L’extracteur et le

chirurgien

Pierre Bordachar, Laurent Barandon

Service de cardiologie et de chirurgie cardiaque

Hôpital Cardiologique Haut-Lévèque

Pour les infections …

Une seule solution: l’extraction !!!

Indications pour explantation

Class I

Indications de demain…

Class IIa

Class IIb

A

A

Photographs courtesy of Dr. Josh Cooper and Dr. Avi Fischer

Class IIa

Indications de demain…

RV pacing lead after upgrade to ICD

Class IIa

Class IIb

Indications de demain…

Ce que l’on voit …

Ce que l’on ne voit pas …

Ce que l’on ne voit pas…

mais que l’on sait

Venous entry

Innominate /

SVC

RA

RV

RA tip

RV tip

Sites d’adhérences des sondes

Subclavian vein tear / AV fistula

Innominate tear / perforation

High SVC tear / perforation

SVC tear / perforation

SVC / RA junction tear / perforation

Atrial wall perforation

Inferior Vena Cava

Valvular damage

Ventricular wall perforation

Sites de complications

1ère question

Faut-il explanter???

Infection:

Indication classe I AHA 2009

Sonde cassée

Upgrading

Indication classe IIB AHA 2009

2ème question

Chirurgie ou percutanée ???

12% de mortalitéFrame R et al PACE 1993; 16: 2343-2348.

2ème question

Chirurgie ou percutanée ???

ETO

Taille des Végétations

<15 mm >15 mm

Ablation percutanée Ablation chirurgicale

20 mm ?

2ème question

Chirurgie ou percutanée ???

Co-morbidités

EXTRACTION MECANIQUE

PAR VOIE HAUTE

Libération des attaches

proximales

Left PARight PA

Libération des attaches

distales: mandrin métallique classique

1: close 2: open

Libération des attaches

distales: avec mandrin bloqueur

Libération des attaches

distales: avec mandrin bloqueur

Extraction de la sonde

EXTRACTION LASER

PAR VOIE HAUTE

Extraction de la sonde

Laser

Photochemical

Photothermal

Photomechanical

Breaking molecular

bonds

Producing thermal

energy

Creating

kinetic energy

Photoablation is the use of light to vaporize and

remove tissue

Three distinct mechanisms of action contribute to

excimer laser photoablation

Improvement in laser technology

Extraction de la sonde

Laser

Extraction de la sonde

Laser

EXTRACTION MECANIQUE

PAR VOIE BASSE

Extraction de la sonde

Voie basse

Comparison of laser sheath versus femoral

approach for extraction of old pacemaker or

defibrillator leads

A multicenter study

Aims of the study

2) in a multicenter non randomized study, to compare respective

registry of different French centers specialized in femoral or

superior approach

1) in a prospective single center randomized study, to compare

the respective safety, effectiveness and radiation exposure

associated with laser sheath and femoral snare extractions

Methods: single center study

101 consecutive patients were randomly and prospectively

assigned to extraction with:

- a laser sheath (group I: n=50)

- a Dotter™ helical basket (group II: n=51)

Single center study

Characteristics of the patients

Laser

(n=50)

Femoral

(n=51)

p value

Age (year) 69 ± 15 72 ± 15 0.46

Gender: male/female 38/12 40/11 0.77

Left ventricular EF (%) 57 ± 14 53 ± 14 0.25

Time from implantation (year) 12 ± 6 13 ± 6 0.73

Number of leads/patient (n) 2.3 ± 0.7 2.1 ± 0.6 0.23

Device 0.59

Pacemaker 44 (88%) 43 (84%)

ICD 6 (12%) 8 (16%)

Primary indication 0.63

Endocarditis 21 (42%) 19 (37%)

Pocket infection 25 (50%) 25 (49%)

Malfunction or upgrading 4 (8%) 7 (14%)

0%

20%

40%

60%

80%

100%

1 2

Failure

Incomplete

Complete

Laser Femoral

p = ns

Single center study: success rate

- Complete extraction: 88% versus 88%

- Partial extraction: 10% versus 10%

- Failed extraction: 2% versus 2%

Single center study: major complications

We did not observe any per or peri-procedural death

Major complications (p=ns) were observed in:

- 2 patients of group laser (superior vena cava perforation

requiring sternotomy; haemothorax requiring drainage)

- 1 patient of group femoral approach (right atrial

perforation requiring sternotomy)

0

10

20

30

40

p<0.01

Laser Femoral approach

Minutes

Single center study: fluoroscopy time

0

40

80

120

160

200

p<0.01

Minutes

Single center study: procedure time

Laser Femoral approach

Methods: multicenter study

3 centers

Femoral approach

n = 138

3 centers

Superior approach

n = 218

Laser

(n=218)

Femoral

(n=138)

p value

Age (year) 71 ± 15 69 ± 15 ns

Gender: male/female 168/50 106/32 ns

LVEF (%) 53 ± 18 50 ± 13 ns

Time from implantation (year) 9 ± 5 10 ± 5 ns

Number of leads/patient (n) 2.1 ± 0.7 2.1 ± 0.8 ns

Device

Pacemaker 180 114

ICD 38 24

Primary indication

Endocarditis 88 50

Pocket infection 94 61

Malfunction or upgrading 36 27

Multicenter study

Characteristics of the patients

Multicenter study: success rate

0%

20%

40%

60%

80%

100%

1 2

Failure

Incomplete

Complete

Laser Femoral

p = ns

- Complete extraction: 85% versus 86%

- Partial extraction: 12% versus 11%

- Failed extraction: 3 % versus 3%

Multicenter study: major complications

We observed 2 per or peri procedure-related deaths in group laser versus 1 in

group femoral approach

Major procedural complications were observed in 4% of patients in group laser,

versus 3% of patients in group femoral approach (p=0.72)

In group laser, major complications included:

- 1 case of haemothorax and 2 cases of tamponade requiring drainage

- 1 case of superior vena cava perforation and one case of subclavian

vein injury requiring urgent surgery

- 1 case of important tricuspid regurgitation

In group femoral approach, major complications included:

- 1 case of tamponade and 1 case of haemothorax requiring drainage

- 2 cases of important tricuspid regurgitation.

Conclusion

- Old transvenous leads were similarly successfully

extracted by the femoral and superior approaches

- Rates of complete extraction and of complications

were similar

- The femoral approach was associated with longer

procedures, longer fluoroscopic times, and a higher

radiation exposure of patients and operators

Plus difficile à

extraire qu’à

implanter

Conclusion