Management of Malfunctioning ICD Lead: Single Referral Center Experience

Aims: ICD leads malfunction is an increasing problem, rising the need of Transvenous Lead Removal (TLR). Transvenous extraction of Defibrillating Leads (DL) is a highly effective technique. Aim of this report is to analyse the longstanding experience of malfunctioning DL in a single Italian Center.

Methods and Results: since January 1997 to December 2014, among 786 DL managed, we extracted 193 consecutive patients (148 men, mean age 54±17 years) with 207 malfunctioning DL (mean pacing period 59± 38 months). Regarding DL, 157 (76%) were dual coil and 138 (67%) had an active fixation mechanism. Sprint Fidelis were 32 (15%) and Riata leads 46 (22%). Cause of malfunctions were: inappropriate ICD shocks on noise in 86 DL (41%), noise in 24 (12%), high pacing impedance in 24 (12%), high pacing thresholds in 20 (10%), cable externalizations in 7 (7%). We performed a transvenous lead entry site mechanical dilatation (MD) using a single polypropylene sheath technique and, if ineffective, an alternative Internal Trans-jugular Approach (TJA). 203 leads were completely removed (98%) with failure in 3 cases because of tenacious atrial fibrous adherences. One hundred eighty two (90%) required a venous entry site MD and TJA was necessary for 21(10%) DL. Fifteen (7%) DL were removed by simple manual traction No major complications occurred. All patients received an ipsilateral ICD reimplantation without complications. At follow up, overall mortality was 2%, 3% and 5% respectively at 6 months, 12 months and 24 months.

Conclusions: our experience shows that TLR with a single sheath MD has is safe and effective for removal of malfunctioning DL. TJA increases the effectiveness and safety of the procedure in case challenging extractions.