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How to Handle Lead Problems in Pediatric & Congenital Heart Disease

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Presentation on theme: "How to Handle Lead Problems in Pediatric & Congenital Heart Disease"— Presentation transcript:

1 How to Handle Lead Problems in Pediatric & Congenital Heart Disease
Alpay Celiker MD. Acıbadem University Department of Pediatric Cardiology Istanbul

2 16 year old boy with congenital AV block. VDD pacemaker . No complaints
ECHO: Tricuspid valve problem. Some signs of left ventricular dysfunction What to do???

3 Ways of Pacing Transvenous Epicardial Hybrid

4 Epicardial & Transvenous Pacing
Epicardial pacing Better for preserving venous system Better results for long-term pacing regarding pacing induced heart failure Applicable for all conditions More frequent lead problems Transvenous pacing system Less lead problems More problems on venous system

5 Complications of Pacing System
Infection; Superficial, deep pocket Lead Endocarditis Lead malfunction Fracture Insulation & other problems Venous occlusion Damage to cardiovascular system

6 Pacing System Infection
Localized or superficial infection Localized pain, swelling Purulent discharge Deep infection Fever Pulmonary thromboembolism Recurrent pulmonary infection Sepsis

7 Pediatric Pacemaker Infections*
Perioperative Infections (before discharge): Superficial 1,2 % Deep 0,2 % Early Pacemaker Infections (< 60 days)‏ Superficial 3,1 % Deep 1,2 % Late Pacemaker Infections Superficial 0,5 % Deep 0,7 % Staphylococcus species were isolated in 44 % Increased Risks Reintervention Down syndrome Subcutaneous  preperitoneal pocket * Cohen et al J Thorac Cardiovasc Surg 2002; 124.

8 Treatment Localized Infection Intravenous and oral antibiotics
Local debridman Infrequently pacing system removal Deep Infection Pacing system removal Antibiotics >2 weeks intravenously  6 weeks total

9 Treatment Choices Intervention Surgery Small vegetations
Strand formation Lead amenable to extraction Surgery Large vegetations (> 10mm)‏ Abcess formation Broken lead Abandoned old leads Concomitant surgery need

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11 Lead Malfunction Compromised pacing Compromised sensing
Failure to capture, high threshold Extra-cardiac stimulation Compromised sensing Under-oversensing Lead-lead interaction Electrical Abnormality Abnormal pacing impedance Abnormal high voltage impedance Low-amplitude electrogram

12 Signs of Lead Fracture No stimuli or stimuli without capture
Oversensing of false signals Permanent or intermittant high lead impedance

13 Patient- and lead-related factors affecting lead fracture in children Olgun, Karagoz, Celiker and Ceviz Europace (2008) 10, 844–847

14 Structural Problems Conductor failure Insulation failure
Connector failure Fixation failure

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16 Methods to Determine Device interrogation Imaging
ECG, marker channel, impedance, event recording Imaging X-ray, fluroscopy Physical inspection or test at the time of implant

17 Treatment of Malfunctioning Lead
Lead surgically abandoned or capped Lead electrically abandoned (mode change)‏ Lead explanted/repaired Device reprogrammed (polarity)‏ Lead related intervention: reposition, partially abandone

18 Factors to Consider When Managing Leads
Patient Pacemaker dependence Patient prognosis Risk of revision/replacement procedure Lead Malfunction characteristics Adverse clinical consequencce Availability of reporogramming

19 Lead Extraction in Children. Why?
Remove the intravascular and intracardiac lead material Relieve and reconstruct the venous access for the new leads Prevent lead related infection

20 Indications Class I: a: sepsis b: life-threatening arrhythmia
c: life threatening condition d: thromboembolic event caused by retained lead Obliteration of all useable veins Lead interfereres with the operation of another device

21 Procedure Basic lab tests and crossmatch for blood should be obtained
All x-rays related with pacemaker and leads must be evaluated Arterial and venous catheters for BP monitor and fluid supply Anesthesia

22 Lead Extraction Methods
Simple traction Snares Needles eye, Goose neck Lead locking devices Cook, Spectranetrics Laser sheaths Radiofrequency sheaths Rotating sheaths

23 The main barrier to lead extraction is fibrosis, which can occur wherever the lead chronically touches tissue. The three most common sites for fibrosis are: · Venous insertion site · SVC vein (curvature area) · Endocardium fixation site Both passive and active fixation leads are prone to all three areas of fibrosis; however, the screw-in mechanisms of active fixation leads usually can be easily unscrewed from any endocardial fibrosis.

24 Pulleys & Weights Traction can be accomplished with either gentle manual traction or with a simple pulley mechanism and weights. With manual traction, a hemostat is clipped to the exposed lead end and gently pulled. Fluoroscopy should be used to observe lead movement. With the pulley system, the hemostat is tied to a line that hangs over a pulley and the line is attached to a weight (e.g., small solid weights or a bag with water). The weight starts at about 350 grams. Additional weight is added as needed. This weighted traction procedure may take several hours. PVCs are noted on the EKG as the lead tip begins to disengage from the endocardium.

25 Locking Stylets This slide illustrates the essential components of a pacing lead. The following topics will be discussed for each component: · Purpose · Design factors · Performance factors

26 Spectranetics Lead Locking Device
Expanded Compressed

27 Counter traction requires one or two sheaths and a locking stylet
Counter traction requires one or two sheaths and a locking stylet. Sheaths are made of stainless steel, Teflon, or polypropylene. Telescopic Sheaths

28 The femoral approach is seldom used as the initial attempt to remove the implanted lead. Usually it is used only after the subclavian approach has failed.

29 Laser Sheaths Rotating Sheaths

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34 Classification of Complications
Major Complication Death Cardiac or vascular avulsion or tear Pulmonary embolism Stroke Minor Complication Pericardial effusion or hemothorax Vascular repair need Pneumothorax requiring a chest tube Pulmonary embolism not requiring surgical intervention

35 Definition of Success Complete Success - Removal of all lead material from the vascular space. Partial Success - Removal of all but a small portion of the lead. Failure – Abandoning a significant length of lead (more than 4cm) Love CJ et al. PACE 2000; 23

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37 Lead Problem n Lead fracture 14 Upgrade 8 Infection 7 Dislodgement 5
Other reasons 5

38 Surgery for Lead Problems
Infection Lead can not be explanted by interventional methods Lead should not be explanted by interventional methods Concomitant surgery need

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40 New Problems !!! Coronary sinus leads ICD leads Lumenless electrodes
Multipl leads Venous obstruction Tricuspid valve impingement

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42 Conclusions Lead problems is frequent than in adult population
Although interventional methods have been successfull, surgery may be needed infrequently. Newer techniques may offer more success and less complications. Technologic improvement at epicardial and transvenous pacing may lower the incidence of lead problems.

43 Teşekkür Ederim


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