Difficulty of extraction of chronically implanted tined ventricular endocardial leads

Abstract

The dislodgment rate of permanent pacing ventricular and atrial endocardial leads has significantly decreased with the incorporation of tines as a fixation device. In contrast, transvenous manual extraction of chronically implanted endocardial leads is, at times, clinically indicated, particularly when pacemaker system infection is present. The success rate of such extraction attempts for ventricular endocardial leads over the past 5 years was reviewed. Extraction was usually successful (six of seven attempts) in patients with silicone rubber nontined (or short-tined) older ventricular endocardial leads (Group A). However, in patients with newer urethane long-tined ventricular endocardial leads (Group B), extraction was unsuccessful in three of four attempts. Because of entrapment of the distal electrode tip in the right ventricular apex, manual traction of these leads resulted in permanent conductor material stretching with resultant urethane insulator material breakage in the region of the joints with proximal and distal electrodes. The one successful extraction in Group B was technically difficult and appeared to create a significant risk of intracardiac lead separation. This experience indicates that with improved pacemaker lead design decreased lead dislodgment has been obtained at the cost of increased difficulty of ventricular endocardial lead extraction. Such difficulty should be anticipated when a clinical decision is made to attempt to extract the new urethane long-tined ventricular leads.

The challenges of transvenous lead extraction

“…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.…”

Intravascular Lead Extractions: Tips and Tricks

“…The force is thus concentrated at a small area of the scar tissue and the myocardium without gross displacement of the myocardium (Figure 6). Telescopic sheaths are made of different materials (stainless steel, Teflon, and polypropylene) and are available in various sizes (7)(8)(9)(10)(11)(12)(13)(14)(15)(16) (Figure 7). Sheath selection is determined by the clinical situation and the operator's preference and experience.…”

“…Indeed, the options for lead extraction were initially very limited and dedicated tools were not available. Life threatening situations such as infection with sepsis were the only reason to attempt a lead removal with these highly morbid and often ineffective techniques [8]. As a necessity to overcome these limitations a significant evolution in lead extraction technology occurred over the past 30 years.…”

Excimer Laser for Pacemaker and Defibrillator Lead Extraction: Techniques and Clinical Results

“…In the early experience either direct surgical removal or simple traction strategies were used. Simple traction often failed because either the lead disrupted before adherences gave way or venous (or cardiac) tears occurred [5]. Once the limitations of simple traction were realised a system of counter-traction was developed [6,7].…”