Removal vs tunneling

Hi DWELSH .......

by Tattoo Man1 - 2017-03-13 16:23:08

....this may or may not be of use, so apologies if not.     I had my left hand PM and leads removed because of lead infection.  The replacement PM  and leads were then sited on my right hand side. My understanding is that this is not a rare event. The leads are longer but your word 'tunneling' is not what happens..the leads are still run within the large blood vessels to the heart.

My concern is more that your surgeon has sufficient experience with lead extraction...does the plan actually specify this ?

Please keep this forum up to date with developments. Collectively PM Club has an immense fund of knowledge and, in my experience, is always keen to expand its database of solid facts..ie not rumour based knowledge.

All the best Tattoo Man

lead removal

by Tracey_E - 2017-03-13 17:04:25

The first thing I would do is ask for a venogram, an iv with dye done in the cath lab. It can tell them right away if you have room or not so you can make an informed decision where to go next.

I had doctor tell me that once when I needed a new lead- if there wasn't room he'd just tunnel it from the other side. I was not  comfortable with that. 1. I want all my leads on the same side, not criss-crossing my chest with one on the left and one on the right. 2. extraction might have been a better choice and he was not the surgeon I'd choose in that case. I didn't have a good feeling about him and his methods so I found another ep, the one who did the venogram. Turned out I had room so getting the new one in was not a big deal.

When we have very old leads, our removal can be higher risk than someone with newer (but still old) leads. That means we want someone highly specialized who does at least 100 per year. I recently switched from a regular cardiology clinic to one that specializes in adult congenital. My new doc is their head ep, and he does many extractions. That was part of my reason for choosing him, I know an extraction is in my future so while shopping for a new doc, why not get one who can do it all. I was very surprised when talking to him that when the time comes, he will refer me out to another surgeon who is even more specialized than he is. He said part of the reason I'll be higher than average risk is age of the leads, the other part is I've never had a heart surgery. He said congenital patients who have had OHS have more scar tissue which makes extraction easier. Anyway, there are a few very highly specialized clinics and I would definitely consider traveling to get to one of them, for an opinion at the very least if not for the surgery.

Tat Man, I had a surgeon once tell me he'd just run it on the right. He didn't mean move the whole device to the right. He was going to leave the device on the left and tunnel the new lead to the right then back to the left to the heart. That sounded way too contorted and complicated to me so I moved on to another surgeon.

Up to date doctors are not putting in so many leads....

by Terry - 2017-03-13 17:47:32

...that is, if you are evaluated for His bundle pacing, you could look forward to a natural ventricular physiological activation. Less chance of heart failure and atrial fibrillation. See His-pacing.org for an accumulation of the latest scientific studies. You will get natural ventricular activation with only one lead, and it will not go through the tricuspid valve. The His bundle (Google that) is located on the atrial aspect of the annulus of the tricuspid valve.

Bi-ventricular pacing, called CRT is a poor substitute for natural ventricular activation the way I see it. That's why Mayo and university hospitals that are up to date replace CRT with His bundle pacing.

All the best,

Terry

this is the guy

by dwelch - 2017-03-13 22:52:28

The doc I talked to IS the local lead removal person, 100+ a year all of that. 

With tunneling they come up the right side vein and then tunnel under the skin to the pacer on the left (which will re-use the two existing leads). 

The alternative is removal of the broken lead.  (this is all assuming plan A of there being room doesnt happen, Im a big guy so one can hope).

They are going to do the dye test to determine if we have to even have this decision or if there is just room. 

The risk of removal problems is 3 times higher for 25+ year old leads so they say that means 1% chance of problems to 3%. 

They wanted to keep the right side untouched since I am not yet 50 (got my first pacer at 19 years of age, currently on number 4) and leave that for the future.  But if they tunnel 1) it is a newer lead if it has to come out for some reason than the others.  2) they can pull it over and use it as a right side lead if they need to move everything over (assuming there is no rejection problem, I dont know if the odds of rejection start over each time or the fact that I am 3/5ths of my life with this stuff and 4 surgeries related to this with no rejection problems means anything). 

Have been with this set of docs for 10+ years, have had a number of docs for various reasons, moving and work insurance policy changes, so maybe they are are are not using new techniques, but comfort with these folks counts for something.  Have had at least one bad apple, but generally end up with good docs, and this set is on that list. EP, surgeon, etc.

Thanks!

decisions, decisions

by Tracey_E - 2017-03-14 11:13:49

Sounds like you are in excellent hands and they are being very thoughtful, can't ask for more than that! Fingers crossed there is room for one more, keep it simple.

I'm in a similar situation, 50 and on my 5th device. We are trying to put off extraction and moving anything to the other side as long as possible. The longer we put if off, the higher the chance the next set of leads will be my last. 

Good luck!!! 

no problems

by dwelch - 2017-04-26 14:57:09

In the end there was room for another lead on the left side.  I had chosen tunelling, still 50/50 on that but doesnt matter now, in hindsight would have had both shoulders out of commision not just the one or perhaps the right moreso than the left which would have been okay (at least one).  

Three lead interrogation testing is a bit different than two lead, there is a test or two there that is not comfortable, but only lasts for a few seconds...It may be one where they intentionally run the ventricles out of sync with each other.  will see if that test is used again or was just a one time thing.

lead

by srf - 2017-05-14 20:39:41

My wife is facing similar as previous persons. She had three leads already all 25 years old.

To make matters a bit tougher she has scoloius and our EF said that will make it even more difficult.

He refered us to who I feel is the man Dr. Schearf at St. Joesph, Burbank , Ca.

He apparently is the doctor that invented the ex laser. We go for our consult in a couple days, obviously hoping he says it's tough but I got this.

Anyone else had leads extracted and have scolious ? 

Any input appreciated

Thx.