Implications and Outcome of Permanent Coronary Sinus Lead Extraction and Reimplantation

Antidromic snare technique for re-implantation of a coronary sinus lead into the same cardiac vein after transvenous lead extraction: a case report

Background

After coronary sinus (CS) lead extraction in patients with cardiac resynchronization therapy (CRT), occlusion of the branch vessel from which CS lead was extracted is a major obstacle to re-implantation, particularly if that vessel is the only optimal vessel for resynchronization.

Case summary

A 75-year-old female who underwent CRT implantation 11 years prior presented with worsening dyspnoea, right ventricle-only pacing rhythm, and increased CS lead pacing threshold. Because she was a CRT responder, we decided to replace the malfunctioning CS lead. After successful extraction, the vessel from which CS lead was extracted was not visualized, and guidewire re-insertion attempts failed. No other branch vessels suitable for re-implantation were observed. Fortunately, distal portion of the target vessel was viewed by a retrograde flow of contrast. A guidewire was advanced retrograde into the target vein via a connecting vessel, and the distal end of the guidewire was snared around CS ostium and then pulled out of the sheath. A new CS lead was inserted through the distal end of the guidewire and successfully implanted antegrade into the same target vein using a veno-venous loop of the guidewire ('anti-dromic snare technique'). The patient was discharged 2 days after the procedure without complications.

Discussion

Antegrade re-implantation of CS lead may not be possible after extracting CS leads with long dwell times, possibly due to extraction-induced vessel occlusion. If the occluded vessel is the only proper vessel for CS lead re-implantation, the anti-dromic snare technique could be a safe and effective bail-out strategy.

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.

Cardiac resynchronization therapy coronary venous left ventricular lead removal and reimplantation: Experience from a single center in China

The present study aimed to investigate the success rate, methods and associated complications of left ventricular lead (LVL) extraction and venous pathway reimplantation in patients with cardiac resynchronization therapy device/defibrillator (CRT/CRTD). A retrospective analysis was performed in the patients who underwent CRT/CRTD extraction and reimplantation at our hospital from January 2012 to October 2018. The methods, patient complications and success rate of extraction and reimplantation of LVL were analyzed. A total of 54 patients underwent CRT/CRTD removal (pacemaker infection, n=51; LVL dysfunction, n=3; CRT/CRTD, 34/20). A total of 54 LVLs were removed (3 active electrodes and 51 passive electrodes). The average implantation duration of the LVL was 53.5 months (range, 1-204 months), whereas the success rate of the LVL extraction was 100% (94% completely removed and 6% clinically removed. A total of 6 patients (11%) were treated only by manual traction, whereas the remaining patients had their LVL successfully removed using extraction tools. In the peri-operative period, one fatality occurred (2%). The highest complication rate of the lead extraction was 2% and no minor complications were observed. A total of 36 patients were reimplanted on the right side, which was successful in 31 cases (success rate, 86.1%), whereas 3 cases were successfully reimplanted on the left side. The total success rate of LVL reimplantation was 87.2%. The procedure of the LVL removal and reimplantation exhibited a high success rate and a lower incidence of complications compared with that in patients with cardiac devices.

Explanting Chronic Coronary Sinus Leads

Cardiac resynchronization therapy (CRT) has become the gold standard for patients with systolic left ventricular function, left ventricular ejection fraction less than or equal to 35%, wide complex QRS, and symptomatic heart failure. Annual implantation volume has steadily increased because of expanding indications for CRT. Improved survival resulted in many of these patients having their CRT devices for many years and eventually requiring an increased number of device-related procedures, including coronary sinus lead revisions and replacements following a coronary sinus lead extraction.

Understanding non-response to cardiac resynchronisation therapy: common problems and potential solutions

Heart failure is a complex clinical syndrome associated with a significant morbidity and mortality burden. Reductions in left ventricular (LV) function trigger adaptive mechanisms, leading to structural changes within the LV and the potential development of dyssynchronous ventricular activation. This is the substrate targeted during cardiac resynchronisation therapy (CRT); however, around 30-50% of patients do not experience benefit from this treatment. Non-response occurs as a result of pre-implant, peri-implant and post implant factors but the technical constraints of traditional, transvenous epicardial CRT mean they can be challenging to overcome. In an effort to improve response, novel alternative methods of CRT delivery have been developed and of these endocardial pacing, where the LV is stimulated from inside the LV cavity, appears the most promising.

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.

New left ventricular active fixation lead: The experience of lead extraction

Left ventricular active fixation lead is fundamental for targeted pacing site. The challenge is the extraction but in our experience Attain^® Stability™ was removed without any problem. As usual the lead can cause a thrombosis of the coronary vein but we performed a venoplasty in order to place again a lead in the target site and maintain the CRT response.

Late Manifestation of Coronary Sinus and Left Atrial Perforation of a Left Ventricular Pacemaker Lead at Extraction

A 56-year-old man presented for lead extraction of a left ventricular (LV) lead that had been deactivated due to hiccups and of a right ventricular (RV) lead with a high threshold. Pus was noted upon entering the pocket. The right atrial and RV leads were extracted, but traction on the LV lead caused ischemia and was not performed. An echocardiogram demonstrated the lead in the left atrium and a robotic-assisted thoracotomy was used to remove the lead that had unroofed the coronary sinus, gone into the left atrium, and perforated through the free wall into the pericardium.

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.

Development of a technique for left ventricular endocardial pacing via puncture of the interventricular septum

BACKGROUND

Left ventricular (LV) pacing through the coronary sinus is the standard approach for cardiac resynchronization therapy. When this route is unavailable, the alternatives have major limitations. LV endocardial pacing through the interventriuclar septum may offer a simpler solution. We describe an initial case series to demonstrate technical feasibility and to describe our refinement of the puncture technique.

METHODS AND RESULTS

Ten patients with previous failed coronary sinus lead implant or with nonresponse to cardiac resynchronization therapy and a suboptimal LV lead position were selected. All patients were anticoagulated. Left ventriculography and coronary angiography were performed to identify LV borders and septal vessels. Subclavian vein access was used for a superior approach ventricular transseptal puncture under fluoroscopic guidance, using a steerable sheath and a standard transseptal needle, radiofrequency needle, or radiofrequency energy delivered through a guidewire. An active-fixation pacing lead was successfully delivered to the endocardial wall of the lateral LV in all patients (9 men; age, 62±10 years). LV lead implant procedure time shortened with experience. The use of radiofrequency energy delivered through a guidewire was the most effective technique. Mean threshold and R wave at implant were 0.8±0.3 V and 10.8±3.9 mV. At follow-up (mean, 8.7 months; minimum, 0; and maximum 19), thresholds were stable, and there were no thromboembolic events. Of 9 patients, 8 were classed as clinical responders (1 had inadequate follow-up to assess response).

CONCLUSIONS

LV endocardial pacing through a ventricular septal puncture is a feasible approach for cardiac resynchronization therapy.

Survival of patients with biventricular devices after device infection, extraction, and reimplantation

OBJECTIVES

This study sought to compare outcomes in patients with biventricular device infections who undergo successful treatment including extraction and reimplantation to patients with biventricular devices never known to become infected.

BACKGROUND

Infection of a cardiac implantable electronic device (CIED) is associated with substantial morbidity and mortality. Survival in patients with cardiac resynchronization therapy (CRT) device infections undergoing full system extraction is unknown.

METHODS

We extracted data on all patients undergoing extraction of a biventricular pacing device for an infectious indication at the Cleveland Clinic between February 16, 2000, and June 30, 2011. Survival of patients who presented with a CRT device infection, extraction, and successful reimplantation was compared to that of a large cohort of consecutive patients undergoing initial CRT implantation without a known history of subsequent device-related infection. In addition, long-term outcomes were compared between patients who were extracted and deemed to be cured with and without successful biventricular device reimplantation.

RESULTS

In all, 151 patients underwent biventricular device extraction for infection, of whom 81 were successfully reimplanted. The noninfected cohort consisted of 879 patients. In a multivariate Cox regression model controlling for sex, a history of ischemic cardiomyopathy, creatinine, hemoglobin, beta-blocker use, angiotensin-converting enzyme inhibitor use, and diuretic use, no significant association between subsequent infection with reimplantation and all-cause mortality was noted (p = 0.21). There was a trend toward worse outcomes for patients extracted, deemed cured, and not reimplanted compared to patients with successful CRT reimplantation.

CONCLUSIONS

Patients with a biventricular device infection who are successfully extracted, treated with antibiotics, and reimplanted with a biventricular device have outcomes similar to those of patients with biventricular devices not known to have become infected.

Multicenter experience with transvenous lead extraction of active fixation coronary sinus leads

BACKGROUND/OBJECTIVE

Active fixation coronary sinus (CS) leads limit dislodgement and represent an attractive option to the implanter. Although extraction of passive fixation CS leads is a common and frequently uncomplicated procedure, data regarding extraction of chronically implanted active fixation CS leads are limited.

METHODS

We performed a retrospective cohort study of patients undergoing active fixation CS lead extraction at six centers. Patient and procedural characteristics, indications for extraction, use of extraction sheath (ES) assistance, and outcomes are reported.

RESULTS

Between January 2009 and February 2011, 12 patients underwent transvenous lead extraction (TLE) of Medtronic StarFix® lead (Medtronic Inc., Minneapolis, MN, USA). The cohort was 83% male with mean age 71 ± 14 years. Average implant duration was 14.2 ± 5.7 months (2.3-23.6). All leads but one were removed for infectious indications (67% systemic infection). At the time of explant, the fixation lobes were completely retracted in only one of the 12 cases and ES assistance was required for lead removal in all cases (58% laser, 25% cutting, 25% mechanical, and 25% femoral). The majority of cases required advancement of the sheath into the CS (75.0%) and often into a branch vessel (41.7%). One lead could not be removed transvenously and required surgical lead extraction. There were no major complications. Examination of the leads after extraction frequently revealed significant tissue growth into the fixation lobes.

CONCLUSIONS

Although TLE of active fixation CS leads can be a safe procedure in select patients and experienced hands, powered sheaths and aggressive techniques are frequently required for successful removal despite relatively short implant durations. This raises significant concern regarding future TLE of active fixation CS leads with longer implant durations.

Outcomes and predictors of difficulty with coronary sinus lead removal

With increasing coronary sinus (CS) pacemaker leads for cardiac resynchronization therapy, the need to remove these leads has risen. The purpose of this study is to describe a single center's experience with CS lead removal and to attempt to identify predictors of difficulty with lead removal and complications. We reviewed all percutaneous endocardial CS lead removals performed at our institution through February 2010. Successful removal with traction alone was considered simple while complex extractions required traction devices and/or laser sheaths. Between December 1996 and February 2010, 125 CS leads were percutaneously removed ≥1 week post-implantation from 115 patients. One attempt at CS lead extraction was unsuccessful. The average duration since implantation for the CS leads was 1.54 years (± .75 years, range 8 days to 8.24 years). The majority of the leads were removed by simple traction (n = 114, 91.2 %). The remainder were removed by femoral approach with snare (n = 3, 2.4 %), locking stylet (n = 2, 1.6 %), or locking stylet and laser sheath (n = 6, 4.8 %). Half of CS leads in place greater than 4 years required complex extraction (n = 7/14, 50 %). CS complications (n = 11 patients, 8.8 %) included CS or tributary thrombosis (n = 7/102, 6.9 %) and CS dissection (n = 4/102, 3.9 %). Major non-CS complications (n = 2 patients, 1.6 %) included a cardiac tear requiring pericardiocentesis and thoracotomy (n = 1, 0.8 %) and subclavian vein tear requiring surgical repair (n = 1, 0.8 %). Minor non-CS complications (n = 9 patients, 7.2 %) included a pneumothorax (n = 1, 0.8 %), hematoma (n = 2, 1.6 %), subclavian vein thrombosis (n = 3, x%), and blood transfusion (n = 5, 4.0 %). A longer duration since implantation and larger lead diameter were associated with complex versus simple removal (p < .0001 and p = .0009 respectively). Percutaneous CS lead removal is successful by simple traction alone in the vast majority of cases. CS leads in place greater than 4 years, however, often require complex extraction. Specific extraction techniques can be implemented when simple traction is unsuccessful without an appreciable increase in complications.

Large, single-center experience in transvenous coronary sinus lead extraction: procedural outcomes and predictors for mechanical dilatation

BACKGROUND

The aim of this study was to evaluate procedural outcomes of coronary sinus (CS) lead extraction, focusing on predictors and need for mechanical dilatation (MD) in the event that manual traction (MT) is ineffective.

METHODS

The study assessed results in 145 consecutive patients (age 69 ± 10 years; 121 men)--a total of 147 CS pacing leads--who underwent transvenous CS lead removal between January 2000 and March 2010.

RESULTS

All leads but one (99%) (implantation time 29 ± 25 months) were successfully removed. MT was effective in 103 (70%), and MD was necessary in the remaining 44 (30%) procedures. In multivariate analyses, unipolar design (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43-7.7; P = 0.005) and noninfective indication (OR 4.8, 95% CI 1.8-13, P = 0.002) were independent predictors for MD (P < 0.0001), with a predictive trend for prior cardiac surgery (OR 2.2, 95% CI 0.98-5.26; P = 0.06). Five (3.4%) complex procedures required a transfemoral vein approach (TFA) or repeat procedure. No deaths occurred, and there was one major complication (0.7%), cardiac tamponade, after MT. No complication predictors were identified.

CONCLUSIONS

CS leads were safely and effectively removed in nearly all patients, and 70% were removed with MT alone; 30% required MD. Preoperative predictors suggesting the need for MD or TFA were noninfective indication and unipolar lead design. Complications were rare, and there was no predictable pattern among MT or MD removal techniques.

Cardiac resynchronization therapy after coronary sinus lead extraction: feasibility and mid-term outcome of transvenous reimplantation in a tertiary referral centre

AIMS

Few data are available on cardiac resynchronization therapy (CRT) after coronary sinus (CS) lead extraction. We aimed to evaluate the feasibility and mid-term outcome of transvenous CS lead reimplantation in a tertiary referral centre.

METHODS AND RESULTS

We enrolled all patients who were referred to our hospital for CS lead removal from December 2000 through to May 2009 and were transvenously reimplanted with a CRT system before June 2009. One-year follow-up was performed to evaluate the incidence of infections, malfunctions, and mortality. We studied 113 consecutive patients undergoing successful CS lead extraction; 90 patients (75 male, mean age 69.2, range 35-84) underwent CS lead reimplantation (success rate: 95.6%; right-sided approach: 64.4%). In these patients, cardiac device infection was the usual indication for extraction (74.4%) and the subsequent reimplantation was performed after a median time of 3 days. The coronary sinus lead was usually positioned in the left ventricular (LV) postero-lateral region (62.2%); two procedures were required in two cases (2.2%). Balloon angioplasty was necessary for two patients (failure in one), whereas for the others we used a conventional implant technique. During follow-up, we observed four cases (4.4%) of local infection and six cases (6.7%) of system malfunction, requiring reintervention (two cases during the same hospitalization). One-year mortality was 5.5%.

CONCLUSION

Left ventricular lead reimplantation is in our experience an effective and safe procedure, also in the case of right-sided approach. During follow-up, 1-year mortality was particularly low, whereas overall infection rate was higher than first implant procedures.

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

AIMS

Few data have been currently reported on the outcome of coronary sinus (CS) lead removal, particularly using mechanical dilation (MD). We aimed to evaluate feasibility, safety, and effectiveness of CS lead extraction, focusing on MD usefulness, in the event that lead traction (LT) was ineffective.

METHODS AND RESULTS

We studied 37 consecutive patients (30 males, mean age 68.1, range 52-80), who underwent left ventricle (LV) pacing lead removal; the indication for extraction was local infection in 16 patients (43.3%), sepsis in 11 patients (29.7%), and lead malfunction in 10 patients (27%). The procedure was first attempted by LT, followed, if unsuccessful, by MD using polypropylene sheaths. All CS leads (time from implant 19.5 +/- 16.5, range 2-84 months) were successfully removed; LT was effective (LT group) in 27 patients (73%) and ineffective in 10 patients (27%), for whom MD was necessary (MD group). There were no major complications. The areas of adherence were in the CS in only one patient. No differences were noted in the data analysed between LT and MD groups; in particular, time from implant was similar in the two groups (MD vs. LT group: 17 +/- 8.9 vs. 20.4 +/- 18.6 months; P = ns).

CONCLUSION

Our study suggests that CS leads, after medium-term implantation, can be effectively and safely removed using MD with polypropylene sheaths, in the case of unsuccessful LT. No pre-operative elements predictive of LT failure could be identified. Areas of adherence were rarely located in the CS or its tributaries.

Effect of Percutaneous Interventions within the Coronary Sinus on the Success Rate of the Implantations of Resynchronization Pacemakers

BACKGROUND

Cardiac resynchronization therapy (CRT) becomes a "gold standard" in therapy of selected patients with advanced heart failure. We set out to evaluate the feasibility and safety of percutaneous interventions within coronary sinus (CS) and their effect on the success rate of left ventricular (LV) lead implantation during CRT.

METHODS

The study analyzed eight consecutive patients with the indications for CRT, who needed additional procedures within CS to overcome technical problems during left ventricular (LV) electrode implantation. The analyzed group consisted of three subgroups: patients in whom percutaneous balloon angioplasty within CS was needed (n = 4); patients with acute instability of the lead, requiring stenting of the vein to fix the electrode (n = 2); and patients with the stenting of CS due to late dislocation of the lead (n = 2). Success rate, procedure duration, fluoroscopy, complications, and electrical parameters of leads were analyzed.

RESULTS

Success rate of the procedures was 87.5%; additional interventions increased overall efficacy of CRT implantation at our center from 88% to 98% (P < 0.05). Procedure duration (155.0 minute) and fluoroscopy time (42.5 minute) remained acceptable for the patient and operator; however, both were higher than in the procedures performed routinely in our hospital. Electrical properties of the LV leads were stable and within normal ranges during the observation period. We noted two local dissections of CS during the procedure, which remained clinically silent.

CONCLUSION

Percutaneous interventions within CS seem to be feasible and safe treatment options, which can improve the short- and long-term success rates of CRT.