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Arrhythmias
The challenges of transvenous lead extraction
  1. Melanie Maytin,
  2. Laurence M Epstein
  1. Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Laurence M Epstein, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA; lmepstein{at}partners.org

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Transvenous lead extraction (TLE) has undergone an explosive evolution since its inception as a rudimentary skill with limited technology and therapeutic options. Early techniques involved simple manual traction that frequently proved ineffective for chronically implanted leads and carried a significant risk of myocardial avulsion, tamponade, and death.1 2 The significant morbidity and mortality associated with these early extraction techniques limited their application to life threatening situations such as infection and sepsis. The past 30 years have witnessed significant advances in lead extraction technology resulting in safer and more efficacious techniques and tools, providing the skilled extractor with a well equipped armamentarium. With the development of the discipline, we have witnessed a growth in the community of TLE experts coincident with a pronounced decline in the incidence of procedure related morbidity and mortality, with more recent registries at high volume centres reporting high success rates with exceedingly low complication rates (figure 1).3–6 Future developments in lead extraction are likely to focus on new tools that will allow us to provide comprehensive device management, alternative systems for extraction training, and the design of new leads conceived to facilitate future extraction.

Figure 1

Success, morbidity and mortality in large series. Graphic representation of complete success as a function of time, represented by black columns. Secondary y axis represents percentage morbidity (orange) and mortality (red). Timeline of extraction techniques and tools commensurate with reported trials is at the top of the figure. Values below the graph represent the number of leads (N) extracted in each study. Composite major complication (MC) and mortality (M) rate was calculated. Only studies with ≥50 leads extracted and data regarding mortality and major complications were included.

Pathology of the human–lead interaction

The challenges and risks of TLE are principally related to the body's foreign body response to a cardiovascular implantable electronic device (CIED). This …

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