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Hybrid approach in transvenous laser-assisted extraction of pacemaker and defibrillator leads: the alliance between cardiac surgeon and electrophysiologist.
Alberto Repossini, MD, Laura Giroletti, MD, Gianluigi Bisleri, MD, Lorenzo Di Bacco, MD, Fabrizio Rosati, MD, Luca Bontempi, MD, Antonio Curnis, MD, Claudio Muneretto, MD.
university of Brescia Medical School, Brescia, Italy.

OBJECTIVE: The laser-assisted extraction of chronically implanted pacemaker/defibrillator leads have reduced the necessity of surgical open removal of devices, minimizing the invasiveness of the procedure. However, major complications included right atrial injury, vena cava laceration or disruption could be life threatening requiring emergent surgery with high risk of mortality. A hybrid approach to leads extraction has been developed by associating of right minitoracothomy/thoracoscopic access to visualized cardiac structure during the transvenous procedure. Aim of this study is to evaluate safety and efficacy of this strategy in order to reduce peri-operative complications.
METHODS: Between January and December 2015, 16 patients (44% males, mean age 72±11 years), underwent hybrid leads laser-assisted extraction procedure for pocket/system infection (11 pts) or leads malfunctioning (5 pts). For each patient a LED (Lead Extraction Difficulty) index has been assessed with following criteria: age of the oldest and number of leads, presence of coil defibrillator, absence of vegetations. In case of LED index >10 the procedure were considered as an high risk and a hybrid approach was performed: a right anterior minithoracotomic/thoracoscopic access was performed in Hybrid room and lead extraction conducted under direct control. In case of PM dependency (12 pts), previous transvenous PM implantation was performed in 5 pts. Permanent epicardial PM was placed on left ventricle through left minithoracotomy during leads extraction in 3 patients or before in 4 pts.
RESULTS: Complete lead removal was achieved in all patients. Superior vena cava laceration at level of right atrial junction occurred in two patients. Bleeding was immediately controlled and injury was repaired under direct vision without emergency sternotomy and cardiopulmonary bypass. Hospital mortality was 0%. A mild pericardial effusion without hemodynamic significance was reported in 3 pts, but didn’t require pericardial drainage. No wound complication was reported
CONCLUSIONS: In our early experience, hybrid approach to laser-assisted leads extraction has been proven a safe and efficacy strategy to prevent emergent treatment of any major complications , mainly in patients with high LED index. A very small minithoracotomy or thoracoscopic access avoids the need of full sternotomy, minimizing post-operative complications and hospitalization period.

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