Classification and Surgical Repair of Injuries Sustained During Transvenous Lead Extraction

Abstract

Background-Injuries to cardiac and venous structures during pacemaker and defibrillator lead extraction are serious complications that have been studied poorly. The incidence of these injuries is unknown but likely underestimated. No systematic multicenter review of these injuries or their management has been undertaken. Methods and Results-We interrogated our mandatory administrative database for all excimer laser extractions that sustained a cardiac or venous injury in the province of British Columbia. Injuries were classified according to presentation and compared with respect to nature of injury, type of repair, utilization of cardiopulmonary bypass, and outcome. Of 1082 excimer laser extractions over 19 years, 33 sustained an injury (3.0%). The majority of injuries occurred in women (21/33; 63.6%), and median age of oldest lead extracted was 10.8 (7.5, 12.2) years. A type 1 presentation, defined as circulatory collapse, was found in 12/33 patients (36.4%). A type 2 presentation, defined as progressive hypotension responsive to treatment, was found in 20/33 patients (60.6%). Over half the patients had a moderate or large injury, and cardiopulmonary bypass was required in 13 patients with extensive injury. Despite the presence of devastating injuries, the immediate availability of aggressive salvage measures resulted in a survival of 87.9% of patients at 30 days. Conclusions-The immediate availability of a cardiovascular surgeon, perfusionist, and cardiopulmonary bypass pump facilitates lifesaving repair of injuries sustained during laser lead extraction. The size and complexity of injury correlates closely with the presentation, blood loss, and need for cardiopulmonary bypass to facilitate repair. (Circ Arrhythm Electrophysiol. 2016;9:e003741.

Transvenous Lead Extraction without Procedure-Related Deaths in 1000 Consecutive Patients: A Single-Center Experience

“…The average incidence of major complications in the studies was 1.67%, but this parameter should be evaluated in parallel with implant duration, which is the main risk factor for their occurrence. Only two studies demonstrated a higher rate of MC than in the current investigation, 32,36 but there were only 2 studies with slightly longer implant duration 32,43 and one of them reported a higher rate of MC. 32 Procedure-related death is the most important indicator of the effectiveness of safety measures.…”

“…Only two studies demonstrated a higher rate of MC than in the current investigation, 32,36 but there were only 2 studies with slightly longer implant duration 32,43 and one of them reported a higher rate of MC. 32 Procedure-related death is the most important indicator of the effectiveness of safety measures. Four studies reported a zero procedurerelated mortality rate, 24,27,37,42 but the mean implant duration in those reports was markedly shorter than in the current study (72-92 vs 112 months).…”

“…Out of 25 reports comprising 43,940 patients, summarized in Table 6, 13,15, 13 studies involved more than 1000 TLE procedures. 13,15,22,23,25,32,[34][35][36]42 The average implant duration in those reports was 74.5 months. In the present study, the implant duration was markedly longer (112 months), and there were two smaller studies reporting such a long lead dwell time.…”

“…26,30,34 Laser sheaths were used as a first-line or predominant (50%) tool in 11 reports comprising 22,890 patients. 13,24,25,27,28,30,[32][33][34]36,38 Mechanical dilation with non-powered sheaths was used as a first-line or predominant (50%) option in 11 reports comprising 17,953 patients, 15,22,23,26,29,31,35,39,40,42 whereas mechanical rotational sheaths with threaded tips were used as a first-line or predominant (50%) tool in 2 reports 35,38 (a relatively new tool; 2,605 patients). In one report, femoral approach and Needle's Eye Snare was used as a first-line option in 492 patients.…”

Is Cardiopulmonary Bypass Standby Still Required for Laser Lead Extractions?

“…This requires urgent repair with hemostasis and may require cardiopulmonary bypass. Furthermore, rapid surgical intervention is key as irreversible neurological damage occurs within 5 to 10 minutes of cardiac tamponade [10]. In addition to the serious injuries being seen elsewhere in the literature, our conclusion that a cardiothoracic surgeon is still a vitally important member of the laser lead extraction team is also supported by the research of other groups [14][15][16][17].…”