Extraction of transvenous pacing leads.
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Electrodes, Implanted↗
Biomedical subjects
C L Byrd
Publications and source records attributed to C L Byrd.
Safe introducer technique for pacemaker lead implantation.
Over the last several years, an introducer approach for pacemaker lead insertion has evolved that eliminates most introducer-related complications. The approach consists of defining a safe region for intrathoracic cannulation of the subclavian vein. If specific conditions cannot be met for entering the "safe" region or if the vein cannot be found, the subclavian vein is cannulated extrathoracically. Recently, this technique was used in 263 consecutive patients undergoing pacemaker implantation. The intrathoracic portion of the subclavian vein was used in 239 (90.9%) cases and the extrathoracic portion in 24 (9.1%). One hundred and ninety-eight (75.3%) cases were right-sided and 65 (24.7%) were left-sided. On the right side, 177 (89.4%) used the intrathoracic portion of the subclavian vein and 21 (10.6%) used the extrathoracic portion. On the left side, 62 (95.4%) used the intrathoracic portion and three (4.6%) used the extrathoracic. The introducer technique was successful in all cases and there were no introducer-related complications.
Electrodes, Implanted↗
Lead extraction. Indications and techniques.
Each of the extraction techniques and their ancillary tools was reported as used successfully; however, until now, no technique has been successful when used in more than a few isolated instances. The technique for intravascular countertraction and the associated tools described in this paper were devised and selected in an attempt to develop one technique to be used on all patients, with all types of leads, and with a very low complication rate. Its versatility permitted single or multiple lead extractions combined with the precision of selecting and extracting a specific lead. In our experience, as well as the experience of others, the techniques described in this paper have proved to be superior by minimizing the inherent risk and morbidity, allowing us to expand the indications for lead removal beyond septicemia and free-floating leads, to include infection, abandonment of pockets, and replacement of malfunctioning or fractured leads. Intravascular countertraction was a consistently safe and efficacious method of removing transvenous pacemaker leads regardless of the duration of the implant, thus permitting extractions in patients not considered candidates for a more extensive surgical procedure. Intravascular countertraction encompasses surgical and fluoroscopic techniques possessed by most physicians experienced in pacemaker and automatic implantable cardioverter defibrillator implants. However, there is a learning curve, predicating caution for the inexperienced physician. In addition, advanced surgical skills may be needed in handling associated conditions such as debridement and primary closure of chronically inflamed tissues, especially in submuscular pockets and sinus tracts in the neck. Although the potential for a cardiovascular complication is small, it does exist, and cardiovascular surgical backup is a recommended precaution.
Cardiopulmonary Bypass↗
Intravascular techniques for extraction of permanent pacemaker leads.
Intravascular techniques were used to extract 226 leads from 124 patients. Indications for lead extraction were life-threatening septicemia (30%), complications of free-floating leads (2%), abandonment of pockets (40%), and replacement of malfunctioning leads (28%). Extraction tools included flexible, telescoping sheaths advanced over the lead to dilate scar tissue and apply countertraction, deflection catheters, and wire basket snares. Countertraction is defined as the direct force of traction on the lead countered by the circumference of an extraction sheath. One hundred sixty-four leads were extracted through the superior vena cava by advancing the sheaths over the lead to the myocardial wall. Most of these leads passed through the subclavian vein. An approach through the inferior vena cava was used for the remaining 62 leads. The countertraction sheaths were passed from the femoral vein into the right atrium. A maneuvering catheter and an extracting snare were placed inside the sheaths. The lead was positioned by the maneuvering catheter, entangled in the extracting snare, and the sheaths advanced over the snare and lead to the myocardium. An atriotomy by means of a limited surgical approach was required to free one lead. One infected lead broke 5 cm from the electrode and was removed through a median sternotomy, ventriculotomy, and retrograde extraction. All patients had unremarkable recoveries. Intravascular countertraction techniques proved to be a viable alternative, minimizing the risks and morbidity of lead removal.
Adolescent↗
Computerized pacemaker patient analysis.
We have developed computer hardware and software that imports analog waveforms and other measured data from a patient into the PaceBase database system supported by any IBM PC/AT compatible. The programmable A/D converter has the capacity to acquire the pacemaker artifact from the surface ECG leads. Analysis of the pacemaker artifact permits confirmation of pulse width as well as programmability and facilitates discovery of pacemaker hardware failures otherwise undetectable. Continuous recording of real-time surface ECG can be made as other measurements or storing functions are being performed. In this way, sporadic or infrequent intrinsic events are automatically recorded and can be selected to be played back and reviewed or stored on the permanent record. Pacemaker spike detection enhances identification of paced and intrinsic complexes by emphasizing the paced artifact. Even bipolar atrial spikes with pulse widths as short as 0.05 ms are easily identified; myopotential muscle noise is rejected. Enhancement of pacemaker spikes takes the guesswork out of interpretation of ECGs, especially for bipolar systems and when testing or troubleshooting for myopotential tracking or inhibition.
Analog-Digital Conversion↗
Transatrial implantation of transvenous pacing leads as an alternative to implantation of epicardial leads.
State-of-the-art pacing modalities are not readily utilized with conventional epicardial pacing lead implantation techniques. A transatrial implantation technique was developed combining a limited surgical approach with transvenous leads. Six patients who were poor candidates for transvenous implants have received DDD or DDDR pacemakers by this approach. The limited surgical approach includes resection of the third or fourth costal cartilage through a small skin incision, reflection of the pleura, and opening of the pericardium. The introducer and transvenous leads are inserted through a right atrial pursestring suture. The leads are positioned in the right ventricle and right atrium using standard fluoroscopic techniques. Through the incision, the subcutaneous tissue pocket is constructed on the right anterior chest wall. The leads are connected to the pacemaker without the need for adaptors or tunneling. There were no procedure-related complications. The magnitude of the surgery and postoperative morbidity are significantly less than for a standard thoracotomy, median sternotomy, and transdiaphragmatic epigastric or subcostal approach. The utility of the transatrial implantation technique is that it allows the use of state-of-the- art bipolar dual chamber pacemakers restoring access to all pacing modalities for those patients not candidates for transvenous implantation.
Adult↗
Intravascular lead extraction using locking stylets, sheaths, and other techniques.
UNLABELLED: Septicemia necessitates extraction of chronic pacemaker leads. Using locking stylets and sheaths to extract leads via the implantation vein (subclavian, cephalic, or jugular) and maneuvering devices, sheaths, and retrieval baskets via the femoral approach, extraction of 228 leads implanted 5 days to 240 months (mean 55 months) was attempted in 136 patients (mean 62 years) at 34 institutions. In addition to septicemia (9%) and infection (39%), total 48%, indications included prophylaxis/replacement (40%), and other (12%). Seventy-seven leads were atrial, 151 ventricular; 147 were unipolar, 81 bipolar; 96 had silicone insulation, 127 polyurethane, 1 poly/silicone, and 2 undetermined. Fixation included tines or fins (160), screw (40), flange (12), and other (16). One hundred and ninety-four leads were completely extracted, 19 partly extracted, and 15 not extracted. Procedural complications were: torn atrium requiring open heart repair (1), hemothorax requiring a chest tube and blood transfusions (1), subacute hemothorax requiring drainage 18 days after discharge (1), thrombosis treated by drugs (1), and myocardial avulsion without sequela (1). Important observations included the significant training required due to the large number of possible clinical variables, and the need to be prepared for life-threatening cardiovascular complications. With training, procedures done at higher volume and lower volume institutions met with similar success. CONCLUSION: Intravascular lead extraction is a viable technique whose benefits outweigh the risks, given the proper intensive training and open heart surgical backup, and may obviate the need for open heart surgery for lead extraction.
Adult↗
Intravascular lead extraction using locking stylets and sheaths.
Chronic lead extraction using intravascular countertraction techniques was studied in patients with over 65 different lead models including passive and active fixation devices. Indications for removal of 115 leads implanted 5 days to 264 months (mean 58 months) in 62 patients (mean 65 years) included septicemia, subcutaneous tissue infection, preerosion, free-floating lead, lead trapped in valve, too many leads, pain, and vein thrombosis. The superior vena cava (SVC) approach was attempted in 101 leads and was successful in 82 attempts (71% of total leads). The inferior vena cava (IVC) approach via the femoral vein was required to extract 14 (12%) leads inaccessible to the SVC approach and the 19 leads that failed the SVC approach (29% of total leads). The SVC procedure includes a sized stylet locked at the tip and telescoping sheaths advanced over the lead to the heart. An IVC procedure includes placement of a 16 F sheath workstation via a femoral vein into the right atrium. A deflection catheter and Dotter snare in an 11 F sheath were advanced through the workstation into the right atrium. The lead was maneuvered into position, snared, and pulled into the workstation. For both the SVC and IVC approaches, the leads were removed by applying traction on the lead and countertraction with the sheaths. In experienced hands, these techniques have proven safe and effective for removing chronic transvenous leads.
Adult↗
Atrial capture detection with endocardial electrodes.
A new method of evoked response detection, previously demonstrated in the ventricle, has been studied in the atrium at the time of routine pacemaker implant in 16 patients. The atrial evoked response was readily detectable in all patients due to excellent recovery from poststimulus polarization. In six patients, as experimental threshold-tracking pacemaker was used to automatically verify atrial capture and to generate strength-duration curves. It is concluded that this pacing technique is both simple and reliable, and that automatic atrial threshold tracking is feasible.
Atrial Function↗
DDD pacemakers maximize hemodynamic benefits and minimize complications for most patients.
A 44-month retrospective analysis was performed on 666 pacemakers implanted at Mt. Sinai Medical Center. Mapping techniques and endocardial waveform analyses were used during lead positioning to ensure the best electrical environment. The optimal pacing lead type was selected based on the clinical situation. Follow-up evaluations were rigorous. Patient population ranged in age from 28 to 103 with a mean of 78 years at time of implant. Seventy percent of the patients received DDD pacemakers with an 81% survival incidence at 44 months. Of the VVI population (30% of the implants), there was a 62% survival incidence. Most problems associated with the pacing systems were related to the atrial channel. Loss of atrial sensing occurred in 7.5% of the population and was corrected noninvasively in 5.8%. Due to chronic loss of atrial sensing, 1.7% of the population remained programmed to DVI/VVI. A total of 7.7% were chronically reprogrammed from DDD to VVI, 5.6% secondary to atrial fibrillation. Reoperations were necessary in 1.2% of the malfunctioning systems that could not be corrected by reprogramming. The following conclusions were reached: (1) maximizing hemodynamic benefits and minimizing pacemaker complications permitted a survival rate equal to or better than that of the general population, and (2) chronic problems related to the atrial lead and malfunctions of the pacing system were minimized by careful patient selection, appropriate pacemaker and lead selection, endocardial waveform analysis, and thorough follow-up.
Adult↗
A computerized system for modeling pacemaker rhythms.
We have developed a computer program which simulates a paced cardiac rhythm strip, graphically generating the electrocardiogram (ECG) on a color monitor. Any pacemaker, programmed as desired, dynamically interacts with a preselected intrinsic rhythm. Utilizing symbols prevalent in the pacing industry, this graphics-oriented, interactive system promotes a rapid understanding of pacemaker function by automatically superimposing specific pacemaker events on a rhythm strip. These events include: pacemaker spikes, evoked cardiac depolarization waveforms, refractory periods, upper rate intervals, and blanking periods. Applications of this program include interpreting and verifying appropriate pacemaker function, demonstrating idiosyncrasies of the various pacemakers, and teaching.
Computer Graphics↗
Pacemaker clinic evaluations: key to early identification of surgical problems.
The pacemaker center evaluation was responsible for the timely reoperation of 341 pacemaker patients over the last three years. The most common indication for reoperation was battery end-of-service (46.3%). Battery testing and maintenance of accurate records for trend analysis ensures prompt generator replacement. Atrial and/or ventricular lead malfunction was the second largest indication (26.3%). Lead malfunction detected by bracketing capture and sensing thresholds included: dislodgement, penetration, exit block, fracture, insulation failure, and abnormal sensing. The third largest indication for reoperation was pacemaker pocket erosion and/or infection (15.5%). Examination of the pacemaker pocket site is an integral part of an evaluation. In conclusion, the three largest indications for reoperations can be best demonstrated in a pacemaker center where evaluations are personal and thorough, and accurate record keeping is maintained.
Adult↗
Technique for the surgical extraction of permanent pacing leads and electrodes.
When a pacing lead becomes infected, the most expedient and successful therapy is its removal. A new surgical extraction technique, combining the use of fluoroscopy and a limited surgical dissection of the right atrium, is presented for the removal of a lead entrapped in the heart or venous system.
Aged↗
Long-term results of "simple" thrombectomy for thrombosed Björk-Shiley aortic valve prostheses.
During the past two years 8 patients were seen with thrombosis of their Bjork-Shiley aortic valves. Six patients were from our series, an incidence of 4% and 2 patients had their original valve implanted at another institution. All patients had substantial problems with anticoagulation therapy. Three died prior to operation. Early detection and emergency surgical intervention is mandatory for survival. At operation debridement of all thrombotic material from the valve provided satisfactory immediate hemodynamic improvements as well as freedom from complications for up to two years. Therapeutic levels of anticoagulation with warfarin are the only apparent protection from thrombosis of the Bjork-Shiley aortic valve.
Anticoagulants↗
Noninvasive cardiac evaluation (NICE) of intracardiac shunts using inhaled radioactive carbon dioxide.
A totally new, noninvasive technique is presented for the detection and analysis of left-to-right cardiac shunts. Five millicuries of oxygen 15-labeled carbon dioxide is administered by a single-breath inhalation technique. The resultant lung washout curve accurately reflects the presence or absence of a shunt. The quantitative studies are promising, but the method must be compared with standard techniques in a statistically significant series. This work is in progress.
Carbon Dioxide↗
Effects of dexamethasone and chlorpromazine on skeletal muscle surface hydrogen ion concentration during cardiopulmonary bypass: experimental and clinical results.
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Animals↗
Development of a new technique for explantation of chronic transvenous pacemaker leads: five initial case studies.
Transvenous removal of chronic pacing leads was attempted using a special locking stylet and dilator sheaths. In five initial cases, three of seven leads were infected; six of seven leads were removed. The stylet was inserted into the conductor lumen and locked into the tip to reinforce and control the lead, permitting retraction without stretching the conductor. Sheaths were advanced over the lead to detach and dilate fibrous encapsulation. In one case, force applied exceeded the locking mechanism's strength; no patient complication resulted. It is concluded that transvenous lead removal is facilitated by a locking stylet and dilation of fibrous tissue with sheaths.
Adult↗