Ghosh Nina, Yee Raymond, Klein George J, Quantz Mackenzie, Novick Richard J, Skanes Allan C, Krahn Andrew D
Division of Cardiology and Cardiac Surgery, University of Western Ontario, London, Ontario, Canada.
Pacing Clin Electrophysiol. 2005 Mar;28(3):180-4. doi: 10.1111/j.1540-8159.2005.09368.x.
Laser extraction of device leads offers an attractive alternative to countertraction and electrosurgical dissection sheath, potentially increasing efficacy and reducing complications. Wider adoption of this technology depends on relative ease of use. We report the experience of a new center to define the "learning curve." We performed 76 laser lead extractions in 75 patients (age 63 +/- 17 years, 59 male) from July 2001 to January 2004. Two experienced device implanters who were novice extractors underwent a 2-day site visit to a high volume extraction center for training. Lead extractions were performed in the operating room with immediate surgical backup. The indication for extraction was infection in 39 (systemic in 15), erosion or pain in 11, and lead related or debulking in 25. Complete removal was achieved in 139 of 145 leads (14 ICD, 131 pacemaker). Partial removal (<4 cm retained) was achieved in five leads (4%), and one lead could not be extracted. Complete success was 95% in the first third of patients, 94% in the second third, and 100% in the latter third. Fluoroscopy time fell from 19 +/- 22 minute in the first third of patients to 11 +/- 8 minute in the second third to 8 +/- 4 minute in the latter third (ANOVA P = 0.02). No major complications occurred. Local bleeding required minor left subclavian vein repair in two individuals. Symptomatic venous thrombosis occurred in 3 of the first 11 cases 1-21 days after extraction, but did not occur in the next 64 consecutive patients who received a 1-month anticoagulation regimen (27% vs 0%, P < 0.001). One patient developed venous thrombosis 3 weeks following cessation of warfarin therapy. Practice guidelines reasonably recommend appropriate training prior to independent performance of lead extraction. The current study suggests that experienced device implanters with appropriate operative backup taking a limited, but intensive training program can be safe and effective at lead extraction in a short time, in part a reflection of the improved technology.
激光拔除装置导线为对抗牵引和电外科解剖鞘提供了一种有吸引力的替代方法，可能会提高疗效并减少并发症。该技术的更广泛应用取决于其相对易用性。我们报告了一个新中心确定“学习曲线”的经验。2001年7月至2004年1月，我们对75例患者（年龄63±17岁，男性59例）进行了76次激光导线拔除术。两名经验丰富的装置植入者作为新手拔除者，到一个高容量拔除中心进行了为期2天的实地培训。导线拔除在手术室进行，有即时手术后备支持。拔除的指征为感染39例（全身性感染15例）、侵蚀或疼痛11例、导线相关或减容25例。145根导线中的139根（14根植入式心律转复除颤器，131根起搏器）实现了完全拔除。5根导线（4%）实现了部分拔除（保留<4 cm），1根导线无法拔除。在前三分之一的患者中完全成功率为95%，中间三分之一为94%，后三分之一为100%。透视时间从前三分之一患者的19±22分钟降至中间三分之一患者的11±8分钟，再降至后三分之一患者的8±4分钟（方差分析P=0.02）。未发生重大并发症。两名患者出现局部出血，需要对左锁骨下静脉进行小的修复。在拔除后1至21天，前11例患者中有3例出现有症状的静脉血栓形成，但在接下来连续接受1个月抗凝方案的64例患者中未发生（27%对0%，P<0.001）。1例患者在华法林治疗停止3周后发生静脉血栓形成。实践指南合理建议在独立进行导线拔除之前进行适当培训。当前研究表明，经验丰富的装置植入者在有适当手术后备支持的情况下，接受有限但强化的培训计划，在短时间内进行导线拔除可以是安全有效的，这部分反映了技术的改进。
