Cuándo, a quién y cómo explanto un catéter de

desfibrilador

Sergio L. PinskiCleveland Clinic FloridaWeston, Florida, USA

Simpler Classification of Simpler Classification of IndicationsIndications Infection Lead that represents a risk Need for venous conduit Superfluous lead during revision

or upgrade (abandoned or with failure)

Conductor fracture secondary to compression

Insulation defect and conductor fracture secondary to pinching

Gradau et al. PACE 2003;26:649

Insulation defect due to abrasion

Insulation defect due to traction from lead migration

Gradau et al. PACE 2003;26:649

Figure 1

Hauser et al. Heart Rhythm 2011; 9:742

Kaplan-Meier curve for all-cause lead removal or capping

Borleffs et al. Circ Arrhythm Electrophysiol 2009;2:411

Kaplan-Meier curve for lead failure comparing all leads with the leads from Boston Scientific, Medtronic, and

St Jude Medical, grouped by lead diameter

Strategies for ICD lead Strategies for ICD lead problemsproblems

Ignore it, reprogram around Repair lead Add pacing/sensing lead Add new defibrillation lead Extract and replace defibrillation

lead

Wollman et al. PACE 2005;28:795

Problems with additional pectoral pace/sense lead

Observation/Complication Pectoral Leads

(n = 97)

No. (%)

Oversensing with inappropriate therapy 5 5.2

Oversensing only 4 4.1

Infection 2 2.1

High-voltage defect 5 5.2

Insulation defect

Sensing/pacing threshold/impedance value out of range 3 3.1

Fracture

Dislocation 1 1

Impossible upgrading to DDD because of vein thrombosis

Death in septicemia with vegetations on leads 1 1

Total 21 21.7

Model 6949 High Voltage Conductor Survival after a Pace-Sense Conductor

Fracture

Months after a pace-sense conductor fracture

0 6 12 18 21

% survivalof HV conductors

100 98.7 89 80.3 77

Potential Drawbacks of Potential Drawbacks of Abandoning Non-Infected Abandoning Non-Infected ICD LeadsICD Leads Lead “chatter” causing spurious shocks Insulation breach in pocket causing

electrical shorting during high-voltage shock and generator damage

Large diameter could promote venous obstruction (SVC syndrome) or tricuspid regurgitation

Extraction will be very difficult if needed down the road

Epstein et al. Circulation 1998;98:1517

Epstein et al. Circulation 1998;98:1517

Epstein et al. Circulation 1998;98:1517

Epstein et al. Circulation 1998;98:1517

Epstein et al. Circulation 1998;98:1517

Hauser et al. Europace 2010;12:395

http://circep.ahajournals.org/content/3/4/413/F4.large.jpg

Wollman et al. JCE 2007;18:1172

Perioperative complications after ICD lead replacement

Additional ICD lead

(n = 33)

Replaced ICD lead

(n = 53)

% %

Lead dislodgement 3.1

Pneumothorax 6.3 5.7

Pericardial effusion 3.1 1.9

Pocket hematoma 3.1 3.6

Pleural effusion 3.1

Incomplete extraction 3.6

Total 18.2 15.1

REPLACE: major complications by lead addition or revision.

Poole J E et al. Circulation 2010;122:1553-1561

Factors to ConsiderFactors to Consider Patient age and gender (elderly women higher

risk) Overall health Previous cardiac surgery Number of leads in the intravascular space Duration of the implant Fragility, condition, and physical characteristics of

the lead Experience of the physician Desires of the patient

My “Rules of Thumb”My “Rules of Thumb”

No more than 5 leads through SVC No more than 4 leads from one

side No more than one defibrillation

lead

Figure 1

Subacute lead perforation

Danik et al. Heart Rhythm 2008;5:1667

Figure 1

Generator exchange is associated with an increased rate of

Fidelis lead failure

Lovelock et al. Heart Rhythm 2012;9:16157

What to do during elective What to do during elective replacement upgrade of ICD with replacement upgrade of ICD with not failed Fidelis lead?not failed Fidelis lead?

“Benign neglect” “The minimalist” New pace-sense lead “The next fool’s problem” New ICD lead “The all-the-way out” Extraction and

new lead “The switch” -LV lead in RV port “The downgrade” CRTP, no risk of

spurious shocks

Programmable sensing vector in new MDT ICDs

Patient “downgraded” from CRTD to CRTP 13 months ago. Fidelis lead programmed unipolar pace/sense. Lead fracture to the tip diagnosed during routine clinic check.

BiV capture

Native LBBB

LV pacing with fusion

Physicians who perform lead Physicians who perform lead extraction change their extraction change their implant techniquesimplant techniques

Use leads with excellent long-term track records.

Exclusive use of active-fixation leads Avoid dual-coil defibrillation leads Use leads “easier” to extract

Azygous vein coil for high defibrillation threshold