The cosmetic aspects of device implantation imply achieving an aesthetically pleasing surgical result. It involves concealing the cardiac implantable electronic device, avoiding unsightly scars, device bulges, and protrusion (Figure 1). Cosmetic device implantation is indicated for the extremely thin patient at risk of erosion and the young patient concerned with body image. These techniques are also important in the pediatric population, patients with burn injury, and patients after mastectomy. For years, various techniques have been developed to conceal and protect the device (Table 1). These techniques are more complex but can be performed by an experienced implanting physician. A thorough knowledge of the superficial and deep regional anatomy is essential. The techniques have the potential complications of lead dislodgment, hematoma, and infection. The procedures can be performed with local anesthesia and conscious sedation, but general anesthesia is frequently necessary for patient comfort. This review outlines the various procedures designed to produce a clinically satisfactory cosmetic device implantation. Table 1Techniques that conceal CIED Technique Cosmetic result Comment Subcutaneous pocket: inframammary fold Two incisional scars Requires tunneling techniques Subcutaneous pocket: mid-axilla One incisional scar, optimal cosmetic result. CIED concealed in the axilla Requires a pacemaker or small device Submuscular pocket: anterior pectoralis major One incisional scar CIED well concealed Submuscular pocket: lateral subpectoral at the deltopectoral groove One incisional scar Anterior visible scar, lateral device migration into the shoulder Submuscular pocket: anterior axillary subpectoral at the anterior axillary fold One incisional scar, optimal cosmetic result, no visible scar or device Discomfort from potential lateral device migration into the axilla Submuscular pocket: anterior axillary fold and inframammary fold Two incisional scars, optimal cosmetic result, no visible scar or device Requires tunneling techniques CIED = cardiac implantable electronic device. Open table in a new tab CIED = cardiac implantable electronic device.

Introduction: Atrial fibrillation (AF) confers a five-fold increased risk of stroke. Clinical guidelines emphasize identifying AF as a strategy to reduce stroke risk. Cardiac implantable electronic device (CIED) interrogation at the point of care may facilitate AF detection, increasing opportunities to identify patients at high risk for stroke. This study sought to quantify AF prevalence and assess stroke risk in patients with a CIED who presented to the emergency department (ED). Methods: This non-interventional, retrospective observational study included consecutive adult patients with a CIED who presented at a single facility ED and received device interrogation regardless of reason for the ED visit, by utilizing point of care technology that interprets data from device manufacturers and produces actionable reports regarding device function and detected arrhythmias. Five-hundred and twenty-five device interrogations were conducted across 494 unique patients over an eight month period in 2015. Relevant ...

OBJECTIVES:This study was conceived to determine the safety and efficacy of the subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients with congenital heart disease (CHD).BACKGROUND:The S-ICD is a treatment option for patients with CHD in which a transvenous device is contraindicated due to anatomic considerations. However, efficacy in this group has not been determined.METHODS:A pooled analysis of 865 patients in the EFFORTLESS (Evaluation of Factors Affecting the Clinical Outcome and Cost-Effectiveness) registry (an international observational database) and a U.S. Investigational Device Exemption study were reviewed.RESULTS:Nineteen CHD patients versus 846 non-CHD patients with a median follow-up of 567 days and 639 days, respectively, were included. There were no deaths and no appropriate shocks for ventricular tachycardia/ventricular fibrillation in the CHD cohort, versus 26 deaths (3.1%, p = 0.42) and 111 appropriate shocks in 59 patients (7.1%) in the non-CHD cohort (p = 0.23). There were similar complication rates for the CHD versus non-CHD groups (10.5 vs. 9.6% [p = 0.89]), with inappropriate shocks for T-wave oversensing as the only complication in the CHD group (n = 2). The rate of inappropriate shocks was similar for both groups (10.5% vs. 10.9% [p = 0.96]). Successful defibrillation testing at 80J was comparable for the CHD versus non-CHD groups (100% vs. 98.5%).CONCLUSIONS:The overall analysis of the CHD cohort from the pooled data of the Investigational Device Exemption study and the EFFORTLESS registry shows that the S-ICD is a safe option in CHD patients deemed to be at high risk for sudden cardiac death who do not have pacing indications. Further research to accurately define sudden cardiac death risk in the diverse anatomic substrates of CHD patients is warranted.

The Editor-in-Chief and Associate Editors of the Journal of Interventional Cardiac Electrophysiology wish to thank all the reviewers who have taken time from their busy schedules to contribute to the peer review process. Every year, the top five reviewers will receive a 1-year subscription to the journal for themselves or the colleague of their choice. The reviewers are listed in descending order of number of reviews performed.

BACKGROUND:In November 2011, the Food and Drug Administration issued a class I recall of Riata and Riata ST implantable cardioverter-defibrillator leads. Management recommendations regarding the recall have remained controversial. OBJECTIVE:Data regarding the safety and feasibility of extraction of Riata implantable cardioverter-defibrillator leads are limited. METHODS:We performed a retrospective study of patients undergoing extraction of Riata/Riata ST leads at 11 centers. RESULTS:Between July 2003 and April 2013, 577 Riata/Riata ST leads were extracted from 577 patients (Riata 467, [84%]; Riata ST 89, [16%]). Complete procedural success achieved in 99.1%. The cohort was 78% men, with a mean age of 60 years and a mean left ventricular ejection fraction of 34% ± 14%. The mean implant duration was 44.7 months (range 0-124.6 months). The majority of leads extracted were for infection (305 [53.0%]) and 220 (35.7%) for lead malfunction. Evaluation for lead integrity was performed in 295 cases. Of these, 34.9% were found to have externalized cables. Implant duration was significantly longer in leads with externalized cables (P < .0001). No difference in lead integrity was noted between Riata and Riata ST leads (11.7% vs. 17.7% failure; P = .23). Among leads in which cable externalization was noted, laser sheaths were used more frequently (P = .01). Major complications included 3 superior vena cava/right ventricular perforations requiring surgical intervention with 1 death 12 days after the procedure and 1 pericardial effusion requiring percutaneous drainage (0.87%). CONCLUSION:Extraction of the Riata/Riata ST leads can be challenging, and leads with externalized cables may require specific extraction techniques. Extraction of the Riata/Riata ST leads can be performed safely by experienced operators at high-volume centers with a complication rate comparable to published data.

HomeCirculationVol. 123, No. 11Pacemaker and Defibrillator Lead Extraction Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBPacemaker and Defibrillator Lead Extraction Eric Buch, Noel G. Boyle and Peter H. Belott Eric BuchEric Buch From the University of California, Los Angeles Cardiac Arrhythmia Center (E.B., N.G.B.), Ronald Reagan University of California, Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles; and Sharp Grossmont Hospital, La Mesa, CA (P.H.B.). , Noel G. BoyleNoel G. Boyle From the University of California, Los Angeles Cardiac Arrhythmia Center (E.B., N.G.B.), Ronald Reagan University of California, Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles; and Sharp Grossmont Hospital, La Mesa, CA (P.H.B.). and Peter H. BelottPeter H. Belott From the University of California, Los Angeles Cardiac Arrhythmia Center (E.B., N.G.B.), Ronald Reagan University of California, Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles; and Sharp Grossmont Hospital, La Mesa, CA (P.H.B.). Originally published22 Mar 2011https://doi.org/10.1161/CIRCULATIONAHA.110.987354Circulation. 2011;123:e378–e380Surgically implanted cardiac devices play an important role in the treatment of heart disease. In the 50 years since the first pacemaker was implanted, technology has improved dramatically, and these devices have saved or improved the quality of countless lives. Pacemakers treat slow heart rhythms by increasing the heart rate or by coordinating the heart's contraction for some heart failure patients.1 Implantable cardioverter defibrillators stop dangerous rapid heart rhythms by delivering an electric shock.2 As the range of applications widens, the number of patients with cardiac devices continues to increase. Approximately 400 000 devices are implanted each year in the United States, and there >3 million patients with implanted cardiac devices currently.Occasionally, pacemaker and implantable cardioverter defibrillator systems must be removed. The removal of such systems is potentially a high-risk procedure. With the increasing number of implanted devices, removal is required more frequently. To ensure patient safety, the Heart Rhythm Society has published guidelines for safe lead removal or extraction. These guidelines outline the indications for lead extraction, physician qualifications and training, and the tools and techniques used in the procedure.3One part of the system is the pulse generator, a metal can that contains electric circuits and a battery, usually placed under the skin on the chest wall beneath the collarbone. To replace the battery, the pulse generator must be changed by a simple surgical procedure every 5 to 10 years. The other parts are the wires, or leads, which run between the pulse generator and the heart. In a pacemaker, these leads allow the device to increase the heart rate by delivering small bursts of electric energy to make it beat faster. In a defibrillator, the lead has special coils to allow the device to deliver a high-energy shock and convert dangerous rapid rhythms (ventricular tachycardia or fibrillation) back to a normal rhythm. For both of these functions, leads must be in contact with heart tissue. Most leads pass through a vein under the collarbone that connects to the right side of the heart (right atrium and right ventricle). To remain attached to the heart muscle, most leads have either a small screw or hooks at the end. Within a few months, the body's natural healing process forms scar tissue along the lead and at its tip, which fastens it even more securely in the patient's body. Leads usually last longer than device batteries, so leads are simply reconnected to each new pulse generator (battery) at the time of replacement.When Is Lead Extraction Recommended?Although they are designed to be implanted permanently in the body, occasionally these leads must be removed, or extracted. The most common reason for lead extraction is device infection. If any part of the system becomes infected, it is usually impossible to cure the infection without completely removing all hardware from the body. This requires removal of the pulse generator from the chest wall, as well as removal of all leads from the veins and heart. Another reason for lead extraction is when a lead fails to work properly (for example, due to a break in the metal wire or surrounding insulation). Sometimes, the broken lead can be abandoned in the heart, with a new lead placed alongside. However, veins can only accommodate a limited number of leads due to space constraints, and sometimes, nonfunctioning leads must be extracted to make space for a new lead. Occasionally, younger patients opt for removal of broken leads even if there are no space limitations because they will probably need more leads in the future, and leads are more difficult to extract after more time in the body. An uncommon reason for lead extraction is a mechanical lead failure that could be dangerous to the patient, such as a protruding wire.How Is Lead Extraction Performed, and What Should I Expect From the Procedure?The pulse generator can be removed relatively easily because it is contained in the chest wall pocket and can be reached through a surgical incision. The leads, however, run a long course through the veins into the heart (Figure 1). The body's natural healing process forms scar tissue at multiple sites along the lead that can create strong attachments to the wall of a blood vessel or a heart chamber. Freeing a lead from these attachments requires considerable skill and experience and is more difficult and risky than implanting the leads in the first place. Leads can be extracted from the shoulder area or the leg and shoulder area.Download figureDownload PowerPointFigure 1. Pacemaker and implantable cardioverter defibrillator leads are removed from the inside of the heart by use of specialized tools, such as the laser sheath shown above. The most common approach follows the course of the lead through the subclavian vein under the patient's shoulder. Arrows show areas where scar tissue is most likely to form.Historically, doctors did not have specialized tools for lead extraction. They used pulling force, or traction, to slowly break the lead free of its attachments. Sometimes they applied force gradually with weights and a pulley system. However, these techniques often failed, which resulted in broken leads with fragments left behind or damage to vital body structures and serious complications. A variety of tools have been developed to make lead extraction safer and more successful. One of these is a wire that passes down the length of the lead, locking into place and allowing force to be applied to the tip of the lead. Another tool is a flexible tube called a sheath that passes over the lead, surrounding it and freeing it from the body by disrupting scar tissue as it is advanced toward the heart (Figure 1). Sheaths can be made of stainless steel or plastic. Some work mechanically, relying on force to free the lead. These are much more effective than simple traction.The latest technologies for lead extraction deliver various forms of energy to the tip of the sheath. These are called power sheaths. As the sheath is pushed over the lead and comes to an area of attachment, the operator can turn on the sheath's energy source to heat or vaporize scar tissue. This has the effect of cutting the lead from its attachments, allowing the lead to be removed with much less force. Once the entire lead is freed from scar tissue, it can be pulled out of the body safely. One of these specialized sheaths uses electrocautery, similar to what is used to cut through tissue in surgery. Another commonly used sheath has a ring of tiny lasers at its tip. When activated, the lasers vaporize water molecules in scar tissue within 1 mm, which allows the sheath to be passed slowly over the entire lead until it can be removed (Figure 2). Occasionally, leads cannot be extracted from the chest and are instead removed through the femoral vein in the groin by use of specialized tools. There is also a mechanical cutting tool for breaking through dense or calcified scar.Download figureDownload PowerPointFigure 2. These 3 leads were removed from a single patient. Scar tissue is seen attached to each lead. Specialized sheaths can separate the lead from the blood vessel and heart wall to allow safe extraction.Usually, the lead-extraction procedure is performed with patients under general anesthesia, but sometimes, sedating medications may be used instead. A team of medical professionals, including a cardiologist or cardiac surgeon, anesthesiologist, nurses, and technicians, is required to perform the operation safely. Facility and equipment requirements include a wide array of lead-extraction tools, high-quality x-ray and ultrasound, and a well-equipped operating room. Because of these complex technical requirements, lead extraction is usually performed in specialized centers. Studies have shown that the procedure is more likely to be successful when performed by operators and medical centers with more experience. The overall success rate in a large series of procedures at 89 hospitals in the United States was >90%, but this depends on many factors, such as the specifications of the leads and the amount of time the leads have been implanted. Lead extractions usually take between 2 and 6 hours, and patients are usually admitted to the hospital for a minimum of 1 night. Certain medications, such as blood thinners, might be stopped before the procedure. If the patient needs a new cardiac device and leads, these may be implanted at the same time as the lead extraction or on a different day.What Are the Risks and Complications of Lead Extraction?Lead extraction is a complex surgical procedure with some unavoidable risks. Each time the lead is separated from scar tissue, there is a small chance of tearing the surrounding blood vessel or perforating the heart, which can result in major bleeding in the chest or around the heart. In some cases, this requires blood transfusion or even immediate open heart surgery to save the patient's life. Other major complications of lead extraction include a blood clot lodging in the lung, stroke, or various problems related to anesthesia. Less severe problems that have been reported include fluid accumulation around the heart or lung (not requiring drainage), bleeding under the skin, swelling of the arm, and a small amount of air entry into the vein. In the large published studies on lead extraction, the rate of major complications was 1.6% to 2.0%, or approximately 1 in 50 patients.Summary and ConclusionsWhen an implanted cardiac device must be removed, experts can use specialized tools and techniques according to the Heart Rhythm Society guidelines to extract the device and leads safely and effectively. Patients should discuss the risks and benefits with their physicians before the procedure. As lead extraction becomes more common and more research in the area is performed, this procedure will continue to evolve and improve.DisclosuresDr Belott has served as a consultant to Spectranetics Inc. The remaining authors report no conflicts.FootnotesThe information contained in this Circulation Cardiology Patient Page is not a substitute for medical advice, and the American Heart Association recommends consultation with your doctor or healthcare professional.Correspondence to Eric Buch, MD, UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, A2-237 CHS, 10833 Le Conte Ave, Los Angeles, CA 90095. E-mail ebuch@mednet.ucla.eduReferences1. Wood MA, Ellenbogen KA. Cardiology patient pages: cardiac pacemakers from the patient's perspective. Circulation. 2002; 105:2136–2138.LinkGoogle Scholar2. Reiffel JA, Dizon J. Cardiology patient page: the implantable cardioverter-defibrillator: patient perspective. Circulation. 2002; 105:1022–1024.LinkGoogle Scholar3. Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Wazni OM. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm. 2009; 6:1085–1104.CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Viola G, Szvalb A, Malek A, Chaftari A, Hachem R and Raad I (2022) Prevention of device‐related infections in patients with cancer: Current practice and future horizons, CA: A Cancer Journal for Clinicians, 10.3322/caac.21756, 73:2, (147-163), Online publication date: 1-Mar-2023. 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Ochasi A and Clark P (2014) Reuse Of Pacemakers In Ghana And Nigeria: Medical, Legal, Cultural And Ethical Perspectives, Developing World Bioethics, 10.1111/dewb.12047, 15:3, (125-133), Online publication date: 1-Dec-2015. Ribeiro S, Leite L, Oliveira J, Pereira M, Pinheiro C, Ermida P, António N, Ventura M, Cristóvão J, Elvas L and Providência L (2015) Transvenous removal of cardiac implantable electronic device leadsTransvenous removal of cardiac implantable electronic device leads, Revista Portuguesa de Cardiologia (English Edition), 10.1016/j.repce.2015.11.002, 34:12, (739-744), Online publication date: 1-Dec-2015. Ribeiro S, Leite L, Oliveira J, Pereira M, Pinheiro C, Ermida P, António N, Ventura M, Cristóvão J, Elvas L and Providência L (2015) Extração transvenosa de eletrocateteres de dispositivos eletrónicos cardíacos implantáveis, Revista Portuguesa de Cardiologia, 10.1016/j.repc.2015.07.008, 34:12, (739-744), Online publication date: 1-Dec-2015. Peterson C, Prutkin J, Robinson M, Hall M and Ferreira R (2015) Echocardiography for Electrophysiology Procedures, Current Anesthesiology Reports, 10.1007/s40140-015-0138-1, 5:4, (429-437), Online publication date: 1-Dec-2015. Leahy R and Davenport E (2015) Home Monitoring for Cardiovascular Implantable Electronic Devices, AACN Advanced Critical Care, 10.4037/NCI.0000000000000110, 26:4, (343-355), Online publication date: 1-Oct-2015. Tomson T and Passman R (2015) Management of Device-detected Atrial High-rate Episodes, Cardiac Electrophysiology Clinics, 10.1016/j.ccep.2015.05.010, 7:3, (515-525), Online publication date: 1-Sep-2015. Makovey I, Gad B, Scherer R, Ferry E, Hoffman G and Damaser M (2015) Clinical and regulatory considerations of implantable medical devices Implantable Biomedical Microsystems, 10.1016/B978-0-323-26208-8.00007-8, (137-166), . 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Bonawitz S (2012) Management of Exposure of Cardiac Pacemaker Systems, Annals of Plastic Surgery, 10.1097/SAP.0b013e31822350cc, 69:3, (292-295), Online publication date: 1-Sep-2012. Borton D, Ming Yin , Aceros J, Agha N, Minxha J, Komar J, Patterson W, Bull C and Nurmikko A (2011) Developing implantable neuroprosthetics: A new model in pig 2011 33rd Annual International Conference of the IEEE Engineering in Medicine and Biology Society, 10.1109/IEMBS.2011.6090828, 978-1-4577-1589-1, (3024-3030) March 22, 2011Vol 123, Issue 11 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.110.987354PMID: 21422393 Originally publishedMarch 22, 2011 PDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-DefibrillatorPacemakerTreatment

This article has been selected for the ANESTHESIOLOGY CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue.

There is now a list of device procedures from the simple VVI pacemaker to the complex biventricular automatic implantable cardioverter defibrillator. All depend on venous access for successful delivery of therapy. It is ironic that venous access is key to the success of such therapies. Yet, venous access can result in case delays and a variety of complications. Historically venous access has been achieved by the cutdown technique.1 In recent times, this has been largely replaced by the less tedious and more expeditious percutaneous technique. As with any new technique that improves on the old, the percutaneous has been associated with challenges and problems. Although simple and expeditious, the percutaneous approach has been associated with an increased risk of pneumothorax. Its incidence is estimated to be anywhere between 0.6 and 1.6%. The challenges have been improving success while avoiding such complications. In this issue of Pacing and Clinical Electrophysiology, Lau introduces the concept of needle navigation by parallax to achieve safe and reliable percutaneous venous access.2 Parallax is defined as the apparent change in position of an object resulting from a change in the viewer’s position. The phenomenon of parallax is defined and its application in venous access clearly demonstrated. It is worthwhile to first review the evolution of techniques designed to achieve safe venous access.

Lead extraction using the femoral vein is an alternate approach for lead removal. It has often been dubbed “the inferior approach.” This is because today it is often reserved for use only after a failed primary approach via the implant vein. In reality it is the most versatile approach for lead removal. Prior to the advent of powered sheaths, it was frequently used as a primary approach. It is also the only approach, and the procedure of choice, for removal of broken or cut leads with free ends. These leads and lead parts are usually free-floating in the venous system, heart, or pulmonary arteries. Historically, lead retrieval techniques have evolved from interventional radiology as it became necessary to retrieve or snare catheters, wires, and other spare parts lost in the central circulation. These techniques date back to the 1960s. 1 Massumi R.A. Ross A.N. Atraumatic nonsurgical technique for removal of broken catheters from the cardiac cavities. N Engl J Med. 1967; 277: 195 Crossref PubMed Scopus (82) Google Scholar Today, a number of tools and techniques have been developed for extracting leads by the femoral vein (Table 1, Table 2). Table 1Techniques of femoral lead extraction I Pigtail Catheter, and Dotter Snare II Wire Loop Snare III Amplatz Snare (Microvena Corp) IV Byrd Femoral Work Station, Deflecting wire and Dotter Snare (Cook Vascular Inc) V Byrd Femoral Work Station, Deflecting wire (Cook Vascular Inc), and Amplatz Snare (Microvena Corp) VI Byrd Femoral Work Station and Needle’s Eye (Cook Vascular Inc) Open table in a new tab Table 2Tools for femoral lead extraction I Byrd Femoral Work Station (Cook Vascular Inc., Leechburg, PA) a16 French Outer Sheath with check Valve bInner Sheath cDeflecting Wire dDeflecting Handle II Dotter retriever Snare III Curry Loop Snare IV Amplatz Snares 25 mm, 35 mm (Microvena Corp) V The Needles Eye Snare (Cook Vascular Corp) Open table in a new tab

Background - Implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators have relied on multiple ventricular fibrillation (VF) induction/defibrillation tests at implantation to ensure that the device can reliably sense, detect, and convert VF. The ASSURE Study ( Arrhythmia Single Shock Defibrillation Threshold Testing Versus Upper Limit of Vulnerability: Risk Reduction Evaluation With Implantable Cardioverter-Defibrillator Implantations) is the first large, multicenter, prospective trial comparing vulnerability safety margin testing versus defibrillation safety margin testing with a single VF induction/defibrillation. Methods and Results - A total of 426 patients receiving an implantable cardioverter-defibrillator or cardiac resynchronization therapy defibrillator underwent vulnerability safety margin or defibrillation safety margin screening at 14 J in a randomized order. After this, patients underwent confirmatory testing, which required 2 VF conversions without failure at <= 21 J. Patients who passed their first 14-J and confirmatory tests, irrespective of the results of their second 14-J test, had their devices programmed to a 21-J shock for ventricular tachycardia (VT) or VF >= 200 bpm and were followed up for 1 year. Of 420 patients who underwent 14-J vulnerability safety margin screening, 322 (76.7%) passed. Of these, 317 (98.4%) also passed 21-J confirmatory tests. Of 416 patients who underwent 14-J defibrillation safety margin screening, 343 (82.5%) passed, and 338 (98.5%) also passed 21-J confirmatory tests. Most clinical VT/VF episodes (32 of 37, or 86%) were terminated by the first shock, with no difference in first shock success. In all observed cases in which the first shock was unsuccessful, subsequent shocks terminated VT/VF without complication. Conclusions - Although spontaneous episodes of fast VT/VF were limited, there was no difference in the odds of first shock efficacy between groups. Screening with vulnerability safety margin or defibrillation safety margin may allow for inductionless or limited shock testing in most patients.

The axillary vein has become a desirable structure for venous access for implantation of defibrillator and pacemaker leads because the vein is large, easily accessed, and can accommodate multiple leads. Furthermore, axillary vein access is not associated with problems accompanying subclavian vein access, including pneumothorax and subclavian crush syndrome. 1 Fyke III, F.E. Infraclavicular lead failure tarnish on a golden route. Pacing Clin Electrophysiol. 1993; 16: 373-376 Crossref PubMed Scopus (29) Google Scholar , 2 Magney J.E. Flynn D.M. Parsons J.A. Staplin D.H. Chin-Purcell M.V. Milstein S. Hunter D.W. Anatomical mechanisms explaining damage to pacemaker leads, defibrillator leads, and failure of central venous catheters adjacent to the sternoclavicular joint. Pacing Clin Electrophysiol. 1993; 16: 445-447 Crossref PubMed Scopus (166) Google Scholar

Background: Implantable cardioverter-defibrillators (ICDs) and Cardiac Resynchronization Therapy - Defibrillators have relied on multiple VF induction / defibrillation tests at implantation. ASSURE was the first large multi-center prospective trial comparing inductionless testing utilizing upper limit of vulnerability (ULV) vs a single VF induction/conversion strategy.

Background: Permanent leads with shocking coils for defibrillation therapy are sometimes implanted in the coronary sinus (CS) and great cardiac vein (GCV). These shocking coils, as documented by pathologic examination of animal investigations, often become tightly encapsulated by fibrosis and can be very difficult to remove. Methods: One of three configurations of the Guidant model 7109 Perimeter® coronary sinus shocking lead was implanted into the distal portion of the GCV of 24 sheep for up to 14 months. Group 1 had unmodified coils (control), group 2 had coils backfilled with medical adhesive (MA), and Group 3 had coils coated with expanded polytetrafluoroethylene (ePTFE). Eighteen leads, three from each group at 6 and 14 months were transvenously extracted from the left jugular vein. The remaining six animals were not subject to extraction. All animals were euthanized for pathological and microscopic examination. Results: All six of the control, three of the MA, and one of the ePTFE leads required the use of an electrosurgical dissection sheath (EDS) for extraction. Five control, two MA, and none of the ePTFE leads had significant fibrotic attachments to the shocking coils. Significant trauma was observed at necropsy for those leads requiring the use of the EDS for extraction. Conclusions: Tissue ingrowth is a major impediment to the removal of defibrillation leads implanted in the CS and GCV of sheep. Reduction of tissue ingrowth by coating the shocking coils with ePTFE or by backfilling with MA facilitates transvenous lead removal with reduced tissue trauma.

Chapter 1 Implantation Techniques for Cardiac Resynchroniztion Therapy Peter H. Belott, Peter H. BelottSearch for more papers by this author Peter H. Belott, Peter H. BelottSearch for more papers by this author Book Editor(s):S. Serge Barold MD, FRACP, FACP, FACC, FESC, S. Serge Barold MD, FRACP, FACP, FACC, FESC Professor of Medicine, University of South Florida College of Medicine and J.A. Haley VA Medical Center, Tampa, Florida, USASearch for more papers by this authorJacques Mugica MD, Jacques Mugica MD Pacemaker Center, Chirurgical Val d'Or, St Cloud-Paris, FranceSearch for more papers by this author First published: 01 January 2004 https://doi.org/10.1002/9780470988404.ch1 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Summary This chapter contains sections titled: Introduction Anatomic considerations Implantation Complications Upgrading Epicardial approach Conclusions The Fifth Decade of Cardiac Pacing RelatedInformation

The procedure of lead removal has recently matured into a definable, teachable art with its own specific tools and techniques. It is now time to recognize and formalize the practice of lead removal according to the current methods of medicine and the health care industry. In addition, since at this time the only prospective scientific study of lead extraction is the PLEXES trial, we suggest that studies relating to the techniques of and indications for lead extraction be designed. Recommendations for a common set of definitions, for a framework of training and reviewing physicians in the art, for general methods of reimbursement, and for consistency among clinical trials have been made. Implementation of these recommendations will require additional effort and cooperation from practicing physicians, medical societies, hospital administrations, and industry.

Thoracic electrical bioimpedance (TEB) provides a rapid, accurate, cost-effective method of optimizing the atrioventricular delay in dual-chamber pacemakers. In addition to measurements of cardiac output, TEB provides other hemodynamic indices such as systolic time interval, left cardiac work index, and end diastolic index. The availability of this additional data can assist the clinician in the objective determination of the optimal atrioventricular delay for individual patients. Thoracic electrical bioimpedance is completely noninvasive and takes only minutes to perform.

The axillary vein has been suggested as an alternate site for venous access to avoid the "subclavian crush phenomenon. " Many techniques have been used to access this structure. They include complicated anatomical landmarks, contrast venography, Doppler, and ultrasound. A simple technique using the basic anatomical landmark of the deltopectoral groove and a blind venous stick has been used successfully in 165 of 168 consecutive pacemaker and ICD procedures; there were only three failures. These required an alternate approach. With a thorough knowledge of the regional anatomy, the axillary vein can be safely used as a primary site of venous access.