Circ: Laser lead extraction safe, effective for octogenarians

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Laser lead extraction is a safe and effective treatment for patients 80 years old and older, according to a study published in the October issue of Circulation: Arrhythmia & Electrophysiology. While the findings may help physicians in the management of elderly patients, the authors cautioned that further research is needed to make results more generalizable.

The elderly account for the majority of implants of pacemakers and implantable cardioverter-defibrillators (ICDs) in the U.S., Yasser Rodriguez, MD, MBA, of the department of cardiothoracic surgery at the University of Miami Hospital in Miami, and colleagues wrote. Patients 70 years old or older make up more than 70 percent of pacemaker implants in the U.S., and the average age of a primary pacemaker patient is 75.5 years old. Some two-thirds of ICDs are implanted in patients who are 65 years old and older in the U.S., and the average age of a primary ICD patient is 66.2 years old.

They added that Medicare expenditures associated with arrhythmias and conduction disorders topped $509 million in 2009, making efficient use of resources based on informed clinical decisions imperative.

“When dealing with device complications and clinical outcomes in an octogenarian, clinicians traditionally had to base their decisions regarding management on extrapolations from the general populations used in previous studies,” Rodriguez and colleagues wrote. “”Because of the increasing change in age demographics, the increased use of implantable devices, the prevalence and rise of complications and the lack of literature about this specific group, we decided to analyze the clinical outcomes of device complications and laser-assisted extraction in the octogenarian patient population.”

To do so, the researchers reviewed charts of 506 patients who underwent laser lead extraction at one high-volume facility by a single experienced operator between January 2004 and June 2009. The patients were divided into two groups: patients 80 years old and older (118; 78 men; average age of 85 years old) and patients younger than 80 years old (388; 301 men; average age of 64.2 years old). They then analyzed the records to compare patient and lead characteristics, indications for the extractions, associated medical conditions and clinical outcomes.

In the octogenarian group, a total of 253 leads were extracted; 99 atrial, 145 ventricular and nine coronary sinus. In the nonoctogenarian group, a total of 814 leads were removed; 295 atrial, 442 ventricular and 77 coronary sinus. The most common indication for extraction was infection in both groups. They found no statistically significant difference between the groups in terms of demographics (except for sex), the number of comorbidities, leads, approach, proportion of minor or major complications or composite adverse events.

Pacemakers were more common in the octogenarians (56 percent compared with 36 percent of nonoctogenarians) and ICDs were more common in the younger group (47 percent compared with 28 percent in the octogenarians). The duration of the lead implant was longer in the octogenarian group, 59.6 months, compared with 38.6 months for the younger group.

“All of these patients [octogenarians] underwent successful extraction, with a complication rate comparable to their younger counterparts,” the authors wrote. “The clinical relevance of this finding is that clinicians can consider lead extraction as a safe and effective option when managing patients at the later extreme of life.”

Rodriguez and colleagues acknowledged that while the study population was large, the sample size was limited because it involved only one center. They noted that a multicenter study might show differences that were not apparent in their single-center study and produce results that would be more generalizable.