The Challenges of Removing Conduction System Pacing Leads

Lead wires implanted for conduction system pacing have been deemed feasible to remove despite their challenging characteristics. In a multicenter study, it was reported that the leads were successfully removed with manual traction alone in 91% of the 341 patients. The removal success rate was 90% for leads attached to the His bundle and 92% for those placed in the left bundle branch area.

The study found that another 8% of cases needed mechanical extraction, 2% required laser instruments, and 1% were done with femoral tools. Removal was considered a complete success in 99% of cases, defined by the full removal of targeted leads and all lead material from the vascular space without any permanently disabling complication or death. Vijayaraman highlighted the low complication rate in this cohort.

Lead Dwell Time and Concerns

Despite the success in lead removal, concerns were raised regarding the mean lead dwell time, which was reported to be 22 months on average. Additionally, there are worries about the lead architecture and the potential for leads breaking at their septal insertion point or damaging the tricuspid valve.

Unknown Challenges

Dr. Matthew Zipse also pointed out that the lumenless lead architecture may present unknown challenges, especially in cases where the inner conductor cable is compromised. There is a need to be mindful of the potential complications when extracting older lumenless leads.

Study Findings

The retrospective TECSPAM study included 341 patients undergoing extraction of conduction system pacing leads at 10 international centers. Among them, 224 had His bundle pacing leads and 117 had left bundle branch area pacing leads. All leads were removed for class I or II indications under the 2017 HRS consensus document criteria.

It is worth noting that the operators involved in the study were experts in lead extraction. However, the study highlights the importance of creating a registry for all conduction system pacing leads to assess failure rates, functionality, and extractability. With the industry providing newer defibrillator leads with similar functionalities, there is a need for continuous evaluation and monitoring of lead removal procedures.