Title: Lead Extraction in the Contemporary Setting: The LExICon Study. An Observational Retrospective Study of Consecutive Laser Lead Extractions
Topic: Arrhythmias
Date Posted: 3/9/2010
Author(s): Wazni O, Epstein LM, Carrillo RG, et al.
Citation: J Am Coll Cardiol 2010;55:579-586.
Clinical Trial: No
Related Resources
JACC Article: Lead Extraction in the Contemporary Setting: The LExICon Study. An Observational Retrospective Study of Consecutive Laser Lead Extractions
Study Question: How safe and effective is laser-assisted lead extraction (LALE)?
Methods: This was a multicenter, retrospective analysis of 1,449 consecutive patients (mean age 63 years) who underwent LALE of 1,684 pacemaker leads and 703 defibrillator leads in 2004-2007. Complete success was defined as removal of all lead material and partial success was defined as removal of all but <4 cm of the lead.
Results: The median lead age was 82 months. The two most common indications for extraction were infection (57%) and a nonfunctional lead (27%). LALE was completely successful in 96.5% and partially successful in 2.3% of patients. Predictors of procedure failure were a body mass index <25 kg/m2, lead age >10 years, and an extraction volume of <60 cases/4 years. A major adverse event (MAE) occurred in 4% of patients, and a MAE directly related to LALE (most commonly cardiac avulsion or vascular tear) occurred in 1.4%. In-hospital mortality was 1.9%, and mortality directly related to LALE was 0.3%. The predictors of in-hospital mortality were a history of pocket infection, endocarditis, diabetes, and renal insufficiency.
Conclusions: LALE has a high success rate and a low rate of MAEs. In-hospital mortality is largely a function of comorbidities.
Perspective: Prior to the advent of laser sheaths, the success rate of lead extraction using locking stylets and telescoping sheaths was approximately 65%. With the use of laser sheaths, studies published in 1999-2002 reported success rates of 90-94%. The present study indicates that technological refinements in the laser sheaths and additional operator experience have improved the success rate of LALE in contemporary practice to approximately 98%. Fred Morady, M.D., F.A.C.C.
Title: Percutaneous Pacemaker and Implantable Cardioverter-Defibrillator Lead Extraction in 100 Patients With Intracardiac Vegetations Defined by Transesophageal Echocardiogram
Topic: Arrhythmias
Date Posted: 3/9/2010
Author(s): Grammes JA, Schulze CM, Al-Bataineh M, et al.
Citation: J Am Coll Cardiol 2010;55:886-894.
Clinical Trial: No
Related Resources
JACC Article: Percutaneous Pacemaker and Implantable Cardioverter-Defibrillator Lead Extraction in 100 Patients With Intracardiac Vegetations Defined by Transesophageal Echocardiogram
Study Question: Can lead extraction be safely accomplished in patients with endocarditis and intracardiac vegetations?
Methods: This was a retrospective review of 100 patients (mean age 67 years) who underwent extraction of an infected lead and had an intracardiac vegetation by transesophageal echocardiography. The timing of reimplantation depended on resolution of the vegetations and blood culture sterility.
Results: The mean diameter of vegetations was 1.6 cm (range 0.2-4 cm). Two hundred leads with a mean implant duration of 51 months were extracted percutaneously and no patient required a surgical intervention. The most common pathogens were methicillin-resistant and methicillin-sensitive Staphylococcus aureus. Embolization of a vegetation occurred in 2/100 patients (2%). A new pacemaker or implantable cardioverter defibrillator was implanted in 54% of patients a median of 7 days after extraction and none had a relapse of infection during a mean follow-up of 15 months. Long-term follow-up data were available in 71 patients. Among these patients, in-hospital mortality rate was 14% and late mortality was 13%. The most common cause of death was septicemia.
Conclusions: Standard techniques for percutaneous lead extraction are safe and effective in patients with intracardiac vegetations as large as 4 cm.
Perspective: Patients with an intracardiac vegetation often undergo thoracotomy and lead extraction under direct visualization to avoid septic embolization during percutaneous lead extraction. This study demonstrates that percutaneous lead extraction can be accomplished safely by a skilled operator even in the presence of intracardiac vegetations. However, operator experience is an important determinant of outcomes and should be taken into consideration when deciding on percutaneous versus surgical lead extraction. Fred Morady, M.D., F.A.C.C.
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