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Cuándo, a quién y cómo explanto   un catéter de desfibrilador           Sergio L. Pinski       Cleveland Clinic Florida   ...
Simpler Classification ofIndications Infection Lead that represents a risk Need for venous conduit Superfluous lead during...
Conductor fracture   Insulation defect andsecondary to         conductor fracturecompression          secondary to pinchin...
Insulation defect due to   Insulation defect dueabrasion                   to traction from lead                          ...
Figure 1           Hauser et al. Heart Rhythm 2011; 9:742
Kaplan-Meier curve for all-cause lead removal or capping                              Borleffs et al. Circ Arrhythm Electr...
Kaplan-Meier curve for lead failure comparing all leads with the leads from Boston Scientific, Medtronic, and St Jude Medi...
Strategies for ICD lead problemsIgnore it, reprogram aroundRepair leadAdd pacing/sensing leadAdd new defibrillation leadEx...
Problems with additional pectoral pace/sense lead   Observation/Complication                                     Pectoral ...
Model 6949 High Voltage Conductor Survival after        a Pace-Sense Conductor Fracture                   Months after a p...
Potential Drawbacks of AbandoningNon-Infected ICD Leads Lead “chatter” causing spurious shocks Insulation breach in pocket...
Epstein et al. Circulation 1998;98:1517
Epstein et al. Circulation 1998;98:1517
Epstein et al. Circulation 1998;98:1517
Epstein et al. Circulation 1998;98:1517
Epstein et al. Circulation 1998;98:1517
Hauser et al. Europace 2010;12:395
Perioperative complications after ICD leadreplacement                        Additional ICD lead            Replaced ICD l...
REPLACE: major complications by lead addition or                  revision.                          Poole J E et al. Circ...
Factors to ConsiderPatient age and gender (elderly women higher risk)Overall healthPrevious cardiac surgeryNumber of leads...
My “Rules of Thumb” No more than 5 leads through SVC No more than 4 leads from one side No more than one defibrillation lead
Figure 1Subacute lead perforation                           Danik et al. Heart Rhythm 2008;5:1667
Figure 1Generator exchange is associated with an increased rate of Fidelis leadfailure                                    ...
What to do during elective replacement upgrade of ICD with not failed Fidelis lead?“Benign neglect”“The minimalist” New pa...
Programmable sensing vector in new MDT ICDs
Patient “downgraded” from CRTD to CRTP 13months ago. Fidelis lead programmed unipolarpace/sense. Lead fracture to the tip ...
BiV captureNative LBBBLV pacing  with  fusion
Physicians who perform leadextraction change their implanttechniquesUse leads with excellent long-termtrack records.Exclus...
Azygous vein coil for high defibrillation threshold
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
Icd lead extraction ba nov 2012 final
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Icd lead extraction ba nov 2012 final

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Icd lead extraction ba nov 2012 final

  1. 1. Cuándo, a quién y cómo explanto un catéter de desfibrilador Sergio L. Pinski Cleveland Clinic Florida Weston, Florida, USA
  2. 2. Simpler Classification ofIndications Infection Lead that represents a risk Need for venous conduit Superfluous lead during revision or upgrade (abandoned or with failure)
  3. 3. Conductor fracture Insulation defect andsecondary to conductor fracturecompression secondary to pinching Gradau et al. PACE 2003;26:649
  4. 4. Insulation defect due to Insulation defect dueabrasion to traction from lead migration Gradau et al. PACE 2003;26:649
  5. 5. Figure 1 Hauser et al. Heart Rhythm 2011; 9:742
  6. 6. Kaplan-Meier curve for all-cause lead removal or capping Borleffs et al. Circ Arrhythm Electrophysiol 2009;2:411
  7. 7. Kaplan-Meier curve for lead failure comparing all leads with the leads from Boston Scientific, Medtronic, and St Jude Medical, grouped by lead diameter
  8. 8. Strategies for ICD lead problemsIgnore it, reprogram aroundRepair leadAdd pacing/sensing leadAdd new defibrillation leadExtract and replace defibrillationlead
  9. 9. Problems with additional pectoral pace/sense lead Observation/Complication Pectoral Leads (n = 97) No. (%) Oversensing with inappropriate therapy 5 5.2 Oversensing only 4 4.1 Infection 2 2.1 High-voltage defect 5 5.2 Insulation defect Sensing/pacing threshold/impedance value out of range 3 3.1 Fracture Dislocation 1 1 Impossible upgrading to DDD because of vein thrombosis Death in septicemia with vegetations on leads 1 1 Total 21 21.7 Wollman et al. PACE 2005;28:795
  10. 10. Model 6949 High Voltage Conductor Survival after a Pace-Sense Conductor Fracture Months after a pace-sense conductor fracture 0 6 12 18 21% survival 100 98.7 89 80.3 77of HV conductors
  11. 11. Potential Drawbacks of AbandoningNon-Infected ICD Leads Lead “chatter” causing spurious shocks Insulation breach in pocket causing electrical shorting during high-voltage shock and generator damage Large diameter could promote venous obstruction (SVC syndrome) or tricuspid regurgitation Extraction will be very difficult if needed down the road
  12. 12. Epstein et al. Circulation 1998;98:1517
  13. 13. Epstein et al. Circulation 1998;98:1517
  14. 14. Epstein et al. Circulation 1998;98:1517
  15. 15. Epstein et al. Circulation 1998;98:1517
  16. 16. Epstein et al. Circulation 1998;98:1517
  17. 17. Hauser et al. Europace 2010;12:395
  18. 18. Perioperative complications after ICD leadreplacement Additional ICD lead Replaced ICD lead (n = 33) (n = 53) % %Lead dislodgement 3.1Pneumothorax 6.3 5.7Pericardial effusion 3.1 1.9Pocket hematoma 3.1 3.6Pleural effusion 3.1Incomplete extraction 3.6Total 18.2 15.1 Wollman et al. JCE 2007;18:1172
  19. 19. REPLACE: major complications by lead addition or revision. Poole J E et al. Circulation 2010;122:1553-1561
  20. 20. Factors to ConsiderPatient age and gender (elderly women higher risk)Overall healthPrevious cardiac surgeryNumber of leads in the intravascular spaceDuration of the implantFragility, condition, and physical characteristics ofthe leadExperience of the physicianDesires of the patient
  21. 21. My “Rules of Thumb” No more than 5 leads through SVC No more than 4 leads from one side No more than one defibrillation lead
  22. 22. Figure 1Subacute lead perforation Danik et al. Heart Rhythm 2008;5:1667
  23. 23. Figure 1Generator exchange is associated with an increased rate of Fidelis leadfailure Lovelock et al. Heart Rhythm 2012;9:16157
  24. 24. What to do during elective replacement upgrade of ICD with not failed Fidelis lead?“Benign neglect”“The minimalist” New pace-sense lead“The next fool’s problem” New ICD lead“The all-the-way out” Extraction andnew lead“The switch” -LV lead in RV port“The downgrade” CRTP, no risk ofspurious shocks
  25. 25. Programmable sensing vector in new MDT ICDs
  26. 26. Patient “downgraded” from CRTD to CRTP 13months ago. Fidelis lead programmed unipolarpace/sense. Lead fracture to the tip diagnosedduring routine clinic check.
  27. 27. BiV captureNative LBBBLV pacing with fusion
  28. 28. Physicians who perform leadextraction change their implanttechniquesUse leads with excellent long-termtrack records.Exclusive use of active-fixation leadsAvoid dual-coil defibrillation leadsUse leads “easier” to extract
  29. 29. Azygous vein coil for high defibrillation threshold

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