ICD Lead Extraction

[proman]

In the spirit of the recent clinical threads:

50 year old woman with a history of VF arrest presents for fractured ICD lead extraction by EP. The ICD was implanted in 2000 and she's on her second generator. PMH: HTN, hyperlipidemia, idiopathic VF arrest. Normal airway exam, normal body habitus. She comes to do you with an 18ga PIV.

Go!

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[Noyac]

Go!

 

[bigeyedfish]

Pads on chest. A line. Induction of choice. Cordis. Blood available. Tee to watch for tamponade or other disaster. Hope ep doesn't yank like they're starting a lawn mower.

 

[Gern Blansten]

Saw one of these go quite terribly a few years back.

 

[Noyac]

Saw one of these go quite terribly a few years back.

Was it the hole in the heart or the torn SVC?

 

[sevoflurane]

Yeah.... me too... 'bout 6 mo. ago.

This lma case can turn into disaster quickly.... very quickly.

 

[sevoflurane]

Not really an lma case though....

 

[ssmallz]

Never done one of these. Whats the standard for these cases? Is TEE standard of care for all cases to look for badness? Do they need anesthesia or just a bit of local and some sedation?

 

[smgilles]

Never done one of these. Whats the standard for these cases? Is TEE standard of care for all cases to look for badness? Do they need anesthesia or just a bit of local and some sedation?

Our typical set-up:

1. TEE - assess for tamponade and SVC/TV badness
2. Femoral cordis in case they destroy the IJ/SVC
3. Radial arterial line + large bore PIV
4. Secure airway
5. Either go really well and need none of the aforementioned or median
sternotomy and even temporary RVAD's or VA ECMO
6. We no longer do these in the cath lab due #4

 

[proman]

Yeah.... me too... 'bout 6 mo. ago.

This lma case can turn into disaster quickly.... very quickly.

Our typical set-up:

1. TEE - assess for tamponade and SVC/TV badness
2. Femoral cordis in case they destroy the IJ/SVC
3. Radial arterial line + large bore PIV
4. Secure airway
5. Either go really well and need none of the aforementioned or median
sternotomy and even temporary RVAD's or VA ECMO
6. We no longer do these in the cath lab due #4

This is the safest approach. I've done these cases at 3 different places now, and they are done in the OR. #4 doesn't bother me (Intubating in the cath lab isn't a big deal) but #5 is the big reason. I wouldn't do a lead extraction without echo, I prefer TEE but TTE is appropriate if there's a contraindication to TEE.

So I get a call, "We need you" CLICK. I go to the room, HR is 94, BP is 30. Small pericardial effusion. What do you do?

 

[DrBeaker]

Ask what they did (usually "nothing", or "I don't know")

Support hemodynamics, secure airway, open up IVF's, possibly call for blood. Get ECHO probe of choice.

Tamponade? Drain it

In the cath lab? think about moving

Haven't done one of these in residency yet, but an attending had a recent problem with one of these.

 

[Gern Blansten]

Was it the hole in the heart or the torn SVC?

They were using a laser.
So, yes...and yes.
It was like giving a machine gun to a monkey.

 

[proman]

Ask what they did (usually "nothing", or "I don't know")

Support hemodynamics, secure airway, open up IVF's, possibly call for blood. Get ECHO probe of choice.

Tamponade? Drain it

In the cath lab? think about moving

Haven't done one of these in residency yet, but an attending had a recent problem with one of these.

Ok well the EP attending told your CRNA to call you so something bad has happened. The patient's already intubated since we were doing a GA. The EP literature is littered with the corpses of patients having lead extractions in the cath lab, so you're already in the OR. TEE is already in place and shows an expanding effusion.

First step, delegate one person to call the surgeon and perfusionist. These are pump stand-by cases so everything should be ready. Next I would get them to start CPR, give fluids.

Who wants to drain the tamponade?

 

[Endee]

Ok well the EP attending told your CRNA to call you so something bad has happened. The patient's already intubated since we were doing a GA. The EP literature is littered with the corpses of patients having lead extractions in the cath lab, so you're already in the OR. TEE is already in place and shows an expanding effusion.

First step, delegate one person to call the surgeon and perfusionist. These are pump stand-by cases so everything should be ready. Next I would get them to start CPR, give fluids.

Who wants to drain the tamponade?

The last time this happened (lead removal->hole in ventricle) at our place a month or so ago, the patient was in the cath lab, not the OR. They had to be moved (downstairs) and I think the tamponade effect was the only thing that kept the patient alive long enough for the CT surgeon to come do his thing and fix it. I imagine he could have exsanguinated otherwise.

 

[BLADEMDA]

Ok well the EP attending told your CRNA to call you so something bad has happened. The patient's already intubated since we were doing a GA. The EP literature is littered with the corpses of patients having lead extractions in the cath lab, so you're already in the OR. TEE is already in place and shows an expanding effusion.

First step, delegate one person to call the surgeon and perfusionist. These are pump stand-by cases so everything should be ready. Next I would get them to start CPR, give fluids.

Who wants to drain the tamponade?

What's the EF? 10 percent? 15? What's the quoted mortality in the literature when these cases go badly?

 

[BLADEMDA]

What's the EF? 10 percent? 15? What's the quoted mortality in the literature when these cases go badly?

The mortality is very high when these cases go badly. http://europace.oxfordjournals.org/content/11/suppl_2/NP.55.abstract

 

[TrustMe]

Got called to the cath lab as a CA-3 to help with one of these gone wrong. Pt. had arrested twice before the cardiologist called for help. Perfed RV, tamponade, arrest, drained, re-tamponade, arrest, called for help. Made it to the OR and guy lived.

Anytime cardiology asks for our help for the case we require they are in the OR, not the cath lab. ETT, a-line, introducer, TEE, transvenous pacer in room. As always, better to have it ready and not need it, than need it and really wish you had put it in before it was an emergency.

 

[BLADEMDA]

Got called to the cath lab as a CA-3 to help with one of these gone wrong. Pt. had arrested twice before the cardiologist called for help. Perfed RV, tamponade, arrest, drained, re-tamponade, arrest, called for help. Made it to the OR and guy lived.

Anytime cardiology asks for our help for the case we require they are in the OR, not the cath lab. ETT, a-line, introducer, TEE, transvenous pacer in room. As always, better to have it ready and not need it, than need it and really wish you had put it in before it was an emergency.

Damn right.

 

[BLADEMDA]

But being preapred ony takes you so far when you are outmatched

 

[BLADEMDA]

Medical Malpractice / Cardiology -- Wrongful Death after Pacemaker Lead Extraction -- Verdict -- Affirmed on Appeal


A 56 year old wife and mother of two daughters was evaluated in 2003 by a cardiologist, Richard Weintraub, M.D., at Southeastern Heart and Vascular Center in Greensboro, for a pacemaker change and possible lead extraction. During the extraction of the pacemaker leads, which was done at a "cath lab" at Moses Cone Memorial Hospital, the force applied during the lead extraction caused a tear in the vessels near the heart. As a result, she developed pericardial tamponade, which occurs when blood pools around the heart and the resulting pressure makes it more difficult for the heart to beat normally. A pericardiocentesis was performed in an attempt to relieve the pressure. Emergent surgery was performed, which saved her life, but she suffered permanent and global brain damage because of lack of oxygen. Her family was forced to decide to discontinue life support the next day. Plaintiff alleged that the physician was negligent in removing the lead, in failing to properly prepare for potential complications, and in mis-handling the complications that occurred after the vessel had been torn. The case went to trial in Guilford County Superior Court and the jury returned a verdict in February, 2007, in the amount of $1,047,732.20, which was unanimously affirmed by the North Carolina Court of Appeals in February, 2009. The North Carolina Supreme Court denied defendants' petition for discretionary review in January, 2010. Mag Mutual Insurance Company, which insured the defendant and paid lawyers to defend the case, eventually paid $1,441,105.40 to the clerk of court to satisfy the judgment, plus accumulated interest at the statutory rate of 8% since the date the complaint was filed. In addition, Mag Mutual Insurance Company paid Plaintiff over $60,000 for the costs the estate incurred in prosecuting the claim. The opinion of the Court of Appeals can be found here: http://www.aoc.state.nc.us/www/public/coa/opinions/2009/pdf/070960-1.pdf.

 

[BLADEMDA]

Lead Removal Medical Malpractice

Pritzker Olsen law firm is actively investigating possible claims of medical malpractice in the surgical removal of leads for implantable cardiac devices such as pacemakers and defibrillators (lead extraction malpractice). In addition to injury cases, we are representing the family of a man who died after having a Medtronic Sprint Fidelis lead removed. With the Medtronic Sprint Fidelis cases, we are pursuing product liability and medical malpractice claims. Read about a Medtronic lawsuit.

Removal of an old lead is a very difficult and challenging procedure because the lead may have become overgrown with fibrous tissue and therefore stuck inside a major blood vessel. Extracting the lead can be dangerous but leaving it in place can make it more difficult to remove later because of the growth of fibrous tissue.

If you or a loved one have been the victim of complications during a cardiac lead extraction, please contact attorneys Elliot Olsen and Fred Pritzker for a free consultation.

 

[BLADEMDA]

Due to the complexity of heart lead extraction, it is important that a physician be well trained. The Heart Rhythm Society, a group representing doctors who implant heart devices, plans to issue guidelines about lead extractions later this year. The Society is expected to urge doctors to perform at least 30 removals under the supervision of an experienced extraction surgeon before operating solo. This is because there is a very long and difficult "learning curve" for the removal of these devices which is often done with laser. This is known as "laser lead extraction."
DO YOU HAVE A MEDICAL MALPRACTICE CLAIM FOR NEGLIGENT REMOVAL OF A PACEMAKER OF DEFIBRILLATOR LEAD?

http://www.pritzkerlaw.com/ArticleFolder/FreeConsultation.html

 

[cincincyreds]

I would just call one of the cardiac anesthesia guys to do the case. I don't need the headaches.

 

[proman]

Seems that the proper place to do these is in an OR with pump standby and a surgeon available (as in the OR suite if not the room).

My case had a good outcome. I had the cardiologist start CPR, opened up the fluids and his fellow set up for a pericardiocentesis. The RV seems to be the location for the majority of these injuries and those patients are usually fairly stable. We did the pericardiocentesis because of the arrest. If the patient had not arrested I think we could have held off. The tamponade effect will prevent the RV from bleeding much. SVC injuries are far worse because there's nothing to stop the bleeding.

I have a total of 2.5 mg of epi, crashed onto bypass and transfused 8 PRBC 5 FFP and a total of 3 pharesis platelets. The SVC injury was repaired. There was an LAD hole likely from the pericardiocentesis. Weaned from bypass easily but had some post op bleeding that resolved with factor VII. She was extubated the next day neurologically intact.

 

[BLADEMDA]

Seems that the proper place to do these is in an OR with pump standby and a surgeon available (as in the OR suite if not the room).

My case had a good outcome. I had the cardiologist start CPR, opened up the fluids and his fellow set up for a pericardiocentesis. The RV seems to be the location for the majority of these injuries and those patients are usually fairly stable. We did the pericardiocentesis because of the arrest. If the patient had not arrested I think we could have held off. The tamponade effect will prevent the RV from bleeding much. SVC injuries are far worse because there's nothing to stop the bleeding.

I have a total of 2.5 mg of epi, crashed onto bypass and transfused 8 PRBC 5 FFP and a total of 3 pharesis platelets. The SVC injury was repaired. There was an LAD hole likely from the pericardiocentesis. Weaned from bypass easily but had some post op bleeding that resolved with factor VII. She was extubated the next day neurologically intact.

The reported incidence of this type of complication is less than 2%; some major medical centers with experienced Cardiologists report less than 0.5% of major complications.

 

[sevoflurane]

Seems that the proper place to do these is in an OR with pump standby and a surgeon available (as in the OR suite if not the room).

My case had a good outcome. I had the cardiologist start CPR, opened up the fluids and his fellow set up for a pericardiocentesis. The RV seems to be the location for the majority of these injuries and those patients are usually fairly stable. We did the pericardiocentesis because of the arrest. If the patient had not arrested I think we could have held off. The tamponade effect will prevent the RV from bleeding much. SVC injuries are far worse because there's nothing to stop the bleeding.

I have a total of 2.5 mg of epi, crashed onto bypass and transfused 8 PRBC 5 FFP and a total of 3 pharesis platelets. The SVC injury was repaired. There was an LAD hole likely from the pericardiocentesis. Weaned from bypass easily but had some post op bleeding that resolved with factor VII. She was extubated the next day neurologically intact.

Take home point is to be prepared.

Had a morbidly obese patient not too long ago loose 2.5 liters in about 2 minutes. The case was placement of an EXTERNAL pacer wire, cuz cardio couldn't do it percutaneously. L. Mini-thoracotomy for lead placement that followed with an LV perf.

I only had an 18G.... but did have an a-line. Dropped a MAC supah fast and ended up with the kind of products you gave your patient above.... and this was for an EXTERNAL lead placement. Moral of the story is that...

Seemingly easy EP/cardiac/thoracic cases can turn south quickly... very quickly. So be prepared.

Thx for sharing proman.

 

[fakin' the funk]

Agree with what's been said before. Usually these are uneventful, but when they ARE eventful, they are total clusterf*cks.

We do all of these in the OR with EP and a CT surgeon scrubbed and a perfusionist available in the OR suite. Usually the surgeon does the actual laser lead extraction part. The EP guys then muck around with the new generator/lead(s).

Unlike the OP's case, most of these people don't have AICDs for idiopathic VF but otherwise normal hearts. They have severely depressed systolic function, ischemic cardiomyopathy, the usual attendant CAD/CKD/DM/obesity, making the induction "fun" or at least challenging. Preinduction A-line, pads on, GA/ETT, upper body Cordis, TEE primarily to rule out tamponade after lead extraction.

 

[Arch Guillotti]

Preinduction A-line, pads on, GA/ETT, upper body Cordis, TEE primarily to rule out tamponade after lead extraction.

Why upper body Cordis instead of lower in the event of SVC injury?

 

[Mac4]

Why upper body Cordis instead of lower in the event of SVC injury?

I used to do tons of those (6 to 8 per day) as a resident. It was just easier to do the IJ in the pre-op area and you can line the patients up pretty quickly. SVC injury is very rare and most of the ruptures are ventricular injuries.

 

[BLADEMDA]

I used to do tons of those (6 to 8 per day) as a resident. It was just easier to do the IJ in the pre-op area and you can line the patients up pretty quickly. SVC injury is very rare and most of the ruptures are ventricular injuries.

The latest studies are showing laser lead removals are very safe. Major complications requiring the Operating room are less than 1%.

Yes, most of the injuries are ventricular in origin.


http://www.theheart.org/article/1293563.do

 

[shea01]

Well whatever you do, just make sure a nurse doesn't pull them straight out as the patient is crying, right in front of your dad and 12 year-old sister. It will not end well.

 

[sevoflurane]

We had an SVC injury a couple weeks ago from a laser lead extraction. When they happen they can be very serious injuries requiring quick thinking and crash on CPB.

 

[twoliter]

I was involved with 4 laser lead extractions in residency. Two of those four tore something (SVC in one, LV in the other, if I remember correctly).

 

[sevoflurane]

Well whatever you do, just make sure a nurse doesn't pull them straight out as the patient is crying, right in front of your dad and 12 year-old sister. It will not end well.

Just re-read your post...

All I have to say is...

WTF kind of post is this?

Puuuuhlease tell me you are kidding.

 

[McPoyle]

We do a handful of these each week, our complication rate has certainly gone way down. I'd agree with the roughly 0.5%, though if you think about it that means a handful of people each year have terrible complications... we do GETA with arterial line and then use the cardiologists groin line.


Sent from my iPhone using SDN mobile app

 

[pgg]

Just re-read your post...

All I have to say is...

WTF kind of post is this?

Puuuuhlease tell me you are kidding.

new user (joined today, first and only post)
+ necrobump of 5-year-old thread
+ nurses don't do lead extractions
+ strange bit about dad and kid sister
+ vaguely ominous teaser of "not ending well"
-----------------------------------------------
= layperson who had some bad in-hospital experience that probably had nothing to do with an actual lead extraction as discussed in this thread

 

[drmwvr]

new user (joined today, first and only post)
+ necrobump of 5-year-old thread
+ nurses don't do lead extractions
+ strange bit about dad and kid sister
+ vaguely ominous teaser of "not ending well"
-----------------------------------------------
= layperson who had some bad in-hospital experience that probably had nothing to do with an actual lead extraction as discussed in this thread

+probably talking about an uncomfortable bedside removal of epicardial wires post op cardiac surgery.

 

[shea01]

Just re-read your post...

All I have to say is...

WTF kind of post is this?

Puuuuhlease tell me you are kidding.

Thank you for immediately recognizing that this situation is entirely WTF, because her surgeon did not. It happened to my mom in 2006 when I was a teenager. The surgeon was nowhere in sight and the nurses had been instructed to just "take them out" (I have NO explanation for this at all). Obviously negligence at the very least, but my dad didn't tell me the story or mention malpractice at all until a few years later. And that he'd completely dropped the litigation because he couldn't afford the legal fees and/or was overwhelmed. Yep. After reading the thread I definitely underestimated how much the situation has been minimized over the last 11 years.

But after reading "The Society is expected to urge doctors to perform at least 30 removals under the supervision of an experienced extraction surgeon before operating solo" I'm surprised by the lack of profanity in my comment. I have no idea what types of procedures were used in 2006 (by actual surgeons, not nurses), but I assume a good number of supervisions would be standard in any case. I probably wouldn't have commented had I expected anyone to reply to an old thread

 

[twoliter]

Thank you for immediately recognizing that this situation is entirely WTF, because her surgeon did not. It happened to my mom in 2006 when I was a teenager. The surgeon was nowhere in sight and the nurses had been instructed to just "take them out" (I have NO explanation for this at all). Obviously negligence at the very least, but my dad didn't tell me the story or mention malpractice at all until a few years later. And that he'd completely dropped the litigation because he couldn't afford the legal fees and/or was overwhelmed. Yep. After reading the thread I definitely underestimated how much the situation has been minimized over the last 11 years.

But after reading "The Society is expected to urge doctors to perform at least 30 removals under the supervision of an experienced extraction surgeon before operating solo" I'm surprised by the lack of profanity in my comment. I have no idea what types of procedures were used in 2006 (by actual surgeons, not nurses), but I assume a good number of supervisions would be standard in any case. I probably wouldn't have commented had I expected anyone to reply to an old thread

As mentioned earlier, you are likely (99.999% likely) talking about something completely different than the topic at hand. If a nurse had removed your mother's ICD leads like we are referring to without a surgeon, there would be no legal fees. The hospital would probably beat down your door to pay you off before a lawyer got involved.

 

[shea01]

As mentioned earlier, you are likely (99.999% likely) talking about something completely different than the topic at hand. If a nurse had removed your mother's ICD leads like we are referring to without a surgeon, there would be no legal fees. The hospital would probably beat down your door to pay you off before a lawyer got involved.

I'm merely giving you the explanation I was given by my father, which could very well be made up for whatever reason. About the legal fees, that is

 

[pgg]

This forum (SDN) is not a place for laypeople to ask for medical advice, get feedback on medical care they or family members have received, or air grievances about medical care they or family members have received.

It is a forum for physicians and physicians-in-training, and other health professionals, to discuss said training and the practice of medicine.

Registering on any internet forum to necrobump a five year old thread to gripe about something unrelated to the topic of discussion is rude. Here on SDN it is explicitly against the terms of service.

 

[anbuitachi]

this isn't a mac case? you would a line, introducer, tee probe everyone who comes in for a lead removal? just curious since ive never done one of these. im guessing you guys do all these cause it's a fairly common thing?

 

[Shimmy8]

No.

EP team in room, CT surgery and perfusion on standby, chest and groins prepped to crash on pump, tee in, EP attending looking the resident in the eye and calmly staring "When I pull this lead, if that systolic drops one point you better tell me."

God I was terrified. As a CA-2 did the first one of these after a guy died in the cath lab when they pulled RV lead. So they changed protocol to have this done in hybrid room with CT surgery/perfusion present as well. Fun times!

 

[twoliter]

this isn't a mac case? you would a line, introducer, tee probe everyone who comes in for a lead removal? just curious since ive never done one of these. im guessing you guys do all these cause it's a fairly common thing?

It's a great case for MAC...until something goes wrong.

 

[anbuitachi]

It's a great case for MAC...until something goes wrong.

Doesn't that go for all the mac cases haha. It's like TIPS procedure, MAC is great, unless they mess it up. But still MAC all the way! haha

 

[drmwvr]

this isn't a mac case? you would a line, introducer, tee probe everyone who comes in for a lead removal? just curious since ive never done one of these. im guessing you guys do all these cause it's a fairly common thing?

If this is what you mean by MAC....

 

[nimbus]

View attachment 222143


If this is what you mean by MAC....