Lead extraction is preferred for lead revisions and system upgrades: when less is more.

Cardiovascular implantable electronic device (CIED) use has increased exponentially during the past decade,1,–,3 with >4.5 million active devices and >1 million new leads implanted annually.4,5 With expanded CIED use and indications for device therapy, observed complications have increased in parallel.6,–,14 The occurrence of more frequent device system revisions for complications,6,–,8 system upgrades,15,–,17 and/or lead malfunction9,–,13 and longer patient life expectancies have mandated a paradigm shift toward premeditated lead management strategies from implant to removal or replacement. Consequently, clinicians increasingly are faced with the challenging choice of extraction or abandonment of sterile, superfluous leads. The decision is difficult and highly controversial,4,18,–,26 with limited rigorous evidence and passionate arguments on either side. Response by Henrikson on p 424 We contend that although decisions regarding extraction in these situations must be made on a case-by-case basis after considering multiple patient- and physician-related variables, lead extraction should be the preferred management strategy for lead revisions and system upgrades. Randomized, controlled trials of extraction versus abandonment are lacking, but the available evidence from observational, cohort, and registry studies supports the contention that the potential future benefit of lead extraction outweighs the risks of lead abandonment and that lead abandonment should be viewed as a “palliative procedure” that “just postpones the inevitable future lead extraction.”27 In patients with venous occlusion undergoing the addition of a lead with plans to preserve the existing leads (eg, VVI to DDD implantable cardioverter defibrillator, or DDD implantable cardioverter defibrillator upgrade to BiV implantable cardioverter defibrillator), venoplasty, when possible, is the preferred approach. In many such patients, the venous obstruction is short in length and …

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