The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction

Migliore, Federico; Tarzia, Vincenzo; Dall’Aglio, Pietro Bernardo; Falzone, Pasquale Valerio; Lazzari, Manuel De; Bottio, Tomaso; D’Onofrio, Augusto; Padalino, Massimo A.; Vida, Vladimiro L.; Rosso, Jacopo; Leoni, Loira; Pittarello, Demetrio; Bertaglia, Emanuele; Iliceto, Sabino; Gerosa, Gino

doi:10.1111/pace.14396

Cited by 5 publications

(7 citation statements)

References 23 publications

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“…Recent multicentre studies reported that the second-generation Evolution system (Evolution RL) is an alternative mechanical TLE tool for the extraction of chronically implanted leads. [9][10][11][12]20 The efficacy of the system, which is equal to that of laser-powered sheaths, has led to its increased use in clinical practice as a first-line approach in centers with experienced operators when advanced TLE techniques are needed in complex cases of long lead implant durations. [9][10][11][12] However, data are currently lacking on the efficacy and safety of TLE using a bidirectional rotational mechanical sheath as the first-line approach in patients with exclusively old leads (≥10 years).…”

Section: Discussionmentioning

confidence: 99%

Outcomes of transvenous lead extraction of very old leads using bidirectional rotational mechanical sheaths: Results of a multicentre study

Migliore

Pittorru

Dall’Aglio

et al. 2022

Cardiovasc electrophysiol

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Introduction Lead dwell time >10 years is a recognized predictor for transvenous lead extraction (TLE) failure and complications. Data on the efficacy and safety of TLE using the bidirectional rotational mechanical sheaths in patients with very old leads are lacking. In this multicenter study, we reported the outcomes of transvenous rotational mechanical lead extraction in patients with leads implanted for ≥10 years. Methods A total of 441 leads (median: 159 months [135–197]; range: 120–487) in 189 consecutive patients were removed with the Evolution RL sheaths (Cook Medical, Bloomingtom, IN, USA) and mechanical ancillary tools supporting the procedures. Results The main indication for TLE was infection in 74% of cases. Complete procedural success rate, clinical success rate, per lead were 94.8% and 98.2%, respectively. Failure of lead extraction was seen in 1.8% of leads. The additional use of a snare via the femoral approach was required in 9% of patients. Lead dwell time was the only predictor of incomplete led removal (odds ratio: 1.009; 95% confidence interval [CI]: 1.003–1.014; p = .002). Four major complication (2%) were encountered. During a mean time follow‐up of 31 ± 27 months, 21 patients (11%) died. No procedure‐related mortality occurred. Predictors of mortality included severe left ventricular systolic dysfunction (hazard ratio [HR]: 8.06; 95% CI: 2.99–21.73; p = .001), TLE for infection (HR: 8.0; 95% CI: 1.04–62.5; p = .045), diabetes (HR: 3.7; 95% CI: 1.48–9.5; p = .005), and previous systemic infection (HR: 3.1; 95% CI: 1.17–8.24; p = .022). Incomplete lead removal or failure lead extraction did not impact on survival during follow‐up. Conclusion Our findings demonstrated that the use of bidirectional rotational TLE mechanical sheaths combined with different mechanical tools and femoral approach allows reasonable success and safety in patients with very old leads at experienced specialized centers.

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Section: Discussionmentioning

confidence: 99%

Outcomes of transvenous lead extraction of very old leads using bidirectional rotational mechanical sheaths: Results of a multicentre study

Migliore

Pittorru

Dall’Aglio

et al. 2022

Cardiovasc electrophysiol

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“…At our institution, the strict and valuable collaboration between electrophysiologists and cardiac surgeons has been translated into a multidisciplinary approach to complex CDRIE [ 17 ]. Given the promising efficacy and safety of the AngioVac system for the treatment of life-threatening intracardiac masses [ 16 , 21 , 22 , 23 ], we incorporated this device in our decisional algorithm of CDRIE ( Figure 1 ), as a valid alternative to conventional surgery.…”

Section: Discussionmentioning

confidence: 99%

“…According to the guidelines [ 5 ], all patients with large (>20 mm) CDRIE vegetations or systemic infection underwent a multidisciplinary evaluation to plan a surgical extraction of the infected device [ 17 ] ( Figure 1 ). When feasible, percutaneous vacuum-assisted aspiration of the mass with the AngioVac system was the preferred approach, followed by a transvenous lead removal.…”

Section: Methodsmentioning

confidence: 99%

“…This allowed the suction of small vegetation debrides that were mobilized during the catheters′ extraction. TLE was performed by the electrophysiologist either manually or mechanically using Evolution RL Lead Extraction tools (Cook Vascular Inc.), depending on the encountered tissue resistance, as we previously described [ 17 ]. The AngioVac cannula was extracted and transesophageal echocardiography was used to rule out valvular injury and pericardial effusion.…”

Section: Methodsmentioning

confidence: 99%

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Vacuum-Implemented Removal of Lead Vegetations in Cardiac Device-Related Infective Endocarditis

Tarzia

Ponzoni

Evangelista

et al. 2022

JCM

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When approaching infected lead removal in cardiac device-related infective endocarditis (CDRIE), a surgical consideration for large (>20 mm) vegetations is recommended. We report our experience with the removal of large CDRIE vegetations using the AngioVac system, as an alternative to conventional surgery. We retrospectively reviewed all infected lead extractions performed with a prior debulking using the AngioVac system, between October 2016 and April 2022 at our institution. A total of 13 patients presented a mean of 2(1) infected leads after a mean of 5.7(5.7) years from implantation (seven implantable cardioverter-defibrillators, four cardiac resynchronization therapy-defibrillators, and two pacemakers). The AngioVac system was used as a venous–venous bypass in six cases (46.2%), venous–venous ECMO-like circuit (with an oxygenator) in five (38.5%), and venous–arterial ECMO-like circuit in two cases (15.4%). Successful (>70%) aspiration of the vegetations was achieved in 12 patients (92.3%) and an intraoperative complication (cardiac perforation) only occurred in 1 case (7.7%). Subsequent lead extraction was successful in all cases, either manually (38.5%) or using mechanical tools (61.5%). The AngioVac system is a promising effective and safe option for large vegetation debulking in CDRIE. Planning the extracorporeal circuit design may represent the optimal strategy to enhance the tolerability of the procedure and minimize adverse events.

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“…Patient groups with leads 10–20 years, 20–30 years and >30 years remain comparable in part only with the less numerous groups cited earlier. Notably, bearing in mind the increased risk, the cooperation of a multidisciplinary team, involving electrophysiologist and cardiac surgeon is needed, particularly with the use of rotational tools [ 39 , 40 ].…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Transvenous Extraction of Leads Older Than 20 and 30 Years—A Large Cohort Study

Kutarski

Główniak

Kosior

et al. 2022

IJERPH

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Background: There is limited knowledge on outcome of transvenous lead extraction (TLE) of leads being 20 and 30 years old. Methods: Retrospective single center large database analysis containing 3673 TLE procedures performed from 2006 to 2020 was analysed. We aimed to compare procedure complexity and the incidence of the TLE major complications (MC) in groups where extracted leads were under 10 years, 10–20 years, 20–30 years (old) and over 30 years (very old). Results: Rate of removal of old and very old leads almost doubles with successive five-year periods (3–6-10%). In patients with old and very old leads there is an accumulation of risk factors for major complications of TLE (young age, female, multiple and/or abandoned leads, multiple previous procedures). The removal of old and very old leads was more labour-consuming, more difficult, and much more often required second-line (advanced) tools and complex techniques. Incidence of all MC grew parallel to age of removed leads from 0.6 to 18.2%; haemopericardium—from 0.3 to 12.1%, severe tricuspid valve damage—from 0.2 to 2.1%, need for rescue cardiac surgery—from 0.4 to 9.1%. Notably, there was no procedure-related death when old or very old lead was extracted. The percentages of clinical and procedural success decreased with increasing age of the removed leads from 99.2 and 97.8% to 90.9 and 81.8%. The risk of MC during extraction of leads aged 10–20 years increases 6.7 times, aged 20–30 years—14.3 times (amounting to 8.4%), and aged 30 and more years—20.4 times, amounting to 18.2%. Removal of ventricular leads is associated with a greater complexity of the procedure but not with more frequent MC. Removal of the atrial leads is associated with a higher incidence of MC, especially haemopericardium, regardless of the age of the leads, although the tendency becomes less pronounced with the oldest leads. Conclusions: 1. Extraction of old and very old leads is a rising challenge, since the rate of removal of leads aged 20-and-more years almost doubles with successive five-year periods. 2. Procedure difficulty, complexity and the risk of major complications increases along with the age of extracted lead. TLE is more time-consuming, difficult and much more often requires advanced tools and complex techniques. 3. TLE of old (≥20 years) or very old (≥30 years) leads can be performed with satisfactory success rate and safety profile when conducted at high-volume centre by an experienced operator under optimal safety conditions.

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The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction

Cited by 5 publications

References 23 publications

Outcomes of transvenous lead extraction of very old leads using bidirectional rotational mechanical sheaths: Results of a multicentre study

Outcomes of transvenous lead extraction of very old leads using bidirectional rotational mechanical sheaths: Results of a multicentre study

Vacuum-Implemented Removal of Lead Vegetations in Cardiac Device-Related Infective Endocarditis

Outcomes of Transvenous Extraction of Leads Older Than 20 and 30 Years—A Large Cohort Study

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