Radiofrequency ablation–assisted extraction of a pacing lead fragment

Abstract

Infected cardiac implantable electronic devices require complete extraction, but lead fracture makes complete extraction challenging. When conventional extraction techniques fail, innovative approaches are required. We present a patient with recurrent bacteremia whose pacing lead fractured during extraction, required a novel approach toward extracting the fragment. Case Report A 71-year-old man with ischemic cardiomyopathy and prior coronary artery bypass grafting surgery with a dual-chamber implantable cardioverter-defibrillator (ICD) placed 4 years earlier for a history of ventricular tachycardia was referred for lead extraction because of recurrent fever, vegetations on his atrial lead, and Kocuria varians bacteremia. He had a Guidant 4470 right atrial (RA) lead and a Guidant 0184 right ventricular (RV) lead (Guidant Corp, St. Paul, MN). The RV lead was successfully extracted with a Liberator locking stylet and a Cook Evolution system (Cook Medical, Bloomington, IN) without difficulty. The Evolution system outer sheath was advanced to the right atrium and the rotational sheath was advanced to within the innominate vein; traction-countertraction with an external dilator facilitated removal of the RV lead. Traction of the RV lead did not show significant interaction with the RA lead. A locking stylet was inserted within the atrial lead, but it could not be advanced further than a position 1 cm proximal to the proximal electrode and was deployed at this location. As the Cook Evolution RL mechanical rotational dilator sheath was advanced over the lead, the locking stylet separated at the tip of the proximal electrode, stretching the silicone rubber coating. Further traction completely separated the silicone rubber coating, leaving behind the 2 electrodes and a portion of the silicone outer coating (Figure 1). The proximal fragment of the lead was removed and the pocket was closed. Open in a separate window Figure 1 Fragments of the right atrial lead (arrow) on fluoroscopy.