Author + information
- Charles J. Love, MD∗ ()
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York
- ↵∗Reprint requests and correspondence:
Prof. Charles J. Love, Leon H. Charney Division of Cardiology, New York University Langone Medical Center, 403 East 34th Street, RIV-4, Heart Rhythm Center, New York, New York 10016.
- implantable cardioverter-defibrillator
- transesophageal echocardiography
- transvenous lead extraction
The number of transvenous lead extraction procedures has increased steadily over the past 3 decades, going from a niche procedure practiced by a handful of pioneers to a more mainstream and available operation. Lead extraction is generally a very safe and effective procedure with a mortality risk of around 0.3%, major adverse event rate of around 1.4%, and success rates of 98% to 99% (1). During the procedure, it is not uncommon for the patient’s blood pressure to fall while traction is being placed on the targeted lead as the sheath is being advanced. The differential diagnosis includes:
1. Vasodilation or decreased inotropy due to anesthetic agents.
2. Decreased left ventricular filling due to inversion of the right ventricle.
3. Increased vagal output due to visceral manipulation of sheaths in the veins and traction on the endomyocardium.
4. Small tears in the venous structures with minor and limited blood loss into the mediastinum.
5. Tear of the innominate vein, vena cava, atrium, or ventricle.
Although the first 4 issues usually result in a brief and self-limited blood pressure drop, tear of a major venous structure or the heart can lead to a profound and sustained drop in blood pressure due to pericardial tamponade or massive blood loss into the pleural cavity. The need to rapidly decide whether to perform pericardiocentesis or surgical intervention thus occurs. The goal of the intervention is to prevent the major adverse event from becoming a fatality, although this is not always achievable.
Until recently, I relied upon fluoroscopy to make an initial determination regarding the presence of a complication requiring intervention, using transesophageal echocardiography (TEE) or transthoracic echocardiography (TTE) as needed. It is useful to view the cardiac silhouette for size and motion and to observe the density of the pleural space for opacity. The operator must stop sheath advancement and wait to see if the blood pressure returns to baseline, while viewing the chest with fluoroscopy and comparing the findings to the “scout” fluoroscopic image obtained at the beginning of the case. I preferred not to have a TEE probe in place as I felt it obscured the lead and extraction sheath at certain points.
At my current institution, we perform all of our higher-risk lead extraction procedures in a “hybrid” operating room, utilizing the services of a cardiac anesthesiologist during these cases. We now utilize TEE on all of our higher-risk cases. I have found that the information obtained instantaneously regarding the filling of the heart, condition of the pericardial space, and the pleural space to be highly valuable in making critical clinical decisions much more rapidly. Working with the same team of anesthesiologists and operating room staff, we work seamlessly together, allowing a (slightly) less stressful procedure for me, the operator. Not only do the anesthesiologists now inform me of any significant blood pressure drop, they also follow-up with information regarding what is seen on the TEE. This allows me to either adjust the extraction technique or proceed with an urgent, invasive intervention in rapid fashion. In addition, because the entire chest is prepped for possible open chest rescue, utilization of TTE is more difficult due to the need to maintain a sterile field.
The paper in this issue of JACC: Clinical Electrophysiology by Oestreich et al. (2) looks at the use of TEE during lead extraction procedures in a retrospective manner over a series of 100 patients. They found that there were 4 procedures where the blood pressure fell, and use of TEE prevented termination of the operation by ruling out tamponade or pleural effusion. More importantly, there were 3 events associated with complications that resulted in urgent surgical intervention. In all cases, rapid intervention and repair resulted in a good outcome. It should be noted that even with a rapid response to an injury, some of the venous tears are so extensive that even under the best circumstances repair is not possible. However, delays, whether caused by indecision from not knowing the cause of the blood pressure drop or due to delay in surgical intervention, decrease the chance of preventing a complication from becoming a fatality.
In the series presented, there was 1 complication related to use of the TEE probe (esophageal trauma). Although there is a small risk of TEE use and an expense associated with it as well, the benefit of having the information provided by the TEE is of great value. I have now come to believe that the small risk of probe insertion as well as the small incremental cost of its use is outweighed by the advantage of having the excellent visual information immediately available.
Having a TTE or TEE available has always been recommended (3). Although having the TEE probe in place during the procedure is not mandatory, I have found the information provided, in concert with having a well-trained and coordinated group of professionals, to be very comforting during the stressful decision-making period when the blood pressure drops. At this time, for me and many of my colleagues, having the information provided by TEE during a high-risk lead extraction is, indeed, sound advice.
↵∗ Editorials published in JACC: Clinical Electrophysiology reflect the views of the authors and do not necessarily represent the views of JACC: Clinical Electrophysiology or the American College of Cardiology.
Dr. Love has served on the advisory board of Medtronic (<$10,000) and Spectranetics (>$10,000); and has received speaker fees from St. Jude Medical (<$10,000).
- American College of Cardiology Foundation
- Wazni O.,
- Epstein L.M.,
- Carrillo R.G.,
- et al.
- Oestreich B.A.,
- Ahlgren B.,
- Seres T.,
- et al.