A Novel Retrograde Laser Extraction Technique Using a Transatrial Approach

Abstract

Background— The use of percutaneous lead extraction techniques in a patient with extracardiac or protruding atrial leads could have disastrous consequences. Traditionally, the management of these patients has included a median sternotomy. We describe a minimally invasive technique that involves a transatrial, retrograde laser lead extraction using a video-assisted thoracoscopic approach. Methods and Results— Between January 2004 and June 2009, 14 patients with severed leads at the clavicle and extracardiac leads or lead-caused erosions of the atrial wall were identified through chest radiograph and CT scan. There were 9 men and 5 women aged 19 to 91 years (mean age, 69.71±20.67 years). Ten devices were pacemakers, and 4 were defibrillators. Indications for extraction were 12 infections and 2 malfunctions. Mean ejection fraction was 42±17.67% (range, 10% to 65%). Time of implanted leads was 93.69±51.88 months (range, 33 to 213 months). Laser sheaths size were 12 F (7.1%), 14 F (85.7%), and 16 F (7.1%). A right-side thoracoscopy was performed under general anesthesia. A retrograde laser sheath maneuver was performed, freeing the lead from any adhesions. The lead was removed and the incision closed. One patient experienced a pleural effusion. There was no mortality, and all patients were alive and well at 1-month follow-up. Conclusions— Transatrial, retrograde laser lead extraction is a safe and effective procedure. This procedure may provide an excellent alternative to open sternotomy.

Lead Extraction: The Importance of Preparation and Remaining Opportunities

“…8 Areas of opacification within the cardiac chambers and along the course of the lead indicate calcification prompting consideration for the use of cutting tools rather than laser sheaths. A careful physical examination will reveal dilated veins over the chest wall suggestive of an occluded venous system ipsilateral to the cardiac implantable electronic device (CIED).…”

“…9 Hybrid procedures designed to avoid sternotomy and the consequent morbidity have been reported. [2][3][4][5][6][7][8][9][10] The SVC-RA junction remains the site most prone to injury. These have included novel methods like retrograde laser use via right atriotomy 8 and direct visualization of the SVC-RA junction by a limited local thoracotomy or thoracoscopy.…”

“…Friable tissue, irregular tears, and poor suture retention make hemostasis challenging. 8 The tradeoffs would include increased time to hospital discharge and management in a critical care unit until the sequelae of thoracic pain undergo resolution. Erosion into the surrounding structures causing fistulas may need urgent repair especially if it is a high pressure system.…”

“…Inspection of the SVC and right atrial (SVC-RA) junction on the chest Xray (CXR) may reveal tenting of the underlying myocardium hinting the possibility of a contained atrial rupture. 8 Areas of opacification within the cardiac chambers and along the course of the lead indicate calcification prompting consideration for the use of cutting tools rather than laser sheaths. Interaction within the leads can be visualized well.…”

“…Beyond the safety of the protocol, incremental benefit is unproven for these protocols. These have included novel methods like retrograde laser use via right atriotomy 8 and direct visualization of the SVC-RA junction by a limited local thoracotomy or thoracoscopy. [2][3][4][5][6][7][8][9][10] The SVC-RA junction remains the site most prone to injury.…”