Abstract 13221: A Multidisciplinary Approach to Transvenous Lead Extraction in the Setting of a Large Patent Foramen Ovale

Abstract

Introduction: Increasing cardiovascular implantable electronic devices (CIED) implantation has been associated with a rising incidence of CIED infection. Treatment includes targeted antimicrobial therapy and device hardware removal although larger lead vegetations have historically undergone surgical removal. As many CIED recipients are at high surgical risk, there is growing need for transvenous approaches for safe debulking of vegetation mass. Case: An 80-year-old man with a history of ischemic cardiomyopathy and an indwelling dual chamber implantable cardioverter defibrillator (ICD) for 17 years with previous appropriate shocks was found to have Enterococcus faecalis bacteremia. Transthoracic echocardiography revealed a 3 cm vegetation on the right ventricular lead involving the tricuspid valve in addition to a large patent foramen ovale (PFO). He was started on intravenous antibiotics. Blood cultures revealed no growth. Decision-making: The large-sized vegetation in presence of a PFO posed a risk for pulmonary or systemic embolization from transvenous lead extraction. A multidisciplinary approach was developed which included temporary PFO occlusion, thrombus aspiration with the Inari FlowTriever thrombus aspiration system, and transvenous laser lead extraction (Figure 1). No residual material remained and the Amplatzer was retrieved. Cultures from the pocket, lead tips, and vegetation were collected. The vegetation culture grew E. faecalis. He underwent subcutaneous ICD implant six weeks later following antibiotic therapy. Conclusions: Vegetation suction with a simple handheld device can be safe and effective for vegetation removal in high-risk cases. Furthermore, temporary PFO occlusion can be performed during vegetation debulking and device extraction. These management strategies may gain wider application with an increasing need for lead extraction in older patients with comorbidities that preclude surgical candidacy.