Emergency Cardiac Surgery for Cardiac Device Lead Extraction

Cardiovascular implanted electronic devices (CIEDs) are widely used in the management of heart rhythm disorders, and include bradycardia pacemakers, biventricular pacemakers, and implantable cardioverter–defibrillators (ICDs). Removal of a CIED lead (with or without the entire system) that has been in situ for more than 1 year requires a lead extraction procedure, which should be done in a specialist centre with cardiac surgical capabilities. Lead extraction is an integral part of holistic CIED management and is most commonly indicated due to infection, lead dysfunction, or redundancy. An initial percutaneous transvenous lead extraction (TLE) technique is used initially in most cases, with a wide spectrum of tools and techniques available for this purpose, but in specific situations, an initial open extraction with sternotomy and cardiopulmonary bypass may be preferred. Risk stratification and procedure planning are a critical part of any TLE procedure. The anticipated procedural risk will vary considerably from case to case, depending on various clinical features; the dwell time and type of lead are most critical. All percutaneous TLE cases will require a multidisciplinary team including a device extraction operator (usually a cardiologist trained in TLE) and a cardiac anaesthetist, and in higher risk cases, a cardiac surgeon, perfusionist, and surgical scrub team may be required to be physically present on standby during the procedure. The objective of TLE is to remove the implanted leads in their entirety without causing damage to surrounding structures. The main safety concerns include vascular tear, cardiac perforation, or valvular damage. Emergency cardiac surgery during TLE is required in up to 3% of cases. The surgical principles that govern emergency surgery for TLE complications are access and provision of haemodynamic stability followed by the definitive surgical correction of the cardiac or vascular injury. Each of these aspects is discussed in detail in this chapter. With appropriate pre-procedural risk stratification and patient selection, and a dedicated multidisciplinary team approach, TLE complications can be mitigated, and outcomes optimised even in cases when emergency cardiac surgery is required.