Anesthesia and Lead Extractions Disclosures None Bryan Ahlgren - - PDF document

AnesthesiaandLeadExtractions

BryanAhlgrenDO AssistantProfessor UniversityofColorado Dept ofAnesthesiology

• None

Disclosures

• Defineleadextractionproceduresandwhy

Anesthesiologistsshouldbefamiliarwith them.

• Discussperioperativeandanesthetic

managementofleadextractions.

• Gainabasicunderstandingofhow

transesophageal echocardiographycanbea usefulmonitorinthesecases.

Objectives

• Highnumberofpacemakers/AICD(CIED)

implantedannually

• Leadsbecomedefective,fracture,orget

infectedroutinely

• LeadExtractionbecomingmoreandmore

common.Estimatesthatasmanyas52,000 mustbeextractedannually

LeadExtractions:

• Traction
• TractionDevices
• MechanicalSheaths
• RotatingThreadedTip

Sheath

• ElectrosurgicalSheath

(Bovie)

LeadRemovalTechniques

• LaserSheaths

LeadRemovalTechniques

Ahlgren, Bryan, DO Anesthesia and Lead Extractions

• “Excimer”XeCl lowtemperature(50oC)
• Highenergyshortdurationultravioletpulses

(135nsec)

• Shallowtissuepenetration:100M

– Safety:Cleargoggles

• Produceswater,gasmicrobubbles,andsmall

tissueparticles(<100Mindiameter)

HauserRG,Europace 2010;12:395401

LaserSpecifications

(Spectranetics Inc.,ColoradoSprings,CO)

LaserSheath

• Wilkoff,Byrdetal,1999.Pacemakerlead

extractionwiththelasersheath:resultsofthe pacingleadextractionwiththeexcimer sheath(PLEXES)trial.JAmColl Cardiol 33(6):16716.

• ByrdCL,Wilkoff BL,2002.Clinicalstudyofthe

lasersheathforleadextraction:thetotal experienceintheUnitedStates.PacingClin Electrophysiol 25(5):8048.

LaserLeadExtractionEvidence

• Reportsofmajorcomplications1.9%to3.4%

Majorcomplicationsinclude:

• Cardiacavulsion
• Vascularavulsion
• Pulmonaryembolism
• Stroke
• Newdeviceinfection
• Death

ComplicationsinLeadextraction: 2009HRSsocietystatement:

Ahlgren, Bryan, DO Anesthesia and Lead Extractions

RequiredPersonnel

• PrimaryOperator
• Cardiothoracicsurgeon ifnotPO,

immediatelyavailable

• Scrubbedandnonscrubbedassistant
• Flouroscopy support
• Echocardiographer available
• Anesthesiaavailable

2009HRSsocietystatement:

• Basicallynomentionorpositionontypeof

anesthesia,ormethodofmonitoring.

• ?

2009HRSsocietystatement LeadExtractionPopulation EjectionFraction

Ahlgren,etal.

NYHAClassification

Ahlgren,etal.

• Lengthoftimeleadimplantation
• ICDlead,especiallydualcoil
• Endocarditisand/orpocketinfection?
• Planforvenousaccess?

ProceduralFactors

Ahlgren, Bryan, DO Anesthesia and Lead Extractions

• 13Centers,1449consecutivePts,2406leads

– 20270procedures/site

• Majoradverseevents1.4%,Mortality0.3%

procedural,inhospital1.86%

• Associatedwithmortality:endocarditis (4.3%),

endocarditis+DM (7.9%),endocarditis and creatinine>2(12.4%)

• UnrelatedtoMAEs:GAvs sedationorEPlab

vs OR

MulticenterObservationalStudy

Wazni O,JACC2010;55:57986

• GeneralAnesthesia
• Doneinhybridroomorcardiacoperatingroom

withflouroscopy available

• CTsurgeoninroomandusuallyopensdevice

pocket

• CTanesthesiologist
• Perfusionist standingbywithpump“wetdown”
• Cardiactrainedoperatingroomstaff

ProtocolattheUniversityofColorado

Monitoring

• StandardASAmonitors
• Arterialline +/ priortoinduction
• 2largeboreIV’s
• MedicationsforCPB/resucitation drawnup

andreadytogoonanesthesiacart

• RealtimeTEE

ProtocolattheUniversityofColorado

TEEinLaserLeadExtraction

• IntraproceduralTEEduringtransvenous lead

extractionprovidesvaluablerealtime informationandmaychangeprocedural managementinupto16%ofcases

Takearideintothe“DangerZone”

Ahlgren, Bryan, DO Anesthesia and Lead Extractions

SVC WhentoGetNervous TricuspidFibrosis NewTR?

Ahlgren, Bryan, DO Anesthesia and Lead Extractions

RVLead RVInvagination

TEEforLeadReimplantPositioning

• 34yo female– developedpostpartum

cardiomyopathy8yearsago

• CIEDplacedatthattime
• Heartfunctionhassincerecovered,withnear

normalLVsystolicfunction

• Planistoremoveleads/device

Case:

Ahlgren, Bryan, DO Anesthesia and Lead Extractions

Ahlgren, Bryan, DO Anesthesia and Lead Extractions

Otherfuneventstowatchoutfor…

• Growingprocedure,youmaybelikelyto

encounterincreasingnumberofthesecases.

• Riskfactorsforpotentiallymoredifficultcases
• “Best”anestheticmanagementstill

controversialthoughmaybeleaningtowards GAwithreadinessforCPB

• TEEcanbeusefulintraoperativetool

Conclusions

Ahlgren, Bryan, DO Anesthesia and Lead Extractions