Transvenous Lead Extraction

Transvenous lead extraction (TLE) removes pacemaker and ICD leads from inside the veins and heart without opening the chest. The main reasons are infection of the device pocket or leads (including vegetations on the leads or valves), broken or failed leads, and some system upgrades. Leads that have been in for years become encased in dense scar along the subclavian and innominate veins, the superior vena cava and the heart wall, and simply pulling on them can tear these structures; leads implanted for more than 10 years are especially difficult. The operation follows a stepwise plan, moving to the next tool only when the previous one fails: simple traction with a standard stylet, then a locking stylet that grips the inside of the lead, then telescoping non-powered dilator sheaths passed over the lead to break up the scar, then powered sheaths (a mechanical rotating sheath with a cutting tip, or an excimer laser sheath), and finally a snare passed up from the femoral vein for broken pieces. The sheath is advanced to the heart wall and held there (countertraction) while the lead is pulled, so the heart is not pulled inward. Serious complications occur in about 1 to 3% of cases: tearing of the superior vena cava or innominate vein, or perforation of the atrium or ventricle, which causes sudden massive bleeding or tamponade and needs immediate surgery. For this reason the case is done in an OR or hybrid lab with an anesthesia provider, a cardiac surgeon and a heart-lung machine ready, echo to watch for pericardial fluid, and often a balloon that can be inflated to block a torn superior vena cava. The scrub person must be ready to open for an emergency sternotomy at once.