Elsevier

Heart Rhythm

Volume 5, Issue 4, April 2008, Pages 520-525
Heart Rhythm

Original-clinical
Large, single-center, single-operator experience with transvenous lead extraction: Outcomes and changing indications

https://doi.org/10.1016/j.hrthm.2008.01.009Get rights and content

Background

Lead extraction is increasingly necessary given the exponential growth in cardiac device implantation. Meanwhile, the tools, indications, and outcomes of this procedure continue to change.

Objective

The purpose of this study was to examine contemporary indications, outcomes, and complications of transvenous lead extraction in a large series of patients at a high-volume lead extraction center.

Methods

We performed a retrospective cohort study of consecutive patients undergoing lead extraction at a single, high-volume center. Patient and lead characteristics and the indications, outcomes, and need for laser assistance were analyzed.

Results

From January 2000 to March 2007, a total of 975 chronic endovascular leads were removed from 498 patients. Median implant duration was 5.7 years (range 0.5–32.7 years). Indications were infection (60.3%), mechanical lead failure (29.3%), and upgrade of device system (8.8%). Over the study period, lead malfunction decreased relative to other indications. Laser assistance for extraction was more likely with leads implanted longer than 3.4 years compared to less than 3.4 years (odds ratio 6.15, 95% confidence interval 3.35–11.28) and with implantable cardioverter-defibrillator leads compared to pacemaker leads (odds ratio 3.44, 95% confidence interval 1.84–6.43). Overall, 97.5% of the leads were completely removed. Major complications occurred in 2 (0.4%) patients. Only one patient required cardiac surgery. No deaths occurred.

Conclusion

In a high-volume center, lead extraction has a high success rate and low complication rate. Infection was the most common indication overall. Lead failure has decreased in relative proportion. Implantable cardioverter-defibrillator leads and longer lead implant time are associated with a requirement for laser lead extraction.

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

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    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.

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