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Icd lead extraction ba nov 2012 final
1. Cuándo, a quién y cómo explanto
un catéter de desfibrilador
Sergio L. Pinski
Cleveland Clinic Florida
Weston, Florida, USA
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.
4. Conductor fracture Insulation defect and
secondary to conductor fracture
compression secondary to pinching
Gradau et al. PACE 2003;26:649
5. Insulation defect due to Insulation defect due
abrasion to traction from lead
migration
Gradau et al. PACE 2003;26:649
6.
7. Figure 1
Hauser et al. Heart Rhythm 2011; 9:742
8. Kaplan-Meier curve for all-cause lead removal or capping
Borleffs et al. Circ Arrhythm Electrophysiol 2009;2:411
9. Kaplan-Meier curve for lead failure comparing all leads with the
leads from Boston Scientific, Medtronic, and St Jude Medical,
grouped by lead diameter
10. Strategies for ICD lead problems
Ignore it, reprogram around
Repair lead
Add pacing/sensing lead
Add new defibrillation lead
Extract and replace defibrillation
lead
11. 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
12. 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
13. 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
27. 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
28. 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
34. Figure 1
Generator exchange is associated with an increased rate of Fidelis lead
failure
Lovelock et al. Heart Rhythm 2012;9:16157
35. 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
37. 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.
39. 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
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.
