Laser Extraction Of Retained Right Atrial Pacemaker Lead Via Mini-redo-sternotomy
Christopher L. Tarola, Raymond Yee, A Dave Nagpal.
London Health Sciences Center, Western University, London, ON, Canada.
Infection of implantable cardiac devices can be a catastrophic complication. Transvenous lead extraction (TLE) is commonly employed for device removal, however, surgical lead extraction, cardiopulmonary bypass and cardiotomy are required in some cases and can be highly morbid. We describe the first use of antegrade TLE via an upper-mini-sternotomy to resect a retained pacemaker lead.
We present a 73-year-old male who underwent pacemaker implantation for syncope secondary to bradyarrhythmia and carotid hypersensitivity. Seven years later, he presented with S. epidermidis bacteremia and pacemaker lead endocarditis. After failed TLE via the device pocket, the patient underwent open surgical lead extraction, though had a retained right atrial (RA) lead segment. He was placed on chronic Rifampin treatment for 20 years. Six months following Rifampin dose reduction, he developed a draining granulomatous mass within the pacemaker pocket, for which he presented to us.
Computed tomography demonstrated the retained pacemaker lead within a near occluded brachiocephalic vein, and occluded superior vena cava. We suspected an infected sinus tract was present between the pacemaker pocket and the tip of the lead, which sat in the left subclavian vein. After exploring the left chest wall incision, we discovered and resected the granuloma, and amputated the sinus tract, which connected to the retained wire. We subsequently returned to the operating room to remove the retained lead, via a 2nd intercostal space, inverted “T”, redo, upper-mini-sternotomy. We obtained vascular control of the occluded innominate vein and opened it longitudinally. Two lead
remnants were identified: the retained RA lead, and a separate plastic insulating sheath. The insulating sheath was removed uneventfully with simple traction, and the retained RA lead was removed using antegrade TLE via the exposed innominate vein in conjunction with the electrophysiology team. The patient progressed without complication following both surgeries, and antibiotics were weaned at 6 weeks post-op.
This case demonstrates the advantage of a multi-disciplinary approach to reduce surgical risk in challenging and complex clinical scenarios. The novel combination of antegrade TLE and minimally-invasive exposure of required anatomy obviated the need for redo median sternotomy, CPB, cardiotomy, and their associated risks.
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