Laser-assisted Lead Extraction Research Articles

Octogenarian patients and laser-assisted lead extraction: Should we put a limit?

Transvenous laser lead extraction (TLE) for cardiac implantable electric devices (CIED) is a challenging procedure especially if performed in octogenarians. In this study we evaluated the safety and efficacy of transvenous laser lead extraction in elderly patients. This is a retrospective study of octogenarian patients who underwent laser-assisted lead extraction (LLE) (GlideLight laser sheath, Philips, San Diego, USA). 270 Consecutive patients were included. Patients were divided into two groups. Octogenarian group and non-octogenarian group. The Data was gathered from patients treated between September 2013 and January 2020 and is retrospectively analyzed. Of 270 consecutive patients, 38 (14.0%) were 80 years old or more. The total number of the extracted leads was 556 among which 84(15.0%) from the Octogenarian group. From these leads were 155 single coil leads, 82 dual coil leads, 129 right ventricular pacing leads, 155 right atrial leads, and 35 left ventricular leads. In the Octogenarian group the number of removed leads was as follows: 13 single coil leads, 10 dual coil leads, 28 right ventricular pacing leads, 28 right atrial leads and 5 left ventricular leads. No mortality was recorded in the Octogenarian group. One patient in the YG suffered from a superior vena cava tear and one patient suffered from pulmonary embolism. In octogenarian laser assisted lead extraction patients is a safe and effective procedure. No increase in morbidity, mortality or perioperative complication could be recorded in this group. Age should not be a limiting factor to perform this procedure.

The use of laser lead extraction sheath in the presence of supra-cardiac occlusion of the central veins for cardiac implantable electronic device lead upgrade or revision

The implantation of cardiac implantable electronic devices (CIED) has increased in the last decades with improvement in the quality of life of patients with cardiac rhythm disorders. The presence of bilateral subclavian, innominate or superior vena cava obstruction is a major limitation to device revision and/or upgrade. This is retrospective study of patients who underwent laser-assisted lead extraction (LLE) (GlideLight laser sheath, Spectranetics Corporation, Colorado Springs, USA) with lead revision or upgrade using the laser sheath as a guide rail. Patients with known occlusion, severe stenosis or functional obstruction of the venous access vessels with indwelling leads were included in this study. 106 patients underwent percutaneous LLE with lead revision and/or upgrade. Preoperative known complete occlusion or severe stenosis of access veins was present in 23 patients (21.5%). More patients with implantable cardioverter-defibrillator (ICD) underwent LLE (64.1%) than patients with CRT-Ds (24.5%) and pacemaker patients (11.3%). In total 172 leads were extracted: 79 (45.9%) single-coil defibrillator leads, 35 (20.3%) dual-coil defibrillator leads, 31 (18.0%) right atrial leads, 24 (13.9%) right ventricular leads and three (1.7%) malfunctional coronary sinus left ventricular pacing leads. The mean age of leads was 99.2±65.6 months. The implantation of new leads after crossing the venous stenosis/obstruction was successful in 98 (92.4%) cases. Postoperative complications were pocket hematoma in two cases and wound infection in one case. No peri-operative and no immediate postoperative death was recorded. One intraoperative superior vena cava tear was treated by immediate thoracotomy and surgical repair. In a single-center study on LLE in the presence of supra-cardiac occlusion of the central veins for CIED lead upgrade and revision we could demonstrate a low procedural complication rate with no procedural deaths. Most of the leads could be completely extracted to revise or upgrade the system. Our study showed a low complication rate, with acceptable mortality rates.

Transvenous excimer laser-assisted lead extraction of cardiac implantable electrical devices in the Japanese elderly population

BackgroundThe feasibility and safety of lead extraction of cardiac implantable electronic devices (CIEDs) in the elderly Asian population remain uncertain. We report the outcome and safety of transvenous excimer laser-assisted lead extraction of CIEDs in Japanese patients aged ≥80 years. MethodsConsecutive 235 patients (age 67±15 years, 167 male) undergoing lead extraction of CIED with an excimer laser system (Philips, Andover, MA, USA) were included. ResultsOf 235 consecutive patients, 51 (22%) were ≥80 years (age 86±5 years, 14 were aged ≥90 years; 42 had pacemakers, 3 had implantable cardioverter defibrillators, and 6 had cardiac resynchronization therapy devices). The median implant duration was 110±95 months. Patients aged ≥80 years had lower body mass index (BMI, 20.7±3.1kg/m2 vs. 22.6±3.4kg/m2, p<0.001), higher incidence of CIED infection (98% vs. 63%, p<0.010), and longer duration of hospitalization (31±17 days vs. 24 ± 31 days, p<0.001) than patients aged <80 years. There were no differences between the age groups in the rate of complete retrieval (94.1% vs. 95.1%, p=0.726) and major complications, including cardiac tamponade and cardiogenic shock (2.0% vs. 2.7%, p=1.000). ConclusionsExcimer laser-assisted lead extraction was safe and feasible in the Japanese elderly population with low BMI, despite the high likelihood of procedural complications. Early removal of infected CIEDs should be performed without delay in elderly Asian populations.

Efficacy and safety of transvenous lead extraction in 108 consecutive patients: a single-centre experience.

The number of cardiac implantable electronic devices is growing worldwide because they play a relevant role in improving the survival rate in patients with specific heart diseases. Cardiac implantable electronic devices complications including infection, dysfunction or venous stenosis increase the need for the least traumatic way to explant leads. Our goal was to report the successes and procedural complication rates of transvenous lead extraction (TLE) in a consecutive series of patients. From 2010 to 2016, 108 patients underwent TLE of 227 leads due to endocarditis (n = 21; 19%), pocket infection (n = 58; 54%) or lead dysfunction (n = 29; 27%). In 98% (n = 106) of the patients, laser-assisted lead extraction was performed. In 2% (n = 2) of the patients, the application of a solitary locking stylet was sufficient. The patient mean age was 68 ± 14 years; 25% of the patients had previous cardiac surgery. TLE was performed a mean of 9 ± 6 years after the implantation of the existing device. Complete procedural success (removal of all lead material from the vascular space) was achieved in 98.7% (n = 224), and clinical success (achievement of all clinical goals associated with the indication for lead removal and absence of major complications) was achieved in 98% (n = 106). In 2 patients the procedure failed due to a vascular tear requiring a thoracotomy. In 1 patient, complete lead extraction was not possible due to heavy calcification (coronary-sinus lead). The 30-day mortality rate was 3.7% (n = 4); the patients died of multiorgan failure (n = 1), cardiac failure (n = 1) and septicaemia (n = 2). The procedure-related major complication rate was 2% (n = 2). Laser-assisted TLE seems to be a safe and effective procedure with an acceptable complication rate.

543New onset of phrenic nerve palsy after laser-assisted transvenous lead extraction: a single-centre experience

543New onset of phrenic nerve palsy after laser-assisted transvenous lead extraction: a single-centre experience

Innominate artery injury during routine laser assisted lead extraction

Laser assisted lead extraction is a relatively safe procedure; however, it is an invasive procedure which could involve significant increase in morbidity and mortality associated with risk of concomitant arterial and venous injuries. We report a 69-year-old patient sustained an iatrogenic perforation to subclavian vein and transection of the innominate artery during laser lead extraction, necessitated commencing cardiopulmonary bypass and repair of the injuries.

Creation of the sole regional laser lead extraction program serving Atlantic Canada: initial experience.

An increasing need for laser lead extraction has grown in parallel with the increase of implantation of pacing and defibrillating devices. We reviewed the initial experience of a regional laser-assisted lead extraction program serving Atlantic Canada. We retrospectively reviewed the cases of all consecutive patients who underwent laser lead extraction at the Maritime Heart Centre in Halifax, NS, between 2006 and 2015. We conducted univariate and Kaplan-Meier survivorship analyses. During the 9-year study period, 108 consecutive patients underwent laser lead extractions (218 leads extracted). The most common indication for extraction was infection (84.3%). Most patients were older than 60 years (73.1%) and had leads chronically implanted; the explanted leads were an average of 7.5 ± 6.8 years old. Procedural and clinical success (resolution of preoperative symptoms) rates and mortality were 96.8%, 97.2%, and 0.9%, respectively. Sternotomy procedures were performed in 3 instances: once for vascular repair due to perforation and twice to ensure that all infected lead material was removed. No minor complications required surgical intervention. Survival after discharge was 98.4% at 30 days and 94% at 12 months. Atlantic Canada's sole surgical extraction centre achieved high extraction success with a low complication rate. Lead extraction in an operative setting provides for immediate surgical intervention and is essential for the survival of patients with complicated cases. Surgeons must weigh the risks versus benefits in patients older than 60 years who have chronically implanted leads (> 1 yr) and infection.

Excimer Laser-Assisted Lead Extraction in 88 High-Risk Patients: A Single-Center Experience

Objectives: Laser-assisted lead extraction is a sophisticated and dangerous procedure, especially in patients with old and multiple leads. High frequency Excimer laser with an 80-Hz pulse repetitive rate was applied routinely in our clinic for pacemaker (PM), implantable cardioverter-defibrillator (ICD) or cardiac contractility modulation (CCM) lead extraction.

0382: Transvenous extraction of pacing and defibrillator leads: a highvolume single centre experience

Following the exponential growth of cardiac device implantation, there is an increase of lead extraction indications. In the meantime, the tools, the indications, and the outcomes of those procedures continue to progress. The purpose of this study was to examine contemporary indications, outcomes, and complications of transvenousleadextraction in a large series of patients at a high-volume lead extraction center. We performed a retrospective cohort study of consecutive patients undergoing leadextraction at a single, high-volume center.Our extraction strategy consists in manual traction, locking stylet traction, laser use followed by inferior approach in case of failure. Patient and lead characteristics and the indications, outcomes, and need for laser assistance were analyzed From January 2002 to December 2013, a total of 751 chronic endovascular leads were removed from 391patients.The mean age was years 68 (range 13- 98). Seventy-five percent of patients were males. Median implantation duration was 5,5 years. Indications for extraction were systemic infection (33,3%), pocket infection (25,1%), mechanical lead failure (32,7%), and upgrade of device system (6,1%)due to thrombosis of veinous access. Extraction was successful in 97,7% of patients with complete removal. Laser assistance for extraction wasrecquired in 259 patients (66,2%), completed with an inferior approach in 38 patients(9,7%). Complications were death in 2 patients (0,5%), bleeding in 21 patients (5,4%), pericardial tamponade in 8 patients (2%). In univariate analysis, laser-assisted lead extraction was required more frequently for leads that were implanted more 36 months than others (p<0,001), as well as for passive leads compared to active leads (p=0,04). Lead extraction can be safely and succefully performed in the majority of patients, with limited life-threatening complications.

Cardiopulmonary Bypass Standby Avoids Fatality due to Vascular Laceration in Laser-Assisted Lead Extraction

Vascular laceration is a rare but potentially fatal complication with excimer laser-assisted pacemaker or implantable cardioverter-defibrillator lead extraction. We report our experience on management of vascular laceration during laser-assisted lead extraction. We retrospectively reviewed 140 consecutive patients undergoing laser-assisted lead extraction from May 2004 to March 2011. Clinical outcomes were compared in patients with and without intraoperative vascular laceration. Risk factors were identified by multivariate logistic regression. All cases were performed in the operating room with cardiopulmonary bypass standby. Complete lead removal was achieved in 118 (84.3%) patients. Potentially fatal complications occurred in five patients (3.6%) who had superior vena cava and/or innominate vein laceration. Lacerated veins were repaired under emergency sternotomy and cardiopulmonary bypass. The mean time from vascular laceration to establishment of cardiopulmonary bypass was 6.0 ± 3.6 minutes. All five patients survived without neurological sequelae. The rates of dual-coil leads (80.0% vs. 31.9%, p=0.025) and history of lead revision (100.0% vs. 40.0%, p=0.008) were significantly higher in the five patients who had major vascular laceration than those who did not. Logistic regression showed that dual-coil implantable cardioverter-defibrillator lead was an independent risk factor for vascular laceration (odds ratio 11.264, p=0.048). Cardiopulmonary bypass standby is helpful when performing laser-assisted lead extraction to treat potentially fatal vascular laceration. Dual-coil lead is an independent risk factor to predict intraoperative vascular laceration.

478 The safety of laser-assisted lead extraction with cardiopulmonary bypass standby

478 The safety of laser-assisted lead extraction with cardiopulmonary bypass standby

Pacemaker/ICD lead extraction with the excimer laser sheath: a single center experience

The aim of this study is to investigate the safety and effectiveness of Excimer laser-assisted lead extraction. Consecutive lead extraction in 16 patients using the excimer laser sheath from Veterans Administration Medical Center, University of Minnesota between March 2008 and December 2009 were analyzed retrospectively. The clinical characteristics including basic disease, cardiac function, indication and reason for lead removal, lead characteristic, and complication were summarized. Thirty one leads (laser sheaths were used in 25 leads) in 16 patients [mean age (67.4 ± 9.1) years, range 54 - 82 years] were extracted. All leads were extracted successfully without complication. Most patients had severe heart diseases with left ventricular ejection fraction of 20% - 60% (mean 36.4% ± 13.4%). Mean implant time was (73.9 ± 62.9) months (range 3 - 251 months). Nine patients had Class I indications for lead extraction, 7 patients for Class II indications. Atrial lead fractured in one patient during lead extraction, the remaining part of the lead was taken out from femoral vein by a snare-catheter apparatus. Another patient developed CS dissection and small pericardium perfusion during LV lead implantation (upgrade to BiV-ICD) post successful lead extraction and patient discharged without complication. Our single center experience suggests that Excimer Laser Sheath Lead Removal System is safe and effective in extracting pacemaker and ICD leads.

Device‐Related Infection Among Patients With Pacemakers and Implantable Defibrillators: Incidence, Risk Factors, and Consequences

Device-related infection is a major limitation of device therapy for cardiac arrhythmia. The authors analyzed the incidence and risk factors for cardiac device infection (CDI) among consecutive patients implanted with pacemaker (PM) or implantable cardioverter defibrillator (ICD) (including cardiac resynchronization therapy devices) at a tertiary health center in Hamilton, Ontario, Canada. Most patients with device-related infections were identified by an internal infection control system that reports any positive wound and blood cultures following surgery, between 2005 and the present. A retrospective review of patient records was also performed for all patients who received an ICD or PM between July 1, 2003 and March 20, 2007. A total of 24 infections were identified among 2,417 patients having device surgery (1%). Fifteen of these infections (60%) were diagnosed within 90 days of the last surgical procedure. Univariate analysis showed that patients presenting with CDI were more likely to have had a device replacement, rather than a new implant, had more complex devices (dual/triple chamber vs single), and were more likely to have had a prior lead dislodgement. Multivariate analysis found device replacement (P = 0.02) and cardiac resynchronization therapy (CRT)/dual-chamber devices (P = 0.048) to be independent predictors of infection. One patient developed septic pulmonary emboli after having laser-assisted lead extraction. No patient died and 22 patients received a new device. CDI occurs in about 1% of cases in high volume facilities. Pulse generator replacement surgery and dual- or triple-chamber device implantation were associated with a significantly increased risk of infection.

Lead Extraction in the Contemporary Setting: The LExICon Study: An Observational Retrospective Study of Consecutive Laser Lead Extractions

This study sought to examine the safety and efficacy of laser-assisted lead extraction and the indications, outcomes, and risk factors in a large series of consecutive patients. The need for lead extraction has been increasing in direct relationship to the increased numbers of cardiovascular implantable electronic devices. Consecutive patients undergoing transvenous laser-assisted lead extraction at 13 centers were included. Between January 2004 and December 2007, 1,449 consecutive patients underwent laser-assisted lead extraction of 2,405 leads (20 to 270 procedures/site). Median implantation duration was 82.1 months (0.4 to 356.8 months). Leads were completely removed 96.5% of the time, with a 97.7% clinical success rate whereby clinical goals associated with the indication for lead removal were achieved. Failure to achieve clinical success was associated with body mass index <25 kg/m(2) and low extraction volume centers. Procedural failure was higher in leads implanted for >10 years and when performed in low volume centers. Major adverse events in 20 patients were directly related to the procedure (1.4%) including 4 deaths (0.28%). Major adverse effects were associated with patients with a body mass index <25 kg/m(2). Overall all-cause in-hospital mortality was 1.86%; 4.3% when associated with endocarditis, 7.9% when associated with endocarditis and diabetes, and 12.4% when associated with endocarditis and creatinine > or =2.0. Indicators of all-cause in-hospital mortality were pocket infections, device-related endocarditis, diabetes, and creatinine > or =2.0. Lead extraction employing laser sheaths is highly successful with a low procedural complication rate. Total mortality is substantially increased with pocket infections or device-related endocarditis, particularly in the setting of diabetes, renal insufficiency, or body mass index <25 kg/m(2). Centers with smaller case volumes tended to have a lower rate of successful extraction.

Laser-Assisted Extraction of Pacemaker and Defibrillator Leads: The Role of the Cardiac Surgeon

The development of laser-assisted extraction techniques for chronically implanted pacemaker and defibrillator leads has reduced the need for open surgical removal. Reports of the mortality from laser-assisted extraction range from 1.9% to 3.4%. The purpose of this study was to determine the rate of major cardiovascular injury and emphasize the need for cardiothoracic surgical participation in this procedure. A retrospective cohort study was performed of 112 consecutive laser-assisted lead extractions at a single university medical center during a 6-year period. Patient and lead characteristics were analyzed as well as indications, outcomes, and major complications. Successful lead extraction was accomplished in 103 (92%) of the 112 patients. Elective sternotomy after failure of laser-assisted lead removal was successfully performed in 4 patients. Emergent surgical intervention was required in 4 patients for caval perforation (n = 2), subclavian vein injury (n = 1), or right atrial injury (n = 1). Three of the 4 patients requiring emergent intervention died, for an overall series mortality of 2.6%. In July of 2006, a policy of cardiothoracic surgeon presence during the laser-assisted extraction was instituted. Since that time, there has been one emergent sternotomy and one elective sternotomy for lead removal with no procedure-related deaths. Despite recent advances in laser technology for the removal of pacemaker and defibrillator leads, the potential for major cardiovascular injury and death remains. Involvement of the cardiothoracic surgeon in both the preoperative decision-making process as well as the laser-assisted lead extraction is critical to prevent or emergently treat any major complications.

A single-centre experience of over one thousand lead extractions.

AimsThe aim of the study was to present a single-centre experience of pacemaker and implantable cardioverter defibrillator (ICD) lead extraction using different methods, mainly laser-assisted extraction.Methods and resultsData from 1032 leads and 647 procedures were gathered. A step-by-step approach using different techniques while performing an ongoing risk–benefit analysis was used. The most common indications were local infection, systemic infection, non-functional lead, elective lead replacement, and J-wire fracture. Mean implantation time for all leads was 69 months and for laser-extracted leads 91 months. Laser technique was used to extract 60% of the leads, 29% were manually extracted, 6% extracted with mechanical tools, 4% were surgically removed, and 0.6% extracted by a femoral approach. Failure rate was 0.7%, and major complication rate was 0.9%. No extraction-related mortality occurred. Median time for laser extraction was 2 min. Long implantation time was not a risk factor for failure or for complication.ConclusionPacing and ICD leads can safely, successfully, and effectively be extracted. Leads can often be extracted by a superior transvenous approach; however, open-chest and femoral extractions are still required. Laser-assisted lead extraction proved to be a useful technique to extract leads that could not be removed by manual traction. The results indicate that the paradigm of abandoning redundant leads, instead of removing them, may have to be reconsidered.

Laser-assisted lead extraction: the European experience

The aim of this study is to investigate the safety and effectiveness of Excimer laser-assisted lead extraction in Europe. The final European multi-centre study experience is presented. The Excimer is a cool cutting laser (50 degrees C) with a wavelength of 308 nm. The energy is emitted from the tip of a flexible sheath and is absorbed by proteins and lipids, 64% of the energy is absorbed at a tissue depth of 0.06 mm. The sheath is positioned over the lead, and the fibrosis surrounding the lead is vaporized while advancing the sheath without damaging other leads. From August 1996 to March 2001, 383 leads (170 atrial, 213 ventricular) in 292 patients (mean age 61.6 years, range 13-96) were extracted at 14 European centres. Mean implantation time was 74 months (3-358). Most frequent indications were pocket infection (26%), non-functional leads (21%), patient morbidity (21%), septicaemia or endocarditis (14%), erosion (5%), and lead interference (8%). Median extraction time was 15 min (1-300). Complete extraction was achieved in 90.9% of the leads and partial extraction in 3.4%. Extraction failed in 5.7% of the leads. Major complications = perforations caused 10/22 (3.4/5.7%) of the failures. Most partially extracted patients were considered clinically successful, as only minor lead parts without clinical significance were left. Femoral non-laser technique was used to remove 8/12 of the non-complication failures. The total complication rate, including five minor complications (1.7%), was 5.1%. No in-hospital mortality occurred. Pacing and implantable cardioverter-defibrillator leads can safely, effectively, and predictably be extracted. Open-heart extractions can be limited to special cases. The results indicate that the traditional policy of abandoning redundant leads, instead of removing them, may be obsolete in many patients.

Arteriovenous Fistula After Laser-Assisted Pacemaker Lead Extraction

Acute arteriovenous fistulas have been reported after pacemaker lead extraction. We report a case of an arteriovenous fistula presenting 2 weeks after transvenous laser-assisted lead extraction.

Central Venous Occlusion Is Not an Obstacle to Device Upgrade with the Assistance of Laser Extraction

To assess the efficacy and safety of laser-assisted lead extraction for upgrade of existing pacemakers and defibrillators in patients with central venous obstruction. Implantable cardiac defibrillators and biventricular pacing have become the accepted therapeutic measures for patients with congestive heart failure. Many patients who are candidates for device therapy, however, already have existing right ventricular leads and the presence of central venous obstruction. Upgrade of existing devices in these patients is a dilemma, which is increasingly encountered by device-implanting physicians. Laser-assisted extraction of existing leads can facilitate access for device upgrade and provide an alternative to lead abandonment and contralateral implant. We review our experience with laser-assisted lead extraction in patients, referred for upgrade of existing devices, who were found to have, or known to have, ipsilateral subclavian vein occlusion. Over the past 3 years, 18 patients (13 men, 5 women; mean age 63.9 +/- 16 years) with subclavian vein occlusion underwent successful laser-assisted lead extraction (total 29 leads) and upgrade of existing leads to defibrillators and/or biventricular systems. Mean implant duration prior to extraction was 70.8 +/- 43.5 (11-192) months. Cannulation of the coronary sinus and placement of a transvenous left ventricular lead were achieved in all 13 patients in whom it was attempted. No complications occurred. Laser-assisted lead extraction is a safe and effective approach, allowing for ipsilateral device upgrade in patients with existing devices and central venous obstruction.

A29-1 Laser assisted lead extraction; a seven year single center experience

A29-1 Laser assisted lead extraction; a seven year single center experience