A pacemaker can become infected

Extraction from pacemaker or defibrillator probes

background

The increasing number of implantable devices inevitably leads to increased complications, especially with the SM, ICD or CRT probes. Not only infections (mostly bacterial), which can occur in up to 5% of all interventions, but also the handling of dysfunctional, functionless or disused probes as well as strategies for venous vascular occlusions and anomalies have increasingly become the focus of rhythm surgery in recent years Centers moved. The interdisciplinary removal of electrodes poses a particular challenge. The removal of pacemaker or ICD probes includes probe explantation and probe extraction. While the probe can be removed by simple mechanical pulling during probe exploration, probe extraction describes 1. the removal of probes that were implanted more than a year ago, 2. the removal of probes that require the use of specific instruments or 3. the Removal of probes via a different venous access route than the one initially used.

The following will focus on probe extraction. The aim of probe extraction is to clear an infection, to gain access to an occluded vein, to reduce the risk of probe perforation or arrhythmias, to remove inoperative or broken probes or to eliminate probe-associated symptoms. Infections represent a particular challenge. They can be located in the pocket or on the probes, arise endogenously or occur exogenously in the context of revision or generator replacement operations.

 

Figure 1: (left) Extraction Sheath (Spectranetics)
Figure 2: (right)Laser probe extraction from the subclavian vein

 

Figure 3: chronically infected probe (adapted from Simon C et al. (2008) A case of permanent pacemaker lead infection. Nat Clin Pract Cardiovasc Med doi: 10.1038)

 

Extraction process

A probe extraction requires an experienced teamwork of experienced rhythmologists and specially trained cardiac surgeons who have mastered the entire spectrum of indications, extractions and all possible complications.

The operation is carried out in a special operating unit which, in addition to the availability of all extraction systems, also includes a high-quality fluoroscopy system and the option of an emergency thoracotomy within a few minutes. Depending on the expected complexity of the extraction, the operation is carried out under intubation anesthesia or in anesthesiological stand-by. In addition, the possibility of intraoperative TEE must be given. A number of different extraction systems and options are available today for extraction. The core element of an extraction is the use of so-called lead-locking stylets, which can be inserted into the central inner lumen of the probes and locked there distally or over their entire length by stretching twisted wire loops. In addition, the probes can be retrieved with the help of a flexible extraction loop. Alternatively, especially with probes fixed intracardially or firmly in the subclavian vein, a rotatable extraction sleeve can be inserted into the deep venous system antegrade via an electrode to be extracted. These systems allow intravascular and intracardiac adhesions to be loosened around the target electrode by rotating the helical flexible sheath tip and gently advancing it while simultaneously pulling back on the probe, thus enabling safe electrode removal. In addition, with these systems, a recanalization of initially closed veins is possible, which enables ispilateral implantation of new electrodes.

If there is an infection of the pacemaker or ICD system, due to the increased perioperative bacteremia, an interval of usually at least 2 weeks must be waited until a new SM or ICD can be implanted, usually contralateral. If these patients are also pacemaker-dependent, they must be temporarily stimulated by an external pacemaker until they are re-implanted. Patients with large intracardiac tube vegetation represent a special population. Depending on the size of the vegetation, the involvement of the tricuspid valve and the clinical condition of the patient, a very differentiated indication of closed versus open extraction is required. A transvenous extraction of tube vegetation up to 2 cm seems to be justified based on the current data. Here again, the interdisciplinary interaction with the cardiac surgeon is promising.

Results

Valid results on the probe extractions are only available to a limited extent, as only a few centers have sufficient experience and number of cases. A probe removal succeeds in> 90%. A differentiated extraction strategy using all of the above extraction options can further increase the success rate. Last but not least, in the case of very difficult conditions / adhesions or severe infections (pocket infection, device endocarditis), a complete system exploration using "laser extraction" (Fig. 1,2,3) may be necessary. This form of laser therapy (excimer laser) is only offered by very few centers in northern Germany and only at the UKSH in Schleswig-Holstein.

Guideline-based indications for tube extractions include:

  • chronic or acute tube infection
  • Thrombosis or stenosis in the vein
  • chronic, conservative, non-curable pain
  • Broken leads and defective probes cause arrhythmias or conduction disturbances
  • Inoperative probes whenever there are more than four probes on each side

credentials

  • Borggrefe M, Burkhoff D, Heart Rhythm Society; American Heart Association. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the Ameri-can Heart Association (AHA). Heart rhythm. 2009; 6: 1085-1104 Clinical Effects of Cardiac Contractility Modulation (CCM) a Treatment for Chronic Heart FailureEur J Heart Fail, 2012, 703-12.
  • Bode F, Himmel F, Reppel M, Mortensen K et al. Should all dysfunctional high-voltage leads be extracted? Results of a single-center long-term registry. Europace. 2012, 1764-70.
  • Mortensen K, Aydin MA, Goldmann B et al. Fluoroscopy to assess late heart and lung perforation by a permanent ventricular pacemaker lead. A case complicated by isolated hemothorax. Int J Cardiol. 2008, 104-6.
  • Rastan AJ, Doll N, Walther T et al. Pacemaker dependent patients with device infection - a modified approach. Eur J Cardiot horac Surg. 2005; 27: 1116-1118.
  • Klug D, Lacroix D, Savoye C et al. Systemic infection related to endocarditis on pacemaker leads. Circulation 1997; 95: 2098-2107.
  • Vogler J, Pecha S, et al. Navigation of lead extraction-is it possible? Impact of preprocedural electrocardiogram-triggered computed tomography on navigation of lead extraction. Eur J Cardiothorac Surg. 2018 Mar 30