title: Active fixation mechanism complicates coronary sinus lead extraction and limits subsequent reimplantation targets.
abstract: BACKGROUND
  Implantation of cardiac resynchronization therapy (CRT) devices is technically challenging and can be limited by lead dislodgement. The Attain Starfix active fixation coronary sinus (CS) lead (model 4195, Medtronic, Minneapolis, MN, USA) was introduced to reduce the rate of lead dislodgement, but the active fixation mechanism presents additional difficulties should these leads require extraction.
  
  
  METHODS
  CS lead extraction procedures at our institution from 2003 to 2011 were reviewed. Procedural variables were compared between extraction of the Starfix lead and passive fixation CS leads. Attempts at reimplantation post Starfix lead extraction were examined.
  
  
  RESULTS
  Four Starfix CS leads were extracted in four patients during this time period. The mean implant duration was 784 days (range, 392-1,029 days). The indication for extraction was infection in all four cases. Mean total procedure time was 141.5 min (range, 92-205 min). None of the fixation lobes could be retracted in one lead and only the most proximal lobes could be retracted in the remaining three leads. All four leads were removed in their entirety. The excimer laser sheath (Spectranetics Laser Sheath II, Spectranetics Corp., Colorado Springs, CO,USA) was required to remove the lead in all 4 cases (100 %) compared to 25 of 131 (19.1 %) of passive fixation CS lead extractions (mean implant duration, 659 ± 697 days) performed at our institution over the same time period (P < 0.001). In three cases, the laser sheath had to be advanced past the CS ostium to remove the Starfix lead. After extraction, fibrous material which had grown between the lobes of the fixation mechanism was noted in all four cases. No complications occurred. Transvenous CS lead reimplantation was attempted at a median of 7.5 days post extraction in all four patients. The original target branch was occluded in three patients and the main CS in one patient. Reimplantation was successful in another branch of the CS in three of four patients; one underwent minimally invasive epicardial lead placement.
  
  
  CONCLUSIONS
  The Starfix active fixation CS lead presents additional procedural complexity and uniform use of excimer laser sheath compared to other CS leads. Reimplantation was not possible in the same venous branch in our experience.
authors.affiliation: Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Desk J2-2, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
authors.forename: E M
authors.initials: EM
authors.lastname: Cronin
authors.forename: C P
authors.initials: CP
authors.lastname: Ingelmo
authors.forename: J
authors.initials: J
authors.lastname: Rickard
authors.forename: O M
authors.initials: OM
authors.lastname: Wazni
authors.forename: D O
authors.initials: DO
authors.lastname: Martin
authors.forename: B L
authors.initials: BL
authors.lastname: Wilkoff
authors.forename: B
authors.initials: B
authors.lastname: Baranowski
mesh_terms: D000368:Aged; D058409:Cardiac Resynchronization Therapy Devices / Q000009:adverse effects*; D020878:Device Removal / Q000379:methods*; D004567:Electrodes, Implanted; D004867:Equipment Design; D004868:Equipment Failure; D006801:Humans; D053685:Laser Therapy; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D012086:Reoperation