RESULTS

Data of patients undergoing extraction of permanent pacemaker and defibrillator leads during October 2014-September 2019 were prospectively analyzed. Overall, 242 consecutive patients (aged 71.0 ± 14.0 years, 31.4% female), underwent an equal number of TLE operations for the removal of 516 leads. Infection was the commonest indication (n = 201, 83.1%). Mean implant-to-extraction duration was 7.6 ± 5.4 years. Complete procedural success was recorded in 96.1%, and clinical procedural success was achieved in 97.1% of attempted lead extractions. Major complications occurred in two (0.8%) and minor complications in seven (2.9%) patients. Leads were removed exclusively by using locking stylets in 65.7% of the cases. In the subgroup of noninfective patients, advanced extraction tools were more frequently required compared to patients with CIED infections, to extract leads (success only with locking stylet: 55.8% vs. 67.8%, p = .032). In addition, patients without infection demonstrated lower complete procedural success rates (90.7% vs. 97.2%, p = .004), higher major complication rates (2.4% vs. 0.5%, p = .31) and longer procedural times (136 ± 13 vs. 111 ± 15 min, p = .001).

CONCLUSIONS

Our data demonstrate high procedural efficacy and safety and indicate that in patients with noninfective indications, the procedure is more demanding, thus supporting the hypothesis that leads infection dissolves and/or prohibits the formation of fibrotic adherences.

Safety and effectiveness of coronary sinus leads extraction - single high-volume centre experience

Introduction

Transvenous leads extraction (TLE) of permanently implanted coronary sinus (CS) leads is widely believed to present greater risks than the removal of other leads.

Aim

To assess the safety and efficacy of CS leads extraction based on large research material obtained by one operator performing procedures in two TLE centres.

Material and methods

We extracted 408 CS leads from 389 patients, and the results were compared to a control group of 2465 patients who underwent non-CS lead TLE procedures.

Results

There were no significant differences in the clinical success rate (97.9% vs. 98.0%) or the major complication rate (2.1% vs. 1.8%) between the CS and control group. CS lead destination (LV/LA pacing) and tip location (CS ostium/mid CS /CS tributaries) influenced the procedural and radiological success rates and procedural complexity but not the complications. CS lead extraction did not affect the necessity for a cardiosurgical intervention or presence of procedure-related death.

Conclusions

TLE of CS leads can be achieved with a high procedural success rate. The major complication rate is not higher than that seen in non-CS lead extraction patients. More than half of CS leads cannot be removed by simple traction and the use of mechanical sheaths may be necessary. The detachment of CS leads from connective tissue scars in the venous and atrial areas up to the CS ostium is generally sufficient for further removal of the lead using simple traction.

Neointimal fibrotic lead encapsulation - Clinical challenges and demands for implantable cardiac electronic devices

Every tenth patient with a cardiac pacemaker or implantable cardioverter-defibrillator implanted is expected to have at least one lead problem in his lifetime. However, transvenous leads are often difficult to remove due to thrombotic obstruction or extensive neointimal fibrotic ingrowth. Despite its clinical significance, knowledge on lead-induced vascular fibrosis and neointimal lead encapsulation is sparse. Although leadless pacemakers are already available, their clinical operating range is limited. Therefore, lead/tissue interactions must be further improved in order to improve lead removals in particular. The published data on the coherences and issues related to lead associated vascular fibrosis and neointimal lead encapsulation are reviewed and discussed in this paper.

Coronary Venous Lead Extraction

The increasing number of cardiac resynchronization therapy devices implanted, coupled with the increasing incidence of cardiac implantable electronic device infection, has led to a greater need for extraction of coronary venous pacing leads. The objectives of this study were to review the indications, techniques and published results of coronary venous lead extraction. In this study, we searched PubMed using the search terms "lead extraction," "coronary sinus," "coronary venous," "pacing," and "cardiac resynchronization therapy" for relevant papers. The reference lists of relevant articles were also searched, and personal experience was drawn upon. Published success rates and complications were found to be similar to those reported for non-coronary venous leads in experienced centers. However, reimplantation success differs and can be limited by vessel occlusion postextraction. The available active fixation coronary sinus lead (Attain Starfix™; Medtronic, MN, USA) is a particularly complex lead to extract, whereas limited data on the newer active fixation leads (Attain Stability™, Medtronic, MN, USA) suggest that they are less challenging to remove. The study concluded that coronary venous lead extraction presents unique challenges, especially reimplantation, that require special consideration and planning to overcome.

Coronary Sinus Lead Extraction

Expanded indications for cardiac resynchronization therapy and the increasing incidence of cardiac implantable electronic device infection have led to an increased need for coronary sinus (CS) lead extraction. The CS presents unique anatomical obstacles to successful lead extraction. Training and facility requirements for CS lead extraction should mirror those for other leads. Here we review the indications, technique, and results of CS lead extraction. Published success rates and complications are similar to those reported for other leads, although multiple techniques may be required. Re-implantation options may be limited, which should be incorporated into pre-procedural decision making.

Safety of transvenous lead extraction according to centre volume: a systematic review and meta-analysis

BACKGROUND

Transvenous lead extraction (TLE) is a complex invasive procedure and the experience of the operator and the team is a major determinant of procedural outcomes.

AIM

Because of very limited data available on minimum procedural volumes to enable training and ongoing competency for TLEs, we performed a meta-analysis aimed at assessing the outcomes of TLE in the centres with low, medium, and high volume of procedures.

METHODS

Of the 280 papers initially retrieved until February 2013, 66 observational studies met inclusion criteria and were included in at least one stratified meta-analysis: 17 were prospective studies; 47 had a retrospective design; and 2 were defined 'experience studies'. We included only articles published after the introduction of laser technique (year 1999). We divided the studies in low, medium, and high volume centres utilizing either the European Heart Rhythm Association (EHRA) or Lexicon classification criteria.

RESULTS

When meta-analyses were carried out separately for the studies with larger and smaller sample sizes, either using EHRA or Lexicon classification criteria, no clear differences emerged in the combined rate of major complications or intraoperative deaths. In contrast, both minor complications and mortality at 30 days decreased as centre volume increased.

CONCLUSIONS

In our meta-analysis of observational studies, patients who have been treated in higher volume centres have a lower probability of minor complications and death at 30 days regardless of the infection rate, length of lead duration, type of device, and type of extraction.