10. Effect of pacemaker/defibrillator lead extraction on pulmonary artery systolic pressure

Abstract

As the number of cardiac device implantations are on a rise, there is a parallel increase in their long-term complications including device-related infection that will require lead extraction. As the detachment of fibrosed debris reaching the pulmonary trunk can occur during the extraction, the risk of developing new-onset Pulmonary Hypertension (P. HTN) increases with every extraction. Yet, there is paucity of evidence to support such claim. Given the clinical significance of such findings, we sought to determine the risk. A chart review of 113 patients whom underwent lead extraction at Prince Sultan Cardiac Center in Saudi Arabia during the period of Jan, 2002 to Jul, 2015 was carried out. Six patients had lead extraction twice, making the total number of extractions to be 119. Of this study cohort, only 45 cases had Pulmonary Artery Systolic Pressure (PASP) measurement via Transthoracic Echocardiography (TTE) prior to and after device extraction. PASP measurements were obtained as reported whether a single measurement or a range between two readings, and an average was calculated in case of two readings. A difference of 10 mmHg or more in the PASP, whether progression or improvement, was considered clinically significant.Median follow up of TTE after lead and device extraction was 5 months. Out of 45 patients, 31 (68.9%) were males and 14 (31.1%) were females. Average age was 46.5 (SD = 17) years. Eleven patients (24.4%) experienced a significant increase of PASP after lead extraction (10 had normal pressure readings before extraction, and only one had progression to a more severe form of the disease), 9 patients (20.0%) showed improvement, and the remaining (55.6%) did not show any significant change in PASP. Average implantation-to-extraction duration of the leads was higher among those who had no pressure difference (50.6 vs. 23.3 months). When looking through potential predictors that may increase the likelihood of developing P. HTN, there was no association with a pre-existing lead-attached vegetation (2 patients only), nor the type of lead (6 high-voltage vs. 5 pacing leads across the tricuspid valve). In patients who developed P. HTN, 8 (72.7%) had their devices extracted as a result of a complicated infection (wound infections and/or infective endocarditis), as opposed to 3 (27.3%) whom underwent device extraction for other indications. Our simple descriptive study showed that the risk of developing P. HTN following lead and device extraction is negligible. However, our findings should be interpreted in the light of the limitations such as a small sample size and lack of comparable control group. Paucity of data and evidence on the long-term complications subsequent to device and lead extractions will be a subject of further exploration given the potential connection to patient outcomes and management.