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Cuándo, a quién y cómo explanto
   un catéter de desfibrilador


           Sergio L. Pinski
       Cleveland Clinic Flori...
Simpler Classification of
Indications
 Infection
 Lead that represents a risk
 Need for venous conduit
 Superfluous lead d...
Conductor fracture   Insulation defect and
secondary to         conductor fracture
compression          secondary to pinch...
Insulation defect due to   Insulation defect due
abrasion                   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 E...
Kaplan-Meier curve for lead failure comparing all leads with the
 leads from Boston Scientific, Medtronic, and St Jude Med...
Strategies for ICD lead problems

Ignore it, reprogram around
Repair lead
Add pacing/sensing lead
Add new defibrillation l...
Problems with additional pectoral pace/sense lead
   Observation/Complication                                     Pectoral...
Model 6949 High Voltage Conductor Survival after
        a Pace-Sense Conductor Fracture



                   Months afte...
Potential Drawbacks of Abandoning
Non-Infected ICD Leads
 Lead “chatter” causing spurious shocks
 Insulation breach in poc...
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 lead
replacement

                        Additional ICD lead            Replaced IC...
REPLACE: major complications by lead addition or
                  revision.




                          Poole J E et al...
Factors to Consider
Patient age and gender (elderly women higher risk)
Overall health
Previous cardiac surgery
Number of l...
My “Rules of Thumb”

 No more than 5 leads through SVC
 No more than 4 leads from one side
 No more than one defibrillatio...
Figure 1


Subacute lead perforation




                           Danik et al. Heart Rhythm 2008;5:1667
Figure 1

Generator exchange is associated with an increased rate of Fidelis lead

failure




                           ...
What to do during elective replacement
 upgrade of ICD with not failed Fidelis
 lead?
“Benign neglect”
“The minimalist” Ne...
Programmable sensing vector in new MDT ICDs
Patient “downgraded” from CRTD to CRTP 13
months ago. Fidelis lead programmed unipolar
pace/sense. Lead fracture to the ti...
BiV capture




Native LBBB




LV pacing
  with
  fusion
Physicians who perform lead
extraction change their implant
techniques

Use leads with excellent long-term
track records.
...
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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  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
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    Jun. 23, 2015

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