Predictors and outcomes of lead extraction requiring a bailout femoral approach: Data from 2 high-volume centers

Clinical effectiveness and safety of transvenous lead extraction of very old leads

BACKGROUND

Transvenous lead extraction (TLE) success and safety are heavily influenced by lead dwell time.

OBJECTIVE

In this study, we aim to compare the clinical effectiveness and safety of TLE between young and old leads.

METHODS

We retrospectively identified all TLE procedures at Emory Healthcare from 2007 to 2023. Baseline patients' characteristics and procedural details were collected. The cohort was categorized based on the oldest lead dwell time in each procedure. The very long dwell time (VLDT) group included all procedures with the oldest lead dwell time, ≥15 years, whereas the control group included all procedures with the oldest lead dwell time <15 years. TLE outcomes were compared between the 2 groups.

RESULTS

Of the 1717 TLE procedures, 114 procedures (6.6%) included leads with dwell times ≥15 years. Patients in the VLDT group were older and had a higher number of targeted leads; 57% of TLE in the VLDT group were for infectious indications. Lead extraction procedural and clinical success were significantly lower in the VLDT group compared with the control group (75% vs 95%, 83% vs 97%, P < .001, respectively). There was a trend toward a higher major complications rate in the VLDT group compared with the control group (3.5% vs 1.3%, P = .058).

CONCLUSION

TLE of VLDT leads has a lower procedural and clinical success and a higher complication rate than TLE of leads with a shorter dwell time. These results will allow electrophysiologists to quantify risks and benefits of abandoning leads at the time of lead revisions or upgrades.

Four-Stage Rocket technique: A novel strategy for lead extractions using laser sheaths from the femoral vein

INTRODUCTION

Transvenous lead extractions (TLEs) for cardiac implantable electronic device complications often encounter difficulties with strong adhesions to the myocardium or vessels. In this report, we introduce a novel "Four-Stage Rocket" technique for effective TLE in cases where conventional methods fail.

METHODS AND RESULTS

Two challenging cases where conventional TLE methods failed were treated using a combination of four devices: Needle's Eye Snare, Agilis NxT Steerable Introducer, GlideLight Laser sheath, and GORE® DrySeal Flex Introducer sheath, employed via the inferior vena cava. The "Four-Stage Rocket" technique successfully detached firmly adhered leads near the tricuspid valve annulus, where the traditional superior vena cava approach was inadequate.

CONCLUSION

The "Four-Stage Rocket" technique offers a potential alternative in complex TLE cases, aligning the laser direction with the adhesion detachment and reducing the tissue damage risk.

Safety and efficacy of combined dilation/stenting of venous abnormalities, including complete obstructions, during lead extractions in patients with congenital heart disease

INTRODUCTION

Management of transvenous leads in patients with congenital heart disease (CHD) can be complicated by venous obstructions and residual shunts. We present our experience performing concurrent lead extraction and dilation/stenting of venous pathways, including patients with complete venous obstruction.

METHODS

All cases of concurrent lead extraction and recanalization of vena cavae/baffles between 2017 and 2021 at Boston Children's Hospital were retrospectively included and reviewed for safety and efficacy.

RESULTS

Eight patients, 4 female, median 38.5 years of age (range 16.7-49 years) and 81.6 kg weight (range 41.3-97.8 kg) at time of procedure were included. All patients had CHD, a majority (n = 7) having transposition of the great arteries palliated via atrial switch. All leads were removed in their entirety, with most patients having two leads extracted (n = 7). Median lead dwell time was 13.8 years (range 3.6-35.3 years). Three patients had complete obstructions, three required stenting of their innominate veins and three required recanalization of their femoral vessels. Median procedure time was 9.8 h (range 5.4-12.8 h). Complications included blood transfusion (n = 2), arrhythmia (n = 3), pleural effusion (n = 1), and pressure ulcer (n = 1). There were no cardiac perforations, venous tears, or deaths.

CONCLUSION

Lead extraction along with dilation and stenting of venous anomalies, though long in duration, proved effective with minimal complications. This combined procedure can safely and effectively resolve complete obstructions secondary to transvenous leads.

Lead Management in Patients with Congenital Heart Disease

Pediatric patients with congenital heart disease present unique challenges when it comes to cardiac implantable electronic devices. Pacing strategy is often determined by patient size/weight and operator experience. Anatomic considerations, including residual shunts, anatomic obstructions and barriers, and abnormalities in the native conduction system, will affect the type of CIED implanted. Given the young age of patients, it is important to have an "eye on the future" when making pacemaker/defibrillator decisions, as one can expect several generator changes, lead revisions, and potential lead extractions during their lifetime.

Transvenous lead extraction: Experience of the Tandem approach

AIMS

Transvenous lead extraction (TLE) is important in the management of cardiac implantable electronic devices but carries risk. It is most commonly completed from the superior access, often with 'bail-out' support via the femoral approach. Superior and inferior access may be used in tandem, which has been proposed as an advance in safety and efficacy. The aim of this study is to evaluate the safety and efficacy of the Tandem approach.

METHOD

The 'Tandem' procedure entailed grasping of the targeted lead in the right atrium to provide countertraction as a rotational dissecting sheath was advanced over the lead from the subclavian access. Consecutive 'Tandem' procedures performed by a single operator between December 2020 and March 2023 in a single large-volume TLE centre were included and compared with the conventional superior approach (control) using 1:1 propensity score matching; patients were statistically matched for demographics.

RESULTS

The Tandem in comparison with the conventional approach extracted leads of much greater dwell time (148.9 ± 79 vs. 108.6 ± 77 months, P < 0.01) in a shorter procedure duration (96 ± 36 vs. 127 ± 67 min, P < 0.01) but requiring more fluoroscopy (16.4 ± 10.9 vs. 10.8 ± 14.9 min, P < 0.01). The Tandem and control groups had similar clinical (100% vs. 94.7%, P = 0.07) and complete (94.8% vs. 92.8%, P = 0.42) success, with comparable minor (4% vs. 6.7%, P = 0.72) and major (0% vs. 4%, P = 0.25) complications; procedural (0% vs. 1.3%, P = 1) and 30-day (1.3% vs. 4%, P = 0.62) mortality were also similar.

CONCLUSION

The Tandem procedure is as safe and effective as the conventional TLE. It can be applied to leads of a long dwell time with a potentially shorter procedure duration.

Transvenous Lead Extraction: Work in Progress

Cardiac implantable electronic devices are the cornerstone of cardiac rhythm management, with a significant number of implantations annually. A rising prevalence of cardiac implantable electronic devices coupled with widening indications for device removal has fuelled a demand for transvenous lead extraction (TLE). With advancement of tools and techniques, the safety and efficacy profile of TLE has significantly improved since its inception. Despite these advances, TLE continues to carry risk of significant complications, including a superior vena cava injury and mortality. However, innovative approaches to lead extraction, including the use of the jugular and femoral accesses, offers potential for further gains in safety and efficacy. In this review, the indications and risks of TLE are discussed while examining the evolution of this procedure from simple traction to advanced methodologies, which have contributed to a significant improvement in safety and efficacy.

Lead Extraction at a Pediatric/Congenital Heart Disease Center: The Importance of Patient Age at Implant

OBJECTIVES

This study sought to evaluate the safety and efficacy of transvenous lead extraction (TLE) at a single pediatric/congenital heart disease (CHD) center.

BACKGROUND

Data on TLE in pediatric and CHD patients are limited.

METHODS

Retrospective cohort study evaluating TLE from 2008 to 2019.

RESULTS

A total of 113 patients underwent TLE with 162 leads removed (including 38 high-voltage leads). Median age at lead implantation was 13 years (range 0.6-61.8 years), with a median age at extraction of 21.6 years (6.4-64.3 years). Median lead age was 7.2 years (1.0-35.3 years). Successful extraction occurred in 110 (97%) patients, 159 (98%) leads. Complex extraction was needed for 120 leads; 52 (44%) using laser alone, 27 (23%) mechanical sheath alone, and 21 (18%) using both. Femoral extraction was used for 19 (16%) leads. Risk factors for complex extraction were ≥2 leads extracted (odds ratio: 3.36; 95% confidence interval [CI]: 1.2-9.36; P = 0.021), lead within the right ventricle (odds ratio: 2.8; 95% CI: 1.2-6.5; P = 0.017), and a combination of younger patient age at implant and older lead age at extraction, with patients ≤12 years of age at implant and leads ≥7 years of age having an odds ratio: of 10.1 (95% CI: 2.21-45.9; P = 0.003). Major complications occurred in 5 (4.4%) of patients, with no mortality, but a high incidence of tricuspid valve injury.

CONCLUSIONS

TLE can be performed successfully and safely in a pediatric and CHD center. Patient age at lead implantation, not age at extraction, is an important predictor of needing a complex extraction, with younger patients at implant and older leads at extraction having the highest risk.

Predictors of the need for supportive femoral approach during transvenous extraction of pacemaker and defibrillator leads in Japanese patients

BACKGROUND

Studies on femoral approach during transvenous lead extraction (TLE) are limited.

METHODS

We retrospectively evaluated 75 patients undergoing TLE from September 2014 through November 2019 via supportive femoral approach (Femoral/Superior group; n = 22) and superior approach alone (Superior group; n = 53).

RESULTS

No significant between-group differences were observed regarding patients' baseline characteristics except for a higher incidence of access vein occlusion in the Femoral/Superior group (59.1% vs. 31.4%; P = .037). The Femoral/Superior group exhibited significantly longer dwell times of the oldest extracted lead (median: 13.4 years; interquartile range [IQR]: 8.8-21.2 years vs. median, 7.2 years; IQR: 3.7-10.8 years; P < .001) and a higher incidence of passive fixation ventricular pacemaker lead (81.8% vs. 39.6%; P = .001). Multivariate logistic analysis showed that access vein occlusion (odds ratio [OR]: 4.07, 95% confidence interval [CI]: 1.08-15.3; P < .001) and dwell time of the oldest extracted lead (per year) (OR: 1.22, 95% CI: 1.09-1.37; P = .038) were predictors of the need for supportive femoral approach. Receiver operating characteristic curve analysis revealed that 11.8 years from implant was the cutoff for the need for supportive femoral approach (sensitivity 68.2%, specificity of 81.1%, area under the curve 0.81).

CONCLUSIONS

Access vein occlusion and long dwell time of the oldest extracted lead predict a high probability of the need for supportive femoral approach. Supportive femoral approach may be necessary in patients with leads that are implanted for >11.8 years and whose access veins are occluded.

Transfemoral extraction of pacemaker and implantable cardioverter defibrillator leads using Needle's Eye Snare: a single-center experience of more than 900 leads

The femoral approach with the Needle's Eye Snare (NES) is often used for bailout after failure of the superior approach for transvenous lead extraction (TLE). The safety and efficacy of the NES as a first-line tool for TLE remain unclear. The medical records of patients who underwent TLE via the femoral approach utilizing the NES from May 2014 to June 2019 in Peking University People's Hospital were retrospectively reviewed. Nine hundred and eighty-five leads were extracted in 492 patients (369 men; mean age 72.8 ± 29.0 years). The median (range) number of leads extracted per patient was 2 (1-6). The mean indwelling time of all extracted leads was 112.6 ± 52.0 months. The complete procedure success rate, clinical success rate, and failure rate were 94.1% (463/492), 97.8% (481/492), and 1.1% (11/492), respectively. Major complications including death occurred in nine patients (1.9%), of whom eight developed cardiac tamponade. Among these eight patients, emergency pericardiocentesis followed by rescue surgical repair if necessary was successful in 6 (75.0%) and failed in 2 (25.0%). No significant differences were found in the clinical success rate or major complications rate between patients with pacemakers and implantable cardioverter defibrillators, or between patients with infected and uninfected leads. A femoral approach with the NES is safe and effective for TLE of both pacing and defibrillator leads and could be considered a first-line approach. Cardiac tamponade was the most frequent cardiovascular complication. A strategy of emergency pericardiocentesis followed by a rescue surgical approach seems to be reasonable technique to treat a cardiac tamponade.

Femoral extraction of transvenous leads and leadless pacemakers-A review of the data, tools, and procedural steps

Extraction of transvenous leads via the femoral route might be needed when extraction via the implant vein fails or when retained lead fragments exist. The skill set required for this procedure is unique as it relies on the ability to snare and the use of a variety of shelf tools. In this era of leadless pacing, this skill set might be called upon more frequently. In this article, we review the data, tools, and procedural steps of femoral lead extraction and retrieval/extraction of leadless pacemakers.

Role of cardiac pacing in congenital complete heart block

INTRODUCTION

Congenital complete heart block affects 1/15,000 live-born infants, predominantly due to atrioventricular nodal injury from maternal antibodies of mothers with systemic lupus erythermatosus or Sjogren's syndrome. The majority of these children will need a pacemaker implanted prior to becoming young adults. This article will review the various patient and technical factors that influence the type of pacemaker implanted, and the current literature on optimal pacing practices. Areas covered: A literature search was performed using PubMed, Embase and Web of Science. Data regarding epicardial versus transvenous implants, pacing-induced ventricular dysfunction, alternative pacing strategies (including biventricular pacing, left ventricular pacing, and His bundle pacing), and complications with pacemakers in the pediatric population were reviewed. Expert commentary: There are numerous pacing strategies available to children with congenital complete heart block. The risks and benefits of the initial implant should be weighed against the long-term issues inherent with a life-time of pacing.