SESSION TITLE: Surgery Student/Resident Case Report Posters
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Removal of fractured, infected or retained pacemaker and defibrillator leads has become a common practice. The removal however can be associated with major cardiovascular complications, such as cardiac or vascular avulsion and tamponade.
CASE PRESENTATION: Our patient was a 68 year old man with a pacemaker implant for complete heart block five years ago, who presented with skin erosion of the generator pocket and exposure of the leads. The patient underwent a laser lead extraction of right atrial and right ventricular pacemaker leads with a Spectranetics laser lead extraction system (Colorado Springs, CO). The atrial lead removal was attempted first, however the tip of the lead appeared to be adherent and after a number of attempts, this lead was put aside to attempt the ventricular lead removal, which was freed in its entirety with no issues. The atrial lead removal was again attempted multiple times with no success, after which time we noted that the patient was hypotensive. Under fluoroscopy the heart was not moving, a clear indication that tamponade was likely present. A closed chest massage was started, and a TEE probe was placed revealing fluid in the pericardium indicative of bleeding. An emergency median sternotomy incision was made, the pericardium was opened, clots were removed, and the patient’s hemodynamics stabilized. A perforation was noted in the lower lateral posterior wall of the superior vena cava just at the pericardial reflection. This was controlled by manual gentle pressure while the patient was transfused with PRBC and FFP. The tip of the lead was noted to be adherent to the superior vena caval posterolateral wall where the caval perforation had occurred. The lead was removed with manual palpation of the superior vena cava freeing up the tip of the lead and traction on the lead.
DISCUSSION: A 2010 study highlights the increased risk of complications for ICD lead removal because of the additional adhesions created at the superior vena cava around the shocking coil which further augments the risk of venous tear during extraction. Analysis of 5339 extractions over 10 years revealed a major complication rate of 1.6%, which includes death, cardiac or vascular avulsion requiring a chest tube, and other complications such as pulmonary embolism or stroke.1
CONCLUSIONS: SVC perforation causing tamponade was observed while attempting removal of a fibrosed lead with the active fixation tip adherent to the caval wall at the right atrial-SVC junction before it was even removed. We believe that the lead had been fixed to the SVC wall rather than the right atrial wall because, even under direct vision in the operating room, the tip of the lead had to be manually freed up from the SVC wall before it could be removed.
Reference #1: Farooqi FM, Talsania S, Hamid S, Rinaldi CA. Extraction of cardiac rhythm devices: indications, techniques and outcomes for the removal of pacemaker and defibrillator leads. Int J Clin Pract. 2010 Jul; 64(8):1140-7.
DISCLOSURE: The following authors have nothing to disclose: John Myers, Dalip Singh, Hossein Almassi
No Product/Research Disclosure Information