Zero superior vena cava injury lead extraction with rotational system: A contemporary experience

Background: Transvenous cardiac implantable electronic device (CIED) lead extraction (TLE) is susceptible to superior vena cava (SVC) injury and can be performed in the operating room (OR) or electrophysiology lab via a mechanical device or laser-powered extraction. This study reflects a contemporary experience of mechanical right-left rotational extraction by cardiac surgeons in the OR. Methods: We conducted a retrospective single-center review of adult (age ≥18 years) TLE cases performed by cardiac surgeons between 2019 and 2021. Leads were extracted via a transvenous mechanical right-left controlled-rotation system in the OR under general anesthesia with transesophageal echocardiographic guidance. Procedural success was defined as complete extraction of all leads without major complications, based on the Heart Rhythm Society's 2017 guidelines. Results: A total of 210 leads were extracted from 104 patients, including 72 males (69%). The mean patient age was 63.8 ± 16.7 years, and 26 patients (25%) had undergone prior sternotomy. The most common indication for CIED extraction was infection (69%; n = 72). Removed CIEDs included single-chamber defibrillators (46%; n = 48), pacemakers (33%; n = 34), and cardiac resynchronization therapy devices (21%; n = 22). The mean age of the oldest extracted lead by patient was 9.79 ± 7.25 years. Procedural success was obtained in 95% of cases (99/104). The remaining cases included distal lead fracture (n = 3), inferior vena cava laceration necessitating sternotomy (n = 1), and tricuspid valve damage requiring delayed valve replacement (n = 1). There were zero SVC injuries, and procedure-related mortality was 0%. Conclusions: Mechanical, controlled-rotation TLE is effective and can be performed safely without SVC injury. TLE by cardiac surgeons in the OR enables rapid conversion to sternotomy in the event of major complications.