Lead Replacement... Use the same vein? Come in from the other side?

It's more complex than that

by crustyg - 2021-09-17 03:26:36

Your assessment of options 1 and 2 as being more complex than option 3: why would using the R-subclavian vein be less risky than option 2?  You still have old leads embedded in your heart muscle, if the RV lead is being replaced (you say leads, plural) then you will have two leads through the tricuspid valve.

Lead removal - in a centre that does 100pa or more, with specialist kit, is pretty low risk these days, but it's definitely not 'I'll have a go' territory.  Take the old leads out, new leads in =>probably OK for an MRI (if/when you need one), no spare wire going through tricuspid, no capped lead(s) under the skin.

Leaving lead(s) in situ, OK, but can cause issues later, gets crowded in there, probably not MRI safe.

Coming in from R: pacing leads are curved at the tip, to make it easier to get them where required (esp RA, into RA-appendage), and the stylets used to stiffen them during placement are designed for an approach from the L.  Most EP-docs are much more familiar with the anatomy/muscle memory of an approach from the L, so it's considerably more difficult to introduce new pacing wires from the R.  Can be done, and sometimes is.  Oh, and if it's only the leads to be replaced, how to connect them without moving your PM?

options

by Tracey_E - 2021-09-17 10:33:58

Those are the three options I was presented with. The first surgeon was very blase about it, said if it didn't fit on the left, he'd run it from the right. That did not sound as easy to me as he made it out, the box and other lead would still be on the left. I also wasn't willing to go into surgery without a plan, his casual attitude about where it ended up didn't sit well with me.

Second ep discussed extracting vs adding new. Going from the right was not on the table because I'm young enough he wanted to save the right side for if I ever ran out of options on the left side. I was not in favor of extraction because I was young enough at the time (45) that I was thinking that if I could make this set of leads last long enough, my next set could be my last. He was leaning toward extraction for the reasons crusty mentioned but agreed with my logic.

We did a venogram (iv with dye in the cath lab) to confirm I had room in the vein to add a third lead so there wouldn't be any surprises during surgery. There was room, tho he went in from a different vein, cephalic rather than subclavian. The old one was capped off and is still there.

I'm 55 now with one working lead from 1994 and the newer one from 2010. I've been told that the older lead is still doing ok but will likely not last as long as my current battery (9-10 years). If the next set lasts as long as this one has, that will get me well into my 80's with extracting once, which was my goal.

OTOH, I currently have shoulder and disk problems that could both really use an mri. I'm working around both with PT. If I'd had the extraction, I would have been able to have the mri and a better picture of what we're dealing with. But I don't regret my decision.  YMMV

Minor factor in my choice to put off extraction- due to the structure of my heart and scar tissue and age of original leads, I have been told that I will be high risk. I'm hoping that the longer I put it off, the better the lasers will be, the more experienced the surgeons available. The risk has come way down in the last 10-15 years, I'm hoping it gets even more ordinary and low risk before I need it. 

Edited to ask if you need both or just one replaced? If they extract they will replace everything, whether it needs it or not. If both need replaced, then extraction is clearly the best way to go. Adding a lead only works if you only need one new one. Most veins cannot hold 4. 

Lead extraction

by Finn - 2021-10-05 23:59:47

Hi, I had leads extracted and removed , they were fractured after 9 years. Replaced with MRI compatible leads. At Jude PM, tender leads.

the Dr and I decided to do this instead of capping and putting in new leads with the original.

it depends how long your leads have been in. 
Make sure your Dr does many lead extractions.

Any questions feel free to ask.