Endocardial Lead Extraction

Abstract

This work is a commercial publication and video. It includes a 160-page manual and a 22minute video. The points the author makes are well illustrated in the manual and demonstrated by performing the procedures on the video. The strong parts of this effort are the emphasis on safety issues, an excellent description ofthe preparation of tbe patient, the composition ofthe extraction team, the surgical instruments and extraction tools needed in the procedure room, and a detailed discussion of each type procedure. There is also a very good discussion of the issues a cardiologist faces extracting leads in an operating room verses a catheterization or electrophysiology laboratory.Conventional lead extraction techniques are based upon counterpressure and countertraction. Only counterpressure is defined in this work. However, counterpressure and countertraction techniques are correctly demonstrated in the video examples of leads extracted via the vein entry site (superior approach). The rationale for the nomenclature "superior and inferior approaches" is not given. This terminology is based upon the venous anatomy, not on one being superior or inferior to the other. An approach to the heart through the superior vena cava is called a superior approach, and through the inferior vena cava it is called an inferior approach. An approach through the right atrium is called a transatrial approach.Three examples of femoral extraction techniques were shown on the video. In this reviewer's opinion, proper technique was not used in these examples. In the video, the proximal and distal portions of the lead are both pulled into the workstation at the same time, subjecting the electrode and proximal lead to the same pulling force. In each example, it resulted in the electrode being removed from the heart by simple traction (pulling on the electrode) and not by countertraction. The proximal portion of the lead embedded in the superior veins should be pulled free using snares before attempting to remove the electrode from the heart wall. Countertraction is applied by advancing the workstation over the lead to a site near the heart wall where traction is applied to the electrode, countered by the sheath. Also in contention are the comments in both the manual and video that the Dotter snare-deflection catheter combination are not always reversible. This combination was chosen because it was always reversible and is still used in those situations where the new needle's-eye-snare is not applicable.The comment that all infected debrided subcutaneous tissue pockets cannot be closed in my experience is not true. Even submuscular pockets in the abdomen, which cannot be completely debrided because the posterior tissue is near the peritoneum, can be closed. If a closed incision does not heal, healing by second intention is not adversely affected by the initial primary closure.Some discussion and video sequences taken from the author's experiences and from the literature are confusing or, in my opinion, untrue. Fortunately, these statements are few ...

Extraction of Transvenous Pacing and ICD Leads

“…The technique of counter‐traction comes into play once the sheath is advanced to the lead tip at the myocardial interface 23,28 . The sheath braces the myocardium and localizes the traction force to the scar tissue just around the lead tip (Fig.…”

“…This workstation is placed via the femoral vein and advanced to the inferior vena cava and into the atrium to maintain venous access and provide counter‐traction. Any number of positioning and grasping tools can be used with this conduit 10,28,34–38 . A Needle's Eye snare, deflecting tip guidewire with a Dotter helical basket retriever, Amplatz gooseneck snare, and Curry loop snare are some of the tools that can be used to position and grasp the lead (Fig.…”