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International Journal of Arrhythmia 2014;15(3): 57-61.
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| ECG & EP CASES |
Transvenous Extraction of
30-year-old Pacemaker Leads
in a Patient with Eisenmenger
Syndrome |
 
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Introduction
With increasing rates of pacemaker implantation,
pacemaker infection rates have risen in
parallel.1 In cases of infection, pacemaker removal
and lead extraction are necessary,2 though
the difficulty of extraction increases in line with
pacemaker age. We report a case of transvenous
extraction of 30-year-old pacemaker leads via
the subclavian vein using conventional traction
and counter-traction techniques, and via the
femoral vein using a snaring technique.
Case
A 42-year-old man presented with erythema
and purulent discharge from a pacemaker pocket
site in the left pectoral area (Figure 1). Symptoms
had arisen 1 week previously. The patient had
been diagnosed with incomplete atrioventricular
(AV) septal defect at the age of 12, and had undergone
surgical repair. Complete AV block had
subsequently occurred, and a DDD pacemaker
(unknown manufacturer) was implanted with a
screw-type unipolar atrial lead and a tined unipolar
ventricular lead (unknown manufacturer).
At the age of 20, the patient was fitted with a
new VDD (ventricular pacing, dual chamber
sensing, dual function) pacemaker (Thera VDD,
Medtronic, Minneapolis, MN, USA) in the right
pectoral area, due to pacing failure of the DDD pacemaker. At that time, the DDD generator was
removed, but the atrial and ventricular leads were
left in place. On the first day of the current admission,
the patient’s blood pressure was 110/82
mmHg and his body temperature was 37.2°C.
Laboratory analysis revealed a white blood cell
count of 13,600/μL, a neutrophil count of 89.6%,
and C-reactive protein levels of 15.3 mg/L. A
chest radiograph showed cardiomegaly, the VDD
pacemaker in the right pectoral area, and the
atrial and ventricular leads in the left pectoral
area (Figure 2).
Echocardiography revealed residual
interatrial shunt, severe pulmonary hypertension,
severe tricuspid regurgitation, and no
vegetation. These findings were consistent with
Eisenmenger syndrome. Cefazolin 1 g three times
a day was administered intravenously. Attending
physicians and surgeons recommended repeat
open heart surgery for repair of the AV septal defect
and tricuspid valve, and for pacemaker lead extraction, though the patient refused surgery.
Although blood cultures were negative, clinical
and laboratory findings were consistent with
pacemaker pocket infection. We therefore decided
to extract the pacemaker leads transvenously on
the 2nd day of hospitalization. A skin incision was
made under general anesthesia, and a sample
of discharge was collected from the inside of the
pacemaker pocket for bacterial culture. Following
dissection of surrounding soft tissue, atrial
and ventricular pacemaker leads were exposed.
Two locking stylets (Liberator Beacon Tip Locking
Stylet, Cook Vascular Inc., Vandergrift, PN,
USA) were inserted into each hole of the atrial
and ventricular leads and locked. Traction force
was gently applied to the locking stylets, and two
12 Fr polypropylene telescoping dilator sheaths
(Byrd Dilator Sheath, Cook Vascular Inc.) were
inserted and advanced over the atrial and ventricular
leads (Figure 3).
Counter-traction force
was gently applied to the dilator sheaths and soft tissue surrounding the leads was dissected away.
The atrial lead was extracted successfully (Figure
4A); the ventricular lead was cut at the level of
the superior vena cava during extraction. A snare
catheter (PFM Medical, Nonnweiler, Germany)
was inserted into the right ventricle, via the right
femoral vein, to retrieve the remaining section of
the ventricular lead (Figure 4B). The lead was cut
at the level of the right ventricle, and the middle
portion removed, though a distal 4-cm section
was left in place (Figure 5). The wound was sutured,
and the procedure was completed with no
acute complications. No evidence of infection was
observed during out-patient follow-up.
Discussion
We have presented a case of transvenous extraction
of old unipolar pacemaker leads via the
subclavian vein using conventional traction and
counter-traction techniques, and via the femoral
vein, using a snaring method.
Pacemaker or implantable cardioverter-defibrillator
lead extraction is generally considered
to be a difficult and high-risk procedure.
The main source of risk is adhesion of the pacemaker
leads to a major vein, the right atrium or
ventricle, or the tricuspid valve. The most common
sites of severe adhesion are the subclavian
vein, the superior vena cava, and the apex of the
right ventricle.3 Major complication rates following
pacemaker lead extraction are approximately
2%.4 Major complications include cardiac
avulsion, vascular laceration, hemopericardium,
hemothorax, and acute tricuspid regurgitation.4,5
Complication rates are especially high in patients
with pacemaker infection, cerebrovascular disease,
low ejection fraction, low platelet count,
prolonged prothrombin time, and mechanical or powered sheaths.4 During the pacemaker lead
extraction procedure, adhesiolysis around the
leads is critical. Many new kinds of lead extraction
device are emerging, including laser sheaths.
However, traction and counter-traction techniques,
using locking stylets and telescoping dilator
sheaths, are most commonly employed in
Korea.6,7 Locking stylets supply traction force to
the pacemaker lead tip and decrease the risk of
severing the lead. Telescoping dilator sheaths can
be used to supply counter-traction force and adhesiolysis
around the pacemaker lead; they additionally
decrease the risk of cardiac avulsion.
The snaring technique via a femoral approach
can be used for rescue purposes, in cases where
the pacemaker lead is cut during extraction. The
femoral approach can additionally provide an alternative
vector of traction force.
Because adherence of pacemaker leads to adjacent
tissue increases dramatically with age,
extraction of old pacemaker leads is particularly
challenging. Furthermore, old unipolar leads are
easily severed because there is no supporting core
in the lead body. Although the distal part of the
ventricular lead was left in place in this case, no
further evidence of infection was observed during
follow-up. Consequently, open heart surgery for
complete removal was not considered necessary.
We are aware of only one previous report describing
extraction of pacemaker leads over 30
years old, published in the USA.4 Although the
extraction in our case was not entirely successful,
we believe the pacemaker leads in this study
were the oldest to be extracted in Korea. We have
demonstrated that extraction of pacemaker leads
over 30 years old is feasible, but meticulous and
gentle manual technique is essential.
References
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Heart Rhythm. 2009;6:1085-1104.
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