A hybrid ICD extraction approach using laser and transfemoral extraction technique

Indications for pacemaker and implantable cardioverter defibrillator (ICD) implantations are rapidly expanding. Hence, device-related complications have increased the need for lead extraction. Lead extractions are performed percutaneously or by open surgery. We present a patient with isolated left ventricular noncompaction cardiomyopathy suffering from ICD pulse generator pocket and lead infection with aggregatibacter actinomycetem comitans bacteremia. The complete device was successfully removed by a hybrid two-step approach using excimer laser and transfemoral lead extraction technique in combination with mechanical traction via the subclavian vein. Thereby, open surgery with possible need for cardiopulmonary bypass could be avoided in this patient. A 55-year-old male was referred to the hospital due to exertional dyspnea, fatigue and pain in the ICD pulse generator pocket. ICD implantation was performed due to sustained ventricular tachycardia in isolated left ventricular noncompaction cardiomyopathy 10 years ago. ICD pulse generator was replaced due to battery depletion 3 years ago. On admission, the patient was hemodynamically stable, and the ICD pulse generator pocket was reddened and swollen. Laboratory chemistry revealed slightly elevated C-reactive protein levels (22 mg/l). No intracardiac vegetations were visualized by transesophageal echocardiography, left ventricular noncompaction was documented with a left ventricular ejection fraction of 51%. Coronary computed tomography revealed normal coronary arteries. The ICD pulse generator pocket was punctured and purulent material could be aspirated. Hence, diagnosis of ICD pulse generator pocket infection with possible lead infection was made. Tissue debridement, and extraction of the ICD pulse generator, the atrial lead and the distal part of the ventricular lead insulation were performed with excimer laser-assisted extraction technique in the operating room 3 days after admission. However, the ventricular lead, the proximal part of the insulation and the conductor coil could not be removed and were left in place (Figure 1). Postoperatively, antibiotic therapy with vancomycin and ciprofloxacine was administered. The ventricular lead with its insulation and the conductor coil were extracted in the cardiac catheter laboratory 4 days later. Both, the ventricular lead and its insulation were removed by transfemoral venous access under fluoroscopy using a DRS-100 basket (COOK Medical Inc., Bloomington, IN, USA) as retriever device. Having inserted an eight French femoral sheath, the preloaded basket retriever device was advanced to the heart and opened to grab the ventricular lead with its insulation. After grasping the lead, the basket was closed to fix the lead and traction was applied to pull it from the heart to the inferior vena cava and remove it from circulation (Figure 2). The lead was pulled out with the sheath through a small cutaneous incision, the vein was compressed manually for five minutes and definite hemostasis was completed by a cutaneous Z-suture. The ingrown conductor coil was unwinded via the subclavian vein by mechanical traction with a clamp through the surgically reopened ICD pulse generator pocket after coil location under fluoroscopic visualization (Figure 2D). Hence, both the ventricular lead with its insulation and the conductor coil, could successfully be removed (Figure 3), and open surgery with possible need for cardiopulmonary bypass could be avoided in this patient. In the course, aggregatibacter actinomycetem comitans was isolated from several blood cultures, the material obtained by puncture of the ICD pulse generator pocket, and the extracted device and antibiotic therapy was changed to ceftriaxone.