Zero Svc Injury With Transvenous Lead Extraction Utilizing Mechanical Right-left Rotation System: A Contemporary Experience
Ryan Azarrafiy, Iverson E. Williams, Omar M. Sharaf, John R. Spratt, Eric I. Jeng, George J. Arnaoutakis, Kirsten A. Freeman, Thomas M. Beaver.
University of Florida, Gainesville, FL, USA.
BACKGROUND:
Transvenous device lead extraction (TLE) bridges electrophysiology and cardiac surgery with two main approaches: mechanical extraction or more commonly laser-powered, which is susceptible to superior vena cava (SVC) injury. Debate exists regarding the safety of these approaches and whether extraction should occur in the operating room (OR) or electrophysiology lab. This study reflects contemporary experience with mechanical right-left rotational extraction by cardiac surgeons in the OR.
METHODS:
TLE cases were performed by 4 cardiac surgeons at a university center between January 2019 and December 2021. Cases were performed in the OR under general anesthesia with transesophageal echocardiography guidance to assess for pericardial effusion and valve function. All leads were extracted via transvenous approach utilizing a mechanical right-left controlled-rotation system. Outcomes included procedural success, complications per 2017 Heart Rhythm Society guidelines, and 30-day mortality. Procedural success was defined by complete extraction of all leads without major complication.
RESULTS:
Two hundred ten leads were extracted from 104 patients. Mean age was 63.8±16.7 years and 72/104 (69%) patients were male. Mean BMI was 30.1±7.71. Comorbidities included: hypertension (77%), heart failure (68%) and coronary artery disease (45%, Table 1). Mean ejection fraction was 36.6±17.1%. Indications were infection (69%) and lead malfunction (19%, Table 1). Removed devices included single-chamber defibrillators (46%), pacemakers (33%) and cardiac resynchronization therapy devices (21%, Table 1). Mean age of oldest lead was 9.79±7.25 years. Prior sternotomy was present in 26/104 (25%) of patients. There were no SVC tears. Procedure-related mortality was 0.0%. There were 4 (3.9%) minor complications including 3 wound hematomas and 1 superficial infection. Procedural success was obtained in 99/104 (95%) of cases. The remaining 5 cases included distal lead fracture (3), inferior vena cava laceration requiring sternotomy (1) and tricuspid valve damage requiring delayed valve replacement (1).
CONCLUSIONS:
A mechanical, controlled-rotation system is a safe and effective approach to TLE with no SVC tears in our experience. Cardiac surgeons performing TLE in the OR enables rapid conversion to sternotomy in the event of major complication.
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