This live recorded observation highlights key aspects in lead extraction from pre-case planning to extraction strategy. Drs. Canby and Al-Ahmad share best practices as they progress through the procedure and answer questions from the audience.
My name is Amin al Ahmad and my colleague dr can be and I welcome you to our lab this morning for a live case trans uh for phillips. Uh we're performing a lead extraction um patient with transposition so hopefully we can get through and uh answer questions as we're doing this just to go ahead and tell you a little bit about the case. Um You haven't given next. This is a 29 year old with a transposition. It looks like it's a congenitally corrected transposition. But this is the history we got yes Epstein's anomaly of the systemic valve cork patiently aorta and congenital, complete A. B. Block in 2000 and two at a single chamber pacemaker. In 2009. It was upgraded to a dual chamber which is uh with a 38 30 lead. Uh echocardiogram shows that is systemic ventricle is uh is uh concerning in terms of uh failure. In addition with the abstains, there's some concern with that. So the plan is extraction of the pacing system and upgrade to an I. C. D. Um This is just to give you an idea a little bit about what different types of transposition Zlook like um in this particular case you can see it does not appear there's a baffle but but just so you get an idea what it looks like, keep going. Um This is different patient to also as transposition. So some of the things we care about when we look at um device extraction is how many how many leads are in their number of leads? The type of device. The lead models are very important for us that the type of fixation where the leads are located, the date of the implant. All of these are factors that help us determine how to do our extraction, how to stage, things went to get surgical back up when not to things like that. Some wires are more difficult to take out than others and so forth. Um patient related uh co morbid conditions, age of the patient, prior cardiac surgery we believe is a little bit helpful. And then obviously pre op testing for many of these includes an echo and all patients, a chest X ray and a CT scan in some cases can be done. Although we argue back and forth about the value that okay, informed consent in this particular patient. Somebody may ask, well why not just capital lead? And that's not unreasonable. We typically will uh make sure they understand the risks and benefits of extraction versus capping chest X ray always to make sure there's no surprise leads. And then obviously we have um uh cT scan in some cases surgical backup, appropriate equipment. Always defined roles in case of an emergency type and cross blood is available. We are to really monitor all of these patients. And we have a high volume venus line. Okay, temporary pacing in cases where they're needed. Like in this case we look at the lung fields before we have a T. Probe and a bridge balloon. So, just to give you an idea in this particular case, what we've done already, uh as we have uh, gotten all of the groin access. So, we have an arterial line um already in place. We put in the high volume line, we put in the temporary pacing wire. And we put in the bridge balloon and we've staged the bridge balloon to make sure exactly. We know exactly where to deploy it. Post extraction. If there is a re implant needed, what type is it And then uh do you need to go lead list? You need to put in immediately? Can you wait should you wait all of those things for things we need to think about in each patient with that again, where we are now in the procedure as we've already gotten growing axis. And you can see, I don't know if you can show them the way that we took a minute ago. Mm. Yeah. And what you'll see is we we place the balloon just to be sure where it would go since these are about 20 year old leads. Um, So the groin stuff is all done. Dr camp has already gotten access from above. Typically, we will get access from above before we uh, extract because sometimes as you extract, it may become challenging to get access. So there's the balloon, you can see there's maybe one more picture after that. Yeah. So that's kind of where we thought the balloon ought to sit. And so we marked the balloon itself to ah to be sure where it is okay with this. I think what I'll do is I'm going to go ahead and scrub into the procedure and if you have questions, we'll have a discussion during the procedure as we're doing it, I'll be talking about can be, but if there's questions from the audience, we welcome them. I think there's a method to go and again, thank you to phillips for hosting us and we're delighted to have everybody here in Austin with us remotely. Thank you. Mm hmm, mm. Uh huh. Okay. Are we pacing in there? Yes. Yeah. Please just sneak behind you. Yeah, Yeah. Mhm. Just move the away for me, please. Mhm. All right, Okay. Mhm. Mhm. Okay. So we're up here near the pocket. One of the things that you obviously have to take care of is um in addition to the pacemaker with Bobi, make sure you have a backup ready this patient. The device was set, you know, pullers that creates an additional issue and that the sensing vector is higher. Okay. Mhm. The other issue, of course, is that when you take the device out of the pocket will stop pacing, seem to be ready. And again, as I mentioned, access before is always my rule and dr Campbell's rule. So if there is a patent vein will always get access. The vein is not patent, we will uh use the extraction tools to gain access. We're prepping the laser in anticipation. Are not even, yep. Yeah, this is uh of a skin blade. There looks like there's a bachelor tie here. Okay. Sure. Yeah. Yes, single coil likes to do would be fine. Yeah, I think, you know, comments per second about choice of re implant. General single coils probably adequate. And um in somebody who's this young, you know patients uh fairly young and may need further devices down the road. Having a single coil is advantageous because extraction may become the norm for this guy. Did did you see the Elliot view that I took the pictures? Everything's a morphological. Right, okay. Yeah. Yes. So it looks like it generally corrected with a abstains. Mhm. You have an Alice over there guys Alice the amount of calcium around the device site today. Have you miked up bob or no? I think I am liked up. I don't know if I'm on. Okay. Is bob on? Mhm. Yeah. Mhm. Okay. So now with the device out it will cease casing. But obviously we're pacing transfers were pacing Trans Ministry with our temp wire at this point. What I'm gonna do is go ahead and free up, hold on over the calcium. There you go. I mean to free up the both leads up to their soaring. So even if you're not intending to take the leads out typically will try to free up both leads because there's often a lot of lead lead interaction that occurs and that lead lead interaction, you can manage it a little better if both leads are freed up and ready, there's a balance of course you don't want to damage these leads as you're freeing them up. But I think that on average that's a good strategy, especially if one of the leads you want to uh take out is older and ah lead. You want to preserve maybe ah you know, they may be in the same fiber sheath so that becomes an issue. Yeah, there's a fair amount of calcium in there. Yeah. So there's calcium in the pocket which you see a lot of younger people in particular with older pockets. We like to try to get it all out if we can at some point but we'll see how that goes and it ah makes you always worried a little bit about intravascular calcifications. Mhm. Killer. The 38:30s are also usually fairly long leads so they may have multiple coils in the pocket. Yeah. Yeah. Remember 38 30 is delivered through a sheath so it'll be definitely longer, It has no loom in. So that presents some issues. If we do need to extract it now this 38, I think the plan would be to check to make sure this lead is okay. If it's okay we'll leave it in. If it's not okay then we'll probably have to extract it as well. I just can't tell the path that it's taking. Yeah. Yeah. Yeah, jeez. Mhm. Trying to be careful when I grabbed the 38 30 that I'm not grabbing it too hard with forceps that would enter, you know, that would damage its installation either. Yeah. Yeah. I think that's one of the things that you appreciate after a while is when you take out leads, they do end up being often uh intertwined and while taking one out you can inadvertently damage the other one even with just katari and uh working on one lead, you end up damaging the other. So I think that's something to be cautious about. Yes. Yeah. Yeah. Do you find bob that uh if there's a lot of scarring in the pocket, there's a lot of scarring, intravascular, or does it seem to correlate, do you think there probably is a little bit of a correlation? But you know, we've seen clearly, we've seen cases where there's no almost no calcium in the pocket but the leads thoroughly have a calcium shadow and X ray. There are other times where just the opposite occurred. See a lot of calcium in the pocket leads come out. The problem is this needs it sort of goes laterally somewhere. Can you see it? Or as the, see if I can we're going to free all the calcium. There is. It's a big chop right there. My concern is I thought I saw a break, is it okay? It almost looks like they're say yeah, a insulation insulation issue with that there. And that's not a place where we had actually been working on. So uh if that's there it's it's potentially real. It's potentially real. It's hard to tell for sure. So what I'm gonna do now is try to get down to the soaring so rings on both of them. Yeah. See if we can what we could do in the interim check out. Yeah, let's do that. All right, john I'm gonna undo the a lead so you can just check it real quick. Mhm. Do we have? Mhm. Mhm. Yeah. Okay. Let's take a look here. She'll probably complaining bolding as he's trying to check. Let me know when you want to check and I can Okay, I don't P waves. Mhm. Mhm. Okay. Mhm. Yeah, I see capture on the screen, john Yeah, mm. Yeah. Really? Peter this is stable. Okay, good, mm hmm. Great p waves and lost it there. Okay. The thresholds between one and two. We just have to make sure that there's no insulation issues with this lead and if that's the case, the lead actually might be good. Right? Yeah. Getting down to the Soul. Yeah now there's the service for the HR lead there 1.4. Okay so those are pretty good numbers left to figure out. Of course if things stay stable. Yes hockey looks nice and clean. Everything looks pretty good in there. Mhm. We have a skin blade to cut through the future on the, yep so ring it looks like a single tie sharp up. Mhm. Yeah. Yeah sure freedom. It's fairly it's pretty beat up beat up. Okay just you see if I can help you out of that. Yeah it's coming out piecemeal of the future time. Yeah. Yeah. Mhm mm. One of the things I've seen is people try to take out leads without um tying this you and you'll see people who we'll send the case because they failed to take out a leave. It was two years old when you know it should come out with a distraction. And the reason they failed was they didn't untie the they didn't undo the tiring. Um Yeah the skin blade again I'm gonna do is cut the because there's a little calcium to the lead itself. Mhm. I'm just going to cut the soaring off I think. Oh yeah you see that calcium right there. Yes. Yeah and I think that will get us you ready to disconnect the weed? Yeah I'm just gonna remove a little bit of calcium so the regular razor over it without uh I'm gonna disconnect this even though it's not obviously I'm facing because they're out of the other thing that sometimes is important is to Mhm. Try to dissect down the lead a little bit just to make sure there's not another unexpected sutra tie that slipped off the soaring. Just not sure because every once in a while you do see that. You do see that. All right, let's get the let's get the clearing style it please. Okay, here it goes. So, um I think this is probably one of the most important aspects of the procedure is seeing how far you can get a style it down and notice the heart. Please. Yeah, we got all the way down, getting down, just put you so for so much further ahead because then you can control the lead ah much better. That seems to be a reasonable length for it. Yeah, we'll see if the Felix will re trash. Yes. So one of the things with this is often takes you a lot more turns than normal, but you do have to be careful about overturning this. I think it can tighten up the looming in some leave models. Do you think he came back or not? I don't think so. What I'm gonna do is just move the in and out just to make sure that transmits a few more times. Yeah, I also like doing that just to see how tight this thing gets. Because I've seen a few weeds where it gets tighter and then it really let's get a disadvantage. Yeah, I'll do it a few more turns here. Okay. Mhm. It doesn't really look like it wanting to move very far. No. All right. Just go ahead and prep it for. Okay, there's heavy scissors, The Iowa You give us a little more space, please. Here we go. Go ahead and cut it. Yeah, you can bleed. Okay, sure. So, maybe uh I can talk about what you're doing or if you want to talk what you're doing. So, basically trying to get the inner coil, you can see here that we've exposed the inner coil, which is right there. This is the outer coil inner coil and insulation. So by doing this, we can easily put our locking style it down the inner coil again. That's probably one of the most important aspects of these procedures. This is a an easy locking style it which is Little Wet four x 4 here somewhere. Let me just clean off my fingers. So once we've, once we've demonstrated we gotta clean entry into the lumen. That's why I cut it a second time after I freed it up, we can hopefully be able to put the locking style it down. Yeah, I can get it to do it. Here we go. Mhm. Yeah, the nice thing about this, he shows the you can see this coming down. It's going to be the dark band on the top of the screen. Yeah, advancing on the T. Probe and spending a little bit there. It is, right there, right at the turn and it's coming down toward the proximal electrode. Getting stuck, spending a little bit extra time making sure you can get this. You look like you went through a little bit bob. Yeah, I think you may be in between, yep, that's it perfectly. The this electrode and a proximal electrode. You can see the marker come right through there. So we're down at the tip. Okay. And so we're gonna go ahead and expand this and I think you can see it on camera, but basically that's just pushing this forward so that now it's all crumpled and drive us out for a second please. Okay, so that's one aspect of getting control. The lead. The second aspect is tying to the installation. Mhm. Yeah. And then tying that future to the other part of the locking stay wet. Mhm. Yeah. So I just by the series of square knots to the between the two through the open slot on this particular locking style. Mm. Mhm. All right, perfect. Already, I think we're about ready to start layering at this point. So we got our laser ready and so let me assess Bob. Why did you choose a 16 laser on this patient? This is a medtronic 4068 least it enters through a nine French sheath. So it's a relatively large pacemaker lead. And then we're anticipating being that it's 20 years old. There'd probably be a fair amount of there's likely to be some calcification of the lead where it's where it's scarred in and in order to pass over that we'll probably need a larger, larger lead to our larger sheets to do that. So I think technically we could get away with a 14. But sometimes I tend to oversize on these older leads where I think there's gonna be some calcification. The alternative would be used 14 and maybe an outer sheath on it. Um and then maybe there wouldn't be quite as much of a mismatch in size. But I think for today, I think this will work. Thanks. So, one of the critical things here is getting everything aligned. Um The key with this procedure is really alignment. And then you can you can we see the rest of the room or is it hard to pan out and see the room? Just want to show you the laser sheath is pointing in a way, you know where the bezel is on the laser, based on the based on where the wire is coming off. And so you want to make sure that vessel is pointing away from from the outside of the sbc as you advance sort of basil on the inner side of the vein. Can we make sure our surgeons are available and everything is good. So again on this, we can I'm rotating the sheath itself. You can see that the sheath has a slight angle ation to it. I think about or so. And then what I want to do is get the the basil, the lengthy part of it, sort of on the inside of the vessel. Hmm. And we're positioned to go. So we'll just confirm that we have our surgeons available, surgeons confirmed everybody's kidding. And the other thing you can also see here is just as I'm moving and you can see the atrial lead there clearly as I pull on the one lead, it pulls on the atrial leads, it tells you you are attached at some spot. We might have to pull a little tension on the atrial league if it was not a luminous lead, a aluminum less lead. Sometimes I'll put a style it down that free it up and just give it a little more stiffness. But because this doesn't have a loom and I think we can just sort of pull on the outer insulation a little bit, put a little tension on it so it doesn't coil up around the lead that we're trying to take out already. So well, come on with the laser here, yep. Mhm. All right. Mhm. Forget the technique here is to put traction on the lead. That's what I'm pulling with my left hand on the locking stylus and you can even see already down at the tip of the lead. That logging style that has come back probably three or 4 mm. That's not unusual. We want to sort of watch that a little bit. And then I also used the the laser a little bit mechanically just to sort of see what I'm bumping up against before moving forward. Yes. So I think it's important to note that when, when, when bob's doing that back and forth motion, the lasers off that kind of pushing mechanically. It does tend to work actually get you through uh a lot of areas and I can feel there is some five Roses on that lead a little bit as I move it in there until I'm catching up on some of that. Can't see it. But there's probably a little fibrosis and calcification. There feels like it. Mm And again, it's an issue of balance of force. Trying to make sure that you're not pushing harder than you're pulling. Where where you might um you know be non co axial or pulling harder than you're pushing where you might break the lead. So trying to balance your forces, keep everything co axial and if you do that in our patient um vast majority leads come out. The other leaders sort of caught on it there. Yeah. Uh Can yeah that's a fair amount of tension actually. Mm. Work around that spot a little bit. Yeah I can tell there's there's definitely some something that looks good. There we go a little bit behind it. Mhm. Yeah. Yeah it's definitely got right there. I wonder if we should our options here keep doing what we're doing and see if we can make slow progress. I might take an outer sheath here in a minute and just see if we can get beyond this area. Free it up. Let me just see if I can again mechanically rotate the sheath a little bit. See if I can get past the other lead. Tell we're sort of caught on it. Yeah we're pulling on the other lead. Not much transmitted. Yeah I want to try them out. Yeah. Yeah. Mhm. Let's move the Iowa and sunny. Mhm. Yeah. My pressure is good so far so good. Mhm. I want it on the send. Okay little things. Well I'm just checking for sometimes as you pull it out if there's some calcium and fibrosis on the lead it comes to the exit side here at the vein and if it's there I pull it out and just make sure it's not in the way. But I don't see any today. That's the stuff that will end up snowplowing and getting. Sometimes if you intended to take out both leads going back and forth between the two leads helps. And it's still not out of the question. It's not out of question though. I might have to uh go back to what I'm gonna do is try to work back into where I was a little bit here. Let's see the outer sheet there. May have to come back on a little laser here again. Mhm. Then advanced slowly and I'm using the blunt end of the laser sheath, the outer sheath and that's just side one less pointy object in that I have to deal with. I'm just coming up advancing to where we were seeing. If I could work myself around that area of calcification, that's really stuck in there. Yeah. Be able to push through here a little bit. Looks like your outer just went beyond it, yep. The outer has gone through that area, but I'm still getting you think you can pull back the laser and see how much further the outer goes? Because maybe the outer can do some of the work. Yeah, it's like it's stuck right there to together. Yeah, it really is. Okay. Were the the laser won't go past where we are with the get to the end of the the other sheet. Mm Really got something actually. We're farther now than they were. Go ahead and come on here again, see if you can make some progress. Yeah. Yes, there are options would be keep doing this. Try a mechanical tool, take out the other lead would be an option to ah help free it up. It's really caught on it there. Even that is Here we go. Yeah. Further, yeah. Okay. Yeah, there's just a lot of mm I can't even get to the end of the or the other sheep that uh the leads coming back a little though there's just a lot of stuff in front of me here. The other question is uh mechanical tool might do the trick. Try that. Yeah. Okay. Yeah that's the larger one. Yeah it's hold pressure. You got it remember we'll need that little fish hook to pull that. Oh look at that. This is who's the eye out of the way every bit. So he so here is a little chunka calcium there. Yeah let me hold some hold some pressure there for you. So here's what I was talking about earlier. Here's our chunk of calcium. Let's see if we can pull the lead back through. Let me have a he must adhere to see if I can pull over. Okay. Yeah there we go. Yeah that's what yeah released for a second there and we may be able to go back in before we go with the other one. Does that maybe what was keeping me from our blood pressure still seems to be fine. I'm gonna have to cut this off. Can you guys see this on the camera there? That's what that is. That's a chunk of calcium. The fibrous material, very chunky. Yeah. This is the trying to break it free, cracking it like an egg. There we go. That's right. If you see that, it's a very calcified chunk of fiber optic material. Yeah. All right, that's all. Mhm. So four x 4. About two. okay. Get some more fresh for by force please. So, what I'm going to do, I think what I'm gonna do is I'm going to try to see if I can come forward with the laser again in that area without switching to the mechanical. Because I could feel there was something in front of me and that chunk of calcium would be a would be a good candidate for what was there? Okay, show us uh over the heart police, yep. Much easier to pass where we were. Mhm. So again, the same type of maneuver here, a little bit kind of pulling on the lead to make it further away from the spc. Using the outer yeah, that freed it up a little bit. Yeah, still an area there. It is nice, nice. And we're pulling on the ventricle, you can see that on the blood pressure. I'm coming down with the outer sheet a little bit mm Over the other one mm. Mhm. Yeah, same maneuver, tell by the a little bit of a connection there. Yeah, straighten the lead out a little bit. You passed it. So the outer is going beyond. You can see then. Okay, see if we can take the laser down now. Want to go ahead and plays here a little bit. See if I can free up. I'm gonna pull back the outer sheet a little bit because the laser is a little bit more flexible, so it might get past the curve, as you say, it is nice, but it's still caught up there. So, I'm a little spurning here. Past that. There we go. I'm going to come down with the outer again, Almost remember this is a 20 year old lead. So, uh yeah, this also you can dislodge the pacing wire because this over the distal electrodes passed a proximal. Now, I'm gonna take the laser down. Let's see if I can get it to go. Think my adhesion is actually further than where the laser is. Again. All right, so, in this location, this is where ideally what I'd like to do is get the outer of the laser sheets. Was close to the distal electrodes as we can. And then sort of hold that in place and then pull back on the lead, the traction counter traction technique and just some patience and time. And you see that just Felix actually came back. Now you can see that back. So it's all adhesion. So I'm holding my right arm fairly firm as I'm giving traction on the lead. Yeah, the tip of the laser is almost to the tip of the lead there. The tip of the outer sheath. Sorry, just some time. It's really stuck. And we're still doing OK from a blood pressure standpoint. Go through this technique again, you're right there. Mhm. Feels like it should come there. It goes all right. How's our blood pressure guys? Check the ice tea. That's all right. Killing. I'm gonna go ahead and withdraw everything here. Okay? Yeah, Got it. Then we can take a look at thanks. Breakfast still seems to be doing okay. Okay. Okay, well, watch that. Mhm. Just to show everybody what this looks like. Yeah, There's a tiny effusion risk. Have to watch it. Blood pressure stable. That's kind of This is what was holding a fair amount of fibrosis. It's no plowed up in front of us a little bit. You can see that the helix actually straightened out and that's what allowed it to release. Can they see that on the camera at all? Yeah. You guys see it? Can you see that Okay, guys? Mhm. Yeah. Mhm. Yeah. Blood pressure's still holding. Mhm. Fusion is small but stable. Very small. Okay, so, the next step I would do at this point, I'm going to have a Doctor al Ahmad look at this lead and confirmed that we don't think there's an insulation break on the. Just do one of those. Maybe just put it in the pocket and just fill it with saline or something like that. You try to get that freedom. Yeah, So john, what I'm gonna do is I'm gonna put where I think there might be an installation break on the lead in the pocket and then have you paste bipolar so that uh we'll fill it with some sailing or something just to see if there's a installation issue. Pull the It's just hard to say there's a little tiny dent on the lead. And so it's one of those things where we're trying to decide whether I want to go after the 38, 30 or not. I don't even know what it is. It's like a little tiny dent. I don't feel the coils of the of the conductors. So yeah, anytime you're ready Mr bull, Okay, come on, placing their I'm actually holding it up to a little bit of the pectoral muscle here. Yeah. Put some sailing in just in case there's no stimulation, impedance is stable with them. Okay, I'm moving it. Any noise or anything that you know nothing clean. Okay. It's probably fine. Yeah. Seven goals. Well why don't we uh see if there's any questions from the audience as things are uh wrapping down here? Yeah, I'm gonna go ahead and keep moving. Yeah. All right. Word. Yeah. Oh um keep, keep doing it. I mean, I think if counter traction doesn't work, it just means you may be or not being patient or haven't given enough time. I think on average if you're able to it'll it'll work. Sometimes you do need to uh uh like what bob did is actually used the outer and get the outer all the way down. And with that often counter traction will work. So, but that's a good time to be patient. I mean that's not the time to pull real hard um on the lead. Most of times you do that, then it will come fairly a forceful traction on it, holding the counter attracting sheath in place. Yeah, if you don't want to have happen is holding the sheath in place and you're pulling and do this type of motion as it releases. So you just want to really knock block that one down firmly. All your attraction is really being done at that point on the on the lead itself and sometimes the patient, sometimes they take five minutes and it will ultimately uh pull free from the I don't know if the audience heard the question, but the question is, what do you do if it doesn't release um as you get to the tip and and the answer is generally be patient and and do the maneuver and it should, it should. Okay. Mhm. Okay. So right now the uh the goal is to put down an icy D lead so we already have access to that part at least is done so you can see um yeah, the access was done through the skin, so now that's been dissected into the pocket and it's just gonna come out and so now we'll easy to put down a sheath and ah um go ahead and put in a cd lead for this gentleman again, single coil and somebody who's young unless there's a real good reason not to make a lot of sense. Mm. Yeah. Any other audience questions coming through? Mhm. Yeah. Let me talk a little bit about some of the other strategies that we could have done. Um Just because I think the reason I think this worked was in part just a lot of uh you know patience and um going back and forth and I think that what you may be, uh one of the good examples today was pulling the sheath out and clearing it of uh sort of uh junk that's in there, particularly calcium and stuff that causes snowplowing. That's that's what's causing that. Okay, uh let's take another look at t before we release the hour. Yeah. Yeah. If you could take a look at T one more time and then if that looks good we'll release the O. R. You see like sheep. Mhm. So the uh typically very goes very smoothly will release the or in about five minutes after we extract the leads. Um Obviously we have t available. So we're watching in somebody like this where it's really difficult. Might wait a little longer but again just depends on how the case goes but usually five minutes if everything is smooth. Okay we're gonna take another look at the T. Before the C. O. R. Um And the other techniques that you could have gone with were uh alternate between the two leads. You know potentially sacrifice the uh the uh RV lead the R. A. Lead and and go back and forth between the two. That will sometimes work um and help get some of the fibrous tissue off. Mhm. Yeah yep, correct. Yeah. So the question is great case. Um Did you have a chance to check the track hospital valve? Well we're looking at it now. Um Yeah I mean you often get the question is, is the trick to spit valve worse after these? Uh I would say on average, they're they're not similarly, you know, the other question we sometimes get as somebody who has bad tr and if you take out the lead, will that help? Because the lead is somehow impinge ng? That tends not to be the case either. I can say the the only times that's really worked have been extremely rare. It's uncommon for us to take out a lead and have that lead uh suddenly make the tr better. Um But yeah, sometimes the tr can be marginally worse after you take out the leads. Um But for the most part I would say it's it's not generally a big clinical issue. We have not seen that in big and follow up with these patients where suddenly they've got bad tr significant tr mm. Yeah. Very very yeah. So the question is if you were to take out the 38 30 so we were kind of about to talk about that a little bit in the sense that if you had to you could try to take out the 38 30 in order to um you know help debunk some of the fibrous tissue that's connecting the two leads. So the 38 30 is interesting because it's not a it does not have a luminous so it's a luminous lead. And so in this particular case you could still obviously use the laser but you just can't get a locking style it down it. And so without a locking style it you would have to go and uh either tie the lead and use that to uh to pull. Now the thing about the 38 30 it's that it's got a lot of tensile strength and so it generally would come out if you do that technique. Although you know what's interesting is now there's more and more 38 30 is being put in. It's become quite a popular lead now with uh bundle pacing and so forth. And so we'll have to see Houston left bundle pacing. We'll have to see uh what happens in the long run with that lead in terms of extract ability. Yeah. Yeah. I would say if I was taking out the 38, I would definitely size down because the challenge there is you really, you know, you can get away with a lead mismatch with the size of the sheath, with older leads that are kind of chunky to begin with. But leave that small, definitely want to go to a smaller sheath for sure. And I think that's reasonable. Go back and forth different strategies, you know, laser on one and lays on the other. Or you can go mechanical on both mechanical on one mechanical and the other. It'll work again. If you don't have to uh extract it and the lead is functional then we generally won't extract. That's good. Right? Yeah. So this is a question was what is the indication for extraction? So this is a gentleman who um the pediatric cardiologist taking care of him felt that he would need a defibrillator. His device was at the elective replacement indicator time. And because of his young age the thought was perhaps extract the ventricular lead and and uh um upgrade to an I. C. D. Um Again you could take the strategy of capping. I don't think that's necessarily wrong. But given his young age you're looking at somebody who ideally is going to live for some time and is going to need a lot of leads overtimes. Okay. Oh that's his intrinsic. Okay here, that's interesting. I think we can release the O. R. Let me just double check Doctor Lady how we looking on the T. Yeah we're good. Okay, we can release the O. R. Here. Mhm, yep. So there's there's there's not anything significant going on in the heart there as you can see. I think we're good. Yeah, you could You could cap it. Yeah, I mean that's the strategy it works. I think the problem with capping, it ends up being that you've got a guy who is 30 and then In 10 years he's 40 and you know, he's now got to leeds and if that I see the lead fails, You know, so I think having some idea at least having a discussion or at least talking about it makes sense ideally. Somebody like this, you know you would have maybe extracted him 10 years ago um and you know put in new wires just thinking ahead and somebody who's young but again ah you know you can't I I think I think capping it is not not not unreasonable in him. Mhm. Yeah. So we talked a little bit about mechanical tools, you could use a mechanical tool that does tend to cut through a lot of that calcium stuff a little bit better than laser does obviously. Um That might have been a good strategy when we were stuck. Um The challenge if you're trying to take out one lead with the mechanical tools, sometimes the other lead can kind of get wrapped up a little bit in and although I don't really see that that much but it can't happen. Um And if that does happen then then you end up having to sacrifice both weeds. Ah It can impact your success. Yeah. And We did. In fact, I think I think we showed everybody what we did was because these leads are about 20 years old. What we did was we put the bridge balloon and figured out where it should sit. And then we put a little marker, like a little sticker on the actual balloon. So if we and then we pulled the balloon back so the balloon is actually still in the body, but it's just pull back a little bit. So if we did need to rapidly deploy it, uh we would just push it up real quick. We know exactly where it needs to be and just deploy very quickly so that that part was set. Mhm. So what is it procedure? That's all. Yeah. Mhm. Okay let me rip let me repeat the question. It's a long question. What is your approach to each lead extraction procedure helps you build a successful lead management program? Um. Mhm. Yeah I mean I think thinking about every patient individually and and trying to figure out then you know whether or not they would benefit from lead extraction or not. I can tell you that we you know I don't want people to get the sense that we take out every single lead. We do turn people down. Um You know I had a referral the other day of a guy who's in his seventies who has a 20 year old lead. Um And the question was maybe he needed an M. R. I. System. Well it turns out he doesn't actually need an M. R. I. And um the lead was functional and so imbalance. He was somebody we didn't extracts so things like that I think. Just being very cautious, reasonable, making sure you have a good partnership with the surgeons. Um I look here good partnership with the surgeons. Um It helps you kind of uh figure out how to do a good lead extreme lead management program. Again not everybody needs to be extracted. Um Some people sure not everybody. And when you do extract, make sure there's clear expectations from the patient's, clear understanding of risk, clear understanding of risk from the referring mds, all that sort of stuff before you go ahead and do things. Yeah, relationship with your. Yeah so we we actually have surgery back up. Um It's actually a pretty good setup because they give us first case so that's actually critical I think in doing this if you were trying to wait and do it later in the day, they get backed up with their cases or their case goes long or they have a take back or whatever. But first case actually works really, really well. So for example, today there's two extractions on uh and both will have surgical back up. So the surgeons come here and they they do get paid for their time through a set up with the hospital, which actually I think is fair and reasonable for them also. Um so I think if you want to develop a robust program, that that discussion does need to happen with hospital administrators and so forth, nurse back. Yeah, so they are, so, um we do have some block time, although I would say we we can generally get cases done on uh Mondays, Tuesdays, Fridays, sometimes Wednesdays I think. Is there any, do we have? Uh they're usually reasonable, monday Wednesday and friday some on Fridays. Yeah, so I think generally they're pretty reasonable with us in terms of that and they'll they'll cover us for two cases, each setting, so which usually is adequate. If we have two days, two cases per week, then we can usually do it. It says you do know though, you know, lead extraction sometimes comes as um You know, all or nothing. So there's some weeks where you don't have any and then some weeks where five people show up that need to be extracted. So um that that can become a little bit of a challenge. Uh we do have some of those 50 weeks, but this is the mechanical tool that we didn't end up using. It got pulled, so it's open so I'll show it to you here so you can sort of see um you kind of pull this like a like a trigger, like a gun maybe. And uh what it does is there's a little um sharp thing on the end and it's hidden from the tip, and that will just bite through the fibrous tissue. So the lead goes in in through here and you pull on one end and you just go, the nice thing about the mechanical tool is that you don't have to pull as hard on the lead, so it'll just cut through and kind of work it's way in advance on its own. You do have to pull it out and clean it out because it does junk up over time. So that's that's the other thing. And then it does cause some arm, you know, hand fatigue, at least to me maybe I'm older, but it does cause a little bit. So, you you you know, I alternate hands sometimes, or alternative operators if it's been a tough one. But this is what that is. Okay. Other questions. All right. Let's get this done. River. Yeah. You know this is the this is the last remnant of the lead and you can kind of actually see here at the tip. There's calcium too. It's hard to see it from ah from the camera, but it's definitely there. Yeah. Okay, good. So to close it out. Okay, well, I did want to thank obviously everybody in the lab who's assisted with the procedure, my colleague dr Campbell, who did all the hard work and uh Philips for supporting us in this endeavor. And so we're gonna wrap it up here from Austin and we're happy to take questions uh at a later date if if if necessary. But obviously uh thank you all for joining us and uh hope to see you again. Thank you.