title: Laser-assisted extraction of pacemaker and defibrillator leads: the role of the cardiac surgeon.
abstract: BACKGROUND
  The development of laser-assisted extraction techniques for chronically implanted pacemaker and defibrillator leads has reduced the need for open surgical removal. Reports of the mortality from laser-assisted extraction range from 1.9% to 3.4%. The purpose of this study was to determine the rate of major cardiovascular injury and emphasize the need for cardiothoracic surgical participation in this procedure.
  
  
  METHODS
  A retrospective cohort study was performed of 112 consecutive laser-assisted lead extractions at a single university medical center during a 6-year period. Patient and lead characteristics were analyzed as well as indications, outcomes, and major complications.
  
  
  RESULTS
  Successful lead extraction was accomplished in 103 (92%) of the 112 patients. Elective sternotomy after failure of laser-assisted lead removal was successfully performed in 4 patients. Emergent surgical intervention was required in 4 patients for caval perforation (n = 2), subclavian vein injury (n = 1), or right atrial injury (n = 1). Three of the 4 patients requiring emergent intervention died, for an overall series mortality of 2.6%. In July of 2006, a policy of cardiothoracic surgeon presence during the laser-assisted extraction was instituted. Since that time, there has been one emergent sternotomy and one elective sternotomy for lead removal with no procedure-related deaths.
  
  
  CONCLUSIONS
  Despite recent advances in laser technology for the removal of pacemaker and defibrillator leads, the potential for major cardiovascular injury and death remains. Involvement of the cardiothoracic surgeon in both the preoperative decision-making process as well as the laser-assisted lead extraction is critical to prevent or emergently treat any major complications.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA. jeffrey.gaca@duke.edu
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Gaca
authors.forename: Brian
authors.initials: B
authors.lastname: Lima
authors.forename: Carmelo A
authors.initials: CA
authors.lastname: Milano
authors.forename: Shu S
authors.initials: SS
authors.lastname: Lin
authors.forename: R Duane
authors.initials: RD
authors.lastname: Davis
authors.forename: James E
authors.initials: JE
authors.lastname: Lowe
authors.forename: Peter K
authors.initials: PK
authors.lastname: Smith
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000592:standards*; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D020878:Device Removal / Q000295:instrumentation / Q000379:methods*; D004567:Electrodes, Implanted / Q000009:adverse effects*; D004868:Equipment Failure; D005260:Female; D006323:Heart Arrest / Q000209:etiology; D006801:Humans; D007834:Lasers; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012804:Sick Sinus Syndrome / Q000209:etiology; D017180:Tachycardia, Ventricular / Q000209:etiology; D013903:Thoracic Surgery / Q000706:statistics & numerical data*