Abstract
A 47-year-old female with a dual chamber pacemaker was referred to our institution for transvenous lead removal because of suspected pocket infection.
The history of this patient started in 2002 with a tricuspid valve endocarditis. Therefore, the patient had tricuspid valve repair that yielded a poor outcome.
The patient received biological tricuspid valve in 2006. Due to postoperative total atrioventricular-block a DDDR device was implanted. The biological valve degenerated and thus was replaced by a mechanical one in 2014. During this valve implantation the atrial lead was removed and the ventricular lead was trapped by the mechanical valve between the native tricuspid valve annulus of the right ventricle and the outer ring of the mechanical valve. Three months after the last revision the patient developed signs of inflammation. The pocket was opened and a swab test proved positive for Staphylococcus epidermidis. After disinfection with iodine solution the pacemaker was placed under the pectoralis muscle. However, during the following 3 months the patient suffered from swelling over the pacemaker pocket and severe pain.
In awareness of the previous history and the clinical symptoms we decided to implant a new pacemaker system on the left side and explant the infected system on the right side.
<Learning objective: Pocket infections always require system explantation. Simultaneous explantation of an infected system and implantation of a new system within the same session is not recommended but was necessary in this case. Even complex lead extraction like this one can be successfully performed applying the appropriate tools (locking stylet, Evolution device, Cook Intravascular Inc., Leechburg, PA, USA).>
Keywords: Extraction, Trapped pacemaker lead, Mechanical valve
Introduction
Pacemaker generator replacements are associated with a notable complication risk, particularly if additional leads are implanted. The number of patients who receive a new pacemaker is rising continuously [1], [2], [3], [4]. In the years after initial implantation, device replacement may become necessary for battery depletion or for upgrades to more complex multi-lead cardiac resynchronization therapy (CRT) pacemakers. Complete device and lead removal is recommended in all patients with cardiovascular implantable electronic device (CIED) infection as evidenced by pocket abscess, device erosion, skin adherence, or chronic draining sinus even without clinically evident involvement of the transvenous portion of the lead system (Class I indication) [1], [2], [3].
Case report
A 47-year-old female with a dual chamber pacemaker was referred to our institution for transvenous lead and generator removal because of suspected pocket infection.
The medical history of this patient started in 2002 with a severe tricuspid valve endocarditis due to intravenous drug abuse. Therefore, she had to undergo tricuspid valve repair surgery that yielded a poor outcome with remaining severe regurgitation.
After detoxification the patient received a biological tricuspid valve replacement in 2006. Due to postoperative total atrioventricular block a transvenous dual chamber device was implanted after valve replacement. After 4 years of service, the pacemaker had to be replaced because of battery depletion. In the following 8 years the biological tricuspid valve degenerated noticeably and thus was finally replaced by a mechanical valve in May 2014. During this valve implantation the atrial lead was removed and the ventricular lead was trapped by the mechanical valve between the native tricuspid valve annulus of the right ventricle and the outer ring of the mechanical valve prosthesis. A week after valve implantation a new atrial lead was implanted, which dislodged after one day. After revision of the atrial lead, normal function of the pacemaker could be achieved (Fig. 1). Three months after the last revision, the patient developed local signs of inflammation. The pacemaker pocket was surgically opened and a swab test proved positive for Staphylococcus epidermidis. The pocket was disinfected with iodine solution and the pacemaker was placed under the pectoralis muscle. However, during the following 3 months the patient suffered from swelling over the pacemaker pocket and severe pain. She was assigned to our institution for a second opinion. We evaluated three options to treat this patient.
Fig. 1.
X-ray of dual chamber pacemaker with trapped ventricular lead.
Option 1: Epicardial leads (left atrial and left ventricular) could be implanted through a left mini-thoracotomy with a new device on the left side. After this, complete lead removal and device explantation on the right side would have to be performed.
Option 2: A coronary sinus lead could be implanted with an endoluminal atrial lead with a new device on the opposite left side followed by a complete system explantation from the right at the same time.
Option 3: In a two-step approach, firstly, a temporary pacing lead could be implanted in the coronary sinus with a concomitant extraction of the infected pacemaker system at the same time. Secondly, after repeatedly negative blood cultures, the new system could be implanted on the opposite side after several weeks.
After discussing the case in our heart team and in awareness of the previous history and the clinical symptoms we decided to implant simultaneously a new pacemaker system on the left side and explant the infected system on the right side (option 2). The complete interventional approach was chosen because the patient had already undergone heart surgery three times and a fourth operation (option 1) would have constituted a high-risk procedure. Furthermore, severe scarification in the surroundings of the heart after these several operations probably might have caused epicardial lead dysfunction. Thus, the patient was rejected by the surgeon to be operated on for a fourth time. Option 3 was not chosen because dislodgement of the temporary coronary sinus pacing lead would have had potentially fatal consequences for the patient. As the use of an active fixation lead in the coronary sinus for a temporary pacing is not indicated, the risk of dislodgement of a standard lead was considered too high and thus this option was deemed too risky.
We implanted a CRT pacemaker (Syncra™, Medtronic Inc., Minneapolis, MN, USA) with two coronary sinus leads and a new atrial lead. Coronary sinus leads were the bipolar steroid electrode eluting transvenous 88-cm long ATTAIN ABILITY® 4196 (Medtronic Inc.) for the mid-lateral vein and the unipolar, steroid eluting, transvenous 88-cm long Attain StarFix® 4195 (Medtronic Inc.) for the anterior lateral vein (Fig. 2).
Fig. 2.
X-ray of the old and new pacemaker systems side by side before explantation and lead extraction.
As long QT intervals predispose to ventricular arrhythmias, we strived for keeping the QTc interval as short as possible. The QTc interval was thus measured several times during the implantation of the coronary sinus leads. Dual-site pacing of the left ventricle via the anterior as well as the lateral coronary sinus vein led to a significantly shortened QTc-interval as opposed to pacing from either the anterior or the lateral vein. Furthermore, the additional sinus lead ensures life-saving ventricular pacing if one lead fails.
After implantation of the new device on the left side, we explanted the system on the right in a cardiothoracic operating room with cardiopulmonary bypass pump as well as an experienced cardiothoracic surgeon on standby. After skin dissection, box removal and lead exposure, a lead locking stylet Liberator® (LR-OFA01 Liberator Locking Stylet, Cook Medical, Bloomington, IN, USA) was introduced into both leads followed by the use of a mechanical rotation extraction device Evolution® (Cook Intravascular Inc., Leechburg, PA, USA). The Evolution® system, which uses no electricity and is hand-powered, consists of an outer and inner sheath, fitted with a stainless steel tip at its distal end, and is connected to a handle and trigger that rotates it. Under fluoroscopic guidance the 11 Fr Evolution® was advanced until the ring of the mechanical valve. After that, the outer sheath was located at the synthetic ring of the valve to stabilize the valve and avoid its dislocation during the counter-traction manoeuver. With this technique the ventricular anchor lead as well as the atrial lead could be extracted totally (Fig. 3).
Fig. 3.
Final result – X-ray of cardiac resynchronization system on the left side after extraction of the dual chamber system on the right.
The patient was free of any signs of pacemaker system infection 6 months after the procedure. Wound healing of the previously infected pocket on the right side took 6 weeks. Within this time period two more revisions due to bleeding were necessary. After 6 months the scar on the right side was unremarkable with no signs of infection.
Discussion
In the REPLACE study, major complications were most frequent in the group in which a transvenous lead was added or an upgrade to a device capable of additional therapies was performed [5]. In our patient a total of 5 pacemaker revisions with one lead addition were done within 2 months, causing a severe pocket infection.
At the time of presentation to our department, all signs of inflammation were positive with an additional positive blood culture. Ipsilateral re-location of the same device with disinfection of the contaminated area proved insufficient. In our opinion, it is reasonable to disinfect an area of infection but eliminating any foreign material – which is supporting the infection – is paramount [1], [2], [3]. As opposed to current guideline recommendations, we had to perform a one-step procedure because no temporary pacing was possible in a patient with complete heart block without an escape rhythm and a mechanical tricuspid valve [1], [2], [3]. In our opinion, a mechanical valve was not the ideal solution for this type of patient. The compliance of patients with intravenous drug abuse with regard to oral anticoagulation is uncertain. Furthermore, the international normalized ratio needs to be high for a tricuspid mechanical valve. A clotting of this valve can be fatal. Implanting another bioprosthetic valve in this patient may have been a better option.
When stimulating the myocardium via a coronary sinus electrode, significant QT prolongation can occur according to the anatomical area of the target vein. This is due to the fact that the action potentials of different myocardial layers look different and are inhomogeneous. Physiologically, the electrical excitation radiates from the endocardium to the epicardium. Therefore, arrhythmias with an epicardial origin have a higher risk regarding the development of ventricular fibrillation or torsades [6], [7]. If you pace the left ventricle from epicardium only, you must be aware of this fact.
We thus measured the QTc interval from the anterior vein as well as from the lateral and from the posterolateral vein. The QTc interval from anterior region was 520 ms and from the lateral/posterolateral region greater than 508 ms. Dual-site pacing of the left ventricle via the anterior as well as from the lateral coronary sinus vein was finally chosen, as it led to a significantly shortened QTc-interval (482 ms) as opposed to pacing from either the anterior or the lateral vein.
In our opinion it was wise to choose the endovenous approach to treat this patient as opposed to an implantation of epicardial leads, as another thoracotomy after several heart operations would have been very risky. It was possible for this patient to ensure dual chamber pacing with leads in the right atrium and the coronary sinus via a minimal invasive procedure. This case underscores the importance of complete device removal in the case of infection, as local disinfection and re-implantation of the same device proved insufficient.
Conflict of interest
No authors have a conflict of interest in relation to this work.
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