1. How to Handle Lead Problems in Pediatric & Congenital Heart Disease
Alpay Celiker MD.
Acıbadem University
Department of Pediatric Cardiology
Istanbul

2. 16 year old boy with congenital AV block. VDD pacemaker . No complaints
ECHO: Tricuspid valve problem. Some signs of left ventricular dysfunction
What to do???

3. Ways of Pacing
Transvenous
Epicardial
Hybrid

4. Epicardial & Transvenous Pacing
Epicardial pacing
Better for preserving venous system
Better results for long-term pacing regarding pacing induced heart failure
Applicable for all conditions
More frequent lead problems
Transvenous pacing system
Less lead problems
More problems on venous system

5. Complications of Pacing System
Infection;
Superficial, deep pocket
Lead
Endocarditis
Lead malfunction
Fracture
Insulation & other problems
Venous occlusion
Damage to cardiovascular system

6. Pacing System Infection
Localized or superficial infection
Localized pain, swelling
Purulent discharge
Deep infection
Fever
Pulmonary thromboembolism
Recurrent pulmonary infection
Sepsis

7. Pediatric Pacemaker Infections*
Perioperative Infections (before discharge):
Superficial 1,2 %
Deep 0,2 %
Early Pacemaker Infections (< 60 days)‏
Superficial 3,1 %
Deep 1,2 %
Late Pacemaker Infections
Superficial 0,5 %
Deep 0,7 %
Staphylococcus species were isolated in 44 %
Increased Risks
Reintervention
Down syndrome
Subcutaneous  preperitoneal pocket
* Cohen et al J Thorac Cardiovasc
Surg 2002; 124.

8. Treatment Localized Infection Intravenous and oral antibiotics
Local debridman
Infrequently pacing system removal
Deep Infection
Pacing system removal
Antibiotics
>2 weeks intravenously
 6 weeks total

9. Treatment Choices Intervention Surgery Small vegetations
Strand formation
Lead amenable to extraction
Surgery
Large vegetations (> 10mm)‏
Abcess formation
Broken lead
Abandoned old leads
Concomitant surgery need

11. Lead Malfunction Compromised pacing Compromised sensing
Failure to capture, high threshold
Extra-cardiac stimulation
Compromised sensing
Under-oversensing
Lead-lead interaction
Electrical Abnormality
Abnormal pacing impedance
Abnormal high voltage impedance
Low-amplitude electrogram

12. Signs of Lead Fracture No stimuli or stimuli without capture
Oversensing of false signals
Permanent or intermittant high lead impedance

13. Patient- and lead-related factors affecting lead fracture in children Olgun, Karagoz, Celiker and Ceviz
Europace (2008) 10, 844–847

14. Structural Problems Conductor failure Insulation failure
Connector failure
Fixation failure

16. Methods to Determine Device interrogation Imaging
ECG, marker channel, impedance, event recording
Imaging
X-ray, fluroscopy
Physical inspection or test at the time of implant

17. Treatment of Malfunctioning Lead
Lead surgically abandoned or capped
Lead electrically abandoned (mode change)‏
Lead explanted/repaired
Device reprogrammed (polarity)‏
Lead related intervention: reposition, partially abandone

18. Factors to Consider When Managing Leads
Patient
Pacemaker dependence
Patient prognosis
Risk of revision/replacement procedure
Lead
Malfunction characteristics
Adverse clinical consequencce
Availability of reporogramming

19. Lead Extraction in Children. Why?
Remove the intravascular and intracardiac lead material
Relieve and reconstruct the venous access for the new leads
Prevent lead related infection

20. Indications Class I: a: sepsis b: life-threatening arrhythmia
c: life threatening condition
d: thromboembolic event caused by retained lead
Obliteration of all useable veins
Lead interfereres with the operation of another device

21. Procedure Basic lab tests and crossmatch for blood should be obtained
All x-rays related with pacemaker and leads must be evaluated
Arterial and venous catheters for BP monitor and fluid supply
Anesthesia

22. Lead Extraction Methods
Simple traction
Snares
Needles eye, Goose neck
Lead locking devices
Cook, Spectranetrics
Laser sheaths
Radiofrequency sheaths
Rotating sheaths

23. The main barrier to lead extraction is fibrosis, which can occur wherever the lead chronically touches tissue. The three most common sites for fibrosis are:
· Venous insertion site
· SVC vein (curvature area)
· Endocardium fixation site
Both passive and active fixation leads are prone to all three areas of fibrosis; however, the screw-in mechanisms of active fixation leads usually can be easily unscrewed from any endocardial fibrosis.

24. Pulleys & Weights
Traction can be accomplished with either gentle manual traction or with a simple pulley mechanism and weights. With manual traction, a hemostat is clipped to the exposed lead end and gently pulled. Fluoroscopy should be used to observe lead movement. With the pulley system, the hemostat is tied to a line that hangs over a pulley and the line is attached to a weight (e.g., small solid weights or a bag with water). The weight starts at about 350 grams. Additional weight is added as needed. This weighted traction procedure may take several hours. PVCs are noted on the EKG as the lead tip begins to disengage from the endocardium.

25. Locking Stylets
This slide illustrates the essential components of a pacing lead.
The following topics will be discussed for each component:
· Purpose
· Design factors
· Performance factors

26. Spectranetics Lead Locking Device
Expanded
Compressed

27. Counter traction requires one or two sheaths and a locking stylet
Counter traction requires one or two sheaths and a locking stylet. Sheaths are made of stainless steel, Teflon, or polypropylene.
Telescopic Sheaths

28. The femoral approach is seldom used as the initial attempt to remove the implanted lead. Usually it is used only after the subclavian approach has failed.

29. Laser Sheaths
Rotating Sheaths

34. Classification of Complications
Major Complication
Death
Cardiac or vascular avulsion or tear
Pulmonary embolism
Stroke
Minor Complication
Pericardial effusion or hemothorax
Vascular repair need
Pneumothorax requiring a chest tube
Pulmonary embolism not requiring surgical intervention

35. Definition of Success
Complete Success - Removal of all lead material from the vascular space.
Partial Success - Removal of all but a small portion of the lead.
Failure – Abandoning a significant length of lead (more than 4cm)
Love CJ et al. PACE 2000; 23

37. Lead Problem n Lead fracture 14 Upgrade 8 Infection 7 Dislodgement 5
Other reasons 5

38. Surgery for Lead Problems
Infection
Lead can not be explanted by interventional methods
Lead should not be explanted by interventional methods
Concomitant surgery need

40. New Problems !!! Coronary sinus leads ICD leads Lumenless electrodes
Multipl leads
Venous obstruction
Tricuspid valve impingement

42. Conclusions Lead problems is frequent than in adult population
Although interventional methods have been successfull, surgery may be needed infrequently.
Newer techniques may offer more success and less complications.
Technologic improvement at epicardial and transvenous pacing may lower the incidence of lead problems.

43. Teşekkür Ederim