The Lead Episode 135: A Discussion of Mechanical Vacuum Aspiration and Debulking of Large Vegetations During Cardiac Implantable Electronic Device Extractions-The Lead Episode 135 Visual Aid

The Lead Episode 135 Visual Aid

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A recent multicenter retrospective study (Malyshev et al., JACC, 2025) evaluated the use of the AlphaVac mechanical vacuum aspiration device for debulking large vegetations (≥1 cm) on infected cardiac implantable electronic device (CIED) leads during transvenous lead extraction (TLE). Large vegetations pose high risks of embolism and mortality, with surgery traditionally preferred, though percutaneous approaches like AlphaVac are emerging. The study included 42 patients from three centers between 2015 and 2025, comparing TLE with AlphaVac debulking (PMD, n=13) versus TLE alone (Control, n=29). AlphaVac is a manual, single-operator device without an extracorporeal circuit.<br /><br />Key findings showed that the AlphaVac system was feasible and safe, achieving 100% complete debulking in treated cases without major procedural complications. The PMD group demonstrated a significantly smaller increase in white blood cell count (8.4% vs. 21.1%, p=0.046), suggesting a reduced inflammatory response. Length of hospital stay (LOS) trended lower in the PMD group (8.2 vs. 15.8 days, p=0.056), and one-month mortality was 0% compared to 14% in controls. These promising results indicate potential benefits in reducing embolic risk, inflammation, hospitalization duration, and mortality.<br /><br />However, the study has limitations including small sample size, retrospective design, historical (non-contemporary) controls, single-operator PMD use, and absence of subclinical embolization imaging. Thus, findings are hypothesis-generating and not definitive.<br /><br />In summary, percutaneous AlphaVac mechanical vacuum aspiration appears to be a safe and promising adjunct to TLE for managing large vegetations on infected CIED leads, potentially reducing complications and improving outcomes. Nevertheless, larger prospective studies are needed to validate these results before widespread adoption. The discussion involved experts Dr. Rahul Doshi and Dr. Robert Schaller, hosted by Dr. Danesh Kella, reflecting evolving cardiovascular electrophysiology practices.

Keywords

AlphaVac

mechanical vacuum aspiration

large vegetations

cardiac implantable electronic device

CIED lead infection

transvenous lead extraction

TLE

percutaneous debulking

embolism risk

inflammatory response