Laser Pacemaker Lead Extraction in Octogenarians
Abstract & Commentary
By John P. DiMarco, MD, PhD, Professor of Medicine, Division of Cardiology, University of Virginia, Charlottesville.
Source: Rodriguez Y, et al. Laser lead extraction in the octogenarian patient. Circ Arrhythm Electrophysiol 2011;4:719-723.
In this paper, Rodriguez and his colleagues from the Department of Cardiothoracic Surgery at the University of Miami report their experience with laser-assisted cardiac rhythm device lead extraction in a large group of patients. They separated the patients into those older and younger than 80 years of age and compared results in the two groups. During the period of study from 2004 and 2009, this center performed laser lead extractions in 506 patients. There were 118 patients 80 years of age or older and 388 patients younger than 80. Procedures were done in the operating room using laser sheaths. Indications and complications were analyzed using standard techniques for assessing lead extraction results.
The octogenarian group had a higher proportion of females, but overall comorbidities, including hypertension, diabetes, coronary disease, and renal insufficiency, were almost evenly distributed in the two age groups. In the nonoctogenarian group, 34% of the patients were classified as having New York Heart Association class III or class IV heart failure, whereas only 27% of the octogenarians had similar findings. In both groups, infection was the most common indication for lead extraction (76% among nonoctogenarians vs 84% among octogenarians). Lead malfunction accounted for 21% and 14% of the extractions in the nonoctogenarian vs octogenarian groups, respectively. A mixture of right atrial, right ventricular, and coronary sinus leads were extracted in both groups. The average implant time was higher in the octogenarian group (59.6 ± 53 months) compared to the implant duration in the nonoctogenarian group (38.6 ± 44 months). A subclavian approach could be used in 98% of the patients in both groups. All procedures were deemed successful. There was no effect of age on either success or complications. Minor complications occurred in 16 of 388 nonoctogenarians (4%), compared to 6 of 118 (5%) octogenarians. Major complications were seen in four nonoctogenarians (1%) compared to 2% of octogenarians. There was only one death secondary to pericardial tamponade and this was in a nonoctogenarian.
The authors conclude that laser lead extraction can be used safely in patients older than age 80 with results and complications comparable to those observed in younger patients.
This is a large series of laser lead extraction that is impressive for its efficacy and safety. The University of Miami has been the center for development of lead extraction techniques for many years. This report is a single operator experience from one of the pioneers in the field. Therefore, it is not certain that similar excellent results could be obtained in lower-volume centers or by less-experienced operators. Recently, a consensus statement on transvenous lead extraction was published.1 This document stressed the need for adequate training and adequate annual volumes to maintain proficiency in a high-risk procedure such as lead extraction. As more and more patients have implanted cardiac rhythm devices, we can expect to see a higher incidence of infections and lead malfunctions for which laser lead extraction may be considered. Centers planning to begin active lead management programs should make certain that they have adequate facilities, a reasonable expected annual volume, and well-trained and highly proficient operators before beginning their programs.
1. Wilkoff BL, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management. Heart Rhythm 2009;6:1085-1104.