CE: Swati; JCM-D-13-00150; Total nos of Pages: 4;
JCM-D-13-00150
Research letter
Extraction of a coronary sinus lead: always so easy? Luca Bontempia, Francesca Vassanellia, Alessandro Liparia, Elisa Locantorea, Marco Belotti Cassaa, Francesca Salghettia, Mohamed Elmaghawryb, Enrico Vizzardia, Antonio D’Aloiaa, Rashad Mahmudovc, Manuel Cerinia and Antonio Curnisa Lead extraction is a complex procedure associated with potential risks and requires considerable experience of the operator in the use of specific techniques and tools. With the exception of active fixation leads, the extraction procedure of coronary sinus leads is less complex and risky, in the absence of adhesions with other vascular leads. We report a difficult coronary sinus lead extraction, which required both superior (subclavian) and inferior (femoral) approaches and the use of multiple lead extraction tools. In order to perform a well tolerated and effective extraction procedure, well trained and experienced staff in a well equipped setting is, therefore, mandatory even for apparently simple cases.
Letter to the Editor In recent years, the use of cardiac implantable devices (pacemakers and defibrillators) has increased as well as the number of device-related complications, such as malfunctions or infections. Lead extraction is a complex procedure associated with potential risks and requires considerable experience of the operator in the use of specific techniques and tools.1–6 The main difficulty is represented by the fibrotic adhesions located not only at the level of the lead tip but also frequently along the entire intravascular course.7–10 With the exception of active fixation leads,11 the extraction procedure of coronary sinus leads is less complex and risky, in the absence of adhesions with other vascular leads. Indeed, the fibrosis within a coronary vein is generally absent.12 We describe a rare case of persistent fibrosis at the coronary sinus Ostium, which resulted in a complex extraction procedure.
Case report A 74-year-old man with diabetes, hypertension, coronary artery disease and history of coronary artery bypass grafting underwent biventricular implantable defibrillator implantation in 2003 for primary prevention of sudden cardiac death and New York Heart Association IV class. The patient obtained a relevant improvement of ejection fraction and functional capacity, and was classified as ‘super-responder’ to the therapy. 1558-2027 ß 2014 Italian Federation of Cardiology
J Cardiovasc Med 2014, 15:000–000
Keywords: biventricular stimulation, coronary sinus lead, lead extraction a Divisione e Cattedra di Cardiologia, Spedali Civili e Universita` degli Studi di Brescia, Brescia, Italy, bAswan Heart Centre, Aswan, Egypt and cCentral Hospital of Oil Workers, Cardiovascular Disease Center, Baku, Azerbaijan
Correspondence to Luca Bontempi, MD, Division and Chair of Cardiology, Brescia, Italy Tel: +393358346850; fax: +390303999152; e-mail: [email protected] Received 8 March 2013 Revised 29 January 2014 Accepted 29 January 2014
Due to a progressive increase in the pacing threshold of the left ventricular lead, over the years, the pacing output was increased to maintain an effective capture. Such programming caused accelerated battery discharge and required frequent and expensive device replacements. The patient was referred to our institution after a further increase in the pacing threshold (pulse amplitude 4.5V, pulse duration 1.5ms) and with the device again near exhaustion. The patient refused to undergo implantation of an epicardial lead; thus, in agreement with the patient’s referring physicians, we attempted the extraction of the malfunctioning lead and the implantation of a new coronary sinus lead, in order to reduce energy drain and extend device life. The procedure was performed in May 2012 at the Laboratory of Electrophysiology and Cardiac Pacing. Before surgery, we performed the angiography of the anonymous venous trunk, verifying the patency of the left subclavian vein and superior vena cava. We also documented that the stimulation system was composed of a right ventricular single-coil lead actively fixed in the septum, an active-fixation atrial lead and a lead placed in a posterior branch of the coronary sinus (Fig. 1). In accordance with our standard protocol, the procedure was performed with cardiothoracic surgery standby available, and with continuous 12-lead ECG and arterial blood pressure monitoring. Moreover, two guidelines were positioned through the right femoral vein to permit the insertion of sheaths, if DOI:10.2459/JCM.0000000000000018
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Swati; JCM-D-13-00150; Total nos of Pages: 4;
JCM-D-13-00150
2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00
Fig. 1
After five 2-sec.-long energy applications, the fibrosis was dissected up to the innominate vein-superior vena cava junction. With a combined traction from the subclavian access and from the femoral access, using the bioptome joined to the distal part of the lead, it was possible to remove the lead from the coronary sinus (Fig. 2a–c). After cutting the extrathoracic portion of the lead, it was completely removed through the femoral access. The subsequent angiography did not reveal injury or dissection of the coronary sinus. A new bipolar coronary sinus lead was positioned (Attain Ability 4196-78cm; Medtronic Inc, Minnesota, USA) in an antero-lateral branch of the coronary sinus (Fig. 3a and b). In the new lead position, the pacing threshold was low, thereby reaching the ultimate goal of the procedure. The total procedure time was 3h and 15min, with no major or minor complications.
Discussion
Preoperative fluoroscopy showing a right ventricular sensig-pacing active fixation lead in the septum, a right ventricular single coil active fixation lead in the apex and a lead placed in a posterior branch of the coronary sinus.
deemed necessary, in order to crossover to a transfemoral approach. Under local anaesthesia, the device pocket was open through a skin incision and the fibrotic tissue on the extravascular portion of the coronary sinus lead was debrided. After puncture of the subclavian vein, a guidewire was introduced to allow the subsequent implantation of the new lead. In order to reduce the risk of vascular rupture of the superior vena cava using the left subclavian approach, it was decided to attempt the removal through the right femoral vein, by catching the lead in its atrial portion and then pulling it out of the coronary sinus. A quadripolar ablation catheter with a narrow curve (Biosense Webster Inc, Diamond Bar, California, USA; type A) was first used; then a Lazo catheter (Amplatz GOOZE NECK snare kit; ev3 Inc, Plymouth, Minnesota, USA) through a long sheath was usually adopted for the transeptal puncture during ablations (Fast-Cath; St Jude Medical, Inc, St. Paul, Minnesota, USA). The last unsuccessful attempt was done using a bioptome modified to grasp the lead. Thus, a locking stylet (Liberator lead docking stylet; Cook Medical Inc, Indiana, USA) was passed through the lead to prevent possible fractures and a powered Laser Sheat 80Hz 12 Fr (Spectranetics, Colorado Springs, Colorado, USA) was used from the left subclavian access.
We report a difficult coronary sinus lead extraction, which required both superior (subclavian) and inferior (femoral) approaches and the use of multiple lead extraction tools. Although the lead was not infected, extracting this coronary sinus lead still has a Class I indication according to the Heart Rhythm Society (HRS) expert consensus on transvenous lead extractions.13 This is because the coronary sinus failing lead with its high pacing threshold interfered with the function of the CRT-D device leading to early battery drainage. Moreover, it would have been impossible to implant a new coronary sinus lead while leaving the old one in place due to the coronary sinus ostium adhesions and the difficulty in manoeuvring the new lead into the lateral branch. Lead extraction is a complex procedure that requires a high level of expertise. According to the analysis of lead extraction outcomes in relation to the operator’s training and volume,14,15 the HRS recommends that operators with more than 40 procedures experience as a first operator and who maintain a minimum of 20 procedures done annually should perform the procedure.13 It is also recommended that an emergency cardiac surgery team, facility and equipment must be readily available. In our institution, we have performed over 1000 lead extractions in the last 15 years with 100 lead extractions last year. Our protocol for lead extraction procedures include the following obligations: continuous invasive hemodynamic monitoring for prompt recognition of any compromise; an emergency operating theatre with a senior cardiac surgeon and anaesthetist made available for the whole course of the procedure; and adequate blood products prepared for any major bleeding. In addition, the HRS recommends the availability of a variety of extracting tools including locking stylets, mechanical and powered sheaths.13 The presence of multiple extracting tools in the operating room permits
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Swati; JCM-D-13-00150; Total nos of Pages: 4;
JCM-D-13-00150
Extraction of a coronary sinus lead Bontempi et al. 3
Fig. 2
Hybrid approach to remove the coronary sinus lead. (a) Traction of the body lead using a modified bioptome (arrow) through a femoral approach. (b) Traction of the body lead: tight fibrosis between coronary sinus lead and defibrillation lead at the superior vena cava (star). (c) The powered laser sheet advancing along the lead via subclavian vein approach (white star) to free adherences between coronary sinus and right ventricular lead. The long sheet from the femoral access maintains the traction of the lead (black arrow).
tailoring the approach of lead extraction according to each patient’s condition. From our experience, simple hooking and traction with a deflectable catheter sometimes suffice in removing nonadherent leads. In our institution, we have developed a modified bioptome with elongated crocodile teeth that provides more traction power and stability for extracting adherent leads. Stronger traction force can also be exercised using the Amplatz GOOZE NECK snare kit, which proved to be useful in many cases reported on successful retrieval of intravascular foreign material16,17 When the femoral approach deemed to fail because of right ventricular to coronary sinus leads adhesions, we resolved to liberate these adhesions using the laser sheath. The CVX-300 Excimer laser (Spectranetics, Colorado Springs, Colorado, USA) is a xenon chloride laser with a wavelength of 308nm, which delivers pulsed
light at a maximum fluence of 60mJ/mm.18 In our case, an 80Hz repetition rate was used. The Excimer is a cool cutting laser; the temperature of the emitted light is nearly 508C. At a tissue depth of 0.06mm, 64% of the emitted energy is absorbed, and at 0.18mm, 95% is absorbed. The energy is absorbed by tissue lipids and proteins but not by water, in contrast to other lasers. The laser acts by breaking intracellular tissue bonds.18 Due to these characteristics, the Excimer laser can vapourize fibrotic sheaths surrounding targeted leads without damaging surrounding leads, which is ideal for our case in which there were adhesions between the coronary sinus and the right ventricular leads. Recent published data on 125 cases of coronary sinus lead extraction confirm that it is a rather simple procedure
Fig. 3
(a) The angiography of the coronary sinus after the extraction confirmed the absence of vascular injuries. (b) The new coronary sinus lead was positioned in a lateral vein.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Swati; JCM-D-13-00150; Total nos of Pages: 4;
JCM-D-13-00150
4 Journal of Cardiovascular Medicine 2014, Vol 00 No 00
requiring simple traction in 91.4% of the cases. Only 14 cases required complex extractions, half of which were placed for more than 4 years.19 This is in accordance with our experience, wherein coronary sinus lead was extracted by simple traction in 95% of our cases. However, it is important to note that the active fixation coronary sinus lead StarFix (Medtronic Inc) represents an exception for coronary sinus lead extraction. Despite the excellent results of StarFix on rates of dislodgment, a multicentre report on Starfix lead extraction including 12 cases revealed that there was significant tissue growth into the fixation lobes of the lead resulting in difficulty in retracting those fixation lobes. In fact, fixation lobes were completely retracted in only one of the 12 cases and extra support assistance was required for lead removal in all cases. One lead could not be removed transvenously and required surgical extraction.11 There were no complications in our procedure except for coronary sinus tributary occlusion. Expected complications include coronary sinus or tributary thrombosis, coronary sinus dissection, cardiac tear and tamponade, superior vena cava and subclavian vein punctures or tears, hematoma, pneumothorax and blood transfusion. Due to the excessive manoeuvres at the level of the coronary sinus ostium, we anticipated a possible acute or subacute thrombosis of the coronary sinus. Therefore, we decided to implant the new coronary sinus lead in the same setting, although this would lengthen the procedural time. Although the lateral vein position was anatomically more favourable, the previous operator resolved to the more accessible posterior branch. In fact, this posterior position improved the clinical outcome of the patient, as he responded well to CRT. This highlights the fact that in a scenario in which the operator is obliged to place the lead in the only accessible vein which is not at the optimal anatomical position, the patient may still gain the benefit of left ventricular pacing. A recent study supports this notion, reporting the effect of left ventricular position on the clinical outcome of 457 CRT patients and concluding that despite anterolateral or posterolateral positions being more preferential for achieving optimal CRT benefit, the patient can still profit from any left ventricular position.20
Conclusion In order to perform well tolerated and effective extraction procedure, well trained and experienced staff in a well equipped setting is therefore mandatory even for apparently simple cases.
References 1 2 3 4
5 6 7 8 9
10 11
12
13
14
15 16
17
18 19
20
Bilgutay AM, Jensen NK, Schmidt WR, et al. Incarceration of transvenous pacemaker electrode: removal by traction. Am Heart J 1969; 77:377–379. Byrd CL, Schwartz SJ, Hedin N. Lead extraction: indications and techniques. Cardiol Clin 1992; 10:735–748. Imparato AM, Kim GE. Electrode complications in patients with permanent cardiac pacemakers: ten years’ experience. Arch Surg 1972; 105:705–710. Myers MR, Parsonnet V, Bernstein AD. Extraction of implanted transvenous pacing leads: a review of a persistent clinical problem. Am Heart J 1991; 121:881–888. Wallace HW, Sherafat M, Blakemore WS. The stubborn pacemaker catheter. Surgery 1970; 68:914–915. Smith CM, Love JC. Extraction of transvenous pacing and ICD leads. PACE 2008; 31:736–752. Lagergren H, Dahlgren S, Norderstam H. Cardiovascular tissue response to intracardiac pacemaking. Acta Chir Scand 1966; 132:696–704. Robboy SJ, Harthorne JW, Leinbach RC, et al. Autopsy findings with permanent pervenous pacemakers. Circulation 1969; 39:495–501. Becker AE, Becker MJ, Claudon DG, Edwards JE. Surface thrombosis and fibrous encapsulation of intravenous pacemaker catheter electrode. Circulation 1972; 46:409–412. Spittell PC, Hayes DL. Venous complications after insertion of a transvenous pacemaker. Mayo Clin Proc 1992; 67:258–265. Maytin M, Carrillo RG, Baltodano P, et al. Multicenter experience with transvenous lead extraction of active fixation coronary sinus leads. PACE 2012; 35:641–647. Di Cori A, Bongiorni MG, Zucchelli G, et al. Large, single-center experience in transvenous coronary sinus lead extraction: procedural outcomes and predictors for mechanical dilatation. PACE 2011; 35:215–222. Wilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009; 6:1085–1104. Smith HJ, Fearnot NE, Byrd CL, et al. Five-years experience with intravascular lead extraction. U.S. Lead Extraction Database. PACE 1994; 17:2016–2020. Bracke FA, Meijer A, Van Gelder B. Learning curve characteristics of pacing lead extraction with a laser sheath. PACE 1998; 21:2309–2313. Rafie IM, Viswanathan G, Penny WJ. Transfemoral contralateral technique to retrieve knotted coronary artery catheter using Amplatz Goose Neck snare catheter. BMJ Case Rep 2010; 2010:pii: bcr1220092598. Yang Soon C, Chong E, Sangiorgi GM. A challenging case of dislodged stent retrieval with the use of Goose neck snare kit. Catheter Cardiovasc Interven 2010; 75:630–633. Snow JS, Parekh S. Update on laser lead extraction. J Invasive Cardiol 2009; 21:230–232. Sheldon S, Friedman PA, Hayes DL, et al. Outcomes and predictors of difficulty with coronary sinus lead removal. J Interven Cardiac Electrophysiol 2012; 35:93–100. Dong YX, Powell BD, Asirvatham SJ, et al. Left ventricular lead position for cardiac resynchronization: a comprehensive cinegraphic, echocardiographic, clinical, and survival analysis. Europace 2012; 14:1139–1147.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
JCM-D-13-00150
Research letter
Extraction of a coronary sinus lead: always so easy? Luca Bontempia, Francesca Vassanellia, Alessandro Liparia, Elisa Locantorea, Marco Belotti Cassaa, Francesca Salghettia, Mohamed Elmaghawryb, Enrico Vizzardia, Antonio D’Aloiaa, Rashad Mahmudovc, Manuel Cerinia and Antonio Curnisa Lead extraction is a complex procedure associated with potential risks and requires considerable experience of the operator in the use of specific techniques and tools. With the exception of active fixation leads, the extraction procedure of coronary sinus leads is less complex and risky, in the absence of adhesions with other vascular leads. We report a difficult coronary sinus lead extraction, which required both superior (subclavian) and inferior (femoral) approaches and the use of multiple lead extraction tools. In order to perform a well tolerated and effective extraction procedure, well trained and experienced staff in a well equipped setting is, therefore, mandatory even for apparently simple cases.
Letter to the Editor In recent years, the use of cardiac implantable devices (pacemakers and defibrillators) has increased as well as the number of device-related complications, such as malfunctions or infections. Lead extraction is a complex procedure associated with potential risks and requires considerable experience of the operator in the use of specific techniques and tools.1–6 The main difficulty is represented by the fibrotic adhesions located not only at the level of the lead tip but also frequently along the entire intravascular course.7–10 With the exception of active fixation leads,11 the extraction procedure of coronary sinus leads is less complex and risky, in the absence of adhesions with other vascular leads. Indeed, the fibrosis within a coronary vein is generally absent.12 We describe a rare case of persistent fibrosis at the coronary sinus Ostium, which resulted in a complex extraction procedure.
Case report A 74-year-old man with diabetes, hypertension, coronary artery disease and history of coronary artery bypass grafting underwent biventricular implantable defibrillator implantation in 2003 for primary prevention of sudden cardiac death and New York Heart Association IV class. The patient obtained a relevant improvement of ejection fraction and functional capacity, and was classified as ‘super-responder’ to the therapy. 1558-2027 ß 2014 Italian Federation of Cardiology
J Cardiovasc Med 2014, 15:000–000
Keywords: biventricular stimulation, coronary sinus lead, lead extraction a Divisione e Cattedra di Cardiologia, Spedali Civili e Universita` degli Studi di Brescia, Brescia, Italy, bAswan Heart Centre, Aswan, Egypt and cCentral Hospital of Oil Workers, Cardiovascular Disease Center, Baku, Azerbaijan
Correspondence to Luca Bontempi, MD, Division and Chair of Cardiology, Brescia, Italy Tel: +393358346850; fax: +390303999152; e-mail: [email protected] Received 8 March 2013 Revised 29 January 2014 Accepted 29 January 2014
Due to a progressive increase in the pacing threshold of the left ventricular lead, over the years, the pacing output was increased to maintain an effective capture. Such programming caused accelerated battery discharge and required frequent and expensive device replacements. The patient was referred to our institution after a further increase in the pacing threshold (pulse amplitude 4.5V, pulse duration 1.5ms) and with the device again near exhaustion. The patient refused to undergo implantation of an epicardial lead; thus, in agreement with the patient’s referring physicians, we attempted the extraction of the malfunctioning lead and the implantation of a new coronary sinus lead, in order to reduce energy drain and extend device life. The procedure was performed in May 2012 at the Laboratory of Electrophysiology and Cardiac Pacing. Before surgery, we performed the angiography of the anonymous venous trunk, verifying the patency of the left subclavian vein and superior vena cava. We also documented that the stimulation system was composed of a right ventricular single-coil lead actively fixed in the septum, an active-fixation atrial lead and a lead placed in a posterior branch of the coronary sinus (Fig. 1). In accordance with our standard protocol, the procedure was performed with cardiothoracic surgery standby available, and with continuous 12-lead ECG and arterial blood pressure monitoring. Moreover, two guidelines were positioned through the right femoral vein to permit the insertion of sheaths, if DOI:10.2459/JCM.0000000000000018
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Swati; JCM-D-13-00150; Total nos of Pages: 4;
JCM-D-13-00150
2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00
Fig. 1
After five 2-sec.-long energy applications, the fibrosis was dissected up to the innominate vein-superior vena cava junction. With a combined traction from the subclavian access and from the femoral access, using the bioptome joined to the distal part of the lead, it was possible to remove the lead from the coronary sinus (Fig. 2a–c). After cutting the extrathoracic portion of the lead, it was completely removed through the femoral access. The subsequent angiography did not reveal injury or dissection of the coronary sinus. A new bipolar coronary sinus lead was positioned (Attain Ability 4196-78cm; Medtronic Inc, Minnesota, USA) in an antero-lateral branch of the coronary sinus (Fig. 3a and b). In the new lead position, the pacing threshold was low, thereby reaching the ultimate goal of the procedure. The total procedure time was 3h and 15min, with no major or minor complications.
Discussion
Preoperative fluoroscopy showing a right ventricular sensig-pacing active fixation lead in the septum, a right ventricular single coil active fixation lead in the apex and a lead placed in a posterior branch of the coronary sinus.
deemed necessary, in order to crossover to a transfemoral approach. Under local anaesthesia, the device pocket was open through a skin incision and the fibrotic tissue on the extravascular portion of the coronary sinus lead was debrided. After puncture of the subclavian vein, a guidewire was introduced to allow the subsequent implantation of the new lead. In order to reduce the risk of vascular rupture of the superior vena cava using the left subclavian approach, it was decided to attempt the removal through the right femoral vein, by catching the lead in its atrial portion and then pulling it out of the coronary sinus. A quadripolar ablation catheter with a narrow curve (Biosense Webster Inc, Diamond Bar, California, USA; type A) was first used; then a Lazo catheter (Amplatz GOOZE NECK snare kit; ev3 Inc, Plymouth, Minnesota, USA) through a long sheath was usually adopted for the transeptal puncture during ablations (Fast-Cath; St Jude Medical, Inc, St. Paul, Minnesota, USA). The last unsuccessful attempt was done using a bioptome modified to grasp the lead. Thus, a locking stylet (Liberator lead docking stylet; Cook Medical Inc, Indiana, USA) was passed through the lead to prevent possible fractures and a powered Laser Sheat 80Hz 12 Fr (Spectranetics, Colorado Springs, Colorado, USA) was used from the left subclavian access.
We report a difficult coronary sinus lead extraction, which required both superior (subclavian) and inferior (femoral) approaches and the use of multiple lead extraction tools. Although the lead was not infected, extracting this coronary sinus lead still has a Class I indication according to the Heart Rhythm Society (HRS) expert consensus on transvenous lead extractions.13 This is because the coronary sinus failing lead with its high pacing threshold interfered with the function of the CRT-D device leading to early battery drainage. Moreover, it would have been impossible to implant a new coronary sinus lead while leaving the old one in place due to the coronary sinus ostium adhesions and the difficulty in manoeuvring the new lead into the lateral branch. Lead extraction is a complex procedure that requires a high level of expertise. According to the analysis of lead extraction outcomes in relation to the operator’s training and volume,14,15 the HRS recommends that operators with more than 40 procedures experience as a first operator and who maintain a minimum of 20 procedures done annually should perform the procedure.13 It is also recommended that an emergency cardiac surgery team, facility and equipment must be readily available. In our institution, we have performed over 1000 lead extractions in the last 15 years with 100 lead extractions last year. Our protocol for lead extraction procedures include the following obligations: continuous invasive hemodynamic monitoring for prompt recognition of any compromise; an emergency operating theatre with a senior cardiac surgeon and anaesthetist made available for the whole course of the procedure; and adequate blood products prepared for any major bleeding. In addition, the HRS recommends the availability of a variety of extracting tools including locking stylets, mechanical and powered sheaths.13 The presence of multiple extracting tools in the operating room permits
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Swati; JCM-D-13-00150; Total nos of Pages: 4;
JCM-D-13-00150
Extraction of a coronary sinus lead Bontempi et al. 3
Fig. 2
Hybrid approach to remove the coronary sinus lead. (a) Traction of the body lead using a modified bioptome (arrow) through a femoral approach. (b) Traction of the body lead: tight fibrosis between coronary sinus lead and defibrillation lead at the superior vena cava (star). (c) The powered laser sheet advancing along the lead via subclavian vein approach (white star) to free adherences between coronary sinus and right ventricular lead. The long sheet from the femoral access maintains the traction of the lead (black arrow).
tailoring the approach of lead extraction according to each patient’s condition. From our experience, simple hooking and traction with a deflectable catheter sometimes suffice in removing nonadherent leads. In our institution, we have developed a modified bioptome with elongated crocodile teeth that provides more traction power and stability for extracting adherent leads. Stronger traction force can also be exercised using the Amplatz GOOZE NECK snare kit, which proved to be useful in many cases reported on successful retrieval of intravascular foreign material16,17 When the femoral approach deemed to fail because of right ventricular to coronary sinus leads adhesions, we resolved to liberate these adhesions using the laser sheath. The CVX-300 Excimer laser (Spectranetics, Colorado Springs, Colorado, USA) is a xenon chloride laser with a wavelength of 308nm, which delivers pulsed
light at a maximum fluence of 60mJ/mm.18 In our case, an 80Hz repetition rate was used. The Excimer is a cool cutting laser; the temperature of the emitted light is nearly 508C. At a tissue depth of 0.06mm, 64% of the emitted energy is absorbed, and at 0.18mm, 95% is absorbed. The energy is absorbed by tissue lipids and proteins but not by water, in contrast to other lasers. The laser acts by breaking intracellular tissue bonds.18 Due to these characteristics, the Excimer laser can vapourize fibrotic sheaths surrounding targeted leads without damaging surrounding leads, which is ideal for our case in which there were adhesions between the coronary sinus and the right ventricular leads. Recent published data on 125 cases of coronary sinus lead extraction confirm that it is a rather simple procedure
Fig. 3
(a) The angiography of the coronary sinus after the extraction confirmed the absence of vascular injuries. (b) The new coronary sinus lead was positioned in a lateral vein.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Swati; JCM-D-13-00150; Total nos of Pages: 4;
JCM-D-13-00150
4 Journal of Cardiovascular Medicine 2014, Vol 00 No 00
requiring simple traction in 91.4% of the cases. Only 14 cases required complex extractions, half of which were placed for more than 4 years.19 This is in accordance with our experience, wherein coronary sinus lead was extracted by simple traction in 95% of our cases. However, it is important to note that the active fixation coronary sinus lead StarFix (Medtronic Inc) represents an exception for coronary sinus lead extraction. Despite the excellent results of StarFix on rates of dislodgment, a multicentre report on Starfix lead extraction including 12 cases revealed that there was significant tissue growth into the fixation lobes of the lead resulting in difficulty in retracting those fixation lobes. In fact, fixation lobes were completely retracted in only one of the 12 cases and extra support assistance was required for lead removal in all cases. One lead could not be removed transvenously and required surgical extraction.11 There were no complications in our procedure except for coronary sinus tributary occlusion. Expected complications include coronary sinus or tributary thrombosis, coronary sinus dissection, cardiac tear and tamponade, superior vena cava and subclavian vein punctures or tears, hematoma, pneumothorax and blood transfusion. Due to the excessive manoeuvres at the level of the coronary sinus ostium, we anticipated a possible acute or subacute thrombosis of the coronary sinus. Therefore, we decided to implant the new coronary sinus lead in the same setting, although this would lengthen the procedural time. Although the lateral vein position was anatomically more favourable, the previous operator resolved to the more accessible posterior branch. In fact, this posterior position improved the clinical outcome of the patient, as he responded well to CRT. This highlights the fact that in a scenario in which the operator is obliged to place the lead in the only accessible vein which is not at the optimal anatomical position, the patient may still gain the benefit of left ventricular pacing. A recent study supports this notion, reporting the effect of left ventricular position on the clinical outcome of 457 CRT patients and concluding that despite anterolateral or posterolateral positions being more preferential for achieving optimal CRT benefit, the patient can still profit from any left ventricular position.20
Conclusion In order to perform well tolerated and effective extraction procedure, well trained and experienced staff in a well equipped setting is therefore mandatory even for apparently simple cases.
References 1 2 3 4
5 6 7 8 9
10 11
12
13
14
15 16
17
18 19
20
Bilgutay AM, Jensen NK, Schmidt WR, et al. Incarceration of transvenous pacemaker electrode: removal by traction. Am Heart J 1969; 77:377–379. Byrd CL, Schwartz SJ, Hedin N. Lead extraction: indications and techniques. Cardiol Clin 1992; 10:735–748. Imparato AM, Kim GE. Electrode complications in patients with permanent cardiac pacemakers: ten years’ experience. Arch Surg 1972; 105:705–710. Myers MR, Parsonnet V, Bernstein AD. Extraction of implanted transvenous pacing leads: a review of a persistent clinical problem. Am Heart J 1991; 121:881–888. Wallace HW, Sherafat M, Blakemore WS. The stubborn pacemaker catheter. Surgery 1970; 68:914–915. Smith CM, Love JC. Extraction of transvenous pacing and ICD leads. PACE 2008; 31:736–752. Lagergren H, Dahlgren S, Norderstam H. Cardiovascular tissue response to intracardiac pacemaking. Acta Chir Scand 1966; 132:696–704. Robboy SJ, Harthorne JW, Leinbach RC, et al. Autopsy findings with permanent pervenous pacemakers. Circulation 1969; 39:495–501. Becker AE, Becker MJ, Claudon DG, Edwards JE. Surface thrombosis and fibrous encapsulation of intravenous pacemaker catheter electrode. Circulation 1972; 46:409–412. Spittell PC, Hayes DL. Venous complications after insertion of a transvenous pacemaker. Mayo Clin Proc 1992; 67:258–265. Maytin M, Carrillo RG, Baltodano P, et al. Multicenter experience with transvenous lead extraction of active fixation coronary sinus leads. PACE 2012; 35:641–647. Di Cori A, Bongiorni MG, Zucchelli G, et al. Large, single-center experience in transvenous coronary sinus lead extraction: procedural outcomes and predictors for mechanical dilatation. PACE 2011; 35:215–222. Wilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009; 6:1085–1104. Smith HJ, Fearnot NE, Byrd CL, et al. Five-years experience with intravascular lead extraction. U.S. Lead Extraction Database. PACE 1994; 17:2016–2020. Bracke FA, Meijer A, Van Gelder B. Learning curve characteristics of pacing lead extraction with a laser sheath. PACE 1998; 21:2309–2313. Rafie IM, Viswanathan G, Penny WJ. Transfemoral contralateral technique to retrieve knotted coronary artery catheter using Amplatz Goose Neck snare catheter. BMJ Case Rep 2010; 2010:pii: bcr1220092598. Yang Soon C, Chong E, Sangiorgi GM. A challenging case of dislodged stent retrieval with the use of Goose neck snare kit. Catheter Cardiovasc Interven 2010; 75:630–633. Snow JS, Parekh S. Update on laser lead extraction. J Invasive Cardiol 2009; 21:230–232. Sheldon S, Friedman PA, Hayes DL, et al. Outcomes and predictors of difficulty with coronary sinus lead removal. J Interven Cardiac Electrophysiol 2012; 35:93–100. Dong YX, Powell BD, Asirvatham SJ, et al. Left ventricular lead position for cardiac resynchronization: a comprehensive cinegraphic, echocardiographic, clinical, and survival analysis. Europace 2012; 14:1139–1147.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
