title: Implications and outcome of permanent coronary sinus lead extraction and reimplantation.
abstract: OBJECTIVE
  We examined the implications and outcome of coronary sinus (CS) lead removal including the feasibility of laser use within the CS.
  
  
  BACKGROUND
  Cardiac anatomy and lead interactions are more complex with the advent of biventricular pacemakers and atrial cardioverters requiring permanent lead/shocking coil placement in the coronary sinus and its branches.
  
  
  METHODS
  Fifty-five permanent cardiac leads were extracted during 2003 in 28 consecutive patients. Our study population included a 10/55 (18%) subset (all males; age 73 +/- 6 years; EF = 0.24 +/- 0.09) that underwent CS (1/10) or vein branch (9/10) lead extraction. Leads were extracted with an excimer laser sheath (n = 4) or by direct traction (n = 6). Median times between implantation and lead removal were 9.5 months (range 5-59) in the laser group and 3 months (range 3-4) in the direct traction group. Indication for extraction was infection (n = 4), dislodgement (n = 3), diaphragm stimulation (n = 2), and elevated threshold (n = 1). The CS was divided into distal, mid, and proximal segments by venogram.
  
  
  RESULTS
  Entry of the laser sheath into the CS was necessary in three of four laser patients. The two distal CS laser cases (left lateral CS coil and anterior-lateral left ventricular (LV) lead) required both 14- and 12-Fr sheaths, separately. The proximal CS laser case (posterior-lateral LV lead) required a 12 Fr sheath. The remaining laser patient required a 12-Fr sheath to pass to the mid SVC. There were no procedural complications as a result of CS lead extraction. Reimplantation of a CS lead was attempted in 7/10 patients at a median of 4 days (range 1-300). CS venograms were available for review in patients before initial implantation (6/10) and after extraction (7/10). The postextraction venograms demonstrated complete occlusion of the vein from which the lead was extracted, and its distal branches, which were unusable in 5/10 (50%). The vein occlusions were present in patients with indwelling leads for greater than 3 months and were independent of extraction method.
  
  
  CONCLUSIONS
  Laser lead extraction in the coronary sinus appears feasible in carefully selected cases with mandatory indications. However, special intraoperative monitoring and echocardiographic imaging with surgical backup ready is strongly recommended. Target vein selection may be limited for the purpose of reimplantation when leads are indwelling for greater than 3 months.
authors.affiliation: Section of Cardiology, University of Chicago, Illinois 60637, USA. mburke@medicine.bsd.uchicago.edu
authors.forename: Martin C
authors.initials: MC
authors.lastname: Burke
authors.forename: Joseph
authors.initials: J
authors.lastname: Morton
authors.forename: Albert C
authors.initials: AC
authors.lastname: Lin
authors.forename: Sean
authors.initials: S
authors.lastname: Tierney
authors.forename: Aseem
authors.initials: A
authors.lastname: Desai
authors.forename: Thomas
authors.initials: T
authors.lastname: Hong
authors.forename: Susan
authors.initials: S
authors.lastname: Kim
authors.forename: Yasser
authors.initials: Y
authors.lastname: Salem
authors.forename: Michael
authors.initials: M
authors.lastname: Alberts
authors.forename: Bradley P
authors.initials: BP
authors.lastname: Knight
mesh_terms: D000368:Aged; D020878:Device Removal / Q000379:methods*; D004567:Electrodes, Implanted / Q000009:adverse effects; D006801:Humans; D053685:Laser Therapy; D008297:Male; D010138:Pacemaker, Artificial / Q000009:adverse effects