Surgical Management of Complications Related to Laser Lead Extraction

Objectives: Despite increasing number of cardiac implantable cardiovascular device lead extractions, management of extraction-related complications was not yet sufficiently explored. The aim of this study is to describe the incidence and management of periprocedural complications during laser lead extraction (LLE).

Methods: We retrospectively reviewed the database of all patients undergoing LLE at our institution during the period from September 2011 to July 2018. Procedural characteristics and related complications were evaluated according to severity (major, minor) and their treatment was analyzed.

Results: A total of 670 leads were extracted in 284 consecutive patients (635 leads complete, 24 leads partial, and 11 leads failed extraction). Indications for LLE were local infection in 173 (61%), systemic infection in 62 (22%), and lead dysfunction and/or venous occlusion in 49 patients (19%). Minor complications included pocket bleeding requiring re-exploration (nine patients, 3.2%) and pneumothorax requiring chest tube (two patients, 0.7%). Major complications (four cases, 1.4%) included three vascular and one cardiac tears. All these injuries led to rapid circulatory decompensation and were attempted for repair via immediate median sternotomy. In the first case (pocket infection), bleeding from innominate vein/superior vena cava (SVC) could not be stopped because of severe adhesions after previous cardiac surgery, and a massive bleeding to the right pleura resulted in intraoperative death. In the second case (lead endocarditis), bleeding from SVC below pericardial reflection was repaired with patch, but the patient died after weaning from cardiopulmonary bypass (CPB) due to uncontrollable sepsis resulting from preoperative systemic infection. Third and fourth patients (SVC occlusion and lead dysfunction) survived SVC tear and RV apex tear which could be directly sutured without CPB. Both survivors and recovered were discharged 7 and 10 days after surgery. Overall intraoperative mortality was 0.7%. Both deaths (and all three SVC tears) occurred before the introduction of “bridge occlusion balloon” (BOB).

Conclusion: In this analysis, major and minor LLE-related complications occurred in 1.4 and 3.9%, respectively. Immediate surgical response enabled repair and complete recovery in two of four patients with severe vascular/cardiac tear. The role of BOB remains unclear, and its effectivity should be addressed in a prospective study.