Key result
A chronically perforating right atrial pacemaker lead was successfully extracted without cardiopulmonary bypass using an off-pump hybrid approach with a novel lead-inverting stitch.
Case Report (n=1)
No
An off-pump hybrid approach utilizing a "lead-inverting stitch" allows for the safe removal of an extravascular perforating pacemaker lead while avoiding the risks associated with cardiopulmonary bypass.
May offer bypass-free extraction for select perforating leads; hypothesis-generating and should not yet change practice.
BACKGROUND: The use of cardiac implantable electrical devices continues to increase with the validation of new beneficial indications. While the risks of device implantation decreased significantly over time, significant risk remains associated with their extraction when indicated. A high-risk pacemaker lead extraction case is described, wherein a chronically implanted lead that had perforated the right atrium was successfully removed without the need for cardiopulmonary bypass. In this report we share our approach to this challenging extraction case and describe an infrequently utilized off-pump hybrid technique that we term the "lead-inverting stitch". CASE PRESENTATION: A 74 year-old Caucasian woman with complete heart block and remote pacemaker implantation presents with a swollen and erythematous infected pacemaker pocket necessitating device extraction. Chest computerized tomographic imaging revealed a chronically perforating right atrial lead tip approximately 2 cm within the pericardial space. A successful hybrid transvenous and open surgical extraction approach was undertaken without the need for cardiopulmonary bypass; this was made possible due to a successfully positioned "lead-inverting stitch". CONCLUSION: Implantable cardiac electrical device infections are amongst the most dreaded post implant complications. Risks of device extraction are further complicated in cases of chronic lead perforations. Extraction strategies that avoid cardiopulmonary bypass initiation are preferred.
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Rizkallah et al. (2015) conducted a case report in Pacemaker pocket infection with chronically perforating right atrial lead (n=1). Off-pump hybrid transvenous and open surgical extraction using a lead-inverting stitch was evaluated on Successful lead extraction. A chronically perforating right atrial pacemaker lead was successfully extracted without cardiopulmonary bypass using an off-pump hybrid approach with a novel lead-inverting stitch.
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