Sometimes You Need a Surgeon

Leads extraction:



Sometimes You Need a Surgeon M. Saccocci*, M. Zanobini, A. Dello Russo, F. Alamanni, M. Roberto Dip. Chirurgia Cardiovascolare - IRCCS Centro Cardiologico Monzino Milano - Italy Male, 45yrs 2006 bicameral PM for complete atrio-ventricular block (Romania) 2010 pocket infection-> generator explant, no leads extraction, contralateral implantation of a bicameral PM (St. Jude Identity DDD) 2014 atypical atrial flutter -> NOA (Pradaxa) Progressive clinical deterioration Congestive Heart Failure, TTEcho: left ventricle EF 35-40%, right chamber dilatation, severe tricuspid insufficiency, vegetation on atrial lead. 2015 January – fever, dyspnea NYHA III, cutaneous petechiae, neutrophilia; significant atrial lead impedance reduction-> VVIR -> (Romania) multidisciplinary US equipe evaluation -> too high perioperative risk extraction

At ADMISSION TTEcho: right ventricle dysfunction, normal left ventricle EF TOEcho: oval mass (6 cm. diameter) in right atrium with tricuspid impairment Chest X-ray: atrial lead malposition CTscan: no sign of acute PE, evidence of cardiac perforation due to atrial lead malposition, oval mass in right atrium

IRCCS – Centro Cardiologico Monzino High volume Leads Extraction Center (234 pts in 5yrs, 0% mortality) Hybrid Room • • • •

Clinical caracteristics (age, low EF, …) Infection Intracardiac mass/vegetation Previous cardiac surgery

Surgical Extraction • • • •

Mass >4 cm Cardiac perforation Extra epicardic leads Damaged lead

Pocket incision Peripheral cannulation for ECC Median Sternotomy - > evidence of right atrium perforation, lead fixed in thoracic wall Beating Heart Right atrium incision - Oval mass >6 cm adherent to the leads with Lead tricuspid valve impairment Mass + leads extraction RV Myocardial biopsy -> myocardial dysplasia Tricuspid Valve reparation Epicardial Lead implantation and PM replacement



Patient discharge on 6th postop. day NYHA I, no sign of infection TTEcho: good LV EF, good RV function, Trivial IT

PUS

Mass