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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 of Indications 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 and secondary to conductor fracture compression secondary to pinching Gradau et al. PACE 2003;26:649
  4. 4. Insulation defect due to Insulation defect due abrasion 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 problems Ignore it, reprogram around Repair lead Add pacing/sensing lead Add new defibrillation lead Extract and replace defibrillation lead
  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 77 of HV conductors
  11. 11. Potential Drawbacks of Abandoning Non-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 lead replacement Additional ICD lead Replaced ICD lead (n = 33) (n = 53) % % Lead dislodgement 3.1 Pneumothorax 6.3 5.7 Pericardial effusion 3.1 1.9 Pocket hematoma 3.1 3.6 Pleural effusion 3.1 Incomplete extraction 3.6 Total 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 Consider Patient age and gender (elderly women higher risk) Overall health Previous cardiac surgery Number of leads in the intravascular space Duration of the implant Fragility, condition, and physical characteristics of the lead Experience of the physician Desires 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 1 Subacute lead perforation Danik et al. Heart Rhythm 2008;5:1667
  23. 23. Figure 1 Generator exchange is associated with an increased rate of Fidelis lead failure 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 and new lead “The switch” -LV lead in RV port “The downgrade” CRTP, no risk of spurious shocks
  25. 25. Programmable sensing vector in new MDT ICDs
  26. 26. Patient “downgraded” from CRTD to CRTP 13 months ago. Fidelis lead programmed unipolar pace/sense. Lead fracture to the tip diagnosed during routine clinic check.
  27. 27. BiV capture Native LBBB LV pacing with fusion
  28. 28. Physicians who perform lead extraction change their implant techniques Use leads with excellent long-term track records. Exclusive use of active-fixation leads Avoid dual-coil defibrillation leads Use leads “easier” to extract
  29. 29. Azygous vein coil for high defibrillation threshold

Editor's Notes

  • Defibrillation lead insulation. A, Schematic view of a Medtronic lead that uses both silicone as an inner insulation and polyurethane as an outer insulation. Cross-sectional views show the insulation in a Guidant Endotak Reliance lead ( B ), a Medtronic Sprint Quattro Secure lead ( C ), and a St. Jude Riata lead ( D ).
  • Extracted dual-coil Riata lead showing externalized cables (arrows) in 2 locations between the proximal and distal coils.
  • Figure 1. Kaplan-Meier curve for all-cause lead removal or capping.
  • Figure 2. Kaplan-Meier curve for lead failure comparing all leads with the leads from Boston Scientific, Medtronic, and St Jude Medical, grouped by lead diameter (French).
  • C and D, Lead from patient 6, the only one not implanted long term. Where lead (arrow) crosses tricuspid valve, there is accumulation of thrombotic material connecting lead to valve leaflet.
  • Figure 4. A, Gross photograph of interventricular septum from patient 4 who had received no shocks in the preceding 215 days before transplantation. Sarcoidosis was unexpectedly demonstrated at pathological examination. As with other long-term implanted leads, this one was encased in fibroelastic tissue (curved white arrow) with discrete band of fibrous connective tissue (arrows) adjacent to lead. Dense linear fibrotic band traversed interventricular septum. Fibrotic tissue associated with lead is not distinctly different than fibrous connective tissue associated with sarcoid (curved black arrow) but clearly separated from sarcoid reaction. B, Low-power trichrome-stained section of A. Fibroelastic tissue surrounds lead (L); dense fibrotic tissue radiates from lead and extends across interventricular septum (arrows); fibrous tissue is associated with sarcoid reaction (curved arrow). C, Endocardial surface of right ventricular free wall of patient 8, who had both pacemaker (arrow) and ICD (curved arrow) leads implanted. D, Hematoxylin and eosin–stained section from area in C. Rim of fibroelastic tissue encircles ICD lead and focus of endocardial fibrosis at point of pacemaker lead contact. Fibrosis was more pronounced in association with ICD lead and more attenuated with smaller, smoother pacemaker lead. Because free-wall myocardium was not in current pathway, interstitial fibrosis was absent.
  • ICD lead (arrow) of patient 2 as it appeared looking through right atrium (RA), across tricuspid valve (TV), and into right ventricle (arrowhead). The distal spring was embedded in right side of interventricular septum and encased in dense fibroelastic tissue.
  • Lead from patient 4 (arrow) penetrating the tricuspid valve and embedded in endocardium of right side of interventricular septum. This long-term implanted lead was also encased in dense fibroelastic tissue (arrowhead).
  • Distal portion of lead from patient 3 and section of interventricular septum (IVS). Despite application of enough tension to separate wire coils of distal spring (arrow), myocardium remained attached to lead.
  • Telescoping teflon, polypropylene, and stainless steel sheaths. (B) Evolution™ sheath. This is a flexible plastic sheath with a distal threaded metal tip. A handle is attached to the plastic sheath proximally that rotates the sheath, allowing the threaded metal end to bore through adhesions. (C) The Eximer Laser Sheath is a flexible composite with multiple glass fibers aligned in a circle and terminating distally that vaporize tissue.
  • Figure 8. (A) Byrd Femoral Workstation™. This is a 16F internal diameter sheath with ahemostatic valve, through which various inner sheaths and snares may be passed. (B) Needle's Eye™ Snare. This may be used to grasp and pull on leads. It provides a reversible grip on the lead once the lead is clasped. (C) Dotter helical basket and deflecting tip guidewire. The deflecting guidewire can be used to loop around a lead, then the Dotter helical basket may be used to snare the free end of the lead. Alternatively, the basket can be used to snare the free end of the guidewire once the latter is looped around the lead, to provide additional traction to pull the lead down into the femoral vein.
  • Success, morbidity, and mortality in large series. Graphic representation of complete success as a function of time, represented by black columns. Secondary y axis represents percent morbidity (orange) and mortality (red). Timeline of extraction techniques and tools commensurate with reported trials is at the top of the figure. Values below the graph represent the number of leads (N) extracted in each study. Composite major complication (MC) and mortality (M) rate was calculated. Only studies with ≥50 leads extracted and data regarding mortality and major complications were cited. EDS indicates electrosurgical dissection sheath.
  • Risk versus risk. The decision regarding lead extraction or abandonment requires comparison of the current risks of lead extraction with the future risks of both lead abandonment and potential lead extraction.
  • Cohort 2 major complications by lead addition or revision. The bars represent patient complication event rates and 95% confidence intervals. The numbers in parentheses below each bar (n/nn) indicate the number of patients with a complication/the number of patients with each procedure type. CIs for the accuracy of estimation are displayed within the error bars. The lead categories refer to (1) add/revise a transvenous LV lead for the purpose of CRT upgrade or revision, (2) add/revise a transvenous RA or RV lead for upgrade of single chamber PM or ICD to dual chamber PM or ICD, or revision of existing system, and (3) no lead added or revised. The procedure category is regardless of procedural success. In 47 of 434 patients (10.8%), the transvenous LV lead attempts were unsuccessful; in 9 of 234 patients (3.9%), the transvenous right atrial/right ventricular lead attempts were unsuccessful. In 45 patients, a new lead was ultimately not attempted; in 15 of these 45, the plan to replace a malfunctioning right atrial lead was abandoned because of atrial fibrillation; in 6, a chronic capped lead was used; and in the remainder, the lead was repaired or considered adequate after testing. P=0.004 for the difference across the 3 procedure types. LV indicates left ventricular; RA, right atrial; RV, right ventricular.
  • A and B: Posterior-anterior and lateral chest radiograph 1 day postimplantation of a single-chamber implantable cardioverter-defibrillator with a Riata lead. C and D: Posterior-anterior and lateral chest radiograph of the same patient 4 days postimplantation after developing chest pain 3 days postimplantation. On the lateral film in B, the lead tip points down.
  • Sprint Fidelis lead failure after ICD replacement compared with age-matched controls. Seventy-two of the 479 cohort patients underwent elective replacement of their ICD. The performance of the Fidelis lead after replacement is shown in the circles compared with a group of 150 patients (squares) matched for Fidelis lead implant duration. The failure rate was 20.8% in the year following ICD generator replacement, compared with 2.5% in the controls (P < .001). ICD = implantable cardioverter-defibrillator.
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