High mid-term mortality following successful lead extraction for infection.

BACKGROUND: Transvenous lead extraction patients tend to have multiple medical problems complicated by prolonged infections that may result in high-mortality rates following a successful procedure. METHODS: All adult patients referred for lead extraction for infection over a 4-year period were included in this study. Mortality following the procedure was assessed using hospital records and the Social Security Death Index. RESULTS: Indications for extraction were systemic infection (n = 34) and isolated pocket infection (n = 33). Of the 67 patients, 47 (70%) were still alive at follow-up (6-55 months). No patient died during or within 24 hours of the procedure, and two were sent to emergent surgery and did well. However, five died during prolonged hospitalizations, and two were discharged to hospice care and died shortly thereafter. The remaining 13 deaths occurred after discharge from the hospital at a mean interval of 15 months (range, 24 days to 35 months) following the procedure. Notably, six of seven patients who died in the hospital, and nine of 13 who died after discharge, had bacteremia as their indication for extraction, for an overall mortality risk of 44% in patients with systemic infection. CONCLUSIONS: True risk assessment for lead extraction patients is underestimated and may be related to the focus on the procedural risks, while the underlying illness and physiologic state may account for the excess mortality following a successful extraction. In most cases, the infected hardware contributed to the length and severity of the illness, and thus earlier consideration for extraction may be warranted.

A survey of the practice of lead extraction in the United States.

BACKGROUND: Endovascular lead extraction is an important component of the management of patients with chronically implanted arrhythmia control devices. Although it is associated with the potential for significant morbidity and mortality, there is little information about its scope and practice. METHODS: We surveyed 1,000 physician members of the Heart Rhythm Society via e-mail solicitation. RESULTS: Of the 252 respondents (25%), 221 (88%) reported either performing extractions themselves (63%), or having privileges at a hospital where extractions are performed (25%). Electrophysiologists perform extractions at most sites (83%) but cardiac surgeons perform endovascular lead extraction at a significant minority of sites (20%). Most respondents report low annual volumes of extractions at their site: 15% reported <10 procedures/year, 42% 10-25 procedures/year, 23% 26-50 procedure/year, and only 19% reported >50 procedures/year. Thirty-six percent of respondents reported that extractions were done in the operating room (OR) with surgeon present or immediately available, 39% in the electrophysiology (EP) lab with surgeon and OR identified and available, and 25% in EP lab without a surgeon or OR identified. The overall risks of lead extraction were felt to be 1-5% of major complication and 0.5-1% of mortality, roughly in line with published data. CONCLUSIONS: While there is agreement as to the risk of major complication and death from lead extraction, the degree of surgical availability varies considerably. The new guidelines document recommends the ability to promptly initiate an emergent surgical procedure, and this should be an important goal for all extractionists.

Diagnosis and Management of a Challenging Patient: Ureteroarterial Fistula.

While uncommon, ureteral arterial fistula (UAF) should be a differential diagnosis for persistent hematuria, as management involves coordinated treatment with a multidisciplinary team. Despite various diagnostic modalities available, accuracy in diagnosis remains a challenge. We present a patient with known UAF risk factors, including chronic ureteral stent, history of radiation, and vascular procedures. Despite multiple negative imaging studies, UAF was ultimately diagnosed and successfully managed by an endovascular approach, with resolution of her hematuria.