Southern California Hospital Adds Laser Lead Extraction to Their State of the Art Electrophysiology Program

Risk factors for CD endocarditis include diabetes, immunosuppression, and history of numerous previous CD procedures and/or a compromised surgical site.

Traditional Treatment

Traditional treatment for CD IE has been intensive intravenous antibiotic therapy with device removal and pocket revision. Patients with bacteremia or local pocket infection are advised to have all hardware removed, including any existing lead system. Recurrent infection despite antibiotic therapy is imminent for those that do not have explantation of the CD in its entirety. Percutaneous lead extraction using manual traction is usually reserved for lead implants <6-12 months. In more difficult cases, another conventional technique referred to as rip and tear utilized a cutting sheath and snares to remove implant leads. Both of these procedures are still performed today. In patients with large lead vegetations, long-term CD implantation, or those patients with multiple leads (> 2), lead extraction was traditionally performed by cardiovascular surgeons and employed the use of cardiopulmonary bypass. In these cases, pacemaker-dependent individuals required temporary transvenous pacemakers until a permanent pacemaker could be re-implanted.

Laser Lead Extraction Indications

Lead extraction has historically been reserved for those patients with chronically implanted pacemakers and/or ICDs who have suffered from severe recurrent post-procedural infection. Today, with the availability of newer and safer technology, extraction indications have expanded to include patients with complex device systems and those that have non-functional preserved leads from previous pacemaker implants. The Heart Rhythm Society (HRS; formerly NASPE) categorizes systemic infection as a Class 1 indication for complete device extraction. Localized pocket erosions and infections are considered Class II. As clinical indications for ICDs continue to grow, so does the necessity for lead extraction. Lead extraction in the absence of infection is a viable option for those patients who may have lead malfunction. Due to the increased risk of vascular stenosis or thrombosis, non-functional leads may be recommended for extraction. In young individuals, lead extraction aids in preservation of the contralateral chest wall for future implants.

IE Diagnosis

Clinical signs of pocket infection include localized erythema at the pacemaker site, presence of abscess, extrusion of the device, loss of normal mobility under the skin, and positive tissue cultures. Clinical signs may include fever, chills, sepsis, and WBC >12,000/mm³. Common culprit micro-organisms include a multitude of staphylococcus or streptococcus strains. Kliebsiella pneumonia is a rare, and on occasion, an unrecognizable culpable micro-organism that may confuse the diagnosis by producing a negative culture result. Transesophageal echocardiography (TEE) is useful in detecting the presence of abnormal neostructures that form as a result of persistent bacteremia. These vegetations may present themselves as clumps, thickening of tissue, or masses that arise from the valvular leaflet tips or electrode leads. Positive blood cultures confirm bacteremia and or fungicemia.

Treatment

The innovation of laser lead extraction technology has grown dramatically over the last decade. Powered sheaths are now utilized to facilitate lead removal. These revolutionary tools use an excimer laser sheath to incise through the scar tissue that houses the embedded leads without damaging the vessels or myocardium. Using optical fibers that deliver pulsed ultraviolet laser light also assists with the re-implantation of a new lead system by clearing the fibrotic tissue adjacent to the implant vein. Lead extraction is best performed in the operating room with immediate surgical backup. Some centers may in fact perform lead extraction in their EP lab if it is located adjacent to the operating room. In our hospital setting, the EP team works collaboratively with the operating room staff. The OR completes the patient preparation; an anesthesiologist administers general anesthesia and monitors the patient's airway. The EP staff and physician perform the lead extraction. Intraoperative TEE is performed throughout the procedure to assist in monitoring for potential complications. Severe complications include myocardial perforation, SVC tear, tamponade and thromboembolism. Untoward events tend to be more likely to occur in older females, in patients that have a past history of multiple CD implant procedures, and in patients that have had their current device for > 8 years. In most cases, extraction is performed using a stepwise approach. First, pacer lead removal is attempted with manual counter traction using limited force. If this is unsuccessful, then the laser system is employed. Via a subclavian approach, the pacing or ICD lead is first isolated and a locking stylet is attached. Next, the laser sheath (12, 14, or 16 Fr) is inserted over the stylet and lead. The laser energy is then applied to the scar tissue surrounding the lead. The use of the excimer laser sheath reduces the incidence of incomplete lead removal, providing patients with bacteremia a superior prognosis. Despite the severity of complications, clinical evidence has shown favorable outcomes using the excimer laser technology for CD lead extraction. We believe lead extraction using the excimer laser has shortened procedural times and provides a cleaner, more complete result.

For more information, please visit www.surgery.wisc.edu/cardio/laserlead.