Initial Experience with Hybrid Lead Extraction - The 65th Annual Conference of the Israel Heart Society & The Israel Society of Cardiothoracic Surgery, 24-25 April 2018

Yair Elitzur Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel Ori Wald Department of Cardiothoracic Surgery, Hadassah Medical Center, Jerusalem, Israel Amit Korach Department of Cardiothoracic Surgery, Hadassah Medical Center, Jerusalem, Israel Uzi Yizhar Department of Cardiothoracic Surgery, Hadassah Medical Center, Jerusalem, Israel Ayelet Shauer Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel Oz Shapira Department of Cardiothoracic Surgery, Hadassah Medical Center, Jerusalem, Israel Ehud Rudis Department of Cardiothoracic Surgery, Hadassah Medical Center, Jerusalem, Israel Mohamad Afifi Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel David Orenstein Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel Ahmed Hadieh Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel David Luria Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel

With increasing use of cardiac rhythm devices, there is growing need for device and lead extraction. Despite significant advances in intravascular extraction technology, patient safety remains a concern. Specifically, there remains a small but significant risk of damage to the thoracic venous system, especially the superior vena cava. SVC tear is potentially lethal if not rapidly identified and repaired, usually via emergent mid-sternotomy.

A significant challenge remains the time to diagnosis of SVC tear and the decision to proceed with sternotomy. The initial event is usually hypotension, which may have several reasons, such as anesthetic agents, hypovolemia etc. Unfortunately, the common site of SVC tear is at the innominate - SVC junction well above the pericardium, therefore detection of pericardial fluid by TEE is impossible.

Few case reports have been published describing the use of thoracoscopy for visualization of lead extraction. VATS enables direct visualization of the SVC-innominate junction area during the procedure, facilitating immediate recognition of tear, potentially enabling control of bleeding during balloon deployment and preparation for sternotomy. We describe our initial experience with thoracoscopy-guided lead extraction in two patients.

Patients were 56 and 69 years old with ICD leads implanted 8 and 10 years ago. Indications for extraction were need for percutaneous tricuspid valve repair and infection. The procedure was peformed in a hybrid operating room with fluoroscopic capabilities and standby cardiopulmonary bypass.

Uni-portal fluoroscopy provided an option to apply direct pressure on the SVC in case of injury.

Fluoroscopic access did not significantly prolong procedure time. Selective intubation did somewhat prolong anesthetic preparation of the patient.

Throughout the procedure we were able to visualize the critical innominate-SVC junction and the movement of extraction instruments therein. Fortunately there were no complications; however the ability to visualize the operating field definitely adds a significant level of safety.