Haeberlin Andreas^ab, Holz Alexander^a, Seiler Jens^a, Baldinger Samuel H.^a, Tanner Hildegard^a, Roten Laurent^a, Madaffari Antonio^a, Servatius Helge^a, Jenni Hansjörg^c, Kadner Alexander^c, Erdoes Gabor^d, Reichlin Tobias^a, Noti Fabian^a

Summary

BACKGROUND: Transvenous lead extraction (TLE) is the recommended management strategy for a variety of cardiac implantable electronic device (CIED) infections, malfunctions and other conditions. Large registries have established the safety and efficacy of TLE per se but temporal outcome data after the introduction of an institutional lead management programme remain scarce.

OBJECTIVE: To investigate the impact of a structured institutional lead management programme on TLE outcomes.

METHODS: All patients who underwent TLE at our institution between January 2013 and December 2020 were included. We assessed procedural outcomes after TLE for two separate time periods: from January 2013 to December 2018 and January 2019 to December 2020 (after introduction of a structured institutional lead management programme).

RESULTS: In 2013–2018, the median number of TLE procedures per year at our centre was 14 (range 10–19, total 84). In 2019/2020, the median number of interventions per year increased to 46 (range 41–51, total 92). Noninfectious indications for TLE became more frequent (p <0.001), and the proportion of TLEs due to infections decreased. Median lead dwell time was not different (4.3 years [2013–2018] vs 4.4 years [2019–2020], p = 0.43). Clinical success rates improved from 90% to 98% (p = 0.020) and complete procedural success increased from 85% to 95% (p = 0.027). There was a trend towards a lower number of TLE-associated complications (p = 0.07).

CONCLUSION: A structured institutional lead management programme and increasing experience significantly improve TLE outcomes. TLE can be safely performed in high-volume centres, allowing for a more liberal extraction policy, including in the case of non-infectious TLE indications.

Introduction

Implantation numbers of cardiac implantable electronic devices (CIEDs) are continuously on the rise [1]. In parallel, the incidence of CIED infections is increasing [2] and malfunction of implantable cardioverter-defibrillator and pacemaker leads is not uncommon [3, 4]. All these factors boost the growing demand for CIED system revisions that may include transvenous lead extraction (TLE).

Interventional TLE is an established therapy. Large prospective and retrospective registries such as ELECTRA [5], LEXICON [6] and PROMET [7] have shown that TLE can be performed with high clinical success rates of 97–98%. However, the invasive nature of the procedure constitutes a risk for major complications, which are, fortunately, rare (1.0–1.7%) given appropriate infrastructure, training and precautions. Accordingly, TLE is performed increasingly also for a variety of non-infectious indications [8] and not only for infectious disease complications after CIED implantation – the most widely accepted indication for TLE.

In the present study, we investigated temporal trends of TLE indications associated with the implementation of a structured institutional lead management programme. We provide outcome data as well as a comprehensive overview on contemporary lead management strategies for daily clinical practice

Methods

Study design and patient population

In this investigator-initiated cohort study, we retrospectively enrolled all patients who underwent a TLE procedure between January 2013 and December 2020 at our tertiary referral centre. TLE was defined as intervention with removal of at least one lead that had been implanted for more than one year, or regardless of implant duration if specialised extraction equipment was used (locking stylets, snares, non-powered sheaths, rotational mechanical sheaths, laser sheaths) [9]. All patients had a TLE indication according to current guidelines, no exclusion criteria applied. The study was a subgroup analysis of the SWISSEXTRACT registry, which was approved by the respective cantonal ethics committees.

Structured institutional lead management programme

In January 2019, a dedicated lead management programme was established at our institution. This consists of a specialised lead management clinic, where patients are seen in-office by a device specialist competent in TLE. In addition to patient history and complete device interrogation, fluoroscopy of the CIED system, subclavian venography and additional diagnostic modalities (table 1) are used for a comprehensive evaluation of CIED patients. Patients with possible CIED infections are discussed by a dedicated endocarditis board (including device specialists, infectious disease consultants, cardiac surgeons and echocardiographers) [2]. If TLE is considered, preanaesthesia evaluation is requested. Definite TLE planning requires a perioperative risk assessment with participation of all involved subspecialties (cardiac anaesthetist, cardiac surgeon, perfusionist) in the choice of the extraction strategy. Before the lead management programme was introduced, no structured planning pathway for TLE, no structured risk quantification, and no interdisciplinary TLE planning was implemented. A dedicated outpatient clinic had also not yet been established.

At our centre, TLE procedures that are considered intermediate and high-risk are performed in a hybrid operation room by two lead extraction specialists. The full range of extraction tools (locking stylets, snaring tools, non-powered and rotational mechanical sheaths) is available. TLE is performed under general anaesthesia. Monitoring includes invasive blood pressure measurement and transoesophageal echocardiography, among others. Femoral venous and arterial sheaths are inserted. These sheaths serve as access site for femoral extraction tools, a temporary pacing wire, an occlusion balloon in case of laceration of the superior vena cava, and for emergency extracorporeal circulation. A cardiac surgeon and perfusionist are available on site in case of urgent conversion to open cardiac surgery.

Table 1: 

Structured evaluation for optimal lead management prior to TLE. The list provides a general overview and is not exhaustive. 

Diagnostic procedure	Main focus	When to perform
Medical history	CIED implantation indication, drugs, allergies, other comorbidities.	Always before intervention
Analysis of implantation reports	Implanted material, vascular access routes, challenges during implantation.	Always before intervention
CIED interrogation	Analysis of CIED function and PM depen­dency. In case of lead malfunction provoca­ti­on maneuvers and EGM evaluation.	Always before intervention
Transthoracic echo­cardio­graphy	Biventricular function, lead vegetations, presence of concomitant significant valve disease (vegetations, tricuspid regurgi­tation), pre-operative risk stratification.	Always before intervention
Transoesophageal echocardiography	Lead insertion points, vegetations, pericardial and pleural effusions, presence of right-to-left shunt, hemodynamics.	(Before and) during intermediate and high-risk TLE
Fluoroscopy and subclavian venography	Lead defects, patency of access routes, assessment of connective tissue bridges and lead insertion points, vessel stenosis.	Mostly before intervention
Laboratory tests	Electrolytes, creatinine, coagulation, blood count and group for potential transfusion.	Immediately before intervention
FDG-PET scan	Evidence for CIED infection.	In case of discrete signs of (pocket) infection
Thoracic CT/MRI	General anatomy, lead insertion site, vascular access/occlusion.	In complex situations or perforated leads
Coronary angiography and cardiac catheterisation	Presence of significant concomitant coronary artery disease, grading of valve disease.	In case of planned hybrid procedure involving surgery
Individualised cumulative risk assessment	Calculation of interventional risk for interdisciplinary decision on optimal lead management strategy.	Always before definite intervention planning

CIED: cardiac implantable electronic devices; CT: computed tomography; EGM: electrogram; FDG-PET: fluordesoxyglucose positron emission tomography; MRI: magnetic resonance imaging; PM: pacemaker; TLE: transvenous lead extraction

Follow-up data acquisition

Procedural and follow-up data were collected from our institutional health records. Referring cardiolo­gists and general practitioners were contacted to complete follow-up. The last follow-up was performed in May 2021. Success and complication rates were assessed according to widely recognised definitions [9]. Complete procedural success was defined as removal of targeted leads, without permanently disabling complications or procedure-related death [9]. Clinical success was defined as retention of a small lead portion (<4 cm) neither negatively impacting the outcome of the procedure, nor increasing the risk of complications but absence of permanently disabling complications or procedure-related death [9].

Statistical analysis

R version 4.1.1 for Windows (R Foundation, Vienna, Austria) was used for statistical analysis. Categorical variables are expressed as numbers and percentages. Continuous variables are presented as mean ± standard deviation (SD) or median and interquartile range (IQR), as appropriate. Procedural outcomes of TLE were assessed over time. In particular, interventions performed from January 2013 to December 2018 (no structured institutional lead management programme) were compared with interventions performed from January 2019 to December 2020 (after introduction of a structured institutional lead management programme). Comparisons between categorical variables and groups were performed using a χ² test or Fisher’s test as appropriate. Continuous variable were compared using a Wilcoxon-Mann-Whitney test. A two-sided p-value ≤0.05 was considered significant.

Results

Baseline patient characteristics

Detailed characteristics of all patients who underwent TLE in 2013–2018 and 2019–2020 are shown in table 2. Key baseline parameters were not different for both time periods. However, there was a significant change in TLE indications over time. Noninfectious indications for TLE became more frequent (p <0.001). In particular, lead malfunction became the single most important indication for TLE at our centre, accounting for more than half of the current TLE procedures. In contrast, the relative frequency of infectious indications decreased from 60% to 26% (fig. 1).

Table 2: 

Patient baseline characteristics.

 

Patient characteristics	2013–2018 (n = 84)	2019–2020 ( n=92 )	p-value
Clinical characteristics
Female sex	27 (32%)	29 (32%)	1
Age (years)	69 (54–76)	69 (54–75)	0.58
Body height (m)	1.71 (1.65–1.76)	1.72 (1.65–1.78)	0.35
Body weight (kg)	75 (65–90)	80 (69–90)	0.12
LVEF (%)	55 (35–65)	57 (36–61)	0.76
Arterial hypertension	53 (64%)	58 (63%)	1
Diabetes	20 (24%)	18 (20%)	0.62
Renal failure	22 (27%)	23 (26%)	0.95
Pacemaker dependency	38 (45%)	53 (58%)	0.14
Prior cardiac surgery	27 (33%)	22 (24%)	0.27
Drug therapy
Oral anticoagulation	42 (50%)	47 (52%)	1
Antiplatelet therapy	43 (51%)	24 (26%)	<0.001
Betablocker	52 (62%)	53 (58%)	0.67
ACE inhibitor or AT2 blocker	42 (51%)	58 (63%)	0.11
CIED system
Single- or dual-chamber PM	45 (54%)	50 (54%)	1
CRT-P	3 (4%)	3 (3%)	1
Single- or dual-chamber ICD	25 (30%)	22 (24%)	0.48
CRT-D	11 (13%)	17 (18%)	0.44
CIED indication
Sinus node disease	13 (15%)	16 (17%)	0.89
AV block	29 (35%)	31 (34%)	1
Ventricular tachycardia/fibrillation	13 (15%)	18 (20%)	0.61
Other	29 (35%)	27 (29%)	0.57
TLE indication
CIED or systemic infection	50 (60%)	24 (26%)	<0.001
Non-infectious indication	34 (40%)	68 (74%)	<0.001
– Lead malfunction	26 (31%)	50 (54%)	0.003
– Chronic pain	2 (2%)	2 (2%)	1
– Thrombosis / venous occlusion	0 (0%)	5 (5%)	0.06
– Device upgrade	4 (5%)	5 (5%)	1
– Other	2 (2%)	6 (7%)	0.28

Median values with interquartile ranges in brackets and numbers with percentages are shown. AV: atrioventricular; CIED: cardiac implantable electronic device; CRT: cardiac resynchronisation therapy; ICD: implantable cardioverter-defibrillator; LVEF: left ventricular ejection fraction; PM: pacemaker; TLE: transvenous lead extraction

fullscreen

Procedural characteristics

The total number of TLE procedures for 2013–2020 is shown in figure 2. In 2013–2018 (low-volume era), the median number of TLE procedures per year at our centre was 14 (range 10–19), resulting in a median number of 22 extracted leads per year (IQR 19–30). In 2019/2020 (high-volume era), the median number of interventions per year increased to 46 (range 41–51), resulting in 76 extracted leads per year (IQR 75–78).

Procedural characteristics for the two time periods are shown in table 3. In the high-volume era, more interventions were performed in the hybrid operation room (92% vs 76% in the low-volume era, p = 0.006). The use of rotational mechanical sheaths increased (p <0.001) at the cost of non-powered mechanical sheaths (p <0.001). Laser TLEs were not performed in the high-volume era, since both procedure-related deaths were associated with the use of a laser (vessel laceration). Median lead dwell time was not different (4.3 years [low volume era] vs 4.4 years [high volume era], p = 0.43).

fullscreen

Table 3: 

Procedural characteristics.

Procedural characteristics	2013–2018 (n = 84)	2019–2020 (n = 92)	p-value
Procedural setting
Emergency procedure	21 (25%)	15 (16%)	0.21
Intervention site			0.003
– Electrophysiology laboratory	19 (23%)	6 (7%)	0.005
– Hybrid operation room	64 (76%)	85 (92%)	0.006
– Conventional operation room	1 (1%)	1 (1%)	1
Procedural details
Procedure duration (min)	144 (110–196)	143 (85–240)	0.93
Passive leads	34 (25%)	23 (15%)	0.06
Number of targeted leads for extraction	2 (1–2)	2 (1–2)	0.40
Lead dwell time (years)	4.3 (1.8–8.6)	4.4 (2.4–8.4)	0.43
Use of conventional stylets	18 (22%)	21 (23%)	0.43
Use of locking stylets	65 (78%)	71 (77%)	0.97
Use of laser sheath	22 (27%)	0 (0%)	<0.001
Use of mechanical non-powered sheath	45 (70%)	35 (39%)	<0.001
Use of rotational mechanical sheath	2 (3%)	34 (38%)	<0.001
Use of femoral snares	4 (5%)	12 (13%)	0.10
Procedural outcomes
Clinical success	76 (90%)	90 (98%)	0.020
Complete procedural success	71 (85%)	87 (95%)	0.027
Duration of hospital stay (days)	6 (4–13)	3 (3–6)	<0.001
Total complications	15 (18%)	7 (8%)	0.07
Major complications	4 (5%)	0 (0%)	0.05
– Procedure related deaths due to vessel laceration, haemothorax	2 (2%)	0 (0%)	0.23
– Cardiac tamponade requiring surgery	1 (1%)	0 (0%)	0.47
– Thromboembolic event requiring surgery	1 (1%)	0 (0%)	0.471
– Stroke	0 (0%)	0 (0%)	–
Minor complications	11 (13%)	7 (8%)	0.34
– Femoral bleeding	0 (0%)	2 (2%)	0.50
– Pocket haematoma	5 (6%)	0 (0%)	0.023
– Other	6 (7%)	5 (5%)	0.76

Median values with interquartile ranges in brackets and numbers with percentages are shown.

Procedural outcomes

Whereas overall procedural complexity seemed not to alter over time (median lead dwell time, procedure duration, number of targeted leads, CIED types and patient characteristics were not different), procedural outcomes changed (table 3). Clinical success rate improved from 90% to 98% (p = 0.020) and complete procedural success increased from 85% to 95% (p = 0.027, fig. 2). There was a trend towards a lower number of TLE-associated complications (18% vs 8%, p = 0.07, fig. 2), in particular a reduction of major complications (5% vs 0%, p = 0.05).

Discussion

In this large registry study of 176 TLE procedures performed in Swiss tertiary referral centre, we aimed to investigate the impact of a structured institutional lead management programme on TLE outcomes. The main findings of our study were:

1. The relative frequency of noninfectious TLE indications is increasing. This is likely attributable to a significant rate of lead failures [4], a more liberal extraction policy with increasing experience, favourable outcomes and evolution of our institution into a high-volume TLE centre.
2. Besides the temporal change of TLE indications, patients undergoing TLE seem to exhibit similar characteristics over time and compared with large multicentre registries [5]. However, TLE success rates significantly increase with the increasing use of rotational mechanical sheaths.
3. The introduction of a structured institutional lead management programme including a standardisation of TLE procedures allows individualised patient care and increased TLE success rates while maintaining very low complication rates.
4. The increase in noninfectious TLE (elective) indications may play a causative role in the reduction of overall hospitalisation duration in TLE patients. Patients with infectious CIED complications may require intravenous antibiotics or concomitant surgery, prolonging the hospitalisation.

Safety and efficacy of TLE

The clinical success rate of TLE in our cohort was 98%, which is similar to multicentre registries [5–7]. Major complications were rare in these studies and we did not observe any in the high-volume era. Nonetheless, TLE carries an inherent risk of severe procedural adverse events. Several strategies may minimise the risks and contribute to favourable outcomes:

• Structured preprocedure assessment in the lead management clinic allows individualised patient care. Shared decision making balancing risks and benefits of TLE vs lead abandonment is crucial to optimise the lead management strategy. A multidisciplinary approach and risk stratification involving anaesthesiologists, cardiac surgeons, perfusionists, infectious disease and imaging specialists may improve outcomes [10, 11].

• The use of rotational mechanical sheaths reduces the torque exerted on the extracted lead in comparison with unpowered sheaths, preserving lead integrity and, thus, facilitating extraction. Bidirectional rotational mechanical sheaths have been shown to be highly effective in the recently published prospective RELEASE trial [12]. They are an effective first-line tool for TLE [13] and may even outperform laser sheaths [7, 14].

• Adherence to international recommendations for TLE on-site cardiac surgery, cardiac anaesthesia availability, a full range of CIED extraction and implantation tools and high-quality fluoroscopy should be available [15]. A tertiary centre for TLE should perform at least 30 procedures per year, with each trained primary operator performing a minimum of 15 procedures and extracting at least 20 leads. At our centre, a team of two operators fulfilling the above requirements performs all TLE procedures using a dedicated setting for TLEs (fig. 3A and B). Patients who are treated in higher volume centres (mostly tertiary hospitals) have a lower probability of complications and death [16].

fullscreen

Practical implications for patients with infectious CIED complications

TLE is the recommended approach in patients with pocket infections or CIED endocarditis [2, 8]. CIED infections with large lead vegetations or pocket perforation are easy to diagnose, whereas discrete manifestations pose a diagnostic challenge (fig. 3C). An often forgotten TLE indication is bacteraemia without evidence of CIED infection. Bacteraemia with staphylococcal species and Propionibacteria often warrants proactive TLE [8], in particular in patients with prolonged bacteraemia (the risk of relapse increases if no TLE is performed and bacteraemia lasts >1 day [17]). TLE is critical to improve outcome in these patients even in the case of unconfirmed CIED endocarditis [18]. Conservative management of CIED infections using antibiotic suppression or salvage therapy with isolated pocket revision is rarely curative and might only be considered in very fragile elderly high-risk patients [2, 19].

Practical implications for patients with noninfectious CIED complications

In the past, conservative management of device malfunctions with lead abandonment was often preferred [20]. Lead abandonment may be more economical, since TLEs can be associated with considerable costs (sometimes >15,000 CHF) only for the special extraction equipment and hybrid operating room use. However, abandoned leads are a source of potential complications [21], pain and disability [22]. More recent data – including our experience – show that patients with noninfectious CIED complications can safely undergo TLE. Common noninfectious indications for TLE include stenosis/occlusion of the superior vena cava, thromboembolic events (both class IC [8]), ipsilateral vessel occlusion prior to device upgrade, chronic pain and >4 unilateral leads (all class IIa [8]). TLE in the case of lead malfunction (fig. 3D) may also reduce the long-term risk of repeat lead failure compared with lead abandonment (class IIb [8]). Referral to an extraction centre with a structured institutional lead management programme should be advised in such cases.

Limitations

This was a single-centre retrospective observational study. The generalisability of our findings to other centres may be limited, given the sample size and low number of TLE operators in this study. Since 2018, TLEs at our centre are performed by the first and last author, which may co-explain certain changes observed in the high volume era (e.g., procedural setting, preferred tools for extraction).

Conclusion

A structured institutional lead management programme significantly improves TLE success rates while ensuring a low number of complications. TLE can be safely performed in high-volume centers, allowing for a more liberal extraction policy also in patients with non-infectious TLE indications.

Acknowledgements

The authors would like to thank J. Lukasevic, J. Tomas, S. Shehu, C. Gfeller, and S. Dütschler for their assistance during the local data collection. The authors would like to acknowledge the support of PD Dr F. D. Regoli and the Cardiocentro Ticino, Lugano, Switzerland.

Disclosure statements

No financial support and no other potential conflict of interest relevant to this article was reported.

None of the authors has received any compensation for this study. Drs Haeberlin and Noti have received travel/educational grants from Philips/Spectranetics without impact on their personal remuneration. Dr Haeberlin has received travel/educational grants from Medtronic. He is consultant/advisor for DiNAQOR, Biotronik, and Abbott, as well as Co-founder/head of Act-Inno. Dr Noti has received travel/educational grants from Medtronic, Abbott, and Boston Scientific and speaker honoraria from Medtronic and Abbott. The other authors have received consulting fees/speaker honoraria/travel support from Abbott, Astra Zeneca, Brahms, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Daiichi Sankyo, Medtronic, Microport, Novartis, Pfizer-BMS and Roche.

Correspondence

Dr Andreas Haeberlin, MD, PhD

Dept. of Cardiology Bern University Hospital

Freiburgstrasse 3

CH-3005 Bern

andreas.haeberlin[at]insel.ch

References

1.  A Decade of Information on the Use of Cardiac Implantable Electronic Devices and Interventional Electrophysiological Procedures in the European Society of Cardiology Countries: 2017 Report from the European Heart Rhythm Association. Europace. 2017 Aug;19 suppl_2:ii1–90. http://dx.doi.org/10.1093/europace/eux258 PubMed 1532-2092

2. . European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Europace. 2020 Apr;22(4):515–49. http://dx.doi.org/10.1093/europace/euz246 PubMed 1532-2092

3.  Transvenous extraction profile of Riata leads: procedural outcomes and technical complexity of mechanical removal. Heart Rhythm. 2015 Mar;12(3):580–7. http://dx.doi.org/10.1016/j.hrthm.2014.12.013 PubMed 1556-3871

4.  Unexpected high failure rate of a specific MicroPort/LivaNova/Sorin pacing lead. Heart Rhythm. 2021 Jan;18(1):41–9. http://dx.doi.org/10.1016/j.hrthm.2020.08.010 PubMed 1556-3871

5. . The European Lead Extraction ConTRolled (ELECTRa) study: a European Heart Rhythm Association (EHRA) Registry of Transvenous Lead Extraction Outcomes. Eur Heart J. 2017 Oct;38(40):2995–3005. http://dx.doi.org/10.1093/eurheartj/ehx080 PubMed 1522-9645

6.  Lead extraction in the contemporary setting: the LExICon study: an observational retrospective study of consecutive laser lead extractions. J Am Coll Cardiol. 2010 Feb;55(6):579–86. http://dx.doi.org/10.1016/j.jacc.2009.08.070 PubMed 1558-3597

7.  Results of the Patient-Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: a multicentre retrospective study on advanced mechanical lead extraction techniques. Europace. 2020 Jul;22(7):1103–10. http://dx.doi.org/10.1093/europace/euaa103 PubMed 1532-2092

8.  2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017 Dec;14(12):e503–51. http://dx.doi.org/10.1016/j.hrthm.2017.09.001 PubMed 1556-3871

9. . 2018 EHRA expert consensus statement on lead extraction: recommendations on definitions, endpoints, research trial design, and data collection requirements for clinical scientific studies and registries: endorsed by APHRS/HRS/LAHRS. Europace. 2018 Jul;20(7):1217. http://dx.doi.org/10.1093/europace/euy050 PubMed 1532-2092

10.  The clinical value of the endocarditis team: insights from before and after guidelines implementation strategy. Infection. 2022 Feb;50(1):57–64. http://dx.doi.org/10.1007/s15010-021-01636-3 PubMed 1439-0973

11.  RIsk Stratification prior to lead Extraction and impact on major intraprocedural complications (RISE protocol). J Cardiovasc Electrophysiol. 2019 Nov;30(11):2453–9. http://dx.doi.org/10.1111/jce.14151 PubMed 1540-8167

[12] Performance and outcomes of transvenous rotational lead extraction: Results from a prospective, monitored, international clinical study. Heart Rhythm O2 2021; 2: 113-121.

13.  Comparison between TightRail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction. Pacing Clin Electrophysiol. 2021 May;44(5):895–902. http://dx.doi.org/10.1111/pace.14206 PubMed 1540-8159

14.  Reported mortality with rotating sheaths vs. laser sheaths for transvenous lead extraction. Europace. 2019 Nov;21(11):1703–9. http://dx.doi.org/10.1093/europace/euz238 PubMed 1532-2092

15. . Pathways for training and accreditation for transvenous lead extraction: a European Heart Rhythm Association position paper. Europace. 2012 Jan;14(1):124–34. http://dx.doi.org/10.1093/europace/eur338 PubMed 1532-2092

16.  Safety of transvenous lead extraction according to centre volume: a systematic review and meta-analysis. Europace. 2014 Oct;16(10):1496–507. http://dx.doi.org/10.1093/europace/euu137 PubMed 1532-2092

17.  Staphylococcus bacteremia without evidence of cardiac implantable electronic device infection. Heart Rhythm. 2021 May;18(5):752–9. http://dx.doi.org/10.1016/j.hrthm.2020.12.011 PubMed 1556-3871

18.  Evaluation of European Heart Rhythm Association consensus in patients with cardiovascular implantable electronic devices and Staphylococcus aureus bacteremia. Heart Rhythm. 2022;19(4):570-7. PubMed 1547-5271

19. . Pacemaker pocket infection: innovative conservative treatment in elderly patients with no signs of systemic infection. Pacing Clin Electrophysiol. 2019 Oct;42(10):1340–6. http://dx.doi.org/10.1111/pace.13787 PubMed 1540-8159

20.  Risks of spontaneous injury and extraction of an active fixation pacemaker lead: report of the Accufix Multicenter Clinical Study and Worldwide Registry. Circulation. 1999 Dec;100(23):2344–52. http://dx.doi.org/10.1161/01.CIR.100.23.2344 PubMed 0009-7322

21. . Is there an adverse outcome from abandoned pacing leads? J Interv Card Electrophysiol. 2000 Oct;4(3):493–9. http://dx.doi.org/10.1023/A:1009860514724 PubMed 1383-875X

[22] Assessment of shoulder pain and shoulder disability in patients with implantable cardioverter-defibrillator. Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing 2013; 36: 91-94.

Copyright

Published under the copyright license
“Attribution – Non-Commercial – NoDerivatives 4.0”.
No commercial reuse without permission.
See: emh.ch/en/emh/rights-and-licences/