Original-clinicalLarge, single-center, single-operator experience with transvenous lead extraction: Outcomes and changing indications
Introduction
Transvenous extraction of pacemaker and implantable cardioverter-defibrillator (ICD) leads is an increasingly necessary procedure given the exponential growth in device implantation during the last several decades. Studies have expanded the indications for ICD therapy,1, 2 and cardiac resynchronization therapy (CRT) has proven efficacy for patients with heart failure and ventricular dyssynchrony.3, 4 The increasing indications of cardiac device therapy combined with greater acceptance by the general community have resulted in a wider range of patients receiving this therapy.
Unfortunately, leads are not as “permanent” as hoped and often require removal due to structural failure, infection, and the desire for upgrade to new technology. Although device advisories and recalls are a high-profile topic, the reliability of leads and the impact of lead failure are growing concerns (Figure 1).5, 6, 7, 8 In addition, reports suggest that the risk of infection is increased with generator replacement, an expected result of premature replacement due to recall. For these reasons, changes in the pattern of indications for lead extractions might be expected. This study examined the experience at a tertiary referral center with regard to the changing indications for lead extraction over time and provides a current assessment of the morbidity and mortality of this procedure when performed by a high-volume center.
Section snippets
Methods
The study cohort consisted of all consecutive patients undergoing chronic lead extraction by a single operator (L.M.E.) at the Brigham and Women’s Hospital, Boston, Massachusetts, from January 2000 to March 2007. The Brigham and Women’s Hospital is a 747-bed nonprofit teaching affiliate of Harvard Medical School and serves as a major referral center for lead extractions for the northeastern United States. Leads implanted for fewer than 6 months were excluded from this analysis. One patient with
Results
From January 2000 to March 2007, a total of 975 chronic endovascular leads were removed from 498 patients. Mean patient age at the time of the procedure was 63.2 years (range 14.5–94.5 years), and 69.3% were male (Table 1). Mean number of leads removed was 2.0 ± 0.9. Mean implant duration for these leads was 7.5 ± 5.8 years; the oldest lead was in place for 32.7 years. The removed device was a pacemaker in 265 (53.2%) patients and an ICD in 233 (46.8%) patients (13 [2.6%] devices capable of CRT
Discussion
The purpose of this study was to review the contemporary indications, outcomes, and complications of transvenous lead extraction in a large series of consecutive patients at a high-volume lead extraction center. In one of the largest series of transvenous lead extraction, 97.5% of the 975 leads were removed in their entirety. Excluding small, clinically insignificant fragments, the partial success rate via radiographic outcome was 99.1%. In addition to this excellent clinical outcome, major
Study limitations
The fact that this study is a retrospective review of patients undergoing lead extraction at our institution is the major limitation of this study. A prospective study identifying all patients with device-related issues would have provided the opportunity to evaluate the indications for extraction and the outcomes in patients who underwent transvenous extraction and those who did not. Given the nature of this study, we can provide data only for those patients who actually underwent extraction.
Conclusion
In our high-volume referral center, the indications for device lead extraction are primarily infection, followed by mechanical lead complications and device upgrade. Over the past 7 years, the indication of lead malfunction has decreased, while infection and upgrade have remained stable in relative proportion. Independent predictors of requirement for laser assistance include longer duration of lead implant and the presence of a defibrillator lead. In this single-center, single-operator
References (34)
- et al.
Clinical experience with pacemaker pulse generators and transvenous leads: an 8-year prospective multicenter study
Heart Rhythm
(2007) - et al.
Increased incidence of subacute lead perforation noted with one implantable cardioverter-defibrillator
Heart Rhythm
(2007) - et al.
Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections
J Am Coll Cardiol
(2007) - et al.
Update on infections involving permanent pacemakersCharacterization and management
J Thorac Cardiovasc Surg
(1985) - et al.
Modified temporary cardiac pacing using transvenous active fixation leads and external re-sterilized pulse generators
J Am Coll Cardiol
(2006) - et al.
How to select patients for lead extraction
Heart Rhythm
(2007) - et al.
Feasibility, safety, and determinants of extraction time of percutaneous extraction of endocardial implantable cardioverter defibrillator leads by intravascular countertraction method
Am J Cardiol
(2000) - et al.
Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure
N Engl J Med
(2005) - et al.
Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction
N Engl J Med
(2002) - et al.
Cardiac resynchronization in chronic heart failure
N Engl J Med
(2002)
Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure
N Engl J Med
Pacemaker and ICD malfunction—an incomplete picture
JAMA
Annual rate of transvenous defibrillation lead defects in implantable cardioverter-defibrillators over a period of >10 years
Circulation
Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, trainingNorth American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty
Pacing Clin Electrophysiol
Pulmonary arterial embolization of pacemaker lead electrode tip
Pacing Clin Electrophysiol
Complications associated with implantable cardioverter-defibrillator replacement in response to device advisories
JAMA
Pacemaker and ICD generator reliability: meta-analysis of device registries
JAMA
Cited by (175)
Lead Extraction at a Pediatric/Congenital Heart Disease Center: The Importance of Patient Age at Implant
2022, JACC: Clinical ElectrophysiologyComparison of transvenous vs subcutaneous defibrillator therapy in patients with cardiac arrhythmia syndromes and genetic cardiomyopathies
2021, International Journal of CardiologyComparative Analysis of Procedural Outcomes and Complications Between De Novo and Upgraded Cardiac Resynchronization Therapy
2021, JACC: Clinical ElectrophysiologyOutcomes of cardiac implantable electronic device transvenous lead extractions performed in centers without onsite cardiac surgery
2020, International Journal of Cardiology
Dr. Albert has received research grant support from Boston Scientific and St. Jude Medical. Dr. Epstein has received honoraria from Medtronic, Spectranetics, Guidant, and Boston Scientific.