[Excimer laser extraction of pacemaker and defibrillator leads]

Pacemaker infection or some lead dysfunctions are an indication for removal of all foreign material. The use of laser energy is a new method for extraction of fixed leads that have been in place for a long time. There are only a few reports on results and complications of laser extraction in comparison to conventional methods. Therefore, this study compares results of laser lead extraction and conventional methods.

Since January 1999 we have made use of the laser lead extraction system of Spectranetics, Inc. Inner traction of the leads was performed using a "lead locking device" (LLD) and for laser application 12, 14 und 16 French "laser sheaths" were used. As the energy source, an excimer laser device was used (CVX-300). The intervention was performed under heart-lung machine backup. Results of the laser procedure in 24 patients and 45 leads (including 3 defibrillator leads) are compared to results of manual traction (23 patients, 53 leads), traction devices (24 patients, 38 leads), snare catheters (6 patients, 6 leads) and thoracotomy (5 patients, 9 leads) from the years 1995-1998.

The mean operation time of the laser method (93 +/- 50 min) was not significantly different from manual traction (82 +/- 48 min,) or traction devices (100 +/- 45 min). The mean fluoroscopy time (9.4 +/- 50 min) was similar to traction devices (8.4 +/- 5 min, p < 0.05). In one patient a percardial tamponade developed with the need for urgent thoracotomy. This patient died on the fourth postoperative day due to cerebral hypoxia. The other 23 patients had an uneventful course. All but one lead could be removed without fragmentation, including a malpositioned lead in the left ventricle (success rate 96%). In 62 patients and 97 conventional extractions (53x manual, 38x device, 6x snare) from 1995-1998, one fatal (sepsis due to lead fragmentation) and four severe complications developed (pericardial tamponade, pulmonary abscess, pulmonary embolism, sepsis). In 15/62 patients with conventional methods, lead fragments remained (success rate 76%). Of five patients from 1995-1998, in whom leads with vegetations or tricuspid valve insufficiency were removed by thoracotomy and cardiopulmonary bypass, one patient died perioperatively.

In contrast to conventional methods, excimer laser pacemaker or defibrillator lead extraction allows total removal of all foreign material. This prevents late complications from lead fragments left in place. However, life-threatening complications can occur with conventional as well as with the laser method. Therefore, this intervention should be done only in specialized centers using extended monitoring (invasive blood pressure, TEE).