Hybrid Approach For Intravenous Lead Extraction
Eiki Nagaoka, Tomohiro Mizuno, Masahiko Goya, Keiji Oi, Masafumi Yashima, Tsuyoshi Hachimaru, Hidehito Kuroki, Dai Tasaki, Tatsuki Fujiwara, Masashi Takeshita, Ryoji Kinoshita, Hirokuni Arai, Mitsuaki Isobe, Kenzo Hirao.
Tokyo Medical and Dental University, Tokyo, Japan.
OBJECTIVE: As the number of transvenous electrophysiological device implantation increase, the incidence of chronically implanted lead extraction is also increasing. Although most of the leads can be removed percutaneously with excimer laser sheath, some difficult cases need surgical interventions. We defined scheduled surgical intervention for lead extraction in conjunction with laser extraction as a hybrid approach. The purpose of this study is to review our hybrid approach for the lead extraction.
METHODS: Between 2013 and 2016, 128 consecutive patients underwent lead extraction at our institution. Of the 128, four (3.1%) patients required the hybrid approach. In two cases, right minithoracotomy approach was preoperatively planned. However, full sternotomy was selected in all cases as a result. Before cardiopulmonary bypass, transvenous lead dissection was performed from subclavian vein to the superior vena cava with excimer laser sheath. And then, intra-cardiac portion of the leads were removed surgically through right atriotomy. Concomitantly, tricuspid valve repair was performed if necessary.
RESULTS: The indications for surgical intervention are severe adhesion to tricuspid valve, a large vegetation, the tricuspid regurgitation, and severe adhesion to the innominate vein. In one case, the exposure of the right atrium was started via right minithoracotomy approach. However, the exposure was difficult because of the fourth cardiac operation, followed by the conversion to median sternotomy. In another case, minithoracotomy approach was preoperatively given up because of the calcified aorta. In this case, right ventricle was perforated after lead extraction. The perforation could be easily and directly closed via sternotomy. In another case with severe adhesion to innominate vein, the laser sheath could not dissect the lead from the innominate vein. The innominate vein was opened and the lead was removed surgically. There was no procedural failure and no death related to the lead extractions.
CONCLUSIONS: Lead extraction with our hybrid approach for complicated cases was useful for safety and complete lead extraction. Remarkably, full sternotomy was valuable rather than right minithoracotomy for management of unpredictable complications.
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