Remotely observe a live lead extraction and learn from experienced extractors. This live recorded observation will highlight key aspects in lead extraction from pre-case planning to extraction strategy. Dr. Canby and Dr. Al-Ahmad will share best practices as they progress through the procedure and answer questions from the audience.
morning from Austin, Texas. Ah, we're here today with the live lead extraction education program, uh, hosted by Philips Elite Academy. I'm a mean, al Ahmad. I'm one of the cardiac electro physiologist here, and my colleague Dr Bob can be, uh, we're both going to be performing elite extraction, uh, case for you. Um, first, uh, started. I just wanted to, of course, say good morning to everybody here. Ah, and all around the world, I know there's different time zones. Uh, and welcome toe, Austin Virtually hopefully we'll be able to Yeah, full again soon. I also wanna shout out and say thank you to our lab staff here. A really great job in terms of getting things set up behind stains efforts in terms of getting the audio and the visual and everything set up. So with that, we'll start. We've already done a little bit on this case, and I'll explain to you what we've done so far. But let's go ahead and show you what this case is all about. So this is our patient. He's a 76. A gentleman with a dual chamber pacemaker, a pacemaker put in 2000 and eight for Sinus node dysfunction. It's a, uh, scientific device. Device model is an S 602 The Elite is a Boston, A lead model 4136 And the ventricular lead is a 4137 The right ventricular lead thresholds have increased over time. Now they're at over four volts, and the devices reached the elective placement in. In addition to this, the patient needs Marie's for his back. So in discussing this patient, the discussion waas, do you just accept it? Since he's Sinus dysfunction and live with, uh, you know, poorly functioning V lead? Or if the lead fails, would you implant a new lead? In which case you'd cap the old one and he wouldn't be Emery compatible anymore? Or do you extract? And so, after discussions with the patient, the decision was to go ahead and extract the existing lead or leads and and move forward with with extraction. So the next line. So in terms of this, the way we view this, you know, there's a pre op assessment that has to happen. You have to think about what type of device it is. Icy D by V. All of those things What are the number of leads that you're dealing with in the lead models? What are they? Are they active fixation of a passive fixation or they expendable Retractable. Andi, what was the date of implant? One of the things that's really, really critical here is to get the primary data because oftentimes the patient doesn't know this or lost the card that came from the company. And oftentimes the patients moved or has been to other institutions. So you won't have accurate data. You need thio. Really? Make sure you know this. So you're not surprised with leads that have been capped in the past or epic cardio leads or things that you can't deal with. They're patient related things in the history that you want to make sure of. Co morbid conditions, particular things like diabetes, obesity, people who are really, uh, cock, hectic or thin. Prior surgery is important to know in particular, if you run into a problem. Ah, it's helpful for the surgeons to know what they're dealing with. And so these air these air, uh, these were the things you want to understand before you go forward, and then pre op testing for these patients. An echocardiogram, in my view, is important in particular. If you're going to re implant somebody you know, do you do? If they're f is low, do you re implant them with same device, a different device chest X ray to confirm what leads and where those leads are, since since the again the patient may not always provide you with accurate information. Some people are doing C T scans in order to look at the course of the leads through the vasculature. We've not tended to do that that much. But there has been some data suggesting that in doing that you can. You can see whether the leads might be extra vascular in some in some situations. Now, typically, before any of this, you have to document the indications of the procedure, the risks and alternatives of procedure. This is really, really important in particular, if you're if you're doing something with the class to indication Class one medications. Very straightforward class to indication, you want to make sure that you have the right reason to do it and way all these types of reasons. An example would be if you have a superfluous lead that's 20 years old in a 90 year old woman. It may not be a decision to extract it versus a superfluous lead. For example, in a 50 year old might be something to consider. Um, if it's a Class one indication again, document risk, alternatives and everything. But in those cases, it's clear that the leads need to come out. A Z I mentioned earlier as part of your pre procedural planning Chest X ray always know what leads you're dealing with. I can't tell you how important this is in the sense that again I've been in situations where leads have shown up that you didn't anticipate you. You go into the room and suddenly now there's three lead instead of to somebody capital lead and nobody knew about it because of patients. Uh, you know, being from different centers and so forth and again CT scan we mentioned earlier. Um, when we do these procedures, you know it's important. Thio observe sort of the time out, if you will, and understand that you have all of your backup and everything set up the right way. We typically will have surgical back up, but it's important to know that you have all the appropriate equipment. Um, do the surgeons have everything they need in case something goes bad? Now, this, fortunately, doesn't happen very often. But if it does that the difference of knowing where everything is and how to get everything can be the difference between successful outcome or a nun Successful outcome. You need to have defined roles for the staff in case of an emergency. Make sure everybody knows what they're going to do, how they're going to do it. And you need to respond quickly if something does happen. Uh, well, type and cross, we have blood available for these procedures. Um, that that's very important. If if you do end up having a significant hemorrhage, then then, uh, you know, time is of the essence, typically in the groin will put in an arterial line. You can use an A line in the groin or in the arm. Typically will use the groin, just in case it needs to be used past later. Um, also high volume Venus line for fluid resuscitation, typically also in the groin. So that's always what we way do it. Our center here, um, you need to assess whether they need temporary pacing catheter, so that's important. Well, typically image the lung fields pre extraction. Do a venogram if we're If we're planning on re implanting and make sure that you know how it how it looks on fluoroscope E just in case you have bleeding and there's, uh, hemothorax s, um, transits often you'll echo or inter cardiac echo during the procedure is important. And then, lastly, our routine is placing a wire for a bridge balloon and on occasion, putting in the bridge balloon. We've already, uh, this case have figured out where the bridge balloon would go. We've placed the wire up into the into looks like the jugular vein, and the bridge balloon has already been advanced. And we figured out where it is and we've marked balloon so that we ah, we know how far to push it up in case of an emergency. And then, lastly, um, you know, what's your strategy after you're done? That's also important to think of before. Do you really need to re implant? Not every single patient who has an extraction needs a re implant. It's important to reevaluate that patient. Look at their initial indications. Do they still exist. And then if you're unable to implant them, uh, quickly. For example, if they're back to remake, you may consider something like a temporary pacing catheter or a permanent lead attached to an older device. Or, in some cases, a lead lis pacemaker can be used for these type of circumstances. So with that, I'm going to go ahead and join my colleague, Dr Camby. What we've done already is we've we've getting access in the groin. I think Dr Camby's already taken out the device and has, uh, uh dissected the leads out and is about to unscrew them being around you. All right. I cannot hear anything from in here. So mhm. My dad. Joe. What I'll do. Are we on? Uh, you want to explain where I am right now? We're Where are you with things now, Bob? Alright. So again, I'm Bob can be so the first thing. And again, I'm sorry I didn't hear all the initial conversation, but we did shoot a venogram. Did you show the venogram Dr Al Ahmad? No, I did not. If you want to go ahead and show it runs venogram before cases, I typically shoot a venogram. Try to get an idea. We're a little bit low on here, but I think we could appreciate that. There appear to be collaterals, that air going north, so to speak, very hard to tell whether there's any flow along the the path of the subclavian. And then it sort of reconstitutes toward the midline. First thing I typically try to do even before I access to pocket is I'll get. I'll try Thio get access into the subclavian. And I took a standard needle and essentially did a first rib approach down to those leads. When I got Venus returned, I used a glide wire and we should have some of the I think I did a floral save to try to pass this glide wire through the area of the stenosis because he told multiple collateral vessels, you can see actually on that on that floor of say, there's also the bridge balloon being placed in the appropriate position. Mhm. Um, what do you think this is? A strategy that I've I've also used is getting access before you do the extraction. And I think that one of the things that I've I've seen is that if you do the extraction first? Sometimes it can if especially if it's a tough extraction you can end up with in that vein and make it really hard to get access. So I I think they're getting access before you get started. Ah makes a lot of stuff. And and I like thio. Always maintain some options. You know, if if they're included and you can't obtain access, then you're gonna be very reliant on as you take out that lead being able to retain access and in some cases, inadvertently if you lose, if you lose that central access you may not be able to read, you may not be able to get it back again. So getting access in the first place gives you that additional safety that you should very likely be able to re implant if you're trying to stay on the lateral side. But in terms of the leads, um what what? What do you look at in terms of lead models and when you're using electro Kateri, the models matter to you, you know, for using lead models do make actually a fair amount of difference from several aspects of this case. The constructions of the leads are different, Some are more robust and have more tensile strength, and others are a little bit more friable. Some you can you can actually pull on relatively hard. Others will start to unwrap and eso knowing the construction of the lead and what their tendency to do is when you're tryingto maneuver is important. We typically use a plasma type blade when we're working with with Leeds, because way can actually apply energy down to the installation on the lead. Uh, in general, most pacemaker leads and most defibrillator leads have enough insulation that most of the time you don't have to worry too much about, uh, essentially burning into the insulation itself. But on some of the L V Leeds, particularly if they've been in for a while, they're pretty. They're pretty thin on their installation, and you do have to be a little bit more careful. Do they cost us with those? Okay, so at this stage, we have the two leads are exposed and have we put in a clearing style it at this point yet or that I was gonna put declaring style, It's And now Okay, so this is our next step is we're gonna take us, Gillette, and just clear the looming of lead. It also allows us Thio Ah, unscrew the lead at this point. So when we disconnected from the pacemaker, the ventricular lead is the one I'm holding now. So we'll just go ahead and take a clearing style at to sound the integrity of that lead just sort of advance. This is helpful because if you're if you're going to end up, you know, you have to lock these leads in and really having the ability to lock the whole lead makes a huge difference. If you're unable to get the locking style it all the way down, it could be the difference between a easy case and not so easy case. So this is a 60 centimeter lead and based on the length of the clearing style, and I could tell you were very close to the end. If we're not all the way out, you don't always get to see the clearing style it. But I'm pretty convinced I'm close to the tip. So what I typically do is take a hemostat clip onto the the distal electrode port here and then with that end. Go ahead and rotate and see if that he likes will retract. Now, one of the things the note is that it takes a lot more turns done. Screw it if it's been in for a long time. You know when you screw these in early on at the implant time, it's only 10. You know, 10 or 11, 12 times you screw, you screw. Screw the lead in. But the unscrew the lead actually takes a lot more. So I did probably 15 15 turns or so. But on this, particularly that also tightens down the electrode around the locking style. It sometimes the torque of trying to unscrew the helix doesn't actually transmit to the tip. I found that if you take the sounding, style it and remove it and push it back into place. Sometimes it helps transmit that rotational torque down to the distal electrode. Yeah, that's really good tip, because if you can't over unscrew the lead, if you will and and end up in certain certainly designs, you'll end up with a very tight Lumen, and it'll make the rest of the extraction case more difficult. And again if you if you give it several turns, sometimes just waiting a little bit. And over time that Felix will work its way out. And in the end of the day, it's a balance. If you're unable to unscrew the lead completely, you may just have to go with what you have this one piers that it did not completely retract. So we may be in that situation here. Yeah, And again, the balances and this particular lead design. If you overdo that, it'll tighten up the central loom in. And that makes things worse. Because then you can't advance the locking style. It it's far more important to advance the locking style let than it is to undo the helix in many cases. So I think this is a 53 centimeter atrial lead. Taking that into account, I think again, we're gonna be relatively close, and we'll go through the same motions to see whether this atrial lust I let will retract that helix. You see a little bit of motion on it, maybe. Yep. There goes perfect angel. Screw came back inside the lead. So? So after this, our next step is essentially to prep the leads for extraction. So get a heavy scissors and we'll go ahead and cut the leads here. So I cut the lead, took off the insulation. Another trick that I often do is I look down deep into the pocket is I'm preparing the leads just to make sure that the original and planter didn't do something unusual. Sometimes there's a second sewing style sewing ring there. Sometimes there's a suitor tie that's not on top of the what used to be the soaring. So taking a look down into the pocket and extending sometimes will save you some trouble when you don't understand why you can advance your your sheets. Yeah, I find sometimes. So you go in and you don't find the, uh, the sewing. You know, the bullet that you used to so on. And, uh, most of time. It's just in deep somewhere. But sometimes people take them off, and so you have to be. You have to, but you have to do make the effort to look for them and make sure that you can ah, get rid of them. So here, what you can see is exposing the inner coil so you can see there's the inner coil and what Dr Camby is going to do now is he's going to advanced locking style it through that inner coil. Now this has a radio opaque tip on it, and so when he does, this will be able to follow Where that goes, you can kind of see it going down, and you can see which lead this would be. So looks like that's going down the atrial lead. So as we're doing this, I just like Thio. Remind the viewers that if you have questions about what we're doing or any comments, please go ahead and submit those. You can submit them through the platform and we'll have somebody here read them out to us. But we'll continue thio, narrate the case and talk about what we're doing in the meantime. So under the fluoroscope being here, I think you can see the radio take tip of the locking style, it now just coming up to the proximal electrode and then sort of coming into the electrode itself. So that's where we can advance any further. So will deploy the the woven mesh on this locking style let, which will help it lock into place. Generally, it locks into any place of curvature. We like to think of it being about the whole length of the lead, but it's probably in areas where it hits. Curvature is where it's gonna lock the most. I tend to pull on the lead to try to just make sure that that is deployed well throughout now, as we're doing this. Okay, so the other next thing we're gonna do is tie the installation, so make sure we have control of the bloomin of lead, but also the installation of lead. One of the things I just wanted to mention, um, as we're doing this is if you intend to take only one lead out, what do you do with the other lead Bob Do U S O. Many times there's lead the lead, binding on as you pull on one lead. The other lead may try to be pulled a swell, so I will. If we're trying to maintain one lead and keep it intact, I'll often take a stiff style it in, advance it down the other lead, just to help give it some additional body. And that sometimes helps in the aid of the original of the lead that you're actually targeting for the lock for tying down the insulation on these leads. What I tend to do is use a no Esteban's future. Tie it down tightly to the outer insulation. Once the locking style it has been deployed. Make sure that's tight, and then I typically tie it to the to the locking style. It itself. That's Yeah, there's different ways of doing this. But actually, uh, I like this this way. I used to do it the other way, where I tie two suitors to each other and tie it all the way to the back of the LA Kings. That lab. But I think this way works. Justus. Well, I don't think there's a real major difference. Ah, the to you know, yeah. If you can't get the locking style it down. The question is, if you can't get the locking style it, are there any tips or tricks that that becomes a real challenge? You can still take out leads. You might try a different size locking style. Let um, in some cases, if you can't get it down, you can tie to the installation or use other techniques to try to get it down. But those could become more challenging cases. And then in some cases, if you really can't, you might have toe, you know, go from the groin or do something like that. We need the blade. So again, trying to get the insulation and get the lead ready. Um, prepping this is very important. The more time you spend making sure you get the right is better. You don't wanna be in a situation where you're not, um you don't have it just right that walking still out here and and again, my personal philosophy is try to keep all your options open. So sometimes it's easy to think that it might be easy to take a little bit of a shortcut, not prep something in anticipation. May not need to be doing something with it. But then afterwards you find out that that was a mistake, and sometimes it's very difficult. Thio recover. So try to keep his many options open. We're advancing the locking style that down the ventricular lead way, Yes, you just You just got to the tip. So you put back in advance it you see the floor? Oh, so we got the ball all the way to the tip. I'm gonna go ahead and deploy this, um there it goes. Okay. Yeah, I see the leads are a little different than their construction. So when we're trying toe do a pacemaker lead, it simply has that 11 loom in, which is the pace since loom in now for a nice CD lead. Of course, there is the pace since loom, which gets prepped exactly the same way. But it also has thes, uh, cables. So we'll typically do with those is we'll use suit your and tied to the cables and tie that similar to how we tie the insulation to the back part of the locking style. And that gives you a lot of help and support. I've been you know, there's been cases where I've had situations where could not get a locking style it down the lumen of the lead. But we were able to control the cables and just with the cables and the insulation were able to get leads out. In some cases, were you so Yeah, that that is that is true. They do. They do act a little differently. From that perspective, it's more to pull on and they're a little bit bigger. So you have to consider that. And then the coil is also important. That's where lead construction matters. So some some leads, for example, have silicone backfill of the coil. And that tends to be a nice design for extraction versus leads that don't have silicon backfill. There could be a lot of tissue in growth into the coil making, making your job a little harder in terms of dissection of the fibrous tissue. Okay, so we're about ready to start the laser ring at this stage. We've already I heard you guys already prepped the laser. Um, just a quick question, Bob. What? What? Glaser, She did you choose and why? So, uh, these leads air 77 French. They've been in the individual for over 10 years. You can guarantee us that we're gonna have a fair amount of adhesions to it. I tend thio oversized. Just a little bit. I'm going to use a 14 French are sizes Air 12, 14 and 16. I'm actually gonna use a 14 to start today. I'm gonna put in outer sheaf over it because I have to retain access on at least one of the leads. And that way, in case there is a ah lot of fibrosis on the lead that actually keeps the lead from being pulled through the laser sheath itself. I could pull the lead in the laser sheath out and still have access through the outer sheath. We'll show you how we do that as we move forward. So a couple other things so you could go with the 12. But a 14 I agree, is a better choice. This is the outer sheath. It has a bevel. We're gonna go ahead and put the bevel side in so that it will be a dull side out. Go away with that. And then the other decision that we always make is which lead do you go for first? This individual, I tend to go for lead that you think is going to be the easiest. Thes leads are both the same construction. One had the helix come back. The other one didn't. The atrial leads a little shorter. I think I'm gonna go with the with the atrial lead first on, see how, see how that goes. And then, uh, and then move toward the ventricular lead. And sometimes you have to do both and we'll talk about that as we move forward with us. Yeah, I think that's a good good way to think about it. Because as you take out one of the leads, um, you really do, ah, fair amount to get rid of the fibrous tissue that's binding, the other lied so often times, Uh, you know, taking out the easier lead does help you get the other lead out. So I think that that it actually makes a lot of sense in terms of how to do something. No, we always at this point confirmed that we have surgical back up. Everybody we have our surgical backup is ready. Everybody is ready and we're ready to go. So we got a t ready in case we have everything. So we're ready to start laser at this point. All right, so here it's important. I feel it's important to make sure we're really watching what our leads do. If you tell I'm trying to get try to stay concentric is possible with my laser sheath, which you can see on the edge of the screen. The other other sheet. You can tell this just coming to the the muscle lead interface. There will just sort of leave that for now. I'm manipulating this lead just a little bit to see if I could get underneath that other lead. I'm just rotating it a little bit. Looks like I'm in a good position at this point. I'll put some traction on the lead on targeting and apply some laser energy. I'm gonna keep the bevel generally on the inside of any curve as I go. This has a slight bevel is you can see So the bevel I wanna be on the inside. You can tell what the devil is on the laser lead. By the the attachment of the cord to the lead chief itself. The longest part of the bevel is on this. This aspect of the sheaf, right? All right. Coming on later. So one of the things that you'll see eyes that it's really a matter of trying toe balance your forces. So the force you pull back is similar to the force you push forward on the RV lead. You may be it looks like, uh, a lead looks like a drop, though. Oh, they really dropped. Dropped. So the ah, so the ah, you want to kind of match your forces, meaning you don't pull harder than you push, and you don't push harder than you pull. You kind of try to match them. You can see here that the leads were clearly bound together, Um, and so there's definitely some lead lead interaction, and one of the things we have to decide at some point is, Do we continue on one lead, or do you switch back and forth and get a feel for that as you go? And as you can also tell, I tend to use a little bit of rotational aspect on the sheath just to try to see if I could work through anything that's in the way and get a feel for what's in advance in, you know, different obstructions feel differently. A snowplowing of the insulation feels different than calcium feels different than just fibrosis. I've got something in front of me I can't really tell right now. I don't see a shadow on floral, meaning. It's probably not heavily calcified, so we're just gonna continue to move forward, and one of things you can see is that all of that dissection that the doctor can be is doing is when he's off of Floro off of off of laser. So So he's Ah, he's pushing and pulling and kind of rotating and doing all this sort of stuff with the inner and the outer sheaths when he's not laser When he lasers, he really has a very steady forward motion, as he's as he's trying, you know, pulling back traction again, trying to balance forces. And again, the key here is for the leads lead and the laser sheath to be concentric with each other. You don't wanna have the lead at an off angle with the laser sheath. You want the laser sheath to be centered around the lead. You see there, my outer sheet is ahead of my laser a little bit. I'm just trying to see a little bit of dissection, and you get the idea there. The two leads air really, really attached right in that spot. Looks like you may have passed that the little more dissection with the outer lead here, helping separate the two we may need to go to the to the other week. You can tell the lead is coming back. In fact, it is gonna come back. Yeah, So here, watching that atrial lead, you could see that the electrodes are indeed coming back. I got my laser out as far as I am, I'm just going ahead. Continue some traction here. This lead may actually retract, but it may not. So it's still caught up on that other lead. I think what I would do I mean, is move with lead and see if that helps me. Yeah, again, You can really see the binding of the two leads together. And it's one of the things that can impact you in a good strategy in this case is to switch between the two. Sometimes you have to switch tools, go thio, you know, mechanical tool. But if you're using laser and things were going well, then just switching between two leads is good. You can see here some of the fibrosis that was around the lead that came out inside the chief. Yeah. Is that the guy to put that on? Please? E can hold this year. Yeah. So it's, uh, you know, I think again a good strategy. Sometimes when you have legally binding switch between the leads. Are you talking about that will help. Many times, the area that has been bound that you've lays through before is a little easier on the next pass on the on the other lead. There were still meeting a little bit of that early. Resist early resistance. Now, if there's calcium, uh, I'll let all of Bob do his thing. I'll just talk if there's calcium. Sometimes using a mechanical sheath is helpful either using the outer to break up the calcium outer sheath of the laser or or getting the mechanical rotation type sheets. That worked really well for that, and I'm putting a little bit of gentle traction on the other lead just to keep it straight. I'm watching for my other theatrical lead, which I'm kind of holding just to make sure it doesn't buckle too much or have problems. So when you have two people, one person kind of having some traction on the other lead is sometimes helpful. You see, the ventricular lead is kind of changed position a little bit, which is good. Yes, it feels like snowplowing here a little bit is what I what I'm perceiving. I'm feeling here. You see my outer sheath is advanced in front of it a little bit. I'm just trying to rotate the lead and see whether I could get a free. It doesn't feel like it's freely moving over the lead at this point, which makes me wonder whether I need to up size. Actually, yeah. So that's one strategy is upsizing to another, uh, to the next size would be a 16. You see how the bevel is really pointed away, Which is kind of what that camp was talking about earlier. So that's kind of it looks like you may, it may have You may have just yeah, break it up with the outer a little bit there slow, steady pressure. They're trying to balance the trying to balance the pushing. I'm doing it the laser with how I'm pulling on the lead as well. And see the other thing is, as he pushes through the laser forward, he's pushing the outer forward because remember again, if this lead comes back, if this lead comes back, he's gonna want to retain access, and so that that helps you. So you can just, uh, you know, pull out the laser keeping out or we typically well, But why? We're ready to go. Um, so you don't have toe hold too long? Um, you know, definitely my breath. Yeah, it's stucked in with the outers. Making progress. Uh huh. Something there loosened up. See how the tips air. Really? The were connected right there. It's that last spot. This is kind of towards the SBC, so we're very mindful here to be. Ah, you see, from Dr Alama, the other lead is, uh, e don't wanna break it. Okay. It's, uh you may come back to that, get it. Just re getting my bearings on this other lead. And I'm trying to keep the bevel when I'm active on the laser to the inside curve. As you can see, I still feel that I've got a little bit more of the lead. Snowplowing in front of me is what it feels like. That's why I'm rotating, to see if I can just get over it. It's amazing how these leads get adhere to each other and really there that made progress. That's one of the things again. When you're when you're trying to take out a single lead, be prepared that you might have to take out both always be prepared to prepare the patient for that. Tell the patient in advance that although our plan is to pull out a single lead Okay, you can see the belly there is going. What I want to do here is make sure I don't lose the access. So I'm just gonna look to see if this lead will come back at this point. Still not completely freed up there. That's a stubborn lead is a stubborn lead. You want me to grab that? Yeah, I was trying. Thio, you see out of is the outer toe. You hear that a little bit, boy, I just get it. Not want to come? No. See, if it all comes back in, No thing does. Not when I come out there. What if that's just the big? Yeah. That's where things finally ended up. They have to lose access. Access Way could double wire the other one. Which is the other thing about options, which was what Bob was telling you earlier. You have options because we've okay. Yeah, that's why so that's that's That's a lot of fibrous tissue that ended up getting kind of snow plowed there towards the end. You see that house? Our blood pressure And Ah, can you look at the ah t real quick, please? Okay. Blood pressure is stable, so we're doing okay. Just take a quick look at the T. I don't know. Can the camera see this, Matt? What's him? Cameras. Right here. Yeah, you kind of see. Hear how the tip was kind of free. But a lot of this stuff may have been pushed forward and made this bundle like this making it harder to take it out. Kind of see, here is you As you try to pull it out, it it just doesn't want to come. So pulling the whole thing out made a lot of sense. In this case, blood pressure is stable. Um, and you can see with with the, uh, with these large seats as you pull them out, you Sometimes we'll get bleeding in the pocket. And so holding some pressure is is critical here. Anesthesia made a very important comment for us to hear. Uh, she said they haven't had to give any pressers or anything to help support blood pressure. E then one of the important communications during these cases is with your anesthesia support on physicians is have good communications, so that if for some reason they noticed the blood pressure is low and want to support it, they let you know that that's what's going on. The time where that's critically is important, that this something is going on in the blood pressure is falling and you're worried about bleeding or some other complication from your procedure. But then the patient gets oppressor and the blood pressure looks good. You may think you're out of the woods, but you you're actually just delaying, potentially delaying the inevitable. So having that communication know what's going on is important. All right, So the ventricular leaders out in its entirety, we're gonna see what we can do with the remainder of the atrial lead. One of the things that we've talked about a couple of times and uh, regretted not doing at times is, uh, that's the age. Really? Okay, s so it was really bound up. You can see the whole literally just came right out in the end. It so here it is. Uh, it looks good. So right now, we usually will just take a quick sweep of the of the drop the I please quick sweep of the lung field. Make sure that there's nothing there. But, you know, when you have a super being a cave, a bleed, um, these really bleed fast, and it's not subtle. So all the way over, we're looking at the angles of the pleural space. And just to make sure everything remains looking sharp, which they do on both sides. So that seems to be, uh that seems to be promising. The blood pressure is quite stable. The TV show that there was no evidence of a pericardial fusion. Um, so I think we're in a I think we're in a good position with the leads leads removed. So and then again, the option here is easy implant because we already have access. And we don't have thio worry and weaken double wire that that's not an issue. Um, the one thing I was mentioning is sometimes ah, I've found that, um oh, that. Uh oh, Mike, let me change. Yeah. Okay. Sometimes I found that any new set of gloves um, putting a a suitor around where the leads are helps prevent the back bleeding because sometimes especially with a 16 French. As you remove the leads, you get a ton of back bleeding. That's particularly true in people with heart failure and high Venus pressures as well. While we're waiting, let me just change subjects a little bit. I don't know whether when I when I initially was getting access to the to the pacemaker pocket here, this patient had a very large he Lloyd. And so what I did was I cut around the key, Lloyd. That's why my incision looks wide, but it's not gonna be hard to bring it back together again. So I tend to remove the previous scar by cutting around it. And then and then he's standing down into the pocket on this particular patient. When we got into the pocket, it was actually quite calcified. And in fact, Carlos, do you have the But you out there? Okay, so the the capsule that was very calcified when they're calcified, and I don't know if you can appreciate this. Almost here in eggshell component is I'm moving the outer capsule in fiber Roddick tissue when it's thick and very calcified. That's when I will tend to manage the pocket by removing the capsule. There's a trade off in taking out capsules. There's gonna be a little higher risk of hematomas at the same time, you're gonna be able to implant the device and the more vital tissues. So potentially one could argue that there might be a little lower infection risk a same time. You know, it's a judgment on patient the patient, But I don't know about you. I mean, I don't like a lot of calcium e. Another thing to bring up is, uh, we shall see. I'm actually going to step away a little bit. I'll still talk and take some questions. I'm gonna give Bob a little bit more room here. Um is that he's now going to use him long sheets for re implant. And, um, as he's doing that, we're kind of watching the time and watching how stable the patient is. And at some point, we're just gonna we'll call the O. R off. We'll let them know that they're good to go. We don't keep the o. R. Here for the whole re implant will just keep them here until we believe that everything is safe and stable. That should be soon because this was not you know, terribly difficult. Lead extraction. Um, there wasn't anything that happened during the extraction that was too scary. So we'll call off Theo are pretty soon. Yeah, I think usually it's about 5 to 10 minutes is what we dio five minutes that Dr Neely and my colleagues over there No, everything went fine. We're good. We're good position. So good communication between the teams. But what Dr Campbell is going to use now is a long sheath. And I've been in situations where I have not used the long sheath. And I regretted it, because although you think that you've gotten beyond, uh, some fibrous tissue occasionally you just have problems where you just can't get the ah lead to go down. So a long sheath helps a lot, especially if you if the venogram wasn't great and you couldn't tell exactly where all the fibers binding of the leads ended up. So we'll often use that. And it's not so hard to implant with long sheet. Yes. So the question we got was, can you explain your relationship with the C T surgery team? So hopefully we have a good relationship. Them? Um they work really well. with us, and we work well with them. Typically will have thes cases booked on on our schedule and on their schedule in advance so that we have somebody who's here. If the case is going to be, uh, you know, worrisome. If it's, you know, Lady not long ago that had leads over 20 years might ask the CPI surgeon toe hang out in the room, we might have things more ready. Um, if it's a fairly routine, straightforward case, then we just have to confirm that the SETI surgeon is is in the hospital nearby ready to go in case we have a problem. Having seen problems firsthand, I can tell you they happen quickly, so having a good relationship is critical. We like doing these cases first thing. It's easier that way for us and for them because we're not, you know, worrying about them finishing their case, and it's putting this one on the table. When you put this on the table, how do you time it all that sort of stuff? Do you see the bridge? Yes. So the question is, do you use the bridge balloon all the time or do you use it for high risk patients. And how do you define high risk? Yeah, that's a good question. Honestly, the bridge balloon, um, you know, really is a great idea and that it can It can save your time, you know, again, having seen bleed firsthand and unfortunately, the patient lived through it. I can tell you, there's so much blood. It's unbelievable. So having the ability to at least blow up that balloon delay things allow the certain to see where the problem is is really critical. So if Leeds Air really, really old or the patient factors suggest, um, suggest problems, then then we'll put up the bridge, balloon the actual bridge balloon and and go from there. On the other hand, if they're considered low risk, then what will typically do is just put up the wire and be ready to put up the bridge balloon if we have thio. So those are the two scenarios, so low risk patient might be Thank you. Appreciate it, though the surgeons air off. We're good. Um, if the pay you know, less than 10 year old lead something like that, less than eight year old lead again. It depends a little bit on. What's your what you perceive your risk would be based on your experience and so forth. But we would we would generally, if we feel it's a high risk procedure. Multiple leads. I see the leads, um, patient issues. Then we'll put up the bridge balloon early. Ah, size that figure out where it's supposed to go and then go from there. Any trip tips your tricks taking out of twilight? Fine line or yes, the question is any tips or tricks taking out a fine line or any other challenging leads. So the lead design matters and and the different models matter. So you want to make sure that you you understand what lead you're taking out. The fine lines have a fixed helix, so you're not gonna be able to retract it. You know, trying toe turn the lead around, you know, generally doesn't work to unscrew it. That's one of the problems with fine line. The installation on fine line tends to be a little bit friable, too. What we typically will do with the fine line is actually not cut the lead, so we'll use we'll cut off the ah, the little silicone fins that fit into the header and then and then lock it with the lead still intact, not cut. And then laser over that with the 14 French, and that typically works reasonably well. Look there, Um and then the other leads that air. Particularly, uh, you know, things to think about a reality leads those almost. You know, you almost always tend to have to go to a 16 French laser sheath with those. So that's one thing to consider early on is just go to a bigger, bigger French, uh, extraction system. If you have Thio for those, get a comment from Dr Shower. Congratulations. Great case. Do you think about using a busy? Is it correct? Okay. Mhm. Well, thanks, Rob. You know, if Rob Shaller does it, then it's probably the right thing to do. So, um, we do use it, actually, for some cases? Absolutely. Um, I think you go either way. I mean, we tend to do a lot of that dissection with the outer, um, in certain locations and having a busy sheets actually really nice for that. So I I can't disagree with rob, you know, he he does, he's and he's very good at it. Got it right now. Okay. Questions. Okay. Very good. Yeah. So I think at this stage, we're re implanting the the leads. Um, atrial and ventricular leader about to go in. Looks like Bob may have double wired theatrics. Esports eso that were ableto now put in two seats and two leads for this and again the whole time we're watching the patients, you know, it's rare to get bleeds that occur slowly, but they can happen. You can get a late Tampa nod or a late, um, problems that does occur in some cases. So obviously we watch these patients. Um, many of these patients will stay overnight. Um, in the hospital. It's a really easy extraction upgrade. Whatever you know, some of them make makes you go home. But again, if it's something difficult will watch overnight and be careful. If it's a lead extraction, they start becoming hypotensive later on. It's tamponade until proven otherwise. So you have to be cautious about that, and you'll know, based on the procedure, how much time you spent pulling and pushing in certain areas and so forth. You know, we're doing any other questions, so we should okay up. Oh, yeah. So I'm reminded to remind you all, um, whoever is watching, we appreciate your Ah, you're watching. Ah, toe ask any questions that you have. We have about another eight minutes, and we will ah, will be happy to take any questions. Ah, with it. One question I get, uh, you know, frequently people when they're starting a program is which leads to tackle and and how toe how to go about that 11 way to do this is really start with sort of the class one indications. And, you know, don't be shy about referring cases that you're not ah, comfortable with, um, you know, I've been doing extraction for 17 years, and when I see a tough, tough case, I'll typically, ah, do it with another operator. So we have two people. Um, you know, we can We can bounce ideas off each other if there's problems, things like that. And it's helpful to have a second person in those circumstances. So as you start, start with clear indications, start with leads that you know are going to be straightforward leads. Build up your experience that way on Ben, as someone more experienced I think you can start to tackle more difficult cases. And again, um, you know, don't be shy about referring things that you feel there is still a little bit out of your your experience level. And again, I I've been doing this for a long time, and I still, uh, tag team and double team with others when I have thio still waiting on a few. Okay, 24. One other thing thio bring up. In some cases, we'll use, uh, you know, obviously, um, if it's if it's a infected pocket, we we will break down the whole scrub. And if we're able to implant on the same setting, we will do that on the opposite side. Obviously, Uh um, but a whole new set up. We don't use the same set up for those many times when they're infected. You can't do that, and you have to put in a temporary pacing catheter so we can We can usually do that through, you know, standard pacemaker lead through the jugular vein or through the subclavian vein or something like that. Just put that in, screw it in, and then and then attach that to an old device that works reasonably well for those. Yeah, Yeah. Now, if you do need to snare what's kind of your approach, Yeah, Yeah. There's a lot of different ways to snare these this way. Okay, so a lot of different ways to snare these. So, uh, it depends a little bit on what you're left with. So if you have lied where you can't get the edge of the lead, then you may need sort of a needle. I sneer those who are cumbersome, not always easy to use. Another technique, which I I learned from other people, is you could put up a catheter, uh, get around it and then goose neck the catheter and then use that as a platform to snare. If you do have, ah, lead where the tip is is free, then a goose neck works really, really well. Typically, I I don't mess around like a 10. If I go with the 20 goose neck, so it's big, and you can you can usually get in. It's nice to have lead with a large sheath with a little bit of a can't on it. So not a straight sheath. If you're gonna use a goose neck because you do want to direct it. Um, sometimes you might even need something like in a jealous to direct it to get the goose neck to go where you needed to go. It seems like it should be easy to just put it up there and goose neck something. But sometimes you do have to direct thes to find the right spot to get it so that that's that's, you know, one way to do it way had a question about of McCain. Yeah, there are benefits. I mean, sometimes there's just calcium you can't get through. Um, there's fibrosis, you can't get through. And so the mechanical tools work really, really well. And we've learned from some of the experience from there's other other folks in other countries where laser is not available, mechanical tools are available. They've done a really good job being successful. Um, just with mechanical tools alone. So they do work. Um, there for me. I find that it it'll you know, if you keep, you know, doing that it'll hurt your arm after a while. So you gotta alternate leads, alternate arms. Take a break here and there. But they work. I think for some people, it's very useful for the first, you know, first part. So you can use the mechanical tool, get through the first area of fibrosis and then switched to a laser tool that works really well again. The areas of costing or the superior being a cave area where you wanna pull a little bit, make sure that you're off of the wall of a cave if you can. Okay, so the leads air being implanted. I think we have about a minute left. So I just wanted to take the any questions, Commander. Okay, Yeah, that's a hard one to explain. If you sort of push and you just feel like you're hitting a wall, oftentimes that's especially if you're starting to pull you saw at the end. Okay, so at the end of this case, you saw as we were pulling back, the lead just wouldn't wouldn't come into the sheath. That's kind of what you feel with snowplowing. You're pulling your pulling and you just can't get over the thing that's very different than calcium. Calcium just feels a little different. Uh, it's kind of hard. There's a little more crunchy. I guess you can see it sometimes on then. Oftentimes, the outer helps you get through. That will help you get through both of those circumstances. But even when the outer goes, you still can't get the inner. If it's if it's snowplowing. Eso that's that's one way to tell the difference when e to up size. Yeah, if you're not making progress, I think it's time to think about upsizing or different, different strategy. Go to a different wire or something like that. We're good. Okay? I just wanted to thank everybody here and thank all of our staff here. Thank Doctor Can be my colleagues, everybody and appreciate everybody watching. Thank you so much. Thanks to Phillips also. Thanks.