Extraction des sondes (Dr J. Remes)
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Transcript of Extraction des sondes (Dr J. Remes)
Lead extractions
Dr. RemesCardiac SurgeonBHCNovember 2013
Byrd classifcation: Mandatory, Necessary, Discretionary
2000 ACC: Guidelines for Indication
HRS Lead Extraction Consensus 2009
Class I, class IIa, class IIb, Class IIILevel of evidence A, B, C
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).Bruce L. Wilkoff, MD, FHRS,* Charles J. Love, MD, FHRS,† Charles L. Byrd, MD,‡Maria Grazia Bongiorni, MD, …
PM lead extraction: History
PM lead extraction: IndicationOverview
InfectionChronic pain
Thrombosis – venous stenosis
Non functional leadsFunctional leads
PM lead extraction: IndicationInfection: Class I (Level B)
• Device infection:Valve endocarditis, lead
infection, sepsis
• Pocket infection: Erosion, chronic drainage. Without clinical lead infection
• Valvular infection: Without lead or device infection
• Occult gram+ bacteremia
Removal is recommended
PM lead extraction: IndicationInfection: Bacteremia
• Class I (B): gram+ bacteremia• Class IIa (B): gram- bacteremia
PM lead extraction: IndicationInfection: Class III (Level C)
Removal is not indicated
Superficial incisional infection, without involvement of the device or leads
PM lead extraction: IndicationChronic pain: Class IIa (Level B)
Removal is reasonable:
If there is no acceptable surgical alternative.
PM lead extraction: IndicationThrombosis: Class I (Level c)
Removal is recommended:In patients with clinically significant
thromboembolic events associated with a thrombus on a lead.
PM lead extraction: IndicationVenous stenosis: Class IIa (Level c)
Removal is reasonable:
In patients with ipsilateral venous occlusion, requiring placement of an additional lead, when there is no contra indication for using the contralateral side.
PM lead extraction: IndicationFunctional lead: Class I (Level B)
Removal is recomended:• Live threatening arrhythmias• Immediate threat if left in
place• Leads that interfere with
operation of the device• Leads that interfere with a
treatment of malignancy
PM lead extraction: IndicationFunctional lead: Class IIb (Level B)
Removal may be considered:In patients with leads that are
functional but not being used. Ex: RV pacing lead after upgrade to ICD
PM lead extraction: IndicationNon Functional lead: Class I (Level B)
Removal is recomended:• Live threatening arrhythmias• Immediate threat if left in
place• Leads that interfere with
operation of the device• Leads that interfere with a
treatment of malignancy
PM lead extraction: IndicationMulti lead: Class IIa (B)
Removal is reasonable:If a new device needs 4 leads
on one side or 5 leads through the VCS.
PM lead extraction: IndicationNon Functional lead: Class IIb (C)
Removal may be considered:
At the time of CID, if contra-indications of removal are absent.
PM lead extraction:Contraindications
• Life expectancy less than one year. • Patient not suitable candidate for
sternotomy.• Presence of calcifications on RX in
de VCS or RA• If there is a anomalous placement of
leads through other structures than normal venous and cardiac structures (sublavian art, aorta, systemic atrium/ventricle).
Lead removal techniques
• Direct manual traction. With/Without locking stylet
• Telescoping sheaths (counterpressure)
• Rotational cutting blade sheath.
• Excimer laser sheaths• Surgical removal
Lead removal techniques
• Direct manual traction. With/Without locking stylet.
Direct manual traction:
Lead removal techniquesTelescoping sheaths: Counterpressure
Lead removal techniquesRotational cutting blade sheath:
Lead removal techniquesExcimer Laser:
Lead removal techniquesSurgical removal:
Patient management
• Preoperative management• Intra operative management• Postoperative management
Preoperative management
• Physical examination (infection & thrombosis)
• Previous indication for device implantation.
• Duration of implantation• Lead number – Lead location• Lead type – Lead fixation
machanism• Current medications
(ATB&anticoagulants)
• Cardiac rhythm: PM dependent?
Preoperative management
• Chest X ray (AP&LL)• Laboratory tests• Echocardiography• Venography
Intraoperative management
• General anesthesia• ECG monitoring• O2 monitoring• Arterial line• Large periferal infusion line• Draping: bilat fem&jug, bilat
groin.• Trans Oesophageal
Echocardiography• High quality fluoroscopy
Intraoperative management
• External defib pads• Temporary PM (Left fem vein)
• ICD mode switch off• Blood products availability• Pericardiocentesis tray• Surgical sternotomy
equipment.
Intraoperative managementTools
• Locking stylets.• Polypropylene Sheaths.• Evolution extraction• High quality fluoroscopy.• Additional material: (lasso
catheter, steerable material).
• Femoral working station
Postoperative management
• Temperature monitoring• ECG monitoring• Blood pressure monitoring• Blood exams & cultures• TTE evaluation• Adapted medical treatment
Procedure succes Complications:
• Pericardial effusion without pericardiocentesis
• Hemothorax not requiring drainage• Hematoma requiring revision• Arm swelling/thrombosis• Migrated lead fragments without sequelae• Blood transfusion
Minor complications
Procedure succes Complications:
• Vessel laceration• Cardiac lesion• Cardiac tamponade• Stroke• Infection of a previously non-infected area• Traumatic tricuspid regurgitation (6,7%)• Embolisation of thrombus or vegetation• Death (<1%)
Major complications
Procedure succes
Risk factor for a complication:
Complications:
• Younger age• Longer implantation time• Female sex• Presence of calcification• Multiple leads• ICD leads (Double > single coil)• Passive fixation
Procedure succes
Leads / pts Complete removalByrd 2002 2561 / 1684 90%LExlCon 2010 2405 / 1449 96,5%de Bie 2012 445 85%
Completeness of lead removal:
Procedure succes
Center Technique Pts Leads Clin Major Mortality success compl
Byrd 99 Mechanical 2338 3540 98% 1,4%Byrd 01 RF sheath 265 542 99,4% 2,6%Neuzil 07 RF sheath 60 84 99% 3,3%Wilkoff 07 Laser 1850 3238 99,4% 0,3%Bongiorni 08 Single sheath 1193 2062 99,7% 0,7% 0,3%Epstein 08 Laser 498 975 99,1% 0,4% 0Kennergren 09 Laser 647 1032 99,3% 0,9% 0Saba 08 Laser 212 456 98% 4,2% 0,4%LExlCon 09 Laser 1449 2405 97,7% 1,4% 1,8%Platou 09 Single sheath 420 692 97,6% 1,9% 0,4%
Literature overview:
Lead extractions
Dr. RemesCardiac SurgeonBHCNovember 2013