Discussion
During the last two decades, the number of CIEDs implanted has increased
steadily as technological advances have allowed a wider range of
conditions to be treated with implantable devices. Moreover, the number
of dual chamber vs single chamber pacemakers, along with the use of
cardiac resynchronization devices has also increased (9-12). As such,
not only has the number of CIED implantations but also the number of
implanted leads has increased. This has led to a higher number of lead
related complications, mainly infection, and a greater number of TLE
procedures performed.
This is the first Latin American survey on TLE. Although smaller than
previous surveys (13-15), answers were received from 48 respondents from
44 different institutions (8 different countries). As such the survey
provides valuable information on the current practice of lead extraction
in our continent. Importantly, although TLE is performed in several
institutions in Latin America, most (66%) report a low procedural
volume (i.e., less than 10 procedures per year). This percentage is
higher than that reported in the US (in which less than 20% of
institutions performed <10 lead extraction procedures per
year) and the first European lead extraction survey (in which 40% of
institutions performed <10 procedures each year)(15)
demonstrating a low use of TLE in the continent. Several possible
reasons exist for this finding: high cost of lead extraction tools, a
perceived higher risk for complications (as evidenced by a reluctance to
perform TLE in patients older than 80 years old in 22% of respondents),
and a lack of proper training/knowledge (16). Unfortunately, the number
of implant procedures and the infection rate in Latin America is
currently unknown but taking into consideration European guidelines
which estimate the need of TLE as 1.5 times the infection rate (17), a
significantly higher number of lead extraction procedures is expected.
Lack of public financing in many Latin American countries has a
significant impact on CIED use and waiting times (18), and as such
should also impact the use of TLE techniques. Implementation of training
programs, along with a reduction in costs associated with TLE tools
could have positive impact on the number of lead extraction cases
performed. Taking into consideration that low procedural volume (defined
in the ELECTRa registry as less than 30 lead extraction procedures per
year) is associated with a significant increase in procedural mortality,
efforts should be made to increase training and to perform lead
extraction procedures only in high volume centers (19).
Although most institutions (73%) used mechanical rotating sheaths
(which is similar to what was found in the European survey)(13), 13.5%
of institutions reported the use of laser sheaths. This is particularly
surprising in latin america, taking into consideration the higher cost
of laser sheaths (20), with procedural success rates similar to those
reported with current mechanical rotating sheaths (21-23). In fact, in
the recently published PROMET study laser sheaths were almost entirely
abandoned in favor of mechanical rotating sheaths due to lower costs and
similar effectiveness (24). Regarding safety measures, cardiac surgeons
were included (either in room or within the institution) by 92% of
respondents, similar to what has been described in the ILEEM survey (25)
but higher than reported in the US survey (in which a surgeon was not
identified in 25% of lead extraction procedures)(14). Importantly,
other safety measures including TEE (39%) ICE (16.2%) and the BRIDGE
balloon (13.5%) were used in a significant number of institutions.
Regarding the proposed clinical scenarios, the number of respondents who
perform complete capsulectomy in CIED related infection is lower than
that reported in a recent worldwide survey (57% vs 76%)(26). This is
in line with the most recent guidelines, in which capsulectomy is not
recommended as routine practice (27). Elderly patients (i.e., those
older than 80 years of age) were considered to be at high risk of
procedure related complications and 24% of respondents routinely
avoided extraction in this patient population. Indeed, extraction
procedures in elderly patients have been found to be significantly
associated with a higher periprocedural mortality (2.5% in 18–44 years
compared to 5.3% in 85+ years, P < 0.001) in the US (28).
Finally, regarding malfunctioning leads, 71% of respondents would base
their decision (i.e., lead abandonment or extraction) on individual
patient characteristics. This is similar to what has been described in
previous European surveys, in which malfunctioning lead management was
strongly determined by patient’s age, the presence of damaged leads and
lead dwelling time (29).
Recently, the results of the largest prospective lead extraction
registry in Latin America were published, demonstrating the safety and
effectiveness of lead extraction in a large volume center (30). Future
efforts should thus be focused on increasing the number of centers
performing high volume lead extraction, as this study demonstrates
results comparable to those published in literature can be achieved.