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Troubleshooting during a challenging high-risk pacemaker lead extraction: a case report and review of the literature.

Rizkallah J, Kent W, Kuriachan V, Burgess J, Exner D - BMC Res Notes (2015)

Bottom Line: While the risks of device implantation decreased significantly over time, significant risk remains associated with their extraction when indicated.Risks of device extraction are further complicated in cases of chronic lead perforations.Extraction strategies that avoid cardiopulmonary bypass initiation are preferred.

View Article: PubMed Central - PubMed

Affiliation: Libin Cardiovascular Institute of Alberta, University of Calgary, TRW GE62, 3280 Hospital Drive NW, Calgary, T2N 4Z6, AB, Canada. jacquesyr@yahoo.com.

ABSTRACT

Background: The use of cardiac implantable electrical devices continues to increase with the validation of new beneficial indications. While the risks of device implantation decreased significantly over time, significant risk remains associated with their extraction when indicated. A high-risk pacemaker lead extraction case is described, wherein a chronically implanted lead that had perforated the right atrium was successfully removed without the need for cardiopulmonary bypass. In this report we share our approach to this challenging extraction case and describe an infrequently utilized off-pump hybrid technique that we term the "lead-inverting stitch".

Case presentation: A 74 year-old Caucasian woman with complete heart block and remote pacemaker implantation presents with a swollen and erythematous infected pacemaker pocket necessitating device extraction. Chest computerized tomographic imaging revealed a chronically perforating right atrial lead tip approximately 2 cm within the pericardial space. A successful hybrid transvenous and open surgical extraction approach was undertaken without the need for cardiopulmonary bypass; this was made possible due to a successfully positioned "lead-inverting stitch".

Conclusion: Implantable cardiac electrical device infections are amongst the most dreaded post implant complications. Risks of device extraction are further complicated in cases of chronic lead perforations. Extraction strategies that avoid cardiopulmonary bypass initiation are preferred.

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Related in: MedlinePlus

Illustration of the “lead inverting stitch”. A. Purse-string suture applied around the perforating lead. B. Atrial lead-tip severed with heavy scissors followed by inversion of the remnant atrial lead fragment and surrounding scar beneath the tightened purse-string. Note: the epicardial pacing lead is already in place. C. Cross-section illustration of the severed and inverted atrial lead following tightening of the purse string around the lead (i.e., “lead inverting stitch”).
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Fig3: Illustration of the “lead inverting stitch”. A. Purse-string suture applied around the perforating lead. B. Atrial lead-tip severed with heavy scissors followed by inversion of the remnant atrial lead fragment and surrounding scar beneath the tightened purse-string. Note: the epicardial pacing lead is already in place. C. Cross-section illustration of the severed and inverted atrial lead following tightening of the purse string around the lead (i.e., “lead inverting stitch”).

Mentions: To minimize the risk of vascular disruption and tamponade given the chronic right atrial lead perforation, a combined transvenous and open surgical extraction approach was undertaken. Using a dedicated hybrid operating theatre with cardiopulmonary bypass support if necessary, midline sternotomy was performed. Dense adhesions were found within the pericardial space consistent with likely prior pericarditis. Given the location of the RA lead, care was taken to leave the right atrial dissection until all other vascular structures were exposed. With uneventful dissection of the right atrium, direct visualization of the protruding passive fixation lead was obtained (Figure 2). To avoid the risks associated with cardiopulmonary bypass and given the good visualization of the perforating atria lead, an off-pump technique was considered using a “lead-inverting stitch”. To achieve hemostatic control over the region of the atrial wall where the lead exited, a purse-string stitch was placed circumferentially around the lead tip using 3–0 prolene with multiple pledgets (Figure 3A). The externalized tip of the perforating atrial lead was then mobilized by cutting a rim of surrounding atrial tissue. This allowed the end of the lead to be dunked within the right atrial chamber while the purse-string suture was tightened for hemostasis (Figure 3B and C). With this “lead inverting stitch”, the lead was free within the right atrium and could now be safely extracted using transvenous laser extraction techniques.Figure 2


Troubleshooting during a challenging high-risk pacemaker lead extraction: a case report and review of the literature.

Rizkallah J, Kent W, Kuriachan V, Burgess J, Exner D - BMC Res Notes (2015)

Illustration of the “lead inverting stitch”. A. Purse-string suture applied around the perforating lead. B. Atrial lead-tip severed with heavy scissors followed by inversion of the remnant atrial lead fragment and surrounding scar beneath the tightened purse-string. Note: the epicardial pacing lead is already in place. C. Cross-section illustration of the severed and inverted atrial lead following tightening of the purse string around the lead (i.e., “lead inverting stitch”).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4404126&req=5

Fig3: Illustration of the “lead inverting stitch”. A. Purse-string suture applied around the perforating lead. B. Atrial lead-tip severed with heavy scissors followed by inversion of the remnant atrial lead fragment and surrounding scar beneath the tightened purse-string. Note: the epicardial pacing lead is already in place. C. Cross-section illustration of the severed and inverted atrial lead following tightening of the purse string around the lead (i.e., “lead inverting stitch”).
Mentions: To minimize the risk of vascular disruption and tamponade given the chronic right atrial lead perforation, a combined transvenous and open surgical extraction approach was undertaken. Using a dedicated hybrid operating theatre with cardiopulmonary bypass support if necessary, midline sternotomy was performed. Dense adhesions were found within the pericardial space consistent with likely prior pericarditis. Given the location of the RA lead, care was taken to leave the right atrial dissection until all other vascular structures were exposed. With uneventful dissection of the right atrium, direct visualization of the protruding passive fixation lead was obtained (Figure 2). To avoid the risks associated with cardiopulmonary bypass and given the good visualization of the perforating atria lead, an off-pump technique was considered using a “lead-inverting stitch”. To achieve hemostatic control over the region of the atrial wall where the lead exited, a purse-string stitch was placed circumferentially around the lead tip using 3–0 prolene with multiple pledgets (Figure 3A). The externalized tip of the perforating atrial lead was then mobilized by cutting a rim of surrounding atrial tissue. This allowed the end of the lead to be dunked within the right atrial chamber while the purse-string suture was tightened for hemostasis (Figure 3B and C). With this “lead inverting stitch”, the lead was free within the right atrium and could now be safely extracted using transvenous laser extraction techniques.Figure 2

Bottom Line: While the risks of device implantation decreased significantly over time, significant risk remains associated with their extraction when indicated.Risks of device extraction are further complicated in cases of chronic lead perforations.Extraction strategies that avoid cardiopulmonary bypass initiation are preferred.

View Article: PubMed Central - PubMed

Affiliation: Libin Cardiovascular Institute of Alberta, University of Calgary, TRW GE62, 3280 Hospital Drive NW, Calgary, T2N 4Z6, AB, Canada. jacquesyr@yahoo.com.

ABSTRACT

Background: The use of cardiac implantable electrical devices continues to increase with the validation of new beneficial indications. While the risks of device implantation decreased significantly over time, significant risk remains associated with their extraction when indicated. A high-risk pacemaker lead extraction case is described, wherein a chronically implanted lead that had perforated the right atrium was successfully removed without the need for cardiopulmonary bypass. In this report we share our approach to this challenging extraction case and describe an infrequently utilized off-pump hybrid technique that we term the "lead-inverting stitch".

Case presentation: A 74 year-old Caucasian woman with complete heart block and remote pacemaker implantation presents with a swollen and erythematous infected pacemaker pocket necessitating device extraction. Chest computerized tomographic imaging revealed a chronically perforating right atrial lead tip approximately 2 cm within the pericardial space. A successful hybrid transvenous and open surgical extraction approach was undertaken without the need for cardiopulmonary bypass; this was made possible due to a successfully positioned "lead-inverting stitch".

Conclusion: Implantable cardiac electrical device infections are amongst the most dreaded post implant complications. Risks of device extraction are further complicated in cases of chronic lead perforations. Extraction strategies that avoid cardiopulmonary bypass initiation are preferred.

Show MeSH
Related in: MedlinePlus