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An interdisciplinary approach for minimal invasive pacemaker lead extraction and epicardial pacemaker implantation
Hassina Baraki, Thomas Rodt, Bernhard Meyer, Axel Haverich, Ingo Kutschka.
Hannover Medical School, Hannover, Germany.

OBJECTIVE: A growing number of patients require surgery for pacemaker infection. Minimal invasive, interdisciplinary approaches should be preferred, especially in multimorbid patients. Here, we present an innovative approach for a complex redo-case with severe device infection and biventricular heart failure.
METHODS: A 59-year-old pacemaker-dependent man presented with severe sepsis and renal failure due to an infected CRTD-system. The patient was listed for heart transplantation since 2007. Ejection fraction was 10-15%. In 1987 he underwent replacement of the aortic valve and the ascending aorta. He underwent ICD (via left subclavian vein) implantation followed by CRTD (via right subclavian vein) implantation in 2003 for AV-block III°. Replacement of the aortic valve prosthesis and the mitral valve was performed in 2005. Blood cultures turned positive for Staphylococcus aureus and 4 pacing leads had to be extracted.
RESULTS: First, we implanted a temporary percutaneous VVI pacing lead via the right jugular vein. Then, 3 out of four leads were successfully extracted using excimer laser technique. Unfortunately, the dual coil ICD electrode ruptured in the vena cava superior. The critical clinical status of the patient did not allow for surgical lead removal by re-re-sternotomy. Therefore, we extracted this remaining lead, with the help of our interventional radiologists, using a transvenous femoral approach. The free segment of the lead was looped with a pig-tail catheter and a guide-wire, pulled inside a 20F-sheath and was completely removed using gentle continuous traction. The clinical status of the patient improved. However, single chamber VVI-pacing did not allow for mobilization of the patient. Therefore, after two weeks of antibiotic therapy, we implanted a left ventricular epicardial lead via a left lateral mini-thoracotomy and a right ventricular epicardial lead via a small subxyphoidal incision. Under biventricular pacing, cardiac and renal function improved and the patient was finally dismissed from hospital.
CONCLUSIONS: The transfemoral wire loop technique represents a suitable bail-out approach to remove lead parts after failing complete excimer laser lead extraction. Epicardial leads can be implanted by small lateral and subxiphoidal accesses, to avoid (re-)sternotomy in multimorbid patients.

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