Background: One of the challenges encountered when extracting transvenous leads with long dwell times is the presence of dense calcifications encasing the leads. This is the most likely reason for failure to advance a laser extraction sheath. The Shockwave™ intravascular lithotripsy (IVL) device is an angioplasty balloon that delivers intravascular lithotripsy and fractures calcified lesions in the vasculature, approved for use in coronary and arterial angioplasty. It has also been reported as an adjunctive tool in transvenous lead extraction. Objective: To report the Vanderbilt University Medical Center experience using Shockwave Lithotripsy in the extraction of very old leads. Methods: We report procedural outcomes in this retrospective single-center series of twenty-four patients in whom IVL was performed for pretreatment prior to lead extraction. To use the shockwave balloon, one must have venous access along the path of the leads. In some cases, there was venous access and in others a newer lead was extracted first to allow for the passage of the Shockwave balloon. After IVL pre-treatment, leads were extracted using conventional laser and, when necessary, mechanical tools. Results: Forty-nine total leads were extracted with a median of 2 leads per patient and median dwell time of 16 years with a range of 4-36 years. All transvenous leads were successfully removed and there were no significant complications. An excimer laser system (Philips, Inc.) was utilized for extraction in all cases with a median sheath size of 14 Fr. Despite long dwell times, mechanical extraction tools were only required in 6 (12%) of the leads. Conclusion: Our experience contributes to the growing body of data supporting the use of Shockwave IVL as an adjunctive measure during extraction of calcified leads with long dwell time.

An 80-year-old man had a secondary prevention defibrillator in place for treatment of sustained ventricular tachycardia. After a generator replacement several years later, he developed a series of apparent pulse generator infections requiring extraction. Each purulent appearing pocket eruption was culture negative. Eventually, he was diagnosed with a delayed hypersensitivity reaction to triclosan, an antibacterial that is commonly impregnated in surgical sutures. The evaluation for this is difficult and can be misleading. This entity should be considered in the differential diagnosis of patients with culture negative CIED infections.

Leadless Pacemaker Implantation after Lead Extraction for Cardiac Implanted Electronic Device InfectionJamia Kowal, D.O.andGeorge H. Crossley, M.D., F.H.R.S, F.A.C.C.