Endocardial lead extraction

Belott PH (1998) Endocardial lead extraction. Futura, Ar-monk, p 142... 

Fig. 6.2 Passive fixation lead tip completely encased in encapsulating fibrous scar. (From Belott PH. Endocardial lead extraction A videotape and manual. Armonk, NY Futura Publishing, 1998, with permission.)...

Endocardial lead extraction is ideally performed in the operating room. The procedure should be performed with a cardiac surgical team as a dedicated support staff for this procedure to avoid inconsistencies (Table 6.1). 

Endocardial lead extraction can be safely carried out in the cardiac catheterization laboratory. The cardiac catheterization laboratory can prove to be an ideal place for extracting endocardial leads because it offers optimal radiologic capabilities. The high-quality images can facilitate endocardial lead extraction. 

The monitoring requirements for endocardial lead extraction are somewhat more demanding than those for a permanent pacemaker procedure. In addition to reliable electrocardiographic monitoring, it is recommended that intra-arterial monitoring also be carried out. This helps to readily detect any sudden change or drop in blood pressure caused by a vascular tear or tamponade. 

The surgical instruments for endocardial lead extraction are identical to those for a permanent pacemaker procedure, which merely requires a minor surgical tray with a limited number of instruments. A standard thoracotomy tray should be readily available in addition to a minor surgical set. A pneumatic thoracotomy saw and/or sternotomy saw should be available in the operating room and even in the catheterization laboratory, in case a thoracotomy or sternotomy is required. Unlike the permanent pacemaker procedure, lead extraction should have a source of reliable suction readily available. 

Even when one is prepared to perform an emergency thoracotomy, precious time can be saved and the patient stabilized by performing an emergency pericardiocentesis. It is recommended that a pericardiocentesis tray also be available in the operating room or catheterization laboratory during an endocardial lead extraction procedure. A checklist of required equipment for endocardial lead extraction is shown in Table 6.3. 

The tools of endocardial lead extraction have evolved from the crude pulley-and-weight system of Buck s traction to modem excimer laser sheaths. Today, there is a complete armamentarium of tools designed to make endocardial lead extraction safe and expeditious. Each tool has its place and can play an integral part in any challenging lead extraction case. 

The indications for endocardial lead extraction have increased over the past several years (5, 25,35). It is important to note that previonsly, there were... 

Fig. 6.31 The wire loop has encircled the lead. The loop is closed and the lead bound to the catheter. The catheter is then withdrawn to the Byrd Femoral Work Station. With continuous traction, the sheath is advanced over the lead aU the way to the lead tip, freeing it from the endocardial attachment. (From Belott PH. Endocardial lead extraction A videotape and manual. Armonk, NY Futura Publishing, 1998, with permission.)...

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