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Hybrid Management Of Pacemaker-dependent Patients Undergoing Leads Extraction For Device Related Infection
Fabrizio Rosati1, Claudio Muneretto1, Alberto Repossini1, Laura Giroletti1, Lorenzo Di Bacco1, Manuel Cerini2, Francesca Vassanelli2, Lorenza2, Francesca Salghetti2, Antonio Curnis2, Gianluigi Bisleri3.
1Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy, 2Division of Cardiology, University of Brescia Medical School, Brescia, Italy, 3Division of Cardiac Surgery, Queen's University, Kingston, ON, Canada.
OBJECTIVE: Pacemaker-dependent(PMd) patients undergoing leads extraction for device related infection currently require a temporary transvenous pacemaker as bridge-to-reimplantation. Moreover, patients with high LED(Lead Extraction Difficulty index)requiring laser-assisted extraction may have life-threatening procedural major complications leading to emergent surgery with high risk of mortality. We sought to evaluate hybrid management (either simultaneous or staged) in patients undergoing low-to-high risk leads extraction for device related infection.
METHODS: Hybrid management was planned in 110 consecutive PMd patients with device-related infection. All patients were enrolled to undergo surgical implantation of epicardial leads and permanent PM device via left lateral mini-thoracotomy or uniportal access. The leads were connected to a CRT-P device then placed in an abdominal pocket(Step-1) before leads extraction(Step-2). Patients successively underwent transvenous leads extraction with or without surgical direct visual control according to LEDindex, through right anterior mini-thoracotomic/thoracoscopic access in hybrid room.
RESULTS: No major complications occurred after surgical epicardial implantations: in 25 patients a uniportal left-sided access was the method of choice. All patients were extubated at the end of the surgical procedure with no ICU stay being required. In patients with LED<10(low-intermediate risk-Group1=83pts)Step-2 was performed with no major complications and a 100%of procedural success. In Group2(LED>10, high-risk leads extraction=27pts) superior vena cava laceration at level of right atrial junction occurred in two patients. Bleeding was immediately controlled and injury was repaired under direct vision without emergency sternotomy and cardiopulmonary bypass. Hospital mortality was 0%. This approach resulted in an overall hospital stay of 5±1days following the surgical implantation. Over a follow up of 25±15months, no device malfunctions occurred and the electrical parameters of the epicardial leads were stable over time(implantation vs follow-up mean data: impedance 670±112 vs 430±75Ohm, p=NS;sensing amplitude 6.2±2.9 vs 8.2±2.9mV, p=NS; pacing threshold 1.2±0.5V at 1.5±0.25ms vs. 1.0±0.25V at 1.25±0.5ms, p=NS).
CONCLUSIONS: Minimally invasive epicardial leads and permanent PM implantation before transvenous lead extraction appears to be a safe and effective approach in a selected subgroup of patients. Moreover, hybrid management showed excellent results avoiding emergent treatment of any major complications in patients undergoing high risk (LEDi>10) laser-assisted extraction procedure.
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