Commentary from the Section Editor

DOI: 10.19102/icrm.2012.030305

Samuel J. Asirvatham, MD, FHRS, FACC

Editor-in-Chief

Discovery, Rediscovery, and Cardiac Rhythm Innovation

In this issue of the Journal of Innovations in Cardiac Rhythm Management, Fischer et al.¹ present an expert, concise, and practical review of femoral lead extractions. This technique pre-dates laser-assisted and radiofrequency-based extraction techniques, and, thus, seems unlikely to represent an innovative rhythm management strategy. However, as the authors emphasize, at times innovation stems not from discovery but rediscovery of existing techniques to set the stage for addressing hitherto unanticipated needs.

Intravascular cardiac device component removal

Femoral lead extraction, in its essence, is a series of techniques that allows stabilization, retrieval, and removal of intravascular rhythm device components. As the authors emphasize, familiarity with these techniques is not a prerogative of the femoral access route or existing work stations alone, but rather a general technique to visualize in three-dimensional space with fluoroscopic correlation segments that need to be removed, and anticipate the likely tool or tools that will be able to do so efficiently and safely.

Thus, present operators may use similar tools, such as the gooseneck snare via the subclavian route, and some operators prefer removing leads from a right internal jugular venous approach,² borrowing heavily on techniques and concepts that the decades of femoral lead extraction have taught us.

Lead stabilization

Operators familiar with femoral lead extraction techniques use these skills to stabilize leads. An example is provided by Fischer et al.,¹ where, in the context of an occluded subclavian system, snaring the tip of the lead freed with laser extraction from the subclavian stem stabilizes the lead and allows safe forward passage of the sheath to maintain vascular access. Similarly, snaring the tip of a wire placed via the middle cardiac vein and advanced into a lateral vein, back into the coronary sinus may allow passing a selective sheath into the lateral vein of interest that otherwise could not be negotiated.³

Coronary sinus lead removal

With the burgeoning use of resynchronization devices and implantable cardioverter-defibrillators in the aging and relatively sick population, variations of coronary sinus lead design to enhance stability and the use of unusual locations (coronary sinus, azygos vein, hepatic vein, etc.) to replace defibrillator coils has occurred. Removal of coronary sinus leads in these situations may not be straightforward. However, the natural angle formed from the subclavian access route into the branches of the coronary venous system may not be ideal for extraction, particularly using traction alone. In general, laser sheath engagement of branches of the coronary sinus is not advised, and given the inferior to superior course of the coronary sinus and great cardiac vein, femoral extraction after appropriate snaring of the lead tends to follow the natural axis of the coronary sinus and its anterior lateral branches. Snares have been developed specifically to allow grasping of fragments or portions of the lead within the coronary sinus.

Epicardial leads

Surgically implanted epicardial leads, when infected, have been removed with open surgical approaches. However, with subxiphoid and apical percutaneous pericardial access, lead removal may be performed percutaneously as well. Innovation is needed to develop appropriate retrieval tools and incorporate ease for lead extraction in the design of new epicardial leads meant to be inserted percutaneously. Extraction techniques identical to those used routinely with femoral lead extraction have been used to remove wire and catheter fragments in the pericardial space arising as a complication of epicardial ventricular tachycardia ablation procedures.

Leadless systems

A major area of anticipated growth over the next decade is in the implantation and use of leadless pacing and sensing systems. The primary utilization of femoral lead extraction is the ability to remove lead fragments when they have been cut, and, thus, access for using laser-assisted sheath access, etc., is not possible. Leadless systems will require retrieval using similar techniques. These situations may arise acutely at the time of implant and unwanted dislodgment, or possibly are more chronic as a result of infection. Keeping in mind the femoral lead extraction techniques available—and their limitations—innovative leadless electrode design will need to facilitate potential future intravascular component removal.

Fischer et al.¹ have provided an outstanding review from the historical perspective through general techniques and use of femoral lead extraction in specific complex scenarios. Knowledge of this “old” technique needs to be rediscovered by the present generation of invasive electrophysiologists, and device and lead management operators to innovate appropriately for contemporary and future needs.

Samuel J. Asirvatham, MD, FHRS, FACC
asirvatham.samuel@mayo.edu
Consultant, Division of Cardiovascular Diseases
and Internal Medicine, Division of Pediatric Cardiology
Professor of Medicine and Pediatrics
Mayo Clinic College of Medicine
Rochester, MN

References

Fischer A, Pretorius V, Birgersdotter-Green U. Femoral lead extraction: An underappreciated and underutilized approach to lead removal. J Innov Cardiac Rhythm Management 2012. [CrossRef]
Mazzetti H, Cichero CF, Tentori MC, Mascheroni O. Transjugular approach for lead extraction. Europace 2008; 10:156–160. [CrossRef] [PubMed]
Hayes DL, Wang PJ, Sackner-Bernstein J, Asirvatham SJ. Future of cardiac resynchronization. In: Hayes DL, Wang PJ, Sackner-Bernstein J, Asirvatham SJ, eds. Resynchronization and Defibrillation for Heart Failure: A Practical Approach. Oxford: Blackwell/Futura; 2004:209–228.