The PEAK PlasmaBlade (PEAK Surgical, Inc., Palo Alto, CA) is a novel, low-temperature electrosurgical device originally designed for precision dissection with minimal thermal injury to adjacent tissue. However, there is an additional benefit for cardiologists and electrophysiologists: decreased potential for thermal damage to the insulation of indwelling leads.

In this article, we will discuss the differences between conventional electrosurgical systems and the PlasmaBlade, with a focus on thermal damage to indwelling pacer/defibrillator leads. We also summarize in vitro data regarding the differential effects of these instruments on transvenous lead insulation materials.

Indwelling Lead Damage: A Dangerous and Expensive Problem
Silicone rubber, polyurethane, and silicone-urethane copolymers are widely used in the production of transvenous pacing and defibrillator leads due to their favorable flexibility, insulative and tunneling characteristics. Though widely available and cost effective, they are susceptible to damage from high-temperature electrosurgical instruments.1,2 Clinically, this is of greatest concern during pacemaker and implantable defibrillator generator changes and replacements, where sufficient healing has occurred since the initial implantation so as to render the device and leads effectively embedded in the tissue. In such a situation, dissection using a conventional electrosurgical instrument simplifies device and lead removal compared to the use of surgical scissors; however, surgeons are routinely advised by generator and lead manufacturers to maintain operative vigilance and use low-power settings to avoid thermal damage.3 Unfortunately, this is not always practical or possible.

Damage to transvenous leads from high-temperature electrosurgical devices during generator replacement may be significantly underreported, despite having important consequences, as much of the damage may be microscopic. There are limited options for handling a damaged lead. One solution, lead extraction with reimplantation, carries significant morbidity and mortality and requires expertise and special equipment to carry out. Reimplantation alone is complicated by the frequent incidence of chronic venous occlusion in patients with indwelling pacer/defibrillator leads. Overall, the need for additional surgical intervention involves significant risk, including increased length of stay and death, as well as serious financial implications, averaging between $5,000 and $20,000 per incident.8

Expanding indications for defibrillator implantation, the growing market for pacemakers due to the overall aging population, and the fact that people are living longer with these indwelling devices mean that generator replacement procedures comprise an increasing portion of many electrophysiologists’ practices. Proficiency with appropriate repair and replacement techniques is necessary and critical, but technology that can decrease the potential for thermal damage to transvenous leads in the first place is even more desirable and of obvious benefit to both patient and electrophysiologist.