Cipriani, Alberto

Ferretto, Sonia

Hadas, Dan

Iliceto, Sabino

Leoni, Loira

Migliore, Federico

English

Federico Migliore

Alberto Cipriani

Sonia Ferretto

Dan Hadas

Sabino Iliceto

Loira Leoni

Crossref

Journal of Arrhythmia

Effective and safe lead extraction using the bidirectional rotational Evolution<sup>®</sup>
 sheath in a child with congenital heart disease

Padua Research Archive

Effective and safe lead extraction using the bidirectional rotational Evolution&#174; sheath in a child with congenital heart disease

HADAS, DAN

Archivio istituzionale della ricerca - Università di Padova

Original Citation:Effective and safe lead extraction using the bidirectional rotational Evolution® sheath in a child withcongenital heart diseasePublisher:Published version:DOI:Terms of use:Open Access(Article begins on next page)This article is made available under terms and conditions applicable to Open Access Guidelines, as described athttp://www.unipd.it/download/file/fid/55401 (Italian only)Availability:This version is available at: 11577/3258788 since: 2019-03-21T17:54:56Z10.1002/joa3.12008Università degli Studi di PadovaPadua Research Archive - Institutional RepositoryC A S E R E PO R TEffective and safe lead extraction using the bidirectionalrotational Evolution® sheath in a child with congenital heartdiseaseFederico Migliore MD, PhD | Alberto Cipriani MD | Sonia Ferretto MD |Dan Hadas MD | Sabino Iliceto MD | Loira Leoni MD, PhDDepartment of Cardiac, Thoracic, andVascular Sciences, University of Padova,Padova, ItalyCorrespondenceFederico Migliore, Department of Cardiac,Thoracic and Vascular Sciences, Universityof Padova, Padova, Italy.Email: federico.migliore@libero.itAbstractWe reported a challenging transvenous lead extraction procedure for lead failure ina child with congenital heart disease. Our report demonstrates that the new hand-powered bidirectional rotational Evolution RL (Cook Medical, USA) mechanicalextraction sheath is an effective and safe tool for the extraction of chronicallyimplanted leads in children.K E YWORD Schildren, congenital heart disease, evolution RL, lead extraction, lead failure1 | INTRODUCTIONSeveral large series have investigated the different transvenous leadextraction (TLE) techniques and their safety and efficacy in adultpatients with and without congenital heart disease (CHD).1,2 How-ever, data on lead extraction in pediatric and (CHD) patients remainlimited.3,4 The new Evolution mechanical sheath (Evolution RL, CookMedical, USA) is an effective and safe tool for the extraction ofchronically implanted leads when advanced techniques are requiredin adults.5 However, data on safety and efficacy of the new Evolu-tion sheath in children with CHD undergoing TLE are still lacking.2 | CASE REPORTWe reported a case of an 11-year-old boy referred to our center forTLE because of failure of the PM lead (Medtronic Capsure MRISureScan 5086, active fixation). At 2 years old, he underwent surgi-cal correction of a complete atrioventricular (AV) septal defect com-plicated by complete AV block. A single-chamber transvenous PMwas implanted through the right subclavian vein, because of persis-tent left superior vena cava.Nine years later, during a routine device interrogation, a signifi-cant increase in pacing threshold and decrease in pacing impedanceof the lead were observed. Chest radiography revealed the entrap-ment of the lead between the right clavicle and the first rib, suggest-ing a possible loss of the lead insulation (Figure 1, Panel A). Contrastvenography showed important adherences at the right subclavianand superior vena cava (Figure 1, Panel B). We tried to puncture theright subclavian or axillary vein, but the guidewire (including hydro-philic wire) failed to advance through the vein because of anobstruction. Due to the young age, the ipsilateral vein obstruction,the presence of persistent left superior vena cava, we decided toextract the lead and to implant a new lead.The procedure was performed in a hybrid operating room undergeneral anesthesia, arterial blood pressure monitoring, and trans-esophageal echocardiographic guidance. In addition, a stiff guidewirefrom the right femoral vein to the right internal jugular vein forpotential use of the bridge occlusion balloon (Spectranetics, Color-ado Springs, CO) in case of vascular lacerations was deployed.Before the procedure, contrast venography showed importantadherences at the right subclavian and superior vena cava (Figure 1,Panel B). After the pocket was opened and the generator removed,it was immediately clear that it was impossible both to retract the- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction inany medium, provided the original work is properly cited and is not used for commercial purposes.© 2017 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Heart Rhythm Society.Received: 29 August 2017 | Accepted: 30 September 2017DOI: 10.1002/joa3.12008Journal of Arrhythmia. 2018;34:93–95. www.journalofarrhythmia.org | 93active fixation screw and to advance the locking stylet to the leadtip, because of the lead fracture under the right clavicle. Thus, afterprepping the lead with an extender (Bulldog, Cook Medical, Bloo-mington, IN, USA), an 9Fr Evolution RL, an 9Fr RL Shortie mechani-cal dilator sheaths (Cook Medical, USA), and an outer sheath wereadvanced into the right subclavian vein, but failed to advance fur-ther, because of tenacious fibrotic adherences in the superior venacava (Figure 1, Panel C). After several attempts and adjustments,using first an 11Fr and then an 13Fr Evolution RL sheaths, we werefinally able to advance to the vena cava, to free the lead of any scartissue, and to withdraw it through the sheath without complications(Figure 1, Panel D-F). A guidewire was placed down the Evolutionshortie sheath through the same vein for new PM implantation.Echocardiography showed no tricuspid valve regurgitation and nopericardial effusion. A new single-chamber PM was then implanted,from the right subclavian vein. After 3 months of follow-up, thepatient was asymptomatic, the incision healed cleanly, and the PMwas functioning properly.3 | DISCUSSIONOver the past decade, transvenous PM and defibrillator implanta-tions in pediatric and CHD patients have markedly increased. Thesedevices are often placed at a young age, and with improved survival,the life span of the patient often exceeds that of the device.Patients with CHD experience higher rates of lead malfunction andinfection when compared with older individuals with structurally nor-mal hearts.Despite improvements to extraction techniques, transvenous leadremoval is still a challenging procedure, especially when leads arechronically implanted, and is associated with potential proceduralfailure, morbidity, and life-threatening complications.1,2 Chronicallyimplanted leads develop fibrous adhesions around surrounding struc-tures and thus require different extraction sheaths, such as mechani-cal sheaths, laser sheaths, or electrosurgical dissection sheaths.1,2A recent large study by Fender et al.3 reported informationregarding TLE in CHD patients compared with a control group. With(A) (B) (C)(D) (E) (F)F IGURE 1 Chest radiography showed the entrapment of the lead between the right clavicle and the first rib, suggesting a possibleloss of the lead insulation, arrow (Panel A). Contrast venography showed important adherences at the right subclavian and superior venacava, arrows (Panel B). An 9Fr Evolution RL mechanical dilator sheath and an outer sheath were advanced into the right subclavian vein(Panel C). An 13Fr Evolution RL sheaths with an outer sheath were advanced over the lead, and it was withdrawn through the sheath inthe absence of any complications (Panel D-E). Extracted lead. Of note, the presence of important fibrous material adherent to the lead(Panel F)94 | MIGLIORE ET AL.the use of almost all techniques available for TLE, they concludedthat lead extraction can be safely performed in patients with CHDand despite anatomic abnormalities and longer implantation times,the difficulty of lead extraction in patients with CHD is comparablewith controls.3 Checchin et al. also reported that in pediatric andCHD population older lead age, ventricular leads, and polyurethaneinsulation were independent predictors of the decreased likelihoodof an extraction by simple traction.4 These are established indepen-dent predictors of most difficult procedures also in the populationwithout CHD. These results suggest that TLE can be safely per-formed in patients with CHD.The new Evolution sheath (Evolution RL, Cook Medical, USA)with its bidirectional rotational mechanism and redesigned tip is aneffective and safe tool for the extraction of chronically implantedleads when advanced techniques are required.5 However, data onsafety and efficacy of the new Evolution sheath in children withCHD undergoing lead extraction are still lacking.In our case, a guidewire was placed down the Evolution shortiesheath through the same vein for new lead implantation. Probably, ithas a repeated risk of lead fracture, as the new lead was implantedthrough the same course of the previous lead which was fracturedby the friction at the right clavicle. However, in our experience, thisprocedure is not the same as how to puncture the vein at the samepoint as before. Moreover, lead extraction to regain venous accessof an occluded vein preserves the contralateral side for potentialfuture use and minimizes overall lead burden, especially in children.Although this is only a single clinical case, our report demonstratesthe safeness and feasibility of challenging lead extraction using theEvolution RL mechanical lead extraction sheath in children with CHDand chronically implanted leads. Large prospective studies should beconducted in the future to verify our findings and compare the clinicalsuccess, safety, and cost-effectiveness of different TLE devices.CONFLICTS OF INTERESTAuthors declare no Conflict of Interests for this article.ORCIDFederico Migliore http://orcid.org/0000-0001-8574-9421REFERENCES1. Wazni O, Epstein LM, Carrillo RG, et al. Lead extraction in the con-temporary setting: the LExICon study. J Am Coll Cardiol. 2010;55:579–86.2. Starck CT, Rodriguez H, H€urlimann D, et al. Transvenous lead extrac-tions: comparison of laser vs. mechanical approach. Europace. 2013;15:1636–41.3. Fender EA, Killu AM, Cannon BC, et al. Lead extraction outcomes inpatients with congenital heart disease. Europace. 2017;19:441–6.4. Cecchin F, Atallah J, Walsh EP, et al. Lead extraction in pediatric andcongenital heart disease patients. Circ Arrhythm Electrophysiol. 2010;3:437–44.5. Mazzone P, Migliore F, Bertaglia E, et al. Safety and efficacy of thenew bidirectional rotational Evolution mechanical lead extractionsheath: results from a multicentre Italian registry. Europace. 2017.[Epubahead of print]. https://doi.org/10.1093/europace/eux020How to cite this article: Migliore F, Cipriani A, Ferretto S,Hadas D, Iliceto S, Leoni L. Effective and safe lead extractionusing the bidirectional rotational Evolution sheath in a childwith congenital heart disease. J Arrhythmia. 2018;34:93–95.https://doi.org/10.1002/joa3.12008MIGLIORE ET AL. | 95

Effective and safe lead extraction using the bidirectional rotational Evolution® sheath in a child with congenital heart disease

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