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Table of Contents
LETTER TO EDITOR  
Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 252-253
40-year-old externalized pacemaker lead: To extract or not to extract - That is the risk assessment question


1 Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
2 Divisions of Cardiovascular Medicine, Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, WI, USA
3 Department of Cardiothoracic Surgery, Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, WI, USA

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Date of Web Publication4-Jul-2012
 

How to cite this article:
Gluncic V, Singh D, Almassi G H. 40-year-old externalized pacemaker lead: To extract or not to extract - That is the risk assessment question. Ann Card Anaesth 2012;15:252-3

How to cite this URL:
Gluncic V, Singh D, Almassi G H. 40-year-old externalized pacemaker lead: To extract or not to extract - That is the risk assessment question. Ann Card Anaesth [serial online] 2012 [cited 2019 Nov 16];15:252-3. Available from: http://www.annals.in/text.asp?2012/15/3/252/97987


The Editor,

Skin protrusion and/or infection of the cardiac implantable electrophysiological devices occur in 1-7% of patients. It is crucial to prevent its progression to endocarditis. Complete surgical extraction of the hardware combined with antibiotics is the golden standard in these cases, and still carries a 12.5% mortality. [1],[2],[3]

A 68-year-old patient with a 40-year-old protruded pacemaker lead is presented. Right-sided pacemaker was implanted in 1971 due to sick sinus syndrome. In 1979, after the hardware skin protrusion, it was extracted and replaced with a one on the left. Extraction of the original lead, placed through the right internal jugular vein, was aborted due to the adhesions. This lead resurfaced in 2004 and removal with the laser-assisted extraction system (LAES) was aborted due to bleeding. Both times, the protruding wire was cut and buried in the subcutaneous tissue. In 2011, the patient presented with the same lead exposed for 3 months [Figure 1]a and low-grade skin infection with cultures positive for Proteus mirabilis and Enterococcus faecalis. History of recurrent protrusions with local infection prompted its removal. Because of the past difficulties, we planned its removal on cardiopulmonary bypass (CPB) with open right heart and possible deep hypothermic circulatory arrest (DHCA). Under general anesthesia on CPB, the right atrium was opened and the right lead, encased in calcifications together with the functional left lead, was identified. Atrial, ventricular and superior vena cava (SVC) calcifications/adhesions required DHCA for their dissection. After the right lead was removed [Figure 1]b, several breaks of the left lead insulation were identified and prompted its removal. Calcification in the innominate vein required LAES for its complete removal. Subsequently, the SVC and right atrial incisions were closed, patient rewarmed, CPB restarted, left lead and pacemaker removed [Figure 1]c and d and the patient weaned off CBP without difficulties. The postoperative course was unremarkable. Despite 45 min of DHCA, the patient recovered to his baseline. Most patients tolerate DHCA well up to 30 min, with marked increase in the incidence of brain injury when this period extends beyond 40 min. Neurological sequellae include stroke (2-13%), transitory neurologic disease (TND) (5-20%), hypoxic encephalopathy and seizures. [1],[2],[4]
Figure 1: (a) Preoperative chest X-ray demonstrating an abandoned right cardiac lead and a lead coming from the pacemaker on the left. (b) Extracted right-sided lead with severe calcifications and tissue adhesions. (c) Extracted lead from the pacemaker on the left. (d) Postoperative chest X-ray demonstrating complete hardware removal

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The major indications for the implantable cardiac device hardware removal are lead-related endocarditis, recurrent local infection and/or protruded hardware, nonfunctional leads, thrombotic complications, suspected wires fractures and migrated wires. Nowadays, LAESs have an excellent success rate. However, there is increasing number of cases where open removal is mandated due to frequent calcifications of intravascular leads as pacemakers last longer in patients who live longer. [1],[2],[3],[4],[5] The removal of the exposed infected pacemaker lead is mandatory to prevent potential septic complications unless the patient condition precludes such an approach. The literature indicates that the overall risk is less than the inherent risk of the endocarditis. [1],[2],[3]

Cardiology evaluation before admission indicated that our patient did not need pacing. Discontinuation of pacemaker treatment after lead extraction is reported in 13-52% of patients, and this is another example of their excessive usage. [1],[5]

 
   References Top

1.del Río A, Anguera I, Miró JM, Mont L, Fowler VG Jr, Azqueta M, et al. Surgical treatment of pacemaker and defibrillator lead endocarditis: the impact of electrode lead extraction on outcome. Chest 2003;124:1451-9.  Back to cited text no. 1
    
2.Sohail MR, Uslan DZ, Khan AH, Friedman PA, Hayes DL, Wilson WR, et al. Infective endocarditis complicating permanent pacemaker and implantable cardioverter-defibrillator infection. Mayo Clin Proc 2008;83:46-53.  Back to cited text no. 2
    
3.Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH 3rd, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA).Heart Rhythm 2009;6:1085-104.  Back to cited text no. 3
    
4.Griepp RB. Cerebral protection during aortic arch surgery. J Thorac Cardiovasc Surg 2001;121:425-7.  Back to cited text no. 4
    
5.Selzer A. Too many pacemakers. N Engl J Med 1982;307:183-4.  Back to cited text no. 5
    

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Correspondence Address:
Vicko Gluncic
Department of Anesthesiology, Rush University Medical Center, 1653 W. Congress Parkway, Jelke 7, Chicago, IL 60612
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.97987

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