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Ann Thorac Surg 2009;87:1446-1451. doi:10.1016/j.athoracsur.2009.02.015
© 2009 The Society of Thoracic Surgeons
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Right arrow Electrophysiology - arrhythmias

Original Articles: Adult Cardiac

Laser-Assisted Extraction of Pacemaker and Defibrillator Leads: The Role of the Cardiac Surgeon

Jeffrey G. Gaca, MD*, Brian Lima, MD, Carmelo A. Milano, MD, Shu S. Lin, MD, PhD, R. Duane Davis, MD, James E. Lowe, MD, Peter K. Smith, MD

Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina

Accepted for publication February 9, 2009.

* Address correspondence to Dr Gaca, Duke University Medical Center, DUMC Box 2816, Durham, NC 27710 (Email: jeffrey.gaca{at}duke.edu).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
Background: The development of laser-assisted extraction techniques for chronically implanted pacemaker and defibrillator leads has reduced the need for open surgical removal. Reports of the mortality from laser-assisted extraction range from 1.9% to 3.4%. The purpose of this study was to determine the rate of major cardiovascular injury and emphasize the need for cardiothoracic surgical participation in this procedure.

Methods: A retrospective cohort study was performed of 112 consecutive laser-assisted lead extractions at a single university medical center during a 6-year period. Patient and lead characteristics were analyzed as well as indications, outcomes, and major complications.

Results: Successful lead extraction was accomplished in 103 (92%) of the 112 patients. Elective sternotomy after failure of laser-assisted lead removal was successfully performed in 4 patients. Emergent surgical intervention was required in 4 patients for caval perforation (n = 2), subclavian vein injury (n = 1), or right atrial injury (n = 1). Three of the 4 patients requiring emergent intervention died, for an overall series mortality of 2.6%. In July of 2006, a policy of cardiothoracic surgeon presence during the laser-assisted extraction was instituted. Since that time, there has been one emergent sternotomy and one elective sternotomy for lead removal with no procedure-related deaths.

Conclusions: Despite recent advances in laser technology for the removal of pacemaker and defibrillator leads, the potential for major cardiovascular injury and death remains. Involvement of the cardiothoracic surgeon in both the preoperative decision-making process as well as the laser-assisted lead extraction is critical to prevent or emergently treat any major complications.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
Until recently, the extraction of chronically implanted transvenous pacemaker and defibrillator leads has traditionally been a difficult procedure often requiring open surgical removal [1, 2]. The development of excimer laser technology has facilitated removal of chronically implanted pacemaker and defibrillator leads through a transvenous approach [3]. Despite advances in technology, there remains a small but significant risk of major complications from this procedure [4]. The removal of chronically implanted leads is impeded by dense fibrotic attachments that entrap the leads within the veins and cardiac chambers. The development of locking stylets and telescoping sheaths has allowed for removal of leads by means of manual traction, but significant risks remain [5]. With the addition of the excimer laser, the laser energy can be delivered fiberoptically to the distal end of the sheath to incrementally destroy the fibrous tissue surrounding the lead. In theory, this can be accomplished without significant force or tearing of major cardiac or vascular structures [4]. At some institutions, the development of laser technology has diminished the role of cardiothoracic surgeons in the planning and execution of these procedures. Reports of major complications from laser extraction of chronically implanted leads range from 1.9% to 3.4% [3, 4, 6, 7]. Major complications include major venous injury, myocardial tear, arrhythmia, arteriovenous fistula, pneumothorax, hemothorax, tricuspid valve injury, and pulmonary embolus [8, 9]. Although the rate of complications from these procedures remains low, the complications that do occur can be life threatening, requiring emergent surgery. The purpose of this study is to investigate the efficacy and safety of laser-assisted lead extraction and to delineate the role of the cardiothoracic surgeon in these procedures.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
A retrospective review of a 6-year period beginning in December 2002 and ending in October 2008 revealed that 112 consecutive patients underwent laser-assisted extraction of pacemaker and defibrillator leads at a single university medical center. Data regarding patient demographics, comorbidities, procedural characteristics, and procedural outcomes were obtained by chart review. This protocol was approved by the local institutional review board, which granted a waiver of patient consent for this retrospective study.

All laser extractions were performed in the operating room under general anesthesia using the Spectranectics laser sheath removal system (Colorado Springs, CO). For the period of December 2002 to July 2006, the procedure was performed in the operating room by a cardiologist without the presence of a cardiothoracic surgeon. In July 2006, after several major complications, a policy of cardiothoracic surgeon presence in the operating room during laser lead extraction was instituted. The intraoperative protocol at our institution is as follows: all patients undergoing laser lead extraction are prepared for emergent sternotomy. All patients are typed and screened, a radial arterial line is placed, and in the cases of patients with prior sternotomy, femoral arterial and venous lines are placed. A cardiopulmonary bypass circuit with a staff perfusionist is also available in the room. Continuous transesophageal echocardiography is performed to monitor for pericardial effusion. All procedures are performed under fluoroscopic guidance.

Procedural success and complications were determined according to the North American Society of Pacing and Electrophysiology policy statement on extraction of chronically implanted transvenous pacing and defibrillator leads [10]. In summary, complete success is defined as the removal of all lead material from the vascular space. Partial success is determined as the removal of all but a small portion (<4 cm) of an electrode or coil. Finally, failure of removal is defined as abandoning a significant length of lead (>4 cm) [10]. Procedural complications were classified as major if it resulted in death or serious harm to a structure or required surgical intervention to prevent death.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
The baseline patient demographics are outlined in Table 1; at Duke University Hospital laser lead extraction was performed in 112 patients who required the removal of 205 leads. The average age of the patients was 59.8 ± 18.8 years with 81 (72%) men and 31 (28%) women. Patient comorbidities included coronary artery disease in 50 patients (45%), prior median sternotomy in 35 patients (31%), hypertension in 56 patients (50%), and left ventricular ejection fraction less than 0.40 in 44 patients (39%). The indications for pacemaker or defibrillator implantation were as follows: atrioventricular node or multifascicular block in 25 patients (22%), prior atrioventricular nodal ablation in 2 patients (2%), sinus node dysfunction in 27 patients (24%), and either ventricular tachycardia, ventricular fibrillation, or prior cardiac arrest in 58 patients (52%).


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  		Table 1 Patient Demographics
 
Lead characteristics are listed in Table 2. The mean time from implantation to extraction was 5.8 ± 5.0 years. On average, 1.8 leads per patient were targeted for removal. The type of lead extracted is also outlined in Table 2. The most common lead extracted was ventricular (55%), followed closely by atrial leads (42%). The two most common reasons for lead extraction were lead dysfunction (39%) and pocket infection (39%). Overall, infectious complications of implanted pacemaker and defibrillator leads accounted for operative indications in 66 (60%) patients. Of this group, pocket infection was the most common indication for removal (39%), whereas pocket erosion (4%), sepsis (8%), and endocarditis (8%) were also indications.


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  		Table 2 Lead Characteristics
 
Procedural success is detailed in Table 3. Complete lead removal was achieved in 103 of 112 patients for a success rate of 92%. Partial lead removal was accomplished in 1 patient. Four patients in whom laser-assisted lead extraction was unsuccessful underwent elective sternotomy for lead removal without major complications. During this period, 2 additional patients underwent elective sternotomy for lead removal without an attempt at percutaneous removal. One of these patients had a prior pocket debridement and lead clipping at an outside hospital before referral to our facility. The prior lead clipping made subsequent laser lead extraction impossible. The second patient requiring sternotomy for lead removal had six atrial and ventricular leads with documented endocarditis. Because of the number of leads and size of the vegetation it was determined that open lead removal was the best option. Both of these patients underwent open lead removal with cardiopulmonary bypass without major complications.


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  		Table 3 Results
 
Major complications from laser-assisted lead extraction are listed in Table 4. Overall, 4 patients required emergent surgical intervention for immediate hemodynamic collapse. Three of those patients died, for an overall mortality of 2.6%. The first patient was a 68-year-old man with en-stage renal disease and endocarditis. Attempted laser removal was performed with left subclavian vein access. On removal of the lead, it became entrapped within a previously placed subclavian vein stent, which lacerated the left subclavian vein. An emergent left anterior thoracotomy was performed with repair of the left subclavian vein. However, because of the large volume resuscitation and vasopressor support, the patient experienced right heart failure and died 2 days later. The second patient was a 73-year-old man with an infected pacemaker pocket. During his laser lead extraction he went into pulseless electrical activity with pericardial tamponade. Emergent cardiothoracic surgical consult was initiated. Median sternotomy was performed with initiation of cardiopulmonary bypass. The injury was disruption of the superior vena cava from the base of the right atrium to the pericardial reflection. This injury was repaired; however, the patient never recovered neurologic function and support was withdrawn. The third patient requiring emergent surgical intervention was a 40-year-old woman with a history of sudden cardiac death who was experiencing lead dysfunction. During lead extraction of the ventricular lead, the patient was noted to be pulseless and hypotensive. Emergent surgical intervention included unsuccessful attempts at femoral cannulation followed by median sternotomy. The injury to the heart included a disruption at the junction of the inferior vena cava and the right atrium. This was repaired; however, a severe coagulopathy coupled with heart failure made attempts at weaning from cardiopulmonary bypass unsuccessful, and the patient subsequently expired. In each of the above cases, we believe that the injuries sustained were immediate and catastrophic and a more immediate response was necessary to prevent these devastating complications.


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  		Table 4 Major Complications
 
As a result of the above events, a policy of cardiothoracic surgical presence in the operating room during laser-assisted lead extraction was initiated in July 2006. Since this time, 53 laser-assisted lead extractions have been performed with one requiring emergent sternotomy and no procedure-related deaths (Table 5). The 1 patient requiring emergent sternotomy was a 72-year-old woman with documented Streptococcus agalactiae endocarditis. After laser extraction of the atrial lead the patient became profoundly hypotensive. Transesophageal echocardiography confirmed pericardial tamponade. Emergent median sternotomy was performed within 3 minutes of injury. A right atrial tear was noted extending from the atrioventricular groove to the atrial appendage. This injury was repaired without cardiopulmonary bypass. The patient's recovery was uneventful, and she was discharged home 8 days later. We believe that this patient survived because of immediate surgical intervention by a surgical team prepared specifically for this complication. The rapidity of the response is the key element in preventing mortality from major vascular or cardiac injury owing to lead extraction.


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  		Table 5 Comparison of Number of Patients Undergoing Procedures Before and After Instituting a Policy of Cardiothoracic Surgical Presence in the Operating Room During Laser-Assisted Lead Extraction
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
Although implanted pacemaker and defibrillator leads are thought to be permanently implanted devices, the annual rate of defibrillator lead defects requiring intervention increases with time and reaches 20% in 10-year-old leads [11]. Similarly, the annual rate of infection of pacemaker and defibrillator leads ranges from 1% to as high as 19.9% [12–14]. Overall, during the previous decade there has been an increase in both cardiac device implantations and device infections with the rate of device infections increasing faster [15]. The most recent data available from the Medicare Utilization Files demonstrate that the number of pacemaker and defibrillator implants has increased from 168,837 in 1996 to 284,317 in 2005, a 68% increase [16]. It is clear, therefore, that the removal of chronically implanted pacemaker and defibrillator leads will continue to be a clinically relevant issue for cardiothoracic surgeons in the future.

Complete removal of the device is indicated if device infection is suspected. Treatment with antibiotics alone is not sufficient and has a relapse rate of 100% [17]. Standard indications for removal of pacemaker leads includes (1) pocket infection or erosion, (2) sepsis not attributable to another source, (3) lead dysfunction resulting in life-threatening arrhythmias, and (4) endocarditis. In certain cases, the risks of persisting with percutaneous strategies for lead removal are deemed excessive and the hardware is retained. This technique is rarely successful at eradicating infection [18]. Therefore, open surgical removal of retained infected leads should be considered. In this study, 4 patients required elective surgical removal of leads for retained pacing hardware. One patient had atrial and ventricular leads that could not be separated within the mediastinum as well as a large vegetation on the tricuspid valve. The second patient also failed laser extraction because of an inability to separate three different leads within the venous system. The third and fourth patients experienced fractures of a lead during an attempted laser lead extraction. All 4 patients underwent elective sternotomy for lead removal without incident.

In some instances, open surgical removal is indicated without attempting percutaneous extraction. This should be considered in patients with large vegetations greater than 2 cm as well as in patients likely to require valve repair or replacement [18, 19]. Although not seen in this study, massive pulmonary embolus or pulmonary valve occlusion can occur [20]. During the period of this study, 2 additional patients underwent elective removal of leads owing to vegetation size greater then 2 cm, neither of whom required repair or replacement of the tricuspid valve. The risk of complications is also increased when the number of leads is increased. With the removal of one or two leads per patient the major complication rate is 1.9%; however, when three or more leads are removed the major complication rate increases to 8.6% [21]. Therefore, elective sternotomy for lead removal should be considered in patients with vegetations 2 cm or greater or in patients with multiple leads that are unlikely to be removed safely by percutaneous techniques.

With the advent of laser techniques the need for open surgical removal of leads has greatly diminished. However, as detailed in this study, open surgical removal can be required in both elective and emergent cases. Most authors advocate that laser-assisted extraction should only be performed at experienced centers with access to cardiothoracic surgery support [6, 9]. However, there is no consensus in the literature concerning the ideal venue for performing these procedures (catheterization laboratory or operating room) or the level of participation of the cardiothoracic surgeon in these procedures. The North American Society of Pacing and Electrophysiology Lead Extraction Conference policy statement does not mandate cardiac surgery participation in lead extraction nor does it require these procedures to be performed in the operating room. It states that the institution should have an accredited cardiac surgery program on site and capable of initiating an emergent procedure promptly [10]. It is clear that the majority of these procedures are performed by cardiologists with the role of the thoracic surgeon remaining relatively undefined. Recent Medicare data demonstrate that thoracic surgeons perform approximately 9% of all pacemaker and defibrillator implants and 17% of all percutaneous removals [16]. At our institution before July 2006, these procedures were performed in the operating room by cardiologists with surgeons on call for emergencies. However, as a result of several cases requiring emergent surgical intervention outlined in this study, attending cardiothoracic surgeon presence in the operating room during laser lead extraction was initiated in July 2006. We believe this approach to lead extraction allows for quick and decisive action in potentially life-threatening conditions. It is also our belief that the cardiothoracic surgeon should be involved in the preoperative evaluation of the patient to identify patients in whom primary surgery is indicated, or to develop an operative plan should laser extraction fail. Alternatively, it would seem appropriate that surgeons perform these procedures whether by percutaneous extraction or by open operation.

At our institution laser lead extraction is performed jointly by cardiology and cardiothoracic surgeons in the operating room with central venous access, invasive blood pressure monitoring, transesophageal echocardiography, and cardiopulmonary bypass standby. Although it is possible to perform these procedures in the cardiac catheterization laboratory, we, like others, believe that patients who require emergent intervention would likely die if this were attempted outside of the operating room [6].

In summary, the advent of laser-assisted technology has diminished, but not eliminated, the number of patients requiring open extraction of pacemaker and defibrillator leads. The major complication rate from laser-assisted extraction is low; however, we believe that fatal complications are preventable if a thoracic surgeon is physically present, and that perhaps this event could be mitigated against through elective selection of high-risk patients for planned operative removal.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR J. MARK WILLIAMS (Greenville, NC): I would like to thank the Association for the privilege of discussing this paper and the authors for providing me with a copy of the manuscript before the meeting.

This is a very important retrospective study that looks at the mortality in lead extraction patients before and after initiation of this policy of having a cardiac surgeon in the operating room as opposed to being on call at a distance, and the authors have clearly documented the catastrophic events in 3 of the 4 patients where the surgeon was available but not immediately present; 3 or 4 of those patients died. Following the policy change, a catastrophic collapse from an atrial disruption was effectively repaired with an immediate sternotomy. I think the authors appropriately recognize the importance of a cooperative evaluation between the electrophysiologist and the cardiac surgeon before the procedure in order to identify some of these factors that can help plan the open approach or at least plan a different approach for backup.

At our institution I have had the advantage of being both the extracting physician and the backup surgeon at the same time, which gives me the advantage of being able to successfully argue with myself before surgery about what to do but the disadvantage of having no one to blame but myself for these adverse events, and I can tell that they do occur. And in a similar series of about 150 lead extractions, I have had two cavoatrial disruptions, which is the usual site, both of which are easily recognized by the immediate pericardial effusion—you see that happen before the vital signs start going down—and an immediate sternotomy, digital pressure with one digit usually suffices to control the hemorrhage, and then you can repair and continue with the lead extraction, and both of those patients fortunately went home in 5 days.

I continue to be amazed with this knowledge that patients around the country are having these procedures performed in EP (electrophysiology) labs, in cath labs with various at-a-distance backup, and it is my sincere hope that this paper will help to establish a change in the standard of care, to have the surgeon immediately available in an operating room so that these patients can be protected and can have a good chance of surviving these events, which will continue to occur, not to mention the medicolegal risk that we all face. I have several questions for the authors.

First, in reviewing the manuscript, I noted that 31% of your patients in this series had had prior sternotomy. Do you routinely obtain CT (computed tomographic) scans prior to these procedures so that you can evaluate which patients can have a rapid, safe repeat sternotomy versus those who might have an alternative approach considered, such as a rapid right anterior thoracotomy, which gives you clear access to the likely site of bleeding, which would be the atrium or the cavoatrial junction?

Second, have you been able to leverage your participation in these cases into an ability to have some of your cardiac and thoracic fellows obtain some lead extraction experience in the operating room theater, because many of them will have an opportunity as they go into perhaps community associations where they can proceed with this good technical skill that is going to be used with increasing frequency?

Third, although it is not immediately addressed in your paper and not the intent, what has been your approach to the patients with endocarditis who are relatively pacemaker-dependent and will require repeat lead insertions, specifically, the renal failure patients with end-stage dialysis? Do you consider alternative epicardial pacing modes in order to avoid repetitive transvenous lead insertions, which will almost certainly become reinfected?

And then finally, can you address for the members here the difficult reimbursement issues that are involved in this where a surgeon may be asked to stand by for a considerable period of time, and with current coding status, modifiers for assistant or co-surgeons can generally not be utilized in the category of pacemaker and defibrillator lead extraction procedures.

Again, thank you for allowing me to discuss this paper.

DR GACA: I think the last point is one of the purposes of this paper, to be honest with you. There are significant hurdles to reimbursement and coding, and we wanted to develop literature to try to take this to people who establish these coding rules to get those changed.

I will answer the next one in reverse order. You will notice in our series we put seven epicardial systems in, and yes, that is our approach in the renal failure patients. We do prefer epicardial systems for those people.

And the second question about our fellows and also our faculty participation in these procedures, I participate fully in these procedures, and I think that I would encourage other surgeons to do so as well, because not only is it safe, it allows you to gain experience with wires and catheters and fluoroscopy, all the things that are important to the future of our specialty. So, yes, we are having increasing experience with this.

Now, your point about the patient in the redo sternotomy situation is a very insightful one. We do not routinely get CT scans. What we do routinely do is place femoral, venous, and arterial lines for percutaneous bypass if there is a problem. There is some thought, although not proven in the study because our numbers are small and the event rate is small, that people who already had cardiac surgery are somewhat more protected due to adhesions from lead extraction. And your point about the problem with cavoatrial disruptions is a very important one; it almost always is the atrial lead that is the problem. It is either you rip the SVC (superior vena cava) off the atrium or you just rip the atrium wide open, and it is almost never the ventricular lead. So there is some thought that dense adhesions there may be protective. We haven't had a problem with anyone who has had a prior sternotomy yet, and we do not routinely get CT scans.

DR CHARLES HUDDLESTON (St. Louis, MO): It was my impression that prior sternotomy was in fact protective. There are very large series of lead extractions reported where all of the catastrophic events in those series occurred in the non–prior sternotomy patients.

Jennifer Sue Lawton (St. Louis, MO): I and one of my partners, Mark Moon, do all of the lead extractions at Washington University. I agree with Dr Williams that a cardiac surgeon should be removing these leads. We have done hundreds of these, and we have had devastating complications, not only in first-time sternotomies but in redo sternotomies. I have avulsed the innominate artery from the aortic arch. I have created venous to arterial fistulas not only in the subclavian artery but also the carotid, and that is a case where I am very happy not only that I have a bypass machine, I have a sternal saw and I have my vascular surgeon colleagues across the hall. I had one vascular surgeon come in and stent a subclavian artery fistula immediately at the time the patient was on the table, and that was very handy. I think that having a cardiac surgeon stand by in the cath lab is not only a waste of time but dangerous. You might be able to open the sternum quickly in a first-time sternotomy, but there are going to be patients you will lose because you don't have a pump.

DR GACA: I think the major point of this paper is this shouldn't be done in the cath lab. It should be done in the operating room. The quicker you can get to the problem, the less of a problem it is.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

  1. Brodman R, Frame R, Andrews C, Furman S. Removal of infected transvenous leads requiring cardiopulmonary bypass or inflow occlusion J Thorac Cardiovasc Surg 1992;103:649-654.[Abstract]
  2. Kantharia BK, Kutalek SP. Extraction of pacemaker and implantable cardioverter defibrillator leads Curr Opin Cardiol 1999;14:44-51.[Medline]
  3. Wilkoff BL, Byrd CL, Love CJ, et al. Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the excimer sheath (PLEXES) trial J Am Coll Cardiol 1999;33:1671-1676.[Abstract/Free Full Text]
  4. Byrd CL, Wilkoff BL, Love CJ, et al. Clinical study of the laser sheath for lead extraction: the total experience in the United States Pacing Clin Electrophysiol 2002;25:804-808.[Medline]
  5. Smith HJ, Fearnot NE, Byrd CL, et al. Five-years experience with intravascular lead extraction. U.S. Lead Extraction Database. Pacing Clin Electrophysiol 1994;17(11 Pt 2):2016-2020.[Medline]
  6. Moon MR, Camillo CJ, Gleva MJ, et al. Laser-assist during extraction of chronically implanted pacemaker and defibrillator leads Ann Thorac Surg 2002;73:1893-1896.[Abstract/Free Full Text]
  7. Roux JF, Page P, Dubuc M, et al. Laser lead extraction: predictors of success and complications Pacing Clin Electrophysiol 2007;30:214-220.[Medline]
  8. Lawton JS, Moon MR, Curci JA, et al. Management of arterial injuries caused by laser extraction of indwelling venous pacemaker and defibrillator leads Pacing Clin Electrophysiol 2006;29:917-920.[Medline]
  9. Jones SO4th, Eckart RE, Albert CM, et al. Large, single-center, single-operator experience with transvenous lead extraction: outcomes and changing indications Heart Rhythm 2008;5:520-525.[Medline]
  10. Love CJ, Wilkoff BL, Byrd CL, et al. North American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, training Pacing Clin Electrophysiol 2000;23(4 Pt 1):544-551.[Medline]
  11. Kleemann T, Becker T, Doenges K, et al. Annual rate of transvenous defibrillation lead defects in implantable cardioverter-defibrillators over a period of >10 years Circulation 2007;115:2474-2480.[Abstract/Free Full Text]
  12. Choo MH, Holmes Jr DR, Gersh BJ, et al. Permanent pacemaker infections: characterization and management Am J Cardiol 1981;48:559-564.[Medline]
  13. Morgan G, Ginks W, Siddons H, Leatham A. Septicemia in patients with an endocardial pacemaker Am J Cardiol 1979;44:221-224.[Medline]
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  15. Cabell CH, Heidenreich PA, Chu VH, et al. Increasing rates of cardiac device infections among Medicare beneficiaries: 1990–1999 Am Heart J 2004;147:582-586.[Medline]
  16. 2005 Center for Medicare & Medicaid Services Utilization Fileshttp://www.cms.hhs.gov/MedicareMedicaidStatSupp/ 2004Accessed October 25, 2008.
  17. del Rio A, Anguera I, Miro JM, et al. Surgical treatment of pacemaker and defibrillator lead endocarditis: the impact of electrode lead extraction on outcome Chest 2003;124:1451-1459.[Abstract/Free Full Text]
  18. Klug D, Lacroix D, Savoye C, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management Circulation 1997;95:2098-2107.[Abstract/Free Full Text]
  19. Ruttmann E, Hangler HB, Kilo J, et al. Transvenous pacemaker lead removal is safe and effective even in large vegetations: an analysis of 53 cases of pacemaker lead endocarditis Pacing Clin Electrophysiol 2006;29:231-236.[Medline]
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J. M. Kratz and J. M. Toole
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Ann. Thorac. Surg., November 1, 2010; 90(5): 1411 - 1417.
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