Transvenous lead extraction (TLE) is the standard therapy for cardiac device-related infection, however sometimes the procedure cannot be completed through the transvenous route alone and it is necessary to rely on other techniques. Hybrid surgical and transvenous approach can be useful in these cases. We present 3 cases of hybrid surgical and transvenous approach.
A 64-year-old male patient with a cardiac resynchronization therapy defibrillator (CRT-D) implanted in 2011, with an active-fixation coronary sinus (CS) lead.
In order to perform the extraction, a locking stylet was inserted in the CS lead, then a mechanical sheath was advanced over the lead itself, however failing in detaching the lead from the surrounding adhesions. The lead was then extracted by left mini-thoracotomy.
A 60-year-old male was implanted with a CRT-D in 2012. After the transvenous extraction of atrial and ventricular leads, we attempted to extract the coronary sinus lead, positioned in the anterolateral vein, using a locking stylet, telescoping mechanical sheaths, a 9 Fr hand-powered rotational sheath, and a 16-Fr excimer laser sheath. The lead was extensively fibrosed and could only be retrieved to the proximal part of the vein, approximately 2 cm from the body of the coronary sinus. Considering the high operative risk, a sternotomy was performed with complete extraction of the CS lead.
A 74-year-old male was implanted with a CRT-D in 2012, with a bipolar CS lead positioned in the posterolateral vein. During CS lead extraction we firstly used a locking stylet, followed by the introduction of telescopic mechanical sheaths which ceased to advance at 3 cm from the tip of the lead due to strong fibrosis. The procedure was interrupted due to the risk of coronary sinus tear and a left minithoracotomy was performed, effective in the removal of the lead.
Sometimes the TLE procedure cannot be completed through the transvenous route alone and there is a need for an hybrid approach with the aid of a cardiothoracic surgeon. Hybrid surgical and transvenous approach can be useful in these cases.