BACKGROUND: Lead extraction represents a challenging procedure in managing patients with cardiac implantable electronic devices, involving various endovascular and open techniques.METHODS: We detail the case of a 60-year-old male who received a pacemaker in 2018, subsequently upgrading to a device compatible with magnetic resonance imaging in June 2022. A surgical site infection complicated the procedure, necessitating extraction of the pacemaker generator and abandonment of leads, cut proximally at the subclavian vein. He was discharged without the need for pacemaker re-implantation. In September 2022, the patient presented at our institution with persistent fever, dyspnea, and syncopal episodes. Diagnostic tests confirmed lead-related infective endocarditis and intermittent atrioventricular complete block with ventricular escape rhythm. The Heart-Team found the patient suitable for hybrid lead extraction and bicameral epicardial pacemaker implantation.Under general anesthesia with double-lumen endotracheal tube intubation, a 4-cm right inframammary, anterior mini-thoracotomy at the fourth intercostal space provided exposure to the right atrium. Venous cannulation was achieved with a multistage cannula inserted through the femoral vein, up to the inferior vena cava, complemented by direct superior vena cava cannulation through a designated port. Arterial cannulation was achieved through the femoral artery. Pericardial sutures facilitated diaphragm retraction, with vessel loops snaring the superior and inferior vena cava. A vertical incision of the right atrium was made at the level of the atrial lead; the cephalad portion of both leads was carefully pulled. Given the extensive caudal fibrotic adhesions and endothelialization of the ventricular lead, we induced cardioplegic arrest and employed a mechanic lead-extraction device under fluoroscopic guidance. Implantation of a bicameral epicardial pacemaker through a subxiphoid incision concluded the procedure.RESULTS. Due to his hemodynamic conditions and uneventful surgery, we performed ultrafast-track protocol and continued the patient care process in the ICU, he was able to be discharged home in stable condition after a few days.CONCLUSIONS. This manuscript explores the potential advantages and feasibility of a hybrid approach; this innovative therapeutic modality integrates minimally invasive cardiac surgery with endovascular techniques, presenting a promising avenue for addressing complications arising from abandoned lead pacemakers.LEGEND. Hybrid lead extraction approach.
