Asian Cardiovasc Thorac Ann 2003;11:167-168
© 2003 Asia Publishing EXchange Ltd
Surgical Extraction of Infected Pacemaker Leads After Cardiac Surgery
Seyed Mahmoud Nouraei, FRCS(CTh),
Rodney S Bexton, FRCP,
Asif Hasan, FRCS(CTh)
Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
For reprint information contact: Seyed Mahmoud Nouraei, FRCS(CTh) Tel: 44 191 284 3111 Fax: 44 191 223 1175 email: smnouraei{at}yahoo.co.uk Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
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ABSTRACT
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Surgical extraction of permanent pacemaker leads is performed when noninvasive extraction is felt to be unsafe or has been unsuccessfully attempted. Surgical extraction in patients with previous cardiac surgery presents a particular challenge as resternotomy is hazardous and the presence of surgical adhesions makes video-assisted approaches difficult. We report 2 cases of successful deployment of a surgical technique using femorofemoral cardiopulmonary bypass and right anterior thoracotomy for removal of pacemaker leads.
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INTRODUCTION
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Some 10% of the 400 to 500 thousand permanent pacemaker leads inserted annually worldwide fail or become infected and may need to be removed.1 The most common indications for lead extraction are infection, either in the form of pocket infection, recurrent systemic infections, or endocarditis; nonfunctional or incompatible lead; and problems such as those encountered with Accufix or Encore leads.1,2 The majority of these leads are extracted by cardiologists using closed traction, stylets, or laser sheaths.3,4 In 3% to 5% of cases,1 however, these approaches are not attempted or are unsuccessful because of the presence of fibrotic adhesions or large vegetations,5 and surgical removal is undertaken. The most common approaches are median sternotomy or video-assisted thoracotomy with or without cardiopulmonary bypass (CPB) depending on the circumstances.6–8 Patients with a history of cardiac surgery, however, merit special consideration as the hazards of resternotomy are well known and the presence of adhesions make video-assisted approaches very difficult. We describe a method for the surgical management of this small but high-risk subgroup of patients and present 2 successful cases.
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CASE REPORTS
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Patient 1 was a 74-year-old male who had undergone coronary artery bypass surgery in 1994, which restored him to good health. He continued to be a keen squash and badminton player until he developed complete heart block in 1999, for which a DDD permanent pacemaker system was inserted. Ten months later, he suffered an episode of Streptococcus sanguis endocarditis, which was unresponsive to intravenous antibiotic treatment. He continued to suffer from recurrent septicemia with the same organism despite antibiotic treatment, and transesophageal echocardiography showed dense vegetations slightly under 2 cm in diameter on his right ventricular pacemaker lead. Closed lead extraction was felt to be unsuitable, and he was referred for surgery.
Patient 2 was a 47-year-old female who had undergone repair of tetralogy of Fallot in 1986 with subsequent complete heart block requiring a DDD pacemaker system. She was well until she underwent repositioning of the eroding generator box in 1991 and of the pacing leads and generator box again in 1996. She had a pocket infection manifested by purulent discharge from a left infraclavicular sinus. She subsequently regained sinus rhythm, and her pacing box was removed in July 1997. The pacing wires were tethered in the superior vena cava (SVC), and an attempt to remove them failed. She developed septicemia in 1998, which was treated with antibiotics, and the discharging sinus reopened. In October 2000, she developed septicemia after stopping antibiotics. In view of the recurrence and because of her previous complex heart surgery and the tethered wires in the SVC, she was referred for surgical removal of the pacemaker leads.
In both cases, dissection was undertaken to expose the right femoral artery and vein, as well as right anterior thoracotomy to expose the venae cavae. CPB was established using a 21F femoral arterial cannula with a 23F SVC and 28F inferior vena cava cannula threaded up through the right femoral vein. The patient was cooled to 32°C. Caval snares were tightened, and right atriotomy was undertaken on a beating heart. Both the right atrial and ventricular wires in patient 1 were separated from the adhesions and excised along with the vegetations. The atriotomy was closed in layers. Once the patient was rewarmed to 37°C, CPB was discontinued and withdrawn without difficulties. The chest was closed in the routine fashion leaving behind a chest drain. The right femoral artery and vein were repaired. The subclavian pocket was debrided in patient 2 and then closed. There were no postoperative complications in either case. Patient 1 subsequently had a new pacemaker unit inserted via the right subclavian vein with no complications up to the time of writing. Patient 2 no longer needed pacing.
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DISCUSSION
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Surgical removal of pacemaker leads in patients with previous cardiac surgery is particularly testing as resternotomy is hazardous and the "hostile mediastinum" created by the adhesions of previous surgery renders video-assisted thoracotomy difficult. This is set against the background of increasing numbers of individuals surviving cardiac surgery for longer, raising the likelihood of more of these cases in the future. Our first patient was referred for surgical extraction because of the presence of large vegetations, while the second patient was referred because of the complexity of her previous surgery and the fact that the leads were tethered in the SVC.
We use partial extracorporeal circulation and operate on a beating heart through a right thoracotomy incision under direct vision. This approach offers several advantages, the most important of which is to avoid resternotomy and to adequately deal with the adhesions of previous surgery. We also advocate the prospective use of this approach in patients with a near-certain chance of undergoing cardiac surgery in the future (e.g., patients with angina or valve disease) as a "sternum-sparing" measure.
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REFERENCES
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ABSTRACT
INTRODUCTION
