Occlusion balloon during transvenous lead extraction-Lessons learned from a case series

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: Lead-extraction for infected or dysfunctional electrodes are these days often performed with a high success rate of complete lead removal. The risk for major complications ranges between 1-5 %. The most catastrophic complication is a tear of the superior vena cava with a high mortality despite urgent cardiothoracic surgical intervention. The use of a transvenously placed occlusion balloon has been shown to be associated with a reduced mortality risk in cases where an SVC tear occurred (reference 1). However, there have been reports showing a risk of clot formation on the surface of the occlusion balloon. PURPOSE: To investigate the feasibility and safety of an occlusion balloon during lead extraction. METHODS: Prospective case series of 10 patients where the occlusion-balloon during transvenous lead extraction was used prophylactically. Occurrence of clots on the device, complications as a result of the inflated balloon as well as the handling were recorded and documented. RESULTS: In this prospective analysis, the occlusion-balloon was staged prophylactically in 10 patients undergoing transvenous lead extraction. The device could be placed successfully in all patients without any complications. After correct positioning (figure 1), the balloon was deflated and staged either at the level of the SVC (30 %), within the sheath (40 %) or within the IVC (30%) during lead extraction procedure. The total dwell time was 18.3 10.3 min. After successful extraction of the leads, the balloon could be readvanced over the wire without using fluoroscopy in all cases (final acceptable position was then reconfirmed via fluoroscopy). No clot formation was observed either on TEE during the procedure nor after removal of the balloon as well as no injury to cardiac or venous structures have been found. However, in one patient suffering from severe heart failure, occlusion of the SVC during balloon inflation resulted in a relevant decrease of the cardiac preload and a drop in blood pressure of which the hemodynamic values recovered completely after deflation. CONCLUSIONS: Transvenously positioning of an occlusion balloon is a safe procedure according to this case series. Importantly, no clot formation could have been observed which is most likely due to the much shorter dwelling time compared to previous reports. Furthermore, repositioning of the balloon without fluoroscopy at the same level within the SVC is safe and feasible. In patients with severly impaired cardiac function however, the potential decrease in preload due to the inflated balloon can result in a transient decrease of the cardiac function. [Figure: see text]