Letter from the Editor

DOI: 10.19102/icrm.2013.040701

John Day, MD, FHRS, FACC

Editor-in-Chief

Dear Readers,

Another month has quickly gone by and the summer is nearly over! We have a great issue of the Journal for you this month. As two of our articles this month discuss Riata lead issues, I thought it would be helpful if I focused my comments on this perplexing clinical issue.

Our first article is from Dr. Carrillo and colleagues from the University of Miami. Dr. Carillo certainly has an extremely large extraction practice and reports their experience on extracting 82 Riata leads from 80 patients. They should be commended for having achieved an excellent extraction history with 100% of all Riata leads fully extracted with only one major complication.

The second article is a case report from Dr. Sidiqi and colleagues from Southfield, Michigan, where they present a case illustrating the importance of checking for Riata lead perforation prior to extraction. In this case, a computed tomography (CT) scan prior to the procedure was very helpful in allowing them to prepare for a potentially difficult Riata extraction case.

Both of these articles help us formulate a treatment strategy for patients with Riata leads. As we all know, the FDA has created a clinical conundrum for us in that they have recommend fluoroscopy of these leads but then do not provide any guidance as to what should be done if externalized cables are observed.

What should be done with patients who have externalized cables?

While it is a very common occurrence to see externalized cables, remarkably, the Riata lead generally is functioning normally. Indeed, anecdotally we find that the Riata lead seems to be much more reliable than the Fidelis lead. At our center, we generally just follow these patients closely with remote monitoring and more frequent clinic visits for signs of lead failure. We continue to fluoro these patients each year in addition to close follow-up. If a patient has recurrent appropriate tachy therapies or is pacemaker dependent with a non-cardiac resynchronization therapy system, we may consider prophylactic replacement of the Riata lead, particularly at the time of generator replacement.

How should you evaluate for Riata lead perforation prior to extraction?

As both articles touched on the increased risk of a contained myocardial perforation with the Riata lead, how should this be assessed? While CT scans were recommended, at our center we generally use transesophageal echocardiography (TEE). As our extraction patients are all under general anesthesia and a TEE probe is already in place as part of our routine, it is easy for us to just use this technology to assess for any extra-vascular or extra-cardiac protrusion of the Riata lead. We have found TEE to be very helpful in identifying these cases. Remarkably, even though it is not uncommon for this lead, or any other lead to be extra-cardiac, we generally do not see any complications with extraction.

Should you extract or cap a non-functioning Riata lead?

This is certainly a difficult question to answer. As Riata leads can be much more challenging to extract, it makes it very tempting to just cap this lead. However, capping a Riata lead is very different from capping other abandoned leads, as the Riata lead may continue to unravel over time. Thus, this makes capping not very desirable for our younger patients. If an extraction is planned it should only be at a center very experienced in extraction. The laser approach is generally recommended to make sure all of the cables can be “grabbed” in a bundle for extraction. Fortunately, at our center while our volumes are less than that of the University of Miami, we have had 100% success in fully extracting all components with no significant complications.

I hope you have found this issue of the Journal to be very helpful in your practice and I look forward to hearing about your experiences in managing Riata lead patients.

Warm regards,

John Day, MD, FHRS, FACC
Editor-in-Chief
The Journal of Innovations in Cardiac Rhythm Management
JDay@InnovationsInCRM.com
Director of Heart Rhythm Services
Intermountain Medical Center
Salt Lake City, UT