Indications For Lead Extraction Research Articles

Lead Extraction-Indications, Procedure, and Future Directions.

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

JCS/JHRS 2021 guideline focused update on non-pharmacotherapy of cardiac arrhythmias.

JCS/JHRS 2021 guideline focused update on non-pharmacotherapy of cardiac arrhythmias.

Efficacy and mortality of rotating sheaths versus laser sheaths for transvenous lead extraction: a meta-analysis

BackgroundRotating and laser sheaths are both routinely used in transvenous lead extraction (TLE) which can lead to catastrophic complications including death. The efficacy and risk of each approach are uncertain. To perform a meta-analysis to compare success and mortality rates associated with rotating and laser sheaths.MethodsWe searched electronic academic databases for case series of consecutive patients and randomized controlled trials published 1998–2017 describing the use of rotating and laser sheaths for TLE. Among 48 studies identified, rotating sheaths included 1,094 patients with 1,955 leads in 14 studies, and laser sheaths included 7,775 patients with 12,339 leads in 34 studies. Patients receiving rotating sheaths were older (63 versus 60 years old) and were more often male (74% versus 72%); CRT-P/Ds were more commonly extracted using rotating sheaths (12% versus 7%), whereas ICDs were less common (37% versus 42%), p > 0.05 for all. Infection as an indication for lead extraction was higher in the rotating sheath group (59.8% versus 52.9%, p = 0.002). The mean time from initial lead implantation was 7.2 years for rotating sheaths and 6.3 years for laser sheaths (p > 0.05).ResultsSuccess rates for complete removal of transvenous leads were 95.1% in rotating sheaths and 93.4% in laser sheaths (p < 0.05). There was one death among 1,094 patients (0.09%) in rotating sheaths and 66 deaths among 7,775 patients (0.85%) in laser sheaths, translating to a 9.3-fold higher risk of death with laser sheaths (95% CI 1.3 to 66.9, p = 0.01).ConclusionsLaser sheaths were associated with lower complete lead removal rate and a 9.3-fold higher risk of death.

Social Media in Physician Education.

BackgroundSocial media has fundamentally changed the practice of medicine. It has taken the medical community by storm, benefited patient care, and has become a leading source for distributing medical information. Social media platforms are a low-cost, low-barrier entry means for health systems to highlight their competitive advantage to patients and providers alike. This study aimed to assess the role of social media in the education of physicians.MethodsTo evaluate the utility of social media in engaging physicians, four vignettes were utilized to highlight Class 1 indications for transvenous lead extraction (TLE), an electrophysiology procedure aimed at removing infected or damaged cardiac device leads. Individuals, via Twitter, were presented with cases and multiple-choice response options to determine the next best step in management.ResultsThe clinical vignettes were seen by more than 18,000 individuals worldwide. Survey results indicated that 83% of individuals who participated had correctly identified class 1 indications for this life-saving procedure. Sixteen percent to 21% of physicians incorrectly identified the next step in the management of Class 1 indications for lead extraction, representing a need for education and an opportunity to inform and educate.ConclusionSocial media may be a useful tool in physician education. However, guidelines and further research are needed to continue to understand the role of social media within the medical field.

Transvenous lead extraction – summary of the experience of a single Bulgarian center – a retrospective study

There has been increased rate of cardiac implantable electronic devices (CIED) implanted worldwide. Respectively the numbers of patients with absolute indications for lead extraction (pacemaker and ICD) grow up exponentially. The aim of our study is to present the initial experience and long-term results of pacemaker and ICD lead extraction in patients treated in Cardiology department of University hospital “Sveta Anna” Sofi a. Material and Methods: Retrospective study was performed of patients with CIED implanted greater than 1 year and indications for lead extraction. Clinical and procedural characteristics, success rate, complications rate, and reinfection rate data were collected and analyzed. Results: In the period August 2016 to May 2021, a total of 54 patients were admitted to our department with an absolute indication for lead extraction. A total of 114 pacemakers and ICD electrodes were extracted during 54 procedures. In 47 patients (87%) was shown complete technical success with removal of all hardware and in 53 patients (98.1%) clinical success of the procedure was found. The incidence of major periprocedural complications requiring urgent cardiac surgery in our series was 2 (3.7%). Follow-up revealed a very low recurrence infection rate – only 1 patient (1.9%). Conclusion: Lead extraction is a safe and effective procedure. The establishment of a specialized center with an organized system for lead extraction is key in achieving excellent short- and long-term results.

P1507Experience in chronical lead extraction with ablation catheter and snare via femoral route

Abstract Background Transvenous lead extraction may become a complicated process and special sheath systems used for extraction may not be available in the laboratory. Transvenous lead extraction from femoral vein by using ablation catheter and snare may be an alternative and cost-effective method to transvenous lead extraction with specialized lead extraction sheaths. The aim of the present study is to evaluate the factors that may be associated with the use of transfemoral technique during extraction of chronically implanted leads. Methods We retrospectively analyzed consecutive patients who underwent transvenous extraction of pacemaker, cardiac resynchronization therapy (CRT) and intracardiac defibrillator (ICD) leads in our institution in between 01.01.2016 and 01.01.2019. The indications for lead extraction were based on the European Heart Rhythm Association recommendations. Manual traction was applied to all leads at the beginning of each case. If manual traction was not successful, a subclavian approach by using locking stylet (Liberator Universal Locking Stylet, Cook Medical) or femoral approach was used. Femoral approach was performed using the flexible 13F long sheath and a second sheath for ablation catheter. Ablation catheter was wrapped around the lead and the tip of the ablation catheter was caught with gooseneck snare. Downward traction was applied on the body of the lead by using ablation catheter and gooseneck snare complex to release either end of the lead. Results A total of 160 leads in 94 patients were extracted during the time interval between 01.01.2016 and 01.01.2019. The indications for extraction were cardiac device related pocket erosion and infection in 71 (75.6%) and lead failure in the 23 (24.4%) cases. Extracted system was ICD in 48 (51.1%), CRT in 9 (9.6%) and pacemaker in 37 (39.3%) cases. The median time from the preceding procedure was 62.5 (IQR:32.3- 95.3) months. Lead extraction was performed by manual traction in 35 (37.2%) patients, by locking stylet method in 7 (7.4%) and by femoral approach in 52 (55.3%) patients. Clinical success was achieved in 93 (98.9%) cases and all of the patients discharged uneventfully without a major complication as death, cardiac avulsion or tear requiring pericardiocentesis or emergent surgery. Procedural success with femoral approach was achieved in 51/52 (98%) patients (99 leads). Ordinal regression revealed the time from the preceding procedure as the only parameter that was significantly associated with the usage of femoral approach (OR:1.065 ( 95% CI 1.039-1.100) p &amp;lt; 0.001). Conclusion Based on our experience, transfemoral approach by using ablation catheter and gooseneck snare seems to be an effective and safe method for chronically implanted lead extraction. It may be particularly be useful when manual traction is unsuccessful and special toolkids are not available for extraction.

Analysis of a 10-year period of lead removal in a referral centre.

Our goal was to analyse all lead extraction procedures (transvenous or open surgery) performed in our centre and the short- and long-term follow-up data from these patients. All lead extractions performed from 2008 to 2017 were retrospectively reviewed for patient characteristics and indications for device implantation; indications for lead extraction; techniques used; peri- and postprocedural complications and short- and long-term follow-up data. A total of 159 patients (282 leads) were included [age 70 (62-78) years; 72% men]. The median follow-up time was 57 (25-90) months. Patients with lead explants were excluded. The most common indication for lead removal was infection (77%). A surgical approach was necessary in 14 patients (9%) owing to unsuccessful transvenous removal (n = 3), large vegetation in the lead (n = 4), concomitant valvular endocarditis (n = 2), other indications for open surgery (n = 4) and complicated transvenous removal (n = 1). Removal was tried for 282 leads. Of those, 256 were completely removed. Clinical success was achieved in 155 individual patients (98%). Complications occurred in 6 patients: 3 persistent infections, 1 stroke and 2 blood vessel ruptures. The procedure-related mortality rate was 2% (n = 3). Lead removal was associated with a high success rate and low all-cause complication and mortality rates. Emergency surgery because of acute complications was rare, and open-heart surgery was most frequently elective and not associated with a worse outcome.

Outcomes of video-assisted thoracoscopic surgery for transvenous lead extraction.

To evaluate the outcomes of video-assisted thoracoscopic surgery (VATS) during transvenous lead extractions (TLEs). Ninety-one high-risk patients who underwent TLE in the operating room from January 1, 2015, to March 31, 2017, were included in the study. Of these, 9 patients underwent VATS during TLE. Their clinical characteristics, indications for lead extraction, and complications associated with TLE in the 9 patients who had VATS were compared with those for the 82 patients who did not have VATS. The mean (SD) age of the study patients was 61 (17) years (64.8% were male). The lead dwell time, number of leads extracted, and clinical comorbidities were similar between the 2 groups. Superior vena cava (SVC) tear occurred in 2 of the 9 patients in VATS group and in 1 of the 82 in the non-VATS group (22.2%vs. 1.2%, P=0.03). Of the 2 patients in the VATS group who had SVC tears, in 1 the tear was visualized immediately and there was no hemodynamic compromise. In the other patient, the SVC tear was within the pericardium; the blood pressure recovered quickly after sternotomy and repair. Both patients had complete lead extraction and survived hospitalization. The patient in the non-VATS group who had an SVC tear had a successful repair but died of postoperative complications. Utilization of VATS to facilitate TLE is beneficial for early recognition of SVC tear and timely surgical repair in select high-risk patients.

Consensus document on management of cardiac implantable electronic de­vice leads and lead extraction

New expert consensus document is a result of cooperation of 10 worldwide scientific societes, including HRS and EHRA, updates knowledge and recommendations on management of cardiac implantable electronic device leads and lead extraction. The definition of extraction clinical success was changed limiting the residual part of the lead left in cardiovascular system to 4 cm. Significant part of the document is dedicated to diagnosis of lead failure and its differential diagnosis with other reasons which cause a lead malfunction. New precise definition of different examples of infective complication of CIED from pocket erosion to CIED endocarditis were established. Antibiotic therapy is necessary after all extractions due to infective complication but its longevity should be form 10 days to 6 weeks or more depending on the final diagnosis. All infective indications for lead extraction except for superficial incisional infection belongs to class I indications. Numerous indications for lead extraction due to non-infective indications were simplified and class of recommendation has been lowered. Periprocedural management of patients has been described in details. Risk factors of complications and long term mortality were listed.

Differences in laser lead extraction of infected vs. non-infected leads.

We investigated the effect of systemic infection or lead endocarditis on the complexity and the success of laser lead extraction (LLE) procedures. Medical records of all patients undergoing LLE between January 2012 and March 2017 were screened with regard to information on systemic infection or lead endocarditis. We treated 184 patients using high-frequency 80Hz laser sheaths in patients with lead implant duration of ≥ 12months. Indications for lead extraction were systemic infection and lead endocarditis in 52 cases (28.3%), local infection in 74 cases (40.2%), lead dysfunction in 37 cases (20.1%) and other indications in 21 cases (11.4%). 386 leads were scheduled for LLE: 235 (60.9%) pacing, 105 (27.2%) ICD and 46 (11.9%) CS leads. The mean time from initial lead implantation (systemic infection 96.8 ± 74.7months vs. 102.1 ± 82.6 non-infected: months; p = 0.4155) and ratio of ICD leads (26.8 vs. 27.4%; p = 0.3411) did not differ significantly between the two groups. Complete procedural success was significantly higher in the systemic infection group (100 vs. 94.7%; p = 0.0077). The mean laser treatment (60.2 ± 48.7 vs. 72.4 ± 61.5s; p = 0.2038) was numerically lower in the infection group, while fluoroscopy time (9.3 ± 7.6 vs. 12.8 ± 10.3min; p = 0.0275) was significantly lower in this group. Minor and major complications were low in both groups and did not reveal any statistically significant difference (infected group: one minor complication; pocket hematoma, non-infected: three major complications; emergent sternotomy due to pericardial tamponade). No extraction related mortality was observed. The presence of systemic infection or lead endocarditis in LLE procedures allows for higher complete procedural success. When compared with LLE of non-infected leads, the infected leads require less laser and fluoroscopy times. Due to the scarcity of minor and major complications in general, no statistical significance was found in that regard.

Procedural outcomes and long-term survival associated with lead extraction in patients with abandoned leads

The decision to abandon or extract superfluous sterile leads is controversial. The purpose of this study was to compare procedural outcomes and long-term survival of patients with and those without abandoned leads undergoing lead extraction (LE). Retrospective review of all patients who had undergone transvenous LE at our institution from January 2007 to May 2016 was performed. Patients were stratified into 2 groups based on the presence (group 1) or absence (group 2) of abandoned leads. Among 774 patients who had undergone LE procedures, 38 (4.9%) had abandoned leads (group 1). Dwell time of the oldest extracted lead was longer in group 1 vs group 2 (7.6 ± 4.9 years vs 5.6 ± 4.4 years; P = .017), as was infection as an indication for LE (76% vs 33%; P <.001). A bailout femoral approach was more commonly required in group 1 than in group 2 (18.4% vs 6%; P=.007). Complete procedural success rates were similar (92.1% in group 1 vs 95.0% in group 2; P = .439), but there was a trend toward lower clinical success in group 1 (92.1% vs 97.4%; P=.088), primarily due to failure to remove all hardware in the setting of infection. Major procedural complication rates were similar (2.6% in group 1 vs 1.2% in group 2; P = .397), as was long-term survival (mean follow-up 2.3 ± 2.2 years). Abandoned leads at the time of LE were associated with increased procedural complexity, including a higher rate of bailout femoral extraction, and may be associated with lower clinical success. Among appropriately selected patients, consideration should be given to LE instead of abandonment.

Safety and efficacy of the new bidirectional rotational Evolution® mechanical lead extraction sheath: results from a multicentre Italian registry

The aim of this prospective multicentre study is to evaluate safety and efficacy of the new bidirectional rotational mechanical lead extraction (LE) sheath (Evolution RL, Cook Medical, USA) in chronically implanted leads (>1-year-old leads). Between September 2013 and June 2016, a total of 238 leads in 124 consecutive patients were removed by using the new Evolution RL rotational mechanical sheath. Indications for LE were cardiac device infection in 63 (50.8%) cases, lead malfunction in 41 (33.1%), upgrade in 1 (0.8%) case and for other reasons in the remaining 19 cases (15.3%). Ninety-one leads (38.2%) were implantable cardioverter defibrillator leads (81 dual coil vs. 10 single coil), 38 (16%) right ventricular leads, 86 (36.1%) right atrial leads, and 23 (9.7%) coronary sinus leads. The mean implant duration was 92.2 ± 52.9 months (range 12-336). 91.6% of the leads (218/238) were extracted completely with the Evolution RL alone, with the complete success rate rising to 98.7% (235/238 leads) with combined use of a snare. Overall clinical success rate was 100%. No Evolution sheath-related complications were noted. There were no deaths or major complications. Five minor complications (4%) were encountered. In cases of companion leads no wrapping or lead damage were observed. On the basis of our prospective multicentre study, the new hand-powered bidirectional rotational mechanical LE sheath is an effective and safe tool for the extraction of chronically implanted leads without major complications and lead wrapping or lead damage.

176-64: Lead extraction with high frequency laser sheaths: a single-center experience

Objectives: The aim of the study was to present a single-center experience of pacemaker (PM) and implantable cardioverter defibrillator (ICD) laser lead extraction using new laser sheaths, which deliver a rate of 80 pulses per second, mainly as minimally invasive procedures. Methods: Data from 239 leads and 101 procedures were collected between January 2012 and August 2015. Indications for lead extraction were; local infection 49.5%, systemic infection 29.7%, lead dysfunction 15.8%, upgrade from PM to ICD 3.0% and tricuspid insufficiency 2.0%. Extraction procedures were performed in hybrid operating room with patients under general anesthesia with continuous invasive arterial blood pressure and 3D TEE monitoring. Results: The high frequency laser technique was used to extract 137 PM and 102 ICD leads. Mean implantation duration was 96.5 ± 65.5 months (range 24–408). Leads were completely removed 96.2% of the time, with a 98.0% clinical success rate whereby clinical goals associated with the indication for lead extraction were achieved. Patients were 65.7 ± 14.5 years of age (range 18–90), and 74.3% were men. Complications were observed in three patients, including one minor and two major complications. No extraction related mortality occurred. Conclusions: The high frequency 80 Hz laser sheaths allow for safe and effective and successful extraction of chronically implanted PM and ICD leads, combining high procedural success with low complication rates.

Evaluation of lead extraction procedures using the Evolution Mechanical Dilatator Sheath lead extraction system: A single centre experience

In recent years, there has been an increase in clinical situations requiring extraction of leads of implanted cardiac devices. This study aimed to evaluate the Evolution Mechanical Dilator Sheath system, presently in use in our clinic for lead extraction procedures. Lead extraction procedures carried out on 20 patients (14 men, 6 women; mean age 61±19; range 23 to 85 years) between 2008 and 2013 using the Evolution system were retrospectively evaluated. Procedural success, and major and minor complications were determined by previously published guidelines. Mean implantation duration of the leads was 97±65 months (8-204). Fifteen (75%) patients had undergone pacemaker implantation and 5 (25%) had been implanted with a defibrillator. A total of 35 leads were removed from the patients. Seventeen (49%) were ventricular and 12 (34%) were atrial. Five (14%) were defibrillator coils and 1 a coronary sinus lead. Indications for lead extraction were device infection in 18 (90%) patients and lead dysfunction in 2 (10%). Complete procedural success was 95%. Failure occurred in 1 patient. The major complication rate was 5% and minor complications were seen in 25% of patients. No case of mortality was present. In this single centre study, it was shown that extraction of pacemaker and defibrillator leads of longer implant duration may be successfully carried out using the Evolution system. However, due to potentially serious complications it is advised that extraction be done by an experienced operator in centres with cardiovascular surgery facilities.

Predictors of Long-Term Survival Following Transvenous Extraction of Defibrillator Leads.

Little data exist on long-term outcomes following extraction of implantable cardioverter defibrillator (ICD) leads, particularly for noninfectious indications. We sought to identify predictors of long-term survival after ICD lead extraction. We retrospectively reviewed ICD lead extractions at our institution (n = 508). Procedural outcomes and long-term survival were ascertained by medical records review. Indication for lead extraction was infection in 32.5% and lead failure in 61.8%. Mean dwell time of the oldest extracted lead was 5.1 ± 5.9 years. Complete procedural success was achieved in 96.5% of cases. Major procedure-related complications occurred in 1.6% with six periprocedural deaths. During a mean follow-up of 866 ± 798 days, survival was significantly worse among patients with infection as the indication for extraction. At 1 year after extraction, survival among those with infection was 88.2%, compared to 95.0% in the lead failure cohort (P < 0.001). Procedural failure was a significant predictor of long-term mortality, even after excluding periprocedural deaths. In multivariate models, the presence of chronic kidney disease, increased number of leads requiring extraction, lower ejection fraction, and procedural failure were predictors of mortality. Despite high rates of procedural success, infectious indication for ICD lead extraction is associated with increased long-term mortality. In contrast, among patients undergoing extraction for lead failure, long-term survival was excellent. The presence of procedural failure was a significant predictor of long-term mortality. Further studies will be necessary to better understand the mechanisms by which procedural failure may adversely impact long-term outcomes.

Results of transvenous lead extraction of coronary sinus leads in patients with cardiac resynchronization therapy

Background The need for transvenous lead extraction procedures of coronary sinus (CS) leads is increasing due to rising numbers of implanted cardiac resynchronization therapy devices during the past decade. Methods From January 2009 to June 2013, 27 CS leads were scheduled for extraction in 27 patients (mean age (63.1±14.6) years). Indications for lead extraction were infection in 13 and lead dysfunction in 14 cases. Isolated extraction of CS leads was performed in eight, extraction of multiple leads in 19 cases. Among leads with an implant time of ≥12 months (n=19) mean implant duration (MID) was (46.4±15.2) (12-76) months. Groups were formed depending on infectious or non-infectious indications (INF vs. Non-INF), and the use or non-use of extraction tools (ET1 vs. ET0). Results Among patients with an implant duration of ≥12 months, complete procedural success was 94.7% and clinical success 100%. Operative mortality was zero. In the INF versus NON-INF groups complete procedural success (100% vs. 91.7%, P=0.43), mean number of required extraction tools (0.7 (0-2) vs. 0.9 (0-3), P=0.65) and MID (49.1±15.0 vs. 44.7±15.8, P=0.83) did not differ significantly. Comparing the groups ET1 and ET0 showed no significant differences in complications (n=1 vs. n=1, P=0.81) and MID (47.0±17.5 vs. 45.5±12.6, P=0.71). Conclusions In specialized centers transvenous lead extraction of coronary sinus leads with a mean implant duration of almost four years can be performed safely and effectively. Neither non-infectious indications nor the use of extraction tools negatively affected the outcome of the procedure.

Predictors of Advanced Lead Extraction Based on a Systematic Stepwise Approach: Results from a High Volume Center

Lead extraction (LE) techniques have evolved from simple traction to extraction with dilators and powered sheaths with very high success rates. On the basis of the systematic implementation of a stepwise approach, we aimed to identify those characteristics that can predict the need for advanced LE techniques. Between April 2005 and March 2012, 208 consecutive LE procedures were performed and 456 leads were extracted using an initial superior approach. Advanced techniques for LE (step 4 according to our stepwise approach) were used in 122 patients (58.7%). Younger patient age (odds ratio [OR] = 0.963, P = 0.002), longer duration of the initial implantation (OR = 1.013, P = 0.002), the number of extracted leads (OR = 2.184, P < 0.001), and the presence of right ventricular defibrillator leads (OR = 2.144, P = 0.049) independently predicted the necessity of using step 4 in multivariate analysis. A prediction tool was created taking into account four categorical variables derived even from Receiver Operating Curve analysis of quantitative characteristics (age < 70.7 years, implant duration > 37 months, extraction of at least two leads, one of them being a defibrillator lead). The absence of all the four characteristics was accompanied by 0% positive predictive value for the requirement of step 4 for LE, whereas the coexistence of all four risk factors is characterized by 87% requirement of advanced LE. In most of the patients with indication for LE, use of a powered sheath extraction is necessary in order to obtain clinical success. We have identified four patient and lead characteristics that may help the operator plan the means of extraction.

Endocardial Lead Extraction in the Polish Registry – clinical practice versus current Heart Rhythm Society consensus

IntroductionOver the last 10 years, there has been an increasing number of patients with pacemaker (PM) and cardioverter-defibrillator (ICD). This study is a retrospective analysis of indications for endocardial pacemaker and ICD lead extractions between 2003 and 2009 based on the experience of three Polish Referral Lead Extraction Centers.Material and methodsSince 2003, the authors have consecutively retrospectively collected all cases and entered the information in the database. All patients which had indication for lead extraction according to Heart Rhythm Society Guidelines were included to final analyze. Between 2003 and 2005, the data were analyzed together. Since 2006, data have been collected and analyzed annually.ResultsIn each year, a significant increase in lead extraction was observed. The main indications for LE were infections in 52.4% of patients. Nonfunctioning lead extraction constituted the second group of indications for LE in 29.7% of patients. During the registry period, the percentage of class I indications decreased from 80% in 2006 to only 47% in 2009. On the other hand, increasingly more leads were removed because of class 2, especially class 2b. In 2009, 40% of leads were extracted due to class 2b.ConclusionsPolish Registry of Endocardial Lead Extraction 2003-2009, shows an increasing frequency of lead extraction. The main indication for LE is infection: systemic and pocket. An increase in class 2, especially 2b, LE indication in every center during the study period was found.

Results of transvenous lead extraction of coronary sinus leads in patients with cardiac 4,703 resynchronization therapy.

The need for transvenous lead extraction procedures of coronary sinus (CS) leads is increasing due to rising numbers of implanted cardiac resynchronization therapy devices during the past decade. From January 2009 to June 2013, 27 CS leads were scheduled for extraction in 27 patients (mean age (63.1 ± 14.6) years). Indications for lead extraction were infection in 13 and lead dysfunction in 14 cases. Isolated extraction of CS leads was performed in eight, extraction of multiple leads in 19 cases. Among leads with an implant time of ≥ 12 months (n = 19) mean implant duration (MID) was (46.4 ± 15.2) (12-76) months. Groups were formed depending on infectious or non-infectious indications (INF vs. Non-INF), and the use or non-use of extraction tools (ET1 vs. ET0). Among patients with an implant duration of ≥ 12 months, complete procedural success was 94.7% and clinical success 100%. Operative mortality was zero. In the INF versus NON-INF groups complete procedural success (100% vs. 91.7%, P = 0.43), mean number of required extraction tools (0.7 (0-2) vs. 0.9 (0-3), P = 0.65) and MID (49.1 ± 15.0 vs. 44.7 ± 15.8, P = 0.83) did not differ significantly. Comparing the groups ET1 and ET0 showed no significant differences in complications (n = 1 vs. n = 1, P = 0.81) and MID (47.0 ± 17.5 vs. 45.5 ± 12.6, P = 0.71). In specialized centers transvenous lead extraction of coronary sinus leads with a mean implant duration of almost four years can be performed safely and effectively. Neither non-infectious indications nor the use of extraction tools negatively affected the outcome of the procedure.

Pathways for training and accreditation for transvenous lead extraction: a European Heart Rhythm Association position paper

### Introduction The European Heart Rhythm Association charged the present writing committee with the task of producing a consensus document on training and accreditation for transvenous extraction of chronically implanted pacing and defibrillator leads.1,2 The core curriculum for the European Heart Rhythm Specialist includes implantation of heart rhythm devices but does not specifically mandate learning and accreditation for extraction techniques.3 The lack of such recommendations is related to the limited number of extractions available for training purposes and attaining competency. The present document focuses on the rising burden and the increasing complexity of techniques of lead extraction with an emphasis on the critical issues of training, accreditation, and documentation of results. There is also an educational component felt necessary to include by the Task Force in view of the specialized and emerging nature of this field. Where appropriate, a European perspective is presented and paediatric aspects are treated separately. The aim is to complement two recently published documents, one from the Heart Rhythm Society (HRS)4 on facilities, training, indications, and management of transvenous lead extraction and the other from the American Heart Association on device-related infections.5 The indications for lead extraction have not changed since these publications and are therefore not covered in this present document. ### Need for lead extraction/removal—a European perspective Due to improving recognition of clinical need and wider indications, the implant rate of Cardiovascular Implantable Electronic Devices (CIED) continues to rise in most countries.6,7 The number of leads per patient is increasing with cardiac resynchronisation therapy–pacemaker/defibrillator, upgrades and a higher proportion of dual vs. single-chamber devices. As life expectancy has risen, so have the number of generator and lead changes despite advances in technology. Product advisories are inevitable despite overall improvements in reliability and have led to surges in extraction.8–10 Currently, infection accounts …