Vital Necessity of Total Pacemaker Lead Extraction Following Heart Transplantation

Abstract

Introduction A 53-year-old patient was admitted through our emergency room presenting high fever and sudden fatigue six months after a high-risk heart transplantation (HTx) due to dilated cardiomyopathy and valvular heart disease. Several pacemaker leads and a CRT(D) device were initially abandoned intracorporeally due to extensive thrombosis surrounding the leads. Hemodialysis was initially necessary through an implanted Demers atrial catheter due to postoperative acute kidney injury (AKI) for a total of six months. Case Report The patient was urgently transferred to our ICU with advancing sepsis for immediate broad antibiotic therapy as well as catecholamine-assisted stabilization of hemodynamics. Following total renal recovery, the Demers catheter was successfully removed. Blood cultures revealed a colonization with staphylococcus aureus (MSSA) and candida glabrata, which led to additional antimycotic therapy. Transesophageal echocardiograms excluded an endocardial infestation twice. After achieving stable status, a decision for a high-risk transvenous lead extraction as most-probable focus of infection was made. The CRT-D-device was removed through a left pectoral incision. After lead stabilization with a Lasso Snare and Liberator Lead Locking Device through a femoral, venous sheath, an excimer-laser was implemented to release and extract the right-atrial and right-ventricular leads. Next, the four remaining leads were uncovered through a right pectoral incision and stabilized using a Liberator Lead Locking Device. These were then extracted using a mechanical extraction sheath (Cook Evolution RL). Chest X-rays excluded remaining foreign material. Following surgical removal of all remaining leads and antimicrobial therapy for six weeks, the patient was discharged with normal inflammation parameters and fully recovered. Summary Due to the necessary immunosuppression, patients following HTx show an elevated risk for major infection and rapid development to sepsis, when foreign material is abandoned intracorporeally. Based on this study case, we strongly recommend total extraction of remaining pacemaker leads as soon as possible to avoid severe infection-related complications after HTx. A two-stage transvenous lead extraction with an excimer-laser seems to enable the safest path for extraction of heavily thrombosed pacemaker leads. A 53-year-old patient was admitted through our emergency room presenting high fever and sudden fatigue six months after a high-risk heart transplantation (HTx) due to dilated cardiomyopathy and valvular heart disease. Several pacemaker leads and a CRT(D) device were initially abandoned intracorporeally due to extensive thrombosis surrounding the leads. Hemodialysis was initially necessary through an implanted Demers atrial catheter due to postoperative acute kidney injury (AKI) for a total of six months. The patient was urgently transferred to our ICU with advancing sepsis for immediate broad antibiotic therapy as well as catecholamine-assisted stabilization of hemodynamics. Following total renal recovery, the Demers catheter was successfully removed. Blood cultures revealed a colonization with staphylococcus aureus (MSSA) and candida glabrata, which led to additional antimycotic therapy. Transesophageal echocardiograms excluded an endocardial infestation twice. After achieving stable status, a decision for a high-risk transvenous lead extraction as most-probable focus of infection was made. The CRT-D-device was removed through a left pectoral incision. After lead stabilization with a Lasso Snare and Liberator Lead Locking Device through a femoral, venous sheath, an excimer-laser was implemented to release and extract the right-atrial and right-ventricular leads. Next, the four remaining leads were uncovered through a right pectoral incision and stabilized using a Liberator Lead Locking Device. These were then extracted using a mechanical extraction sheath (Cook Evolution RL). Chest X-rays excluded remaining foreign material. Following surgical removal of all remaining leads and antimicrobial therapy for six weeks, the patient was discharged with normal inflammation parameters and fully recovered. Due to the necessary immunosuppression, patients following HTx show an elevated risk for major infection and rapid development to sepsis, when foreign material is abandoned intracorporeally. Based on this study case, we strongly recommend total extraction of remaining pacemaker leads as soon as possible to avoid severe infection-related complications after HTx. A two-stage transvenous lead extraction with an excimer-laser seems to enable the safest path for extraction of heavily thrombosed pacemaker leads.