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Minimally invasive lead extraction post heart transplant: Avoiding abandoned lead fragments
Samer Hakmi, Simon Pecha, Osamh Noor, Alexander Bernhardt, Markus Barten, Florian Wagner, Hermann Reichenspurner.
University Heart Center Hamburg, Hamburg, Germany.

OBJECTIVE: Most of the heart failure patients are waiting for heart transplant (HTX) have a cardiac implantable electronic device (CIED). Device and lead removal are still a part of the HTX procedure. This study sought to assess the incidence of complete lead removal in HTX patients. Abandoned lead fragments carry a high risk for infections and prohibit MRI imaging. We therefore propose an appropriate minimally invasive lead management algorithm.
METHODS: Between February 2009 and September 2015 ninety consecutive patients underwent HTX at our center. The study population included 80 (88.9%) patients with previously implanted CIEDs. Lead removal was performed by simple traction during HTX. To achieve complete lead removal, abandoned lead fragments were removed in some cases electively under fluoroscopic guidance using extraction sheath at a later time.
RESULTS: Patients were 50.8±12.1 years of age (range 17-68), and 85% were men. Eighty two devices (VVI-PM: 3, DDD-PM: 2, CRT-P: 3, VVI-ICD: 25, DDD-ICD: 13, CRT-D: 34, CCM: 2) were removed. 191 leads were attempted with a mean implant duration of 33.2±39.2 months (range 0.9-268.3). The rate of dual coil ICD leads was 75%. Complete lead removal was only achieved in 48 (60%) patients. Postoperative X-Ray revealed abandoned intravascular lead fragments in 24 (30%) patients. Later on, in five cases, the abandoned lead fragments were completely removed using lead locking devices and excimer laser sheaths. No lead removal related vascular complication occurred.
CONCLUSIONS: The results indicate that pacing and defibrillation leads should be removed after HTX using appropriate minimally invasive lead extraction techniques. Moreover, the use of extraction tools during HTX under fluoroscopic guidance is not always possible. The removal of all lead material is obvious because of infection risk due to lifelong immunosuppressive therapy. In addition, abandoned lead fragments limit magnetic resonance imaging application.

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