Cardiac Rhythm Management
Articles Articles 2011 July

Cardiac Device Procedures: A Package Deal

DOI: 10.19102/icrm.2011.020707

Samuel J. Asirvatham, MD, FHRS, FACC

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KEYWORDS.device implant, lead extraction, device explantation.

In this issue of Innovations in Cardiac Rhythm Management, Varahan et al. provide an elegant review on the importance of careful planning periprocedurally to enhance outcomes with device lead extraction. The value of holistic evaluation- taking into account the patient's medical status, comorbidities, original implant indication and technique used, and the need and timing for reimplantation are well-explained.

Their article and the interest in this topic brings to light a more general issue related to cardiac device procedures that caregivers involved with cardiac device procedures (especially trainees) should think about: the interactions that exist between the various components and techniques related to device management.

From the first development of implantable devices, interaction between devices and cardiac devices and external monitoring, therapeutic, and other equipment was recognized and has been studied in depth.13 However, a new type of interaction has to be appreciated to allow device professionals to provide optimal care. These new “interactions” involve various components of device management that at first seem remotely related: the initial implant and subsequent difficulty with extraction, an extraction complication that hinders reimplantation, and what seems a minor issue with implant or extraction (dye load or bleeding) creating a major difficulty for the overall medical management of the patient and optimizing outcome (acute renal failure).



Experienced lead extractors will invariably be able to recount how their lead implant techniques have changed as a result of difficulties experienced and causes for complications with lead extraction. Choosing an appropriate vascular entrance site, optimizing the amount of lead slack especially on the free wall of the ventricle and atrium, and choice of the lead being used for implantation (single vs. dual coil, backfilled vs. non-backfilled, isodiametric vs. non-isodiametric leads) become more relevant. Perhaps the most significant issue is the feared potentially fatal complication from extraction; when at the time of lead implant, the vein was defected or possibly reentered, reaching an acceptable implant outcome but a potentially devastating extraction complication.


Varahan et al. nicely outline the issues that need to be addressed before extraction concerning reimplantation. Consulting with an Infectious Disease colleague, reexamining the original indication, and choosing appropriate vascular access are difficult to do during a complex extraction procedure and should have been done in the preprocedural setting.


Left ventricular lead implantation techniques are often mastered most quickly with those proficient in overall vascular access issues: maintaining access post extraction, knowledge and facility (possibly institutional facility) with venoplasty, and snaring techniques, etc. Similarly, understanding the options and difficulties with LV lead implantation and exact knowledge of the types of leads, fixation mechanisms, etc, can be paramount when these leads need to be extracted.


The overlap that exists both in the planning and execution of electrophysiology procedures, vascular interventions, and device procedures gives rise to important questions in terms of optimal training pathways and how we “count” number of procedures required to maintain expertise. Electrophysiologists who place coronary sinus catheters and may map or ablate within the venous system three times a week may have a different level of facility for CS lead placement compared to a non-electrophysiologist, and how we optimize training and set minimum numbers of procedures needed could be impacted. The need for vascular interventional skills, including venoplasty and intimate knowledge of extraction and snaring tools, has similar effects and repercussions for optimal training.

Impact on Innovation

Varahan et al.'s article brings to focus the importance of considering all aspects of device management whenever a new technique, lead, or device is being developed. Just as preprocedural planning is essential for individual patient outcomes, understanding the implications for lead extraction has to be considered for any device or lead innovation.46 New locations in the heart to place leads, subcutaneous or epicardial lead implantation, and hybrid surgical/percutaneous approaches for lead placement while providing encouraging new options for patients have to be assessed not only in terms of the safety and the efficacy of the implant and lead performance but ease and safety of extraction, as well.

It is in the Details

Lead extraction, perhaps more so than any other electrophysiology procedure, requires careful attention to detail and appreciation that a specific procedure is a component of overall device management. Varahan et al. spell out for us several such important details, including those related to wound management and reimplantation planning. Perhaps even more important is for administrators and device lab leaders to plan the extraction lab itself. Such planning may include guidelines specific to a given institution on where the extraction procedure is done (operating room versus device lab), the types of tools stocked in the lab, and training requirements for individual lab personnel. As with all overall planning, however, it starts with understanding the need and rationale for individual periprocedural planning, as well-outlined in the present article in this issue of Innovations in Cardiac Rhythm Management.7

Samuel J. Asirvatham, MD, FHRS, FACC
Consultant, Division of Cardiovascular Diseases
and Internal Medicine, Division of Pediatric Cardiology
Professor of Medicine and Pediatrics
Mayo Clinic College of Medicine
Rochester, MN


  1. Baikoussis NG, Apostolakis E, Papakonstantinou NA, Sarantitis I, Dougenis D. Safety of magnetic resonance imaging in patients with implanted cardiovascular electronic devices. Ann Thorac Surg 2011; 91:2006–2011. [CrossRef] [PubMed]
  2. Friedman PA, Glikson M, Stanton MS. Defibrillator challenges for the new millennium: the marriage of device and patient-making and maintaining a good math. J Cardiovasc Electrophysiol 2000; 11:697–709. [CrossRef] [PubMed]
  3. Kapa S, Pierce T, Hayes DL, Holmes DR, Jr., Asirvatham SJ. Electromagnetic interference of magnetic field based auto identification technologies in healthcare settings. Int J Med Inform 2011; 80:239–250. [CrossRef] [PubMed]
  4. Saksena S. The leadless defibrillator or the return of the subcutaneous electrode: episode III in the ICD saga? J Interv Card Electrophysiol 2005; 13:179–180. [CrossRef] [PubMed]
  5. Lobodzinski SS. Subcutaneous implantable cardioverter-defibrillator (S-ICD). Cardiol J 2011; 18:326–331.[PubMed]
  6. Henz BD, Friedman PA, Bruce CJ, Okumura Y, Johnson SB, Danielsen A, Packer DL, Asirvatham SJ. Synchronous ventricular pacing without crossing the tricuspid valve or entering the coronary sinus–preliminary results. J Cardiovasc Electrophysiol 2009; 20:1391–1397. [CrossRef] [PubMed]
  7. Varahan S, Pretorius V, Birgersdotter-Green U. The Cardiac Implantable Device Has Been Extracted: What Next? Innovations in Cardiac Rhythm Management 2011. [CrossRef]