Dr. Pascal Defaye
We co-chaired a session dedicated to lead extraction. It was a very exciting and interactive session with 2 important presentations. The first presenter was Maria-Grazia Bongiorni from Pisa (Italy) concerning the preparation and the achievement of a lead extraction procedure. We know that the indications for lead extraction are rapidly increasing due to a lot of factors, particularly the complexity of the systems, the increased life expectancy, the recalls and the increasing number of infections. When you perform a lead extraction, you need to have in your operating room or EP lab a variety of tools enabling to deal with all complex situations. We know that after years, there are a lot of binding sites with the vascular tissue and the other leads: subclavian vein, superior vena cava, tricuspid annulus, right ventricle. These tools make it possible to cut adherences along the lead: locking stylets, powered (Laser) and non-powered (mechanical powered) counterpressure sheaths. MB Bongiorni described particularly her proper technique by a jugular approach. The discussion focused on complications and how to avoid vascular injury and particularly SVC tears, which is a dreadful complications. MB Bongiorni never had SVC injury with the jugular approach because there is no angle, and no constraints along the lead with the extraction tool. When you prepare a lead extraction procedure, you must have a check phase to understand the patient history, indications for pacing, indications of lead removal, the number of leads and the implant duration. You must look carefully at the chest-X ray before the procedure, to anticipate the difficulties of extraction. Then the collective phase will be prepared with all the heart team (physicians, nurses and surgical back-up) It is clear that TLE is today, in good hands, an effective and relatively safe procedure with a very high success rate (close to 100%).Patience and creativity are crucial in some cases , the procedure must be planned and tailored to the single case. During the second part of the session, Adrian Rozkovec from Bournemouth (UK) described the requirements for the extraction clinic. He summarized the EHRA position paper concerning the pathways for training and accreditation for transvenous lead extraction recently published in 2012. To do lead extraction, you need to have performed at least 40 lead extractions with 10 leads older than 6 years old as a trainee. We know that it is very important to participate in a fellowship programme, to regularly attend an extraction training centre, to invite an outside expert to your centre for training, and finally to only undertake low risk cases at first. The development of simulator training is very important to explore a wide range of scenarios and to accelerate the learning curve. A Roskovec described factors associated with higher procedural risk, such as BMI<25kg/m2, co-morbidities, venous status (occluded or severely stenosed), history of congenital heart disease, fixation mechanism (passive), lead body geometry (non-isodiametric), ICD lead, implantation time and special/damaged leads. The team includes the primary operator, the cardiothoracic surgical back-up, the anaesthesia support, the scrubbed and non-scrubbed assistant and an echocardiographer. To summarize, we know that many current extraction centres do not fully meet the guidelines but it is time, in accordance with the European position paper, to improve the organisation and the training of the future lead extraction centres. The discussion also focused on indications: infection is the main indication and extraction policy lead recall varies between centres. Finally, we need to begin a European registry on lead extraction.
Lead extraction: how to prepare, perform and follow?
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