Minimally Invasive Techniques to Avoid Sternotomy in Complex Lead Extraction Cases.

Ryan Azarrafiy,Roger Carrillo

doi:10.19102/icrm.2019.100201

Abstract

Cardiac device lead extractions have increased in frequency over the past several years. Although most of these procedures are successfully performed through a percutaneous approach, certain cases may be unmanageable using conventional methods. The traditional approach for such complex cases has been median sternotomy. However, four surgical techniques offer a less-invasive alternative. These include the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy. In the present study, we reviewed data from patients who underwent minimally invasive, surgical lead extraction at our institution from January 2003 to October 2017 using an ongoing, prospective registry. Summary statistics were generated for age, sex, device extracted, lead dwell time (years), procedure indication, major/minor complications and procedural success as defined by the 2017 Heart Rhythm Society consensus statement, and survival at discharge. Between January 2003 and October 2017, 14 cases at our center were managed via a transatrial approach, whereas 11 involved the subxiphoid approach, 19 involved a left minithoracotomy or thoracoscopy, and one involved a ministernotomy. For the transatrial approach, all cases were classified as procedural successes and all patients were discharged alive. Additionally, for the subxiphoid approach, all cases were deemed procedural successes, whereas survival at discharge was 90.9%. For the left minithoracotomy/thoracoscopy, all cases were procedural successes and survival at discharge was 94.7%. Lastly, the ministernotomy was successfully used to remove an infected, retained lead fragment from the innominate vein. In conclusion, at our institution, the transatrial approach, the subxiphoid approach, the left minithoracotomy/thoracoscopy, and the ministernotomy were used as minimally invasive, surgical approaches that represent fairly safe and effective alternatives to median sternotomy in complex cases unamenable to management via conventional, percutaneous approaches to lead extraction.

Highlights

Cardiac implantable electronic devices (CIEDs) represent a defined cornerstone of medical practice, as millions of patients worldwide continue to demonstrate cardiac arrhythmias requiring treatment with these devices.[1]
The transatrial approach involves a minimally invasive incision to remove leads directly from the right atrium under fluoroscopic guidance. This procedure offers an alternative to median sternotomy for leads that have perforated the right atrium or lead fragments that have been abandoned and that cannot be retrieved by conventional, transvenous techniques
Out of 1,480 lead extractions performed at our center from January 2003 to October 2017, 45 cases (3%) involved a minimally invasive, surgical approach

Summary

Introduction

Cardiac implantable electronic devices (CIEDs) represent a defined cornerstone of medical practice, as millions of patients worldwide continue to demonstrate cardiac arrhythmias requiring treatment with these devices.[1] Yet, in rare circumstances, CIEDs can become infected or malfunction. In these cases, removal of both the device generator and its associated leads is indicated. Lead extraction has been proven to be a safe and effective procedure that is performed almost exclusively through a percutaneous approach. Electrophysiologists choose to perform the extraction through the subclavian vein, or, in more complex cases, through the

Methods

Results

Conclusion