Shinshu M ed J, 63⑵ :103〜108, 2015

Initial Experience of Percutaneous Extraction of Infected Cardiac
Implantable Electric Devices Using Excimer Laser
Ayako OKADA , Atsushi IZAWA, Hirohiko M OTOKI, Takeshi TOMITA
Yusuke MIYASHITA, Jun KOYAMA, Kazunori AIZAWA
Morio SHODA and Uichi IKEDA
Department of Cardiovascular Medicine, Shinshu University School of Medicine

Background :The estimated incidence of infected cardiac implantable electric devices (CIED) has recently
increased to 1% ‑ 2%. Prompt removal of infected devices improves survival rates. We describe our initial
experience of lead extraction from infected devices using an excimer laser that was approved for thisapplication in 2010.
Methods and results:We retrospectively analyzed the characteristics, type of devices and leads, as well as
indications and complications in 13 patients with CIED infection between 2011 and 2014 at our hospital.
The clinical presentation comprised isolated pocket infection(n＝12),lead endocarditis(n＝3)and methicillin‑
resistant Staphylococcus aureus‑positive blood cultures. The patients had been implanted with a total of 29
leads (atrial,n＝13;ventricular,n＝16)for a median duration of 10.2±5.2 years.The procedure was successful
in all patients, but two patients who developed recurrent infection required repeated removal of devices andan implant device from epicardial cardiac muscle. Acute cardiac tamponade occurred in one patient after
ventricular lead extraction due to perforation of the right ventricle. This patient required an emergency
thoracotomy, but was discharged one month after the procedure.
Conclusion :Infected CIED leads can be quickly extracted using an excimer laser.Shinshu Med J 63 : 103 ―108, 2015
(Received for publication August 18, 2014;accepted in revised form November 28, 2014)
Key words:device infection, complication, cardiac tamponade, septic embolism, generator exchange

Introduction

tions include diabetes mellitus, steroid medication,
renal failure,advanced age,temporary pacemakers

The rate of CIED infection has recently increased

and generator exchange ,which exposes patients toworldwide and aﬀects an estimated 1%‑2% of

increased risk of infection compared with initialdevices in Japan .The number of hospitalizations

device implantation .

related to CIED infection increased 3.1‑fold

Antibiotic prophylaxis and new device implanta-

between 1996 and 2003,and more importantly,CIED

tion are associated with a low risk of infection

infection has increased the risk of in‑hospitaland earlier removal of an infected device results

death ＞2‑fold .Infection rates of CIED range fromin better outcomes . Some reports indicate

1% to 7%that coagulase‑negative Staphylococcus and other. Known risk factors for CIED infec-

Corresponding author:Ayako Okada

Staphylococcus species account for 42% and 25%,

Department of Cardiovascular Medicine,Shinshu Univer-respectively, of CIED infections .

sity School of Medicine,3‑1‑1 Asahi,M atsumoto,Nagano
390‑8621, JapanThe guidelines for dealing with CIED infection

E-mail:ayakookada1026＠yahoo.co.jp

published by the Heart Rhythm Society indicate

Senior co‑authorsthat infected devices must be removed as soon as

No. 2, 2015

103

Okada.Izawa.M otoki et al.

possible. Infected CIED in Japan have histori-

electrocardiographically monitored and assessed bycallybeen removed using trans‑venous manual trac-

transesophageal echocardiography. An open‑hearttion or open heart surgery but surgical removal

surgical kit was prepared by a cardiac surgeon withcan be too invasive,especially for patients who area standby pump oxygen generator.

elderly or who have signiﬁcant co‑morbidities.

Plastic surgeons opened and drained the pocket

The excimer laser sheath (Spectranetics, Colorado

and removed the generator (if present). Fibrotic

Springs, CO, USA) was approved for lead extrac-

tissues surrounding the leads were excised and thetion in Japan in 2010 . Transvenous laser lead

area was exfoliated to expose them.

extraction is associated with lower complication

An LLD locking stylet (Spectranetics, Colorado

rates than manual transvenous extraction and highSprings,CO,USA)was advanced to each lead tip.Asuccess rates.

12 Fr laser sheath was passed over the lead bodyHere, we describe our initial experience of lead

until the ﬁrst binding site was reached.Encapsulat-extraction using an excimer laser sheath to treat

ed adhesive tissue was ablated using laser bursts

CIED infection at a single institution.

and the sheath was advanced to the next binding

Methods
We retrospectivelystudied 13 consecutive patientssite. All bound tissue was dissected by the sheath
and when it reached the lead tip, the lead wasextracted by counter traction .

after they had undergone CIED lead extraction

Thereafter, the pocket was closed with 2‑0 VI-

using an excimer laser at Shinshu University

CRYL sutures (Johnson and Johnson, New Brun-Hospital, Japan between 2011 and 2014.Indications

swick, NJ, USA)and the patients were transferred

for lead extraction were based on the Heart Rhythm

to the intensive care unit for 24 hours.

Society criteria .

Results

Patients who were unable to tolerate open cardiac surgeryor general anesthesia,or who had giant

Table 1 shows the characteristics of the 13

vegetations in leads or valves, were excluded. Wepatients (mean age, 65.0±21.6 y; 11 males) frompercutaneously extracted leads using the excimer

whom 29 leads were extracted using the excimer

laser when surgical removal was considered toolaser.

invasive and manual extraction was likelyto be less

The mean number of leads and the median duration after initial implantation were 2.2±0.4 andsuccessful.
We analyzed the characteristics of the patients10.2±5.2 y, respectively. Of the 29 leads, 13 wereand devices,types of CIED infection,and complica-

located in the right atrium and 16 were located intions associated with device extraction.

the right ventricle. Patients no. 2, 3 and 10 had atThe study proceeded in compliance with ethicalleast one ICD coil lead, which might have beenstandards included in the Declaration of Helsinki.

prone to powerful adhesion and require more care-Extraction Procedure

ful extraction. Importantly, CIED infection wasprimarily diagnosed after generator exchange in 11Leads have been extracted using excimer lasers

patients (84.6%), but not after initial implantation

for four years at selected hospitals in Japan.Use ofin two others, in accordance with the known risks

the excimer laser sheath for this purpose requires

associated with the exchange procedure.Indications

rigorous training to meet speciﬁc criteria,which wefor initial device implantation widelyvaried depend-completed at the Tokyo Womenʼ
s Medical Univer-ing on the disease (Table 2). Table 3 shows local

sity Hospital.

symptoms at the site of the pacemaker pocket ,We extracted leads from patients under generalechocardiographic ﬁndings, and the results of cul-anesthesia in an operating room.The patients weretured blood and extracted leads . At least one

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CIED extraction using excimer laser
Table 1 Patient characteristics
Case No Age Sex

Number of Times after
Infection Time after
Device type
Leads (n) Implantation (y)after GE
GE (M )

1
255
43

M
M

23

13
4

PM
ICD

3482
70

M
M

22

710

ICD
PM

5620
68

M
M

3
2

7
13

PM
PM

787679MM231314PMPM910111236578392

MMFM

2222162209PMICDPMPM1385

M25PM＋＋＋＋＋−＋＋＋−

722426141＋＋42＋4

M :M ale F :Female ICD :implantable cardioverter diﬁbrillator
PM :pacemaker GE :generator exchange
Table 2 Indications for device implantation
Case No
12Sick sinus syndrome
Vf (Brugada syndrome)

345VT (DCM)
Complete atrio-ventricular block
Advanced atrio-ventricular block6789101112

Sick sinus syndromeComplete atrio‑ventricular block
Complete atrio‑ventricular block
Complete atrio‑ventricular block
VT (OM I)
Sick sinus syndrome
Sick sinus syndrome

13

Sick sinus syndrome

Vf:Ventricular ﬁbrillation DCM :Dilated cardiomyopathy VT :Ventricular tachycardia
OMI :Old myocardial infarction

culture from all patients was positive. Samples

one had no pocket infection. Preoperative bloodfrom pocket sites of 12 patients were positive

cultures were positive in only one patient and tran-

except for one in which only blood cultures weresesophageal echocardiography detected vegetations

positive. However, device infection was stillin two others.In contrast,pocket tissues or leads insuspected because that patient had developed sepsis

all patients were mostly positive for methicillin‑

due to Staphylococcus species according to the guide-

resistant Staphylococcus epidermidis,which was cul-lines of the Heart Rhythm Society (2009).

tured from the CIED pockets of nine patients and

The device was exteriorized in eight patients,from the lead tips of three others.

among whom one required emergency extraction toLeads were completely extracted from all

prevent systemic infection. Three patients had

patients with a 100% success rate.The only major

pocket infection without device exteriorization andadverse event was acute cardiac tamponade inNo. 2, 2015

105

Okada.Izawa.M otoki et al.
Table 3 Pacemaker pocket, echocardiographic ﬁndings and result of culture
Case No

Pocket symptom

TEE

Blood culture Pocket culture Lead culture

123Exteriorization

Negative

MRSE

Negative

Exteriorization
Exteriorization

Negative
Negative

MRSE
MRSE

Negative
Negative

45Exteriorization
Exteriorization

Negative
Vegetation

S. aureus
MRSE

Negative
MRSE

67Local infectionExteriorization

Vegetation
Vegetation

MRSE
MRSE

Negative
MRSE

89Local infection
Local infection

Negative
Negative

MRSE
MRSE

Negative
MRSE

10111213

No pocket infection
Exteriorization
Exteriorization
Impending ext

Negative
Negative
Negative
Negative

P. aeruginosa
CandidaMRSE

MRSE
Negative
Negative
Negative

M RSE

Impending ext, impending exteriorization ;M RSE, Methicillin‑resistant S epidermidis;P. aeruginosa,
Pseudomonas aeruginosa ;S. aureus, Staphylococcus aureus;TEE, Transthoracic echocardiography.
Table 4 Perioperative period
Case No.

Anesthesiatime (hour)

Procedure
Length ofBleeding
Blood transfusion
Time (hour) ICU stay (day)
(ml)

12

6.51
5.50

4.12
3.52

1
1150
I50

34

6.23
6.21

4.18
4.27

1
160
100

56

6.36
8.16

4.27
6.52

1
150
100

78
9

5.25
5.4
3.15

3.40
3.2
1.51

1
1
1

100
100
100

1011

4.9
9.16

1.38
7.51

135

50
1600

1213

5.11
4.5

3.31
5.39

1
1

20
40

−
−
−
−
−−−−
−
−
＋
−
−

patient no. 10 (7.8% of all patients). This patient

Importantly, infection recurred in patients no. 7was discharged at 30 days after on‑pump, beating‑and 9, both of whom required subsequent implanta-

heart cardiac repair. Patient no. 3 developed sys-

tion of an epicardial pacemaker via thoracotomy.A

temic infection (7.8% of all patients) with septic

newly re‑implanted pacemaker became infected inlung embolisms after pacemaker re‑implantation.

Patient no. 7, and this was again retrieved one

The mean procedural duration of CIED extrac-

month later.Patient no.9,who had collagen diseasetion was 4.0±1.7h,the average stay in the intensivethat was being treated with high‑dose steroid,care unit was 24 hours and an average of 201 mL of

required temporary pacing after the initial pace-blood was lost during the procedure (Table 4). The

maker extraction, and then developed a high fevercause of bleeding was almost always pocket de-with increased C‑reactive protein levels under anti-

bridement except for cardiac tamponade. The

biotic therapy.Cultures of the extracted temporaryamount of blood loss during procedures was gener-

lead were positive for methicillin‑resistant Sta-ally ＜200 mL.

phylococcus epidermidis.

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CIED extraction using excimer laser

among which the reported incidence of death andDiscussion

fatal injury can be up to 1% , and that of major

We showed that extraction of infected CIED fromcomplications, including superior vena cava lacera-a series of 13 patients using an excimer laser wastion or massive pulmonary embolism, is aboutclinicallyexpedient and completelysuccessful.Vari-1%

ous patient characteristics, indications for device

developed cardiac tamponade, which accounted for

implantation,and duration after initial implantation

a complication incidence of 7.8% among our small

did not appear to restrict application of the excimer

patient cohort.

laser. The success rates of lead removal and in‑.In fact,one of our patients (patient no.10)

The risks must always be weighed against the.The risk of life‑

hospital death due to CIED infection were 100%

success rate of lead extraction

and 0%, respectively, which were superior to thethreatening complications indicates that leadﬁndings of the LExIcon trial (96.5% and 0.3%,extractions should proceed only with the appropri-respectively).

ate equipment and personnel required to address all

Total lead extraction rates with and without thepotential situations, including thoracotomy, ster-excimer laser sheath in the original PLEXES trial

notomy and cardiopulmonary bypass. Potential

were 95% and 64%,respectively .Using the laser

complications are discussed in preoperative meet-signiﬁcantly reduced the mean amount of time

ings when we schedule lead extractions and we aim

required to successfully extract leads compared

to extract leads without incurring adverse events.

with non‑laser techniques.Life‑threatening compli-Conclusion

cations developed in three patients in whom leads
were extracted with the laser, including one whoInfected CIED and leads can be extracted from

died, and in none of those whose leads werepatients using an excimer laser with high successremoved without a laser.The rate of major adverse

rates and a signiﬁcantly reduced surgical duration.

events directly related to the procedure in theHowever, appropriate strategies are essential toLExIcon trial was 1.4% , including death (0.28%),

prevent device infection and rare but serious com-and the clinical success rate was 97.7%. Consider-plications.

ing these ﬁndings, excimer laser extraction canConﬂict of Interest

signiﬁcantlyreduce procedural duration and achieve
substantially high extraction rates. Clinicians

None to declare.

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