Nägele H, Ismail M, Rödiger W
Herzchirurgie Universitätsklinikum Hamburg-Eppendorf Martinistr. 52 20246 Hamburg, Germany.
Z Kardiol. 2001 Aug;90(8):550-6. doi: 10.1007/s003920170123.
Pacemaker infection or some lead dysfunctions are an indication for removal of all foreign material. The use of laser energy is a new method for extraction of fixed leads that have been in place for a long time. There are only a few reports on results and complications of laser extraction in comparison to conventional methods. Therefore, this study compares results of laser lead extraction and conventional methods.
Since January 1999 we have made use of the laser lead extraction system of Spectranetics, Inc. Inner traction of the leads was performed using a "lead locking device" (LLD) and for laser application 12, 14 und 16 French "laser sheaths" were used. As the energy source, an excimer laser device was used (CVX-300). The intervention was performed under heart-lung machine backup. Results of the laser procedure in 24 patients and 45 leads (including 3 defibrillator leads) are compared to results of manual traction (23 patients, 53 leads), traction devices (24 patients, 38 leads), snare catheters (6 patients, 6 leads) and thoracotomy (5 patients, 9 leads) from the years 1995-1998.
The mean operation time of the laser method (93 +/- 50 min) was not significantly different from manual traction (82 +/- 48 min,) or traction devices (100 +/- 45 min). The mean fluoroscopy time (9.4 +/- 50 min) was similar to traction devices (8.4 +/- 5 min, p < 0.05). In one patient a percardial tamponade developed with the need for urgent thoracotomy. This patient died on the fourth postoperative day due to cerebral hypoxia. The other 23 patients had an uneventful course. All but one lead could be removed without fragmentation, including a malpositioned lead in the left ventricle (success rate 96%). In 62 patients and 97 conventional extractions (53x manual, 38x device, 6x snare) from 1995-1998, one fatal (sepsis due to lead fragmentation) and four severe complications developed (pericardial tamponade, pulmonary abscess, pulmonary embolism, sepsis). In 15/62 patients with conventional methods, lead fragments remained (success rate 76%). Of five patients from 1995-1998, in whom leads with vegetations or tricuspid valve insufficiency were removed by thoracotomy and cardiopulmonary bypass, one patient died perioperatively.
In contrast to conventional methods, excimer laser pacemaker or defibrillator lead extraction allows total removal of all foreign material. This prevents late complications from lead fragments left in place. However, life-threatening complications can occur with conventional as well as with the laser method. Therefore, this intervention should be done only in specialized centers using extended monitoring (invasive blood pressure, TEE).
起搏器感染或某些导线功能障碍是移除所有异物的指征。激光能量的使用是一种用于取出长期植入的固定导线的新方法。与传统方法相比，关于激光取出术的结果和并发症的报道较少。因此，本研究比较了激光导线取出术和传统方法的结果。
自1999年1月以来，我们使用了Spectranetics公司的激光导线取出系统。使用“导线锁定装置”（LLD）进行导线的内牵引，并使用12、14和16法国规格的“激光鞘管”进行激光操作。作为能量源，使用了准分子激光装置（CVX - 300）。干预在体外循环备用下进行。将24例患者和45根导线（包括3根除颤器导线）的激光手术结果与1995 - 1998年手动牵引（23例患者，53根导线）、牵引装置（24例患者，38根导线）、圈套导管（6例患者，6根导线）和开胸手术（5例患者，9根导线）的结果进行比较。
激光方法的平均手术时间（93±50分钟）与手动牵引（82±48分钟）或牵引装置（100±45分钟）无显著差异。平均透视时间（9.4±5.0分钟）与牵引装置（8.4±5分钟，p < 0.05）相似。1例患者发生心包填塞，需要紧急开胸手术。该患者术后第4天因脑缺氧死亡。其他23例患者病程平稳。除1根导线外，所有导线均可完整取出，包括1根位于左心室的位置异常的导线（成功率96%）。在1995 - 1998年的62例患者和97次传统取出术（53次手动、38次使用装置、6次使用圈套导管）中，发生1例致命并发症（因导线碎片导致的败血症）和4例严重并发症（心包填塞、肺脓肿、肺栓塞、败血症）。在15/62例采用传统方法的患者中，残留导线碎片（成功率76%）。在1995 - 1998年的5例患者中，通过开胸手术和体外循环取出有赘生物或三尖瓣关闭不全的导线，1例患者围手术期死亡。
与传统方法相比，准分子激光起搏器或除颤器导线取出术可完全移除所有异物。这可防止残留导线碎片导致的晚期并发症。然而，传统方法和激光方法都可能发生危及生命的并发症。因此，这种干预应仅在使用扩展监测（有创血压、经食管超声心动图）的专业中心进行。
