Evolution in Transvenous Extraction of Pacemaker and Implantable Cardioverter Defibrillator Leads Using a Mechanical Dilator Sheath

Abstract

With developing technology, transvenous lead extraction (TLE) has undergone an explosive evolution due to incremental problems related to lead infection and malfunction. We aimed to present our experience in TLE with the Evolution®Mechanical Dilator Sheath (Cook Medical, Grandegrift, PA, USA). Between June 2009 and July 2011, the Evolution®mechanical dilator sheath was used for the extraction of 140 pacemaker (PM) and implantable cardioverter-defibrillator (ICD) leads in 66 patients. Indications for extraction, procedural success, and complications were defined according to Heart Rhythm Society Guidelines. Indications for TLE were infection in 39 patients (59.1%), lead malfunction in 26 patients (39.4%), and lead displacement in one patient (1.5%). Extracted devices were PM in 28 cases (42.3%), ICD in 26 cases (39.4%), and biventricular cardioverter defibrillator in 12 cases (18.2%). Among 140 leads, 31 (22.1%) were right ventricular, 49 (35.0%) were defibrillator coil, 47 (33.6%) were atrial, and 13 (9.3%) were coronary sinus electrodes. The median time interval from the lead implantation to lead extraction was 85 months (range 22-240 months). Complete procedural success with the Evolution®system alone was achieved in 58 (87.9%) patients and overall clinical success was 98.5%. Four leads were completely removed with the help of a femoral snare and partial success was achieved in three leads with a remaining small ventricular tip. Major complication was observed in only one (1.5%) patient without any mortality. Our experience confirms that the hand-powered Evolution system is an effective extraction tool for chronically implanted PM/ICD leads. Randomized controlled studies are required to evaluate success and complication rates in comparison to other techniques.