1Asklepios Klinik St. Georg Kardiologie & internistische Intensivmedizin Hamburg, Deutschland; 2Kerckhoff Klinik GmbH Herzchirurgie Bad Nauheim, Deutschland; 3HELIOS Klinik für Herzchirugie Karlsruhe Karlsruhe, Deutschland; 4Schüchtermann-Klinik Bad Rothenfelde Herzchirurgie Bad Rothenfelde, Deutschland; 5Herzzentrum Dresden GmbH an der TU Dresden Klinik für Herzchirurgie Dresden, Deutschland; 6Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; 7Immanuel Klinikum Bernau Herzzentrum Brandenburg / Kardiologie Bernau bei Berlin, Deutschland; 8Asklepios Klinik St. Georg Abteilung Herzchirurgie Hamburg, Deutschland
Background:
Transvenous lead extraction (TLE) has become one of the most crucial therapeutic pillars in modern cardiac implantable electronic device management, especially for patients with cardiac-device related infections and lead dysfunction. Very old pacemaker and defibrillator leads are known to be risk factors for procedural complications and -failure in patients undergoing TLE.
Aim & Methods:
Aim of this study was to analyze patients with very old leads undergoing TLE. We conducted a retrospective analysis of all patients in the GALLERY with at least one lead aged ≥10 years and compared them to a cohort of patients with leads aged <10 years, in terms of baseline- and lead characteristics, as well as procedural outcomes and potential predictors of adverse events.
Results:
We identified 858 patients with at least one lead aged ≥10 years (Group A) and 1666 patients with leads aged <10 years (Group B). Patients in Group A were older (70.4±13.7 vs. 66.7±13.7; p<0.001) and are less likely to exhibit a highly reduced LVEF (18.5 vs. 30.0%, p<0.001) or coronary artery disease (36.1 vs. 46.4%, p<0.001), compared to Group B. Group A had a higher proportion of patients with pacemaker dependency (38.0 vs. 27.6%, p<0.001). Thus, pacemakers were the most prevalent device in Group A (56.6 vs. 31.2%, p<0.001), whereas ICDs (25.4 vs. 39.4%, p<0.001) and CRT devices (18.2 vs. 28.5%, p<0.001) were more common in Group B. The mean numbers of leads per patient were 2.5±1.1 and 2.4±1.0 (p<0.001) with median ages of the oldest indwelling lead of 161.5 [IQR: 137-206.75] and 72.0 [48-94] months (p<0.001). Patients in Group A had higher proportions of right-sided (47.7 vs. 25.8%, p<0.001) and abandoned leads (41.3 vs. 23.4%, p<0.001). Most patients in Group A had 2 leads with a dwell time ≥10 years (n=533; 62.1%). Median procedural time was longer in Group A with 93.5 [63-145] vs. 75 [52-116] minutes (p<0.001) with an increased necessity for additional tools for extraction (12.6 vs. 3.4%, p<0.001). Overall (5.5 vs. 3.6%, p=0.03) and major complication rates (3.2 vs. 1.4%, p=0.005) were both higher in Group A. Patients in Group A were less likely to achieve complete procedural success rate (84.3 vs. 95.1%, p<0.001) and had a higher rate for procedural failure (3.5 vs. 1.5%, p=0.002). There was no difference in procedure-related 0.7 vs. 0.5%, p=0.592) or all-cause mortality (3.5 vs. 3.2%, p=0.711) between groups. Multivariate analysis in Group A revealed the presence of abandoned leads (OR:1.83, 95% CI:1.0-3.4, p=0.049), female sex (OR:2.15, 95%CI:1.2-3.9,p=0.013) and systemic infection (OR:1.89, 95%CI:1.0-3.5, p=0.039) as predictors for procedural complications. The use of additional extraction tools (OR: 4.4, 95% CI: 2.0-9.7, p<0.001) and a BMI ≥35 kg/m2 (OR:4.4, 95%CI:1.4-14.0, p=0.012) were identified as risk factors for procedural failure. Procedural complications (OR:5.2, 95%CI:2.0-13.7, p<0.001) and systemic infection (OR:18.7, 95%CI: 5.6-62.9, p>0.001) were highly predictive for all-cause mortality.
Conclusion:
Patients with leads aged ≥10 years undergoing TLE suffer from more procedural complications, more often require additional extraction tools and have lower rates for complete procedural success, but do not show any differences in procedure-related- or all-cause mortality, when compared to patients with leads aged <10 years. The necessity of additional tools for extraction and a BMI ≥35 kg/m2 were identified as predictors for procedural failure.