Implanting and Extracting Cardiac Devices: Technique and Avoiding Complications

The surgical technique, facility requirements, and operator requirements for the implantation of pacemaker, defibrillator, and cardiac resynchronization devices are discussed in this chapter. Implanters should be familiar with the techniques and tools available for successful cannulation of the coronary sinus including sheaths, angiographic wires, and deflectable electrophysiology catheters. The assessment of device function after implantation includes assessment of sensing and pacing threshold. The implanter should also be familiar with the indications and techniques for infrequently used implantation sites including epicardial, jugular, and iliac vein. With the increasing utilization of cardiac implantable electronic devices, the ability to safely extract leads has become important. The strongest indication for lead extraction is infection of the device. Most lead extractions are currently performed via the transvenous approach. The majority of extractions are performed through the vein of implantation. Other approaches such as the femoral approach are reserved for leads that cannot be removed through the superior veins such as cut leads with free end in the vascular space. Techniques used for lead extraction include simple traction, countertraction sheaths, locking stylets, and powered mechanical sheaths such as the laser and electrosurgical dissection sheath. With the use of powered sheaths, complete lead extraction can be achieved in >90% of cases with a major complication rate of <2% and mortality of <1%. Transvenous lead extraction should be performed only by experienced operators with the resources to address life-threatening complications including the immediate availability of a cardiac surgeon.