Safety and feasibility of trans-venous cardiac device extraction using conscious sedation alone-Implications for the post-COVID-19 era

Background: Transvenous lead extraction (TLE) for implantable cardiac-devices is traditionally performed under general anesthesia (GA). This can lead to greater risk of exposure to COVID-19, longer recovery-times and increased procedural-costs. We report the feasibility/safety of TLE using conscious-sedation alone with immediate GA/cardiac-surgery back-up if needed. Methods: Retrospective case-series of consecutive TLEs performed using conscious-sedation alone between March 2016 and December 2019. All were performed in the electrophysiology-laboratory using intravenous Fentanyl, Midazolam/Diazepam with a stepwise approach using locking-stylets/cutting-sheaths, including mechanical-sheaths. Baseline patient-characteristics, procedural-details and TLE outcomes (including procedure-related complications/death) were recorded. Results: A total of 130 leads were targeted in 54 patients, mean age +/- SD 74.6 +/- 11.8years, 47(87%) males; dual-chamber pacemakers (n = 26; 48%), cardiac resynchronization therapy-defibrillators (n = 17; 31%) and defibrillators (n = 8; 15%) were commonest extracted devices. Mean +/- SD/median (range) lead-dwell times were 11.0 +/- 8.8/8.3 (0.3-37) years, respectively. Extraction indications included systemic infection (n = 23; 43%) and lead/pulse-generator erosion (n = 27; 50%); mean 2.1 +/- 2.0 leads were removed per procedure/mean procedure-time was 100 +/- 54 min. Local anesthetic (LA) was used for all (mean-dose: 33 +/- 8 ml 1% lidocaine), IV drug-doses used (mean +/- SD) were: midazolam: 3.95 +/- 2.44 mg, diazepam: 4.69 +/- 0.89 mg and fentanyl: 57 +/- 40 mu g. Complete lead-extraction was achieved in 110 (85%) leads, partial lead-extraction (<4 cm-fragment remaining) in 5 (4%) leads. Sedation-related hypotension requiring IV fluids occurred in 2 (managed without adverse-consequences) and hypoxia requiring additional airway-management in none. No procedural deaths occurred, one patient required emergency cardiac surgery for localized ventricular perforation, nine had minor complications (transient hypotension/bradycardia/pericardial effusion not requiring intervention). Conclusion: TLE undertaken using LA/conscious-sedation was safe/feasible in our series and associated with good clinical outcome/low procedural complications. Reduced risk of aerosolization of COVID-19 and quicker patient recovery/reduced anesthetic risk are potential benefits that warrant further study.