Chapters Transcript Video Ten Commandments of Lead Management Dr. Love covers his 10 commandments surrounding the lead extraction procedure. The Bible for these 10 commandments is the 2017 HRS document. Um one of the signatories on this. Um I was lead author on the first document in the year 2000 and then the second author on the next one and one of the many authors on this one. And this became like uh you know it was to my opinion a little bit more than it needed to be. But still this is going to be um exhibit a for both the plaintiff and the defense as well. So I know this stuff it's gonna be very useful. But these are guidelines as a consensus statement and their guidelines, they're not mandated standards of care and that's really really important. So I'm going to provide you with Dr. Lo's 10 commandments. So one that should have no concern greater than the welfare of the patient. Okay. That is if you put everything through that filter statement isn't the safest and best option for my patient, you will never make a bad decision. Okay. You might have bad results for some reason another but it will have been done for the right reasons and I just can't emphasize that enough. And the safest thing for the patient is usually especially infections get that thing out of it. Is the procedure indicated if it's not you're gonna be you know the malpractice guys are on tv every day they're gonna be calling whoever your latest malpractice dude is out there. I walked by barry Glaser's office in town here. Just if you have ever seen the ads for this barry Glazer. What a what a piece of work. This guy. He goes, I'm so rich, I don't need to sue people, but I love suing doctors. He's just such a piece of work. He's got office right here in Federal Hill. So anyway, even the smallest risk is not reasonable if there's no indication for the procedure. So you know, doing something that's not indicated is you might get away with it. But if there's ever a complication there, you won't have a leg to stand on because one, You know, even a 0.1% risk Is a 100% event in the patient who has a bad outcome. So you know, you can tell, 0.1%. But if it happens to you is 100%. And actually if you think about it for each individual patient, it's a binary thing right? You're gonna have a complication, you're not gonna have a complication. But if I have 1000 people in the room, one of you is gonna have a complication, but I don't know which one it is. I don't know if you're the one. Okay? So you've got to have that that indication. Um and proceeding without proper training, experienced personnel and equipment and backup is reckless and it's very hard to defend to the patient's family when you have to go out and tell them that, you know, Aunt Minnie is not coming home for dinner tonight. So second commandment thou shalt be prepared for disaster titanic. Um If it's not happened to you it will. So if it hasn't happened you just not done enough procedures. Uh Your chair picking your cases. Which is not a bad thing when you're first starting out you're better than the rest of us doubt it. Uh So what can happen? We talked about all these things. Lots of things can happen that are bad. These aren't the only things but those are the ones that will kill you or hurt you bad. So we talked about what to have ready your cardio synthesis kit, the economy trade the proper and working saw cardiac ultrasound blood all that kind of good stuff. Um We talked about the good stuff and a surgeon. Okay. Not just any surgeon. Okay. You don't want the first year fellow. You know doesn't know what they're doing. Uh You want a cardiothoracic surgeon and not just any cardio thoracic surgeon. Okay You want a surgeon that is knowledgeable about the kinds of injuries that you can cause and how to fix them. And and that is a really important thing because a lot of these folks have never seen this kind of injury before. And and they need to kind of have a plan ahead of time when when I had my first Emmy at N. Y. U. Was a first year attending that came up to help me. He was a wonderful guy. But he literally froze for a second. He literally when he opened the chest up and all of that blood came out, He literally froze and the anesthesiologist was an ex Vietnam vet. Um And this guy was great all right, put your finger in the hole, take a deep breath and figure out how you're gonna fix this thing. And he did. So you don't want some guy some hack that really doesn't know what he's doing. He's out on the golf course. You need somebody who really knows how to fix the injuries, somebody's immediately available. So the bottom line is I have a plan okay you gotta have a plan for disaster. Alright so third commandment thou shalt have and assemble the best team you can find your scrub assistant circulating nurse monitoring nurse anesthesiologist, documentary and crisis manager because your documentaries the one when it hits there, the one that's gonna call the surgeon call call the O. R. Desk. Get all these people going. They have to really be on point. These people need to know what you're doing and they and what they are doing and what to do in case of trouble. Train them and drill them and and this is actually the document. It's a good idea to have a fire drill. Um You know let's pretend that we just had a bad thing who's doing what, whereas you know who's who's opening up the bridge balloon if it's not already open, who's who's getting the parody artist who's calling the surgeon, who's you know who's opening, you know, where's this guy? Where's the where's where's the pump? Have this stuff going? We we are sometimes doing cases in a different room that we typically do and before we started, we don't walk through with profusion. Okay, in this room, here's your gas is, here's where you're plugging your pump in. We're gonna be standing here. So you're gonna put we had this all mapped out, We had it all figured out before we went into that room. Nothing happened. But we were ready? Fourth commandment thou shalt know thy patient. What was the primary reason for the device? Are they dependent? Do they still need advice? What's their cardiac diagnosis? Do they have big vegetation? You don't want to go, you know, shearing off a three centimeter vegetation that's gonna go out and include the pulmonary valve. What's the condition of the venus anatomy? Is it included? Is there evidence for an anomalous lead implant or anatomy? Cts can be helpful for that. I don't do a lot of that, but it can be helpful. And what are the other comorbidities of that patient that can include bleeding issues? Are they in warfare, in which your I. N. R. I'm okay with an eye on our up to about 1.8 and there's actually some some stuff coming out now that's going to be presented in the upcoming HRS and era meetings about doing cases on warfarin, what about no ax. And oh my God Clopidogrel and Prasugrel. I hate those drugs. Um Sepsis COPD intubation challenges severe heart failure. A need for other cardiovascular procedures. I mean these are things that you want to know about before you go into your to your patient. Uh huh. This one here and know your C. I. E. D. System. What's the condition of a pacemaker in the I. C. D. Do you need to replace it? It's only got two years left on it. It's got nine years left on it. Uh It's something on recall. You know you want to go put a new put another take a device out and you're in there and the devices on a recall and you're gonna put the same device back and that's not too smart either. What's the condition of the non targeted leads? Measure your impedance and capture and sensing thresholds before and after you do the extraction of your targeted leads. And if there's a significant change then you may have to go and remove a lead that you've not planned on removing to begin with. Uh And are there any special extraction issues related to particularly fine line leads? We don't even talk about some of those uh they're very very challenging to remove. So you you may not want to cut that lead. You may not want to cut the connector off. You may want to leave the whole thing intact and then use it as a very thin lead, you're gonna have to use a 16 laser 13 type role and someone or something like that. So I know what you're getting into and if you don't know call call, call, call, call me work with people who do a lot of extraction. Love to talk about it. We love to talk to our colleagues and help people out. Um because we want this to be, we want you to be successful, we want your patients to survive because we want to get rid of this stigma. That every paper I read about extraction always starts off with. This is a high risk procedure is a risky procedure. It's no more risky than than you know, 99% of the other procedures we do if it's done right? Sixth commandment thou shalt know what you are doing, Okay. I watched the training video and I'm ready to go right the is stupid. Um I watched an expert do one or two and I worked on a simulator A little better but still not the brightest thing or you can be like this guy. Uh I studied the techniques, the tools, consensus document trained on the simulator and extracted a minimum of 40 leads while being proctor. Okay, that's hopefully the way most of you folks are going in. Maybe even more than 40 leads because 40 leads depends on the leads. 7th Commandment Thou Shalt have a plan. What approach are you going to use? Where is the incision incision is going to be? If the device is very low, you might want to make a second incision up higher so you've got a straight shot in and your sheet doesn't come up and around, which can be very difficult, especially from the right side. What tools are you going to start using? Is it calcified? You can start right off with a mechanical or do you just I start with mechanical on most of mine? Or as the lead pulled apart, you can't get a locking style into it. So maybe I'm going to use the laser to start off with or maybe I'm gonna use ephemeral approach to start off with. How are we going to maintain access to the vessel? Really, really important if you're going to re implant And what are we going to do after the lead is removed? What's your plan for management of the patient at that point? And even though you've got a plan. One of my favorite quotes. Everyone has a plan until they get punched in the mouth. Okay? You don't know what's gonna happen. You got this great plan and then something happens. The lead breaks. You can't get a locking skylight inn. Um You know, there's there's some kind of thing that's gonna happen. So the eighth commandment is you can have a backup plan? What would you do if the lead cannot be extracted? What are you gonna do? If you have to go to a different venus access approach? What do you do if your temporary lead dislodges, make sure you've got that external transportation device hooked up. What do you do if you can't get the lead out with the tools you have on hand? Lots of different things you want to have an idea. You know, it's not you don't want to do these things on the fly, You kind of want to have an idea where you're gonna go. The ninth commandment thou shalt have all of the tools with which to perform the operation. Having a single tool to take out of the lead is like having a single wrench to fix a car. It might work some of the time, but it's not gonna work all the time. You have to have and be trained to use different kinds of sheaths, snares, style X. And any other tools to help you be successful. We use all kinds of stuff. I mean I used by op tomes from the gastroenterology suite, we use uh the flexible catheters jealous, we use different snares, goose neck snares and snares. Um you know, all sorts of different things. The wrong wrench battle results happen when you use the wrong tool for the job or would use a good tool in a not so good way if something isn't working, don't push or pull harder work. Smarter change, go to the other lead, come back and forth? As eric was talking about. You know where the weak spots are in the anatomy as you come around to the Kaveh as you get to the cable atrial junction. Those are the where you're more likely to have problems. Is that lead plastered against the lateral wall of the Superior Vena Cava. That's where I get a little concerned about things. So the 10th commandment, you shall know your limits and when to seek assistance. Even when the best extractors coming upon leads that can't be removed. Um there are times you shouldn't take things out if they're extra extra vascular, if it's going through an artery. Um There are different, different reasons why one might say, you know what? Maybe a surgeon should help do this. Maybe do a hybrid approach or maybe they should just take this thing out with an open chest. Or maybe this is just the lead we leave behind. We just choose to lose the battle but win the war, communicate and consult with all of these other people that we talked about. Have a team. Talk about these things ahead of time. How we're gonna manage the infection. How are you going to manage these different things? So in conclusion, pay attention to these commandments which I have provided for you this day. If you stray from them, your patients will not fare well and your referrals will dry up. If you heed them, your skills will grow and your colleagues will look upon favorably upon you and your patients will be alive and great. Okay. And now it's time for breakouts and you have questions. Ask her questions, wow, torture. I've got a couple of things that had, I think, I think I got my mic. Don't you want me to? Yeah, I've got the mic on. So um one thing that I've found that it's useful is if you open up the pocket and you see this really calcified pocket, you can break it up. You know, if people have coronary disease, they often have peripheral arterial disease or vice versa. Right? If there's calcium in the pocket, there's probably calcium in the uh in the vascular church. So those are patients, I would just go obviously I look at the whole case but go straight for a mechanical tool in those in those cases. So yeah, this is really good advice. And one of the things that he's saying is the quality of the tissues including calcification in the pocket. If you make really dense hard fiber optic tissue in the pocket, you're probably gonna have it all the way down the vascular, just calcified. It's probably gonna be down there and should consider mechanical instead of laser. If it's if it's calcified that way. But I I agree. I found that that is really, really helpful to know. And on the and on the other side, if you open it up and the lead just kind of fall out and the tissues are just kind of gummy and everything. It's not infected. But just, you know, 98 year old and many just doesn't make very good scar tissue. The leads sometimes they just pull right out even, you know, 67 year old days. But that's that's a great point. Um with respect to when you have a tear. Um One of the things we talked about is um bypass, you know, as as an option to kind of bridge you to definitive repair. So when a tear occurs, the room in an ideal world of rooms really, you know, people are ready. They know what their job is gonna be because he ran through fire drills. But in reality you feel bad because you know, something is happening. The surgeons probably, you know, got an elevated sphincter tone because they know what's about to happen and everyone's a little bit on edge. So knowing what each person can do in that position beforehand is helpful. So you as the person who are not certified in doing this tracheotomy, probably once you get the balloon out, it may be best for you to get out of the way. But if you're gonna go on fem fem bypass, most Gps these days are trained at large bore access and a variety of other things that are good with wires. You're trying to find the surgeon, you're trying to find the surgical assistant if they're not already in the room, you might, if you're trained, be able to do the upsizing for the bypass. I'm not saying that you should do it, have a conversation. But you know, for in fellowship I put a lot of patients on peripheral ECMO as part of moonlight. I can put people on bypass pretty easily. So um we haven't had to do this. But you know, if if need be during a procedure, I could go to the groin and do that while they go up and it just gets you into the chest faster. Just just no don't be in the way in a situation like that. But know what you could do, ask if you can help and maybe just say just get out of the way. Um The other thing is when you have a tear, it's useful for you to sit and watch the repair because you'll learn about that afterwards. Um You may need to go talk to the family and kind of give them an update or something but to the extent that you can stay for the whole procedure to stay for the whole procedure because you're going to learn about what happened and how you can try and prevent it the next time. Uh Last thing I was gonna say is more from a billing perspective. So we talked about the virtual RV US for surgeons. one of the things when I was neglected to mention this last night. But when uh when we were trying to build a program, uh, at Sentara, you know, a question was asked about, you know, relative reimbursement for extraction versus devices versus ablation. And I kind of made the comment that for our view perspective, it's not as, you know, lucrative from a physician perspective is safe ablation. So it's true that you can't build, there's no code for like a third lead or abandoned leads. You can have a discussion with your, with your hospital system about them granting you virtual our views for harder procedures actually did that. So we kind of came with an agreement that, you know, we're gonna have a bigger program and take on leads that weren't super easy and not refer them out. And so we kind of all came together and we came up with a modifier that we just used internally for extra RV use for us. I think those are, those are discussions you can have in the process you might hear no. But if you don't ask, you're not, they use the modifiers, learn how to do this. Most people don't know anything about these modifiers and they just put in just a code for lead extraction. Well, yeah, you can build for the device removal. Some people you don't realize you can build for the breeding that pocket. I mean these things all add up. I'm one of the highest our view generators in, I think I am the highest r value generator in ep and I'm do ablation. Um, but, but I do a lot of this kind of stuff and I do a lot of stuff in the device clinic. And when I got two options, they weren't building for anything out of the device clinic, It's like, what are you nuts? It's all low hanging fruit, so it's uh, it's an important thing and unfortunately, it's not taught during fellowship, should be sure. Published July 8, 2022 Created by Related presenters Charles J. Love, MD, FACC, FAHA, FHRS, CCDS Professor of MedicineJohns Hopkins HospitalPresident, International Board of Heart Rhythm Examiners
