A Novel Retrograde Laser Extraction Technique Using a Transatrial ApproachClinical Perspective
An Alternative for Complex Lead Extractions
Background—The use of percutaneous lead extraction techniques in a patient with extracardiac or protruding atrial leads could have disastrous consequences. Traditionally, the management of these patients has included a median sternotomy. We describe a minimally invasive technique that involves a transatrial, retrograde laser lead extraction using a video-assisted thoracoscopic approach.
Methods and Results—Between January 2004 and June 2009, 14 patients with severed leads at the clavicle and extracardiac leads or lead-caused erosions of the atrial wall were identified through chest radiograph and CT scan. There were 9 men and 5 women aged 19 to 91 years (mean age, 69.71±20.67 years). Ten devices were pacemakers, and 4 were defibrillators. Indications for extraction were 12 infections and 2 malfunctions. Mean ejection fraction was 42±17.67% (range, 10% to 65%). Time of implanted leads was 93.69±51.88 months (range, 33 to 213 months). Laser sheaths size were 12 F (7.1%), 14 F (85.7%), and 16 F (7.1%). A right-side thoracoscopy was performed under general anesthesia. A retrograde laser sheath maneuver was performed, freeing the lead from any adhesions. The lead was removed and the incision closed. One patient experienced a pleural effusion. There was no mortality, and all patients were alive and well at 1-month follow-up.
Conclusions—Transatrial, retrograde laser lead extraction is a safe and effective procedure. This procedure may provide an excellent alternative to open sternotomy.
It is a common and potentially dangerous misconception to assume that all implantable cardiac device leads are intracavitary. In some cases, device leads may find their way outside the confines of the heart. To compound matters, the leads may pace and function normally. The patient may be completely asymptomatic despite the fact that the device leads are extracardiac or in the process of becoming so. This scenario becomes potentially dangerous in the presence of lead complications that warrant an extraction. Experienced clinicians would recognize this scenario and refer these patients for an open surgical procedure; inexperienced clinicians would not recognize this scenario, thereby potentially exposing themselves to disastrous complications and poor patient outcomes. These scenarios may become more common as the use of implantable cardiac devices continues to rise in the United States.
Clinical Perspective on p 505
The use of implantable cardiac devices in the United States has grown exponentially in the past 2 decades. During the 1990s alone, the number of individuals with a pacemaker increased by 22%, and the number of patients with an implantable cardioverter-defibrillator increased 11-fold.1 In the past decade, >2.5 million patients received a cardiac device in the United States.2 Unfortunately, the rate of device complications has increased proportionally. Physicians are encountering device complications that require lead removal much more frequently.
The 1990s ushered in a new era for lead extraction. Electrophysiologists placed a greater focus on effective, minimally invasive extraction methods. Beginning with techniques centered on manual traction and locking stylets, lead extraction techniques evolved to include the laser-based methods that are used regularly today. Laser techniques facilitate the removal of scarring and fibrous adhesions that form with time around long-term leads. Although in certain scenarios, these advanced, minimally invasive percutaneous techniques play a limited role, and the patient traditionally has had to undergo open surgical intervention.3
One scenario that has not been traditionally amenable to the use of percutaneous removal involves extracardiac leads. Initially, a lead may cause a myocardial wall erosion, and a thin, eroded myocardial wall is very susceptible to perforation. Myocardial wall erosion and subsequent perforation is a serious complication that could occur with long-term leads; this complication has been well described in several reports.4–7 A device lead that is next to the myocardial wall can begin to push against it, causing a characteristic appearance on imaging (Figure 1). This protruding segment of the myocardial wall (Figure 2), under increased pressure from the lead, can begin to necrose and erode with time, paving the way for a perforation (Figures 3 and 4). These lead-caused perforations can occur at the time of device implantation through direct trauma, or they can occur weeks to months after an otherwise uncomplicated procedure.
The purpose of this article is to describe a novel, minimally invasive technique for complex lead extraction using a video-assisted thoracoscopic surgical procedure in conjunction with an excimer laser. This novel approach was used in patients who were not candidates for the usual advanced percutaneous techniques, which were not appropriate in these cases because of the presence of an extracardiac lead or a lead that was protruding through an eroding segment of the atrial wall. These patients all had transected leads at the infraclavicular level. This technique served as a substitute for the traditional open surgical approach, which would have included a median sternotomy. The advantage of this procedure is that in contrast to an open sternotomy, it uses a less-invasive method to gain access to the lead. The procedure also is associated with a shortened postoperative recovery period.
We performed a review of 507 patients undergoing laser lead extraction at a single high-volume tertiary cardiovascular referral center between January 2004 and June 2009. All patients undergoing lead extraction are included in a prospective registry. Most of the patients are referred to our institution from outside hospitals. These patients are sent to us because they are considered to need a complex extraction, have previously experienced failed procedural attempts at lead removal, or possibly need an open chest procedure. In addition, our open heart program has a strong referral base for the surgical management of infected valve endocarditis. These factors created an unusual practice where we accrue experience in clinical situations that may be rare in other practices.
From the 507 patients who underwent percutaneous lead extraction during the period of observation, we identified 14 (2.76%) who had transected infraclavicular leads and clinical and radiological signs of atrial lead-caused erosions or perforations. In many cases the leads were deformed and stretched because of previous extraction attempts. Preoperatively, 3 patients had a history of chronic chest pain, 2 had large pericardial effusions, 1 had a right-sided pneumothorax that occurred at the time of the atrial lead implantation, and 1 had a history of symptomatic superior vena cava stenosis.
The right atrial heart border in these 14 patients appeared to be tented by the protruding lead (Figure 1), or the lead appeared to be extracardiac (Figure 3). A lateral chest radiograph confirmed the position of the lead with respect to the lateral right atrial wall. The location of the leads was further confirmed using a gated chest CT scan without contrast. An independent radiologist interpreted the findings, validating the abnormal location of the atrial lead.
All 14 patients underwent the novel retrograde laser lead extraction approach. Data related to their demographic, comorbidity, procedure description, outcome, and follow-up variables were recorded. All laser extractions were performed using the Spectranetics (Colorado Springs, CO) laser sheath removal system. These extractions were performed using general anesthesia in the same operating room by a single surgeon. The protocol used for patients undergoing lead extraction at our institution follows.
Patients were prepared and draped for a possible emergent sternotomy. All had an arterial line placed, and their blood was typed and crossed. A cardiopulmonary bypass pump with a staff perfusionist also was available. The patient's cardiac function was continuously monitored by transesophageal echocardiography. All procedures were performed under fluoroscopic guidance.
The infraclavicular area was dissected, and a complete capsulectomy was performed in cases involving infected devices. Dissection up to the subclavicular space was attempted to locate an extravascular portion of the transected atrial lead. If the ventricular lead was not transected, antegrade extraction of the ventricular lead was performed.
The operator began by identifying the position of the atrial lead using fluoroscopy; this position usually was at the fourth intercostal space. A right parasternal incision was then made at the appropriate intercostal space to expose the lateral wall of the right atrium (Figure 2). A neonatal Finochietto rib spreader was introduced to provide better visualization. The operator made a second (6-mm) incision at the fifth intercostal space at the anterior axillary line. A laparoscopic trocar with a 5-mm 30° rigid thoracoscope (Olympus; Tokyo, Japan) was introduced through this second incision to give the operator the ability to closely monitor the procedure (Figure 5). Insufflation with CO2 was performed, with a flow rate of 8 L/min and a maximum pressure of 15 mm Hg.
The right-side lung was deflated. The operator then made an incision to open the pericardium. The lead tip was visualized at the free lateral wall of the right atrium (Figure 2). A double purse string was placed in the atrium around the protruding lead. After securing the purse string, the lead tip was brought outside of the heart using a Rongeur clamp (Figure 6). A lead-locking device or a suture around the lead was placed at the site where it now crossed the right atrial wall. If traction failed to release the lead, an appropriately sized and calibrated laser sheath (Spectranetics) was positioned over the lead.
Under fluoroscopic guidance, a retrograde laser sheath maneuver was performed, ablating the scar tissue and fibrotic adhesions around the lead all the way up to the superior vena cava and subclavian vein (Figure 7). After the lead was completely freed, the operator carefully removed the lead through the small atrial incision.
In the presence of a ventricular lead that was transected at the clavicular level, the operator detached the lead distally using the Rongeur clamp under fluoroscopic guidance; the lead was then removed through the atrial purse string. Retrograde laser extraction was used only if gentle traction failed to remove the proximal part of the ventricular lead. In the scenario that the distal tip of the ventricular lead could not be released using a Rongeur clamp, a loop segment of the lead could be brought outside of the atrial wall and transected, and the operator could then introduce a laser sheath to release both resulting segments.
The purse strings were closed. The operator used a running 4–0 Prolene suture to further reinforce the closed atrial incision. A small drain was placed through the thoracoscopic port. After removal of the transvenous pacemaker system, the device pocket was extensively debrided, irrigated, and primarily closed with adequate drainage. A temporary pacemaker was introduced through the groin in patients who were pacemaker dependent. The chest drain was removed a few hours after the procedure.
For the 14 patients (9 men; 5 women; mean age, 69.71±20.67 years; age range, 19 to 91 years) who underwent retrograde laser lead extraction through a transatrial approach, all the devices were implanted transvenously through the cephalic or subclavian vein, and the pacemaker generators were previously positioned above the pectoralis major muscle. The Table summarizes the demographic and risk factors of the patients studied. Ten devices were pacemakers and 4 were defibrillators. The time since implantation for the leads was 98±71 months (range, 7 to 232 months) and for the devices, 93.69±51.88 months (range, 33 to 213 months). Both devices and leads were removed in all patients. The most common indications for extraction included infection in 12 (85.71%) patients and malfunction in 2 (14.29%). There were no procedure-related deaths.
As the number of implantable cardiac devices continues to rise in the United States, so will the number of device complications. The past 2 decades saw an increased focus on the development of innovative, minimally invasive lead extraction techniques. These techniques have grown to include laser-based methods. Traditionally, when these advanced percutaneous techniques could not be used, such as in scenarios involving extracardiac or protruding leads, open surgical intervention was performed. This report describes our experience with a dual-combination technique that uses both excimer laser technology and a novel endoscopic transatrial surgical approach. This minimally invasive technique has replaced the traditional approach, which would have included an open sternotomy, in a certain subset of patients.
The patients in this study presented with clinical and radiological signs of lead-caused erosions or perforations. The clinical signs included symptoms such as chest pain, recurrent pericardial effusions, pneumothorax, and symptomatic vena cava stenosis. A common misconception is the belief that extracardiac leads may not pace or that the leads may have a significant change in the impedance; however, based on our experience, this may not always be the case. All of the patients had an abnormal chest radiograph, ranging from tenting of the right atrium to the overt presence of an extracardiac lead. All of the abnormal radiographs were validated by using a gated chest CT scan without contrast. An independent radiologist interpreted these findings to confirm the suspicion of a lead-caused perforation. The present patient series had leads that were previously transected at the clavicular level. The presence of an atrial perforation combined with a transected lead often may force the clinician to refer the patient for open sternotomy. Our purpose was to explore a less-invasive approach to manage these patients.
Transatrial removal involving the use of manual traction through large incisions (ie, thoracotomy) was first suggested by Byrd8 in 1991. We report our experience involving the use of small-incision (<1 inch), minimally invasive thoracoscopy coupled with the use of a videoscope or endoscope to support the surgical procedure. In addition, we advocate the novel use of a retrograde laser approach to remove complex leads that could not otherwise be pulled with traction. To our knowledge, this study is the first to report a transatrial approach used to minimize the need for open chest surgery in this subset of patients.
Our results demonstrate that this novel approach was both safe and effective. Complete removal of both leads and devices was accomplished in all the patients. All the patients had long-term leads (>3 months), with the average time from implantation being 93.69±51.88 months (range, 33 to 213 months). Because of the fibrous adhesions that form with time, the excimer laser played an important role in the removal of these leads.9–12 The complication rate was minimal, with only 1 patient experiencing a pleural effusion related to the procedure, which was promptly treated. All the patients were discharged home, and all were alive and well at 1-month follow-up.
This novel technique provided several advantages. In the 14 patients who underwent a right-side thoracoscopy and retrograde laser lead extraction, the thoracoscopy eliminated the need for an open sternotomy to gain access to the lead. Patients experienced a quick recovery period and subsequent hospital discharge. This technique allowed the operator to remove difficult scar tissue from the leads in complex extractions. In contrast to using a femoral approach, the retrograde laser lead extraction through a right-side thoracoscopy provides the physician with a controlled environment in which to remove extracardiac leads. An alternative approach supported by some operators advocates that in a certain subset of patients, a femoral approach could be successful. In this scenario, the availability of immediate intervention would be required, from pericardiocentesis to proper surgical backup and cardiac bypass. Should a serious complication develop using this approach, emergent open chest surgery may be required, which could result in longer incisions and recovery times, promoting poorer patient outcomes. The belief behind this technique is that significant bleeding may be avoided because of the rapid sealing of the lead track. Based on our experience using a thoracoscope with perforated leads that have not been transected, we have observed variable sealing of the track. At this time, we are unable to predict which cases will bleed and which will not. Currently, there are limited data regarding the femoral technique, meriting further investigation to see as whether it would give our community another minimally invasive option for complex lead extractions. This alternative technique also would allow us to avoid open chest intervention.
This report is on a descriptive study, not a randomized control trial. The overall patient population was small, comprising only 14 patients. It is possible that retrograde laser extraction techniques could result in damage to the subclavian vessel or the superior vena cava, which is an area that needs further exploration. Future studies need to include a greater population size and >1 operator. These 2 factors would help to clarify any possible benefits this technique may have and enhance the generalizability of the results obtained.
The current trend in medicine, fueled by the desire to reduce patient morbidity and mortality and resource utilization, has led to the development of minimally invasive surgical techniques. These techniques can be used in high-risk patients who would otherwise have limited options. These approaches have changed and will continue to change all surgical and procedure-centric subspecialties. We have described our experience with a minimally invasive, safe, and effective lead extraction technique.
Dr Carrillo is a consultant for Spectranetic, Sorin, Medtronic, and Sensormatic/Tyco.
- Received March 10, 2011.
- Accepted April 11, 2011.
- © 2011 American Heart Association, Inc.
The current trend in medicine, fueled by the desire to reduce patient morbidity and mortality and resource utilization, has fostered the development of minimally invasive surgical techniques. These techniques can be used in high-risk patients who would otherwise have limited options. We present our experience with retrograde laser lead extraction, a novel, minimally invasive technique used in patients with perforated or nearly perforated pacing leads. Traditionally, these patients would have been referred for a procedure involving an open sternotomy to remove these leads. This new technique uses a video-assisted thoracoscopic approach to visualize and secure the extracardiac lead for subsequent transatrial extraction. Compared with an open sternotomy, this procedure is associated with smaller incisions and less surgical trauma. In addition to these factors, patients experience a short postoperative recovery period.