1. Safety of Lead Extraction After Decades of Implantation Alpay Çeliker M.D. Acıbadem University, Istanbul

2. 15 year old boy with postoperative AV block. VDD pacemaker. Needs biventricular pacing. What to do???

3. 17 year old boy with postop FT. One abandoned TV lead. History of fever

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

5. Lead Malfunction Compromised pacing ▫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

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

7. Factors to Consider Patient ▫Pacemaker dependence ▫Patient prognosis ▫Risk of revision/replacement procedure Lead ▫Malfunction characteristics ▫Adverse clinical consequencce ▫Availability of reporogramming

8. 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

9. Indications Class I:Class I: ▫a: CIED infection ▫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

10. 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

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

12. Common Areas of Fibrosis

13. Lead Locking Device Types of locking devices Cook Spectranetrics Vascoextor Limitations of usage Broken conducture Distortion of central lumen Expanded Compressed

14. Telescopic Sheaths Locking stylet needed Made from metal, teflon or propylene

15. Laser Sheaths 12-16 F sizes available

16. Bipolar Radiopaque Electrodes Teflon Inner Sheath Outer Sheath Electrosurgical Dissection Sheath & Generator

17. Rotating Sheaths Rotational mechanism Stainless-steel blade tip Ayman et al. Heart Rhythm 20101 41 leads in 29 patients Success alone 77% Needs femoral WU in two cases. Oto et al. Europace 2011 41 leads in 23 patients Success alone 82% Needs femoral WU four patients ** Wrapping of coexistent leads may pose a problem

18. Snares, Sheaths & Baskets

19. Definition of Success Complete Success Complete Success - Removal of all lead material from the vascular space. Partial Success Partial Success - Removal of all but a small portion of the lead. Failure Failure – Abandoning a significant length of lead (more than 4cm)

20. 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

21. Pacing System Infection: Treatment Choices Surgery − Large vegetations (> 10mm) ‏ − Abcess formation − Broken lead − Abandoned old leads − Concomitant surgery need Intervention − Small vegetations − Strand formation − Lead amenable to extraction

22. Lead Problemn Lead fracture 14 Upgrade 8 Infection 7 Dislodgement 5 Other reasons 5

25. Excimer-laser extraction in children 25 patients, 43 leads (36 pacing/7 ICD leads) Median age at extraction 13,9 years (8,4-29,2) Mean duration of lead 49,4 months (3-128) Lead fracture 37/43 leads (86,6%) Lead position: Ventricular 58%, atrial 42% Complete removal 39/43 (91%), partial in four Major complication 2/25 ▫Cardiac perforation and tamponade ▫Thrombosis of left subclavian and innominate vein Moak J et al. PACE 2006.

26. LEAD EXTRACTION WITH SEVERAL METHODS Cecchin et al. Circ Arrhythm Electrophysiol. 2010.

27. Unsuccessfull Simple Extraction: ▫older lead age ▫lead in the ventricular position ▫polyurethane lead insulation

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

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

31. Conclusions Lead problems is relatively more frequent than in adult population Lead extraction results in children are comparable with the adult series Newer techniques may offer more success and less complications. Surgery may be needed infrequently. Technologic improvement at epicardial and transvenous pacing may lower the incidence of lead problems.