Minimally Invasive Thoracoscopy During Lead Extraction – Experience from Two Centers

Introduction

Lead extraction has become more common, especially in cases of lead malfunction and infection. Complications are rare but may be devastating[1], especially vascular/cardiac tear. The rate of this complication is reported at 0.4-0.9% with a mortality rate of ~ 50%[2]. Timely diagnosis of this complication remains challenging.

We report a two-center experience with thoracoscopic surveillance during high-risk extraction procedures.

Materials and Methods

Selective intubation is performed and the patient is prepared for possible sternotomy. Femoral venous access is established for rapid introduction of a balloon. Thoracoscopy is established. A second access point is optional to introduce instruments for intervention. Pericardial access is also optional.

Results and Discussion

Over a 2 year period, 13 cases were attempted in two institutions. In one, thoracoscopy was not possible.

There was one case of extensive SVC rupture with rapid exsanguination and death. In another case, a right atrial tear was seen and sutured via thoracoscopic access.

Thoracoscopy necessitates leaving chest drains in place, usually for 24 hours, and does involve some pain at access sites, generally manageable with analgetics.

Conclusion

Thoracoscopy using a right sided mini-thoracotomy may allow for early detection and at times repair of vascular tear in high risk extraction procedures. Direct vision may contribute to patient safety as well as an atmosphere of increased operator confidence. and may also increase the chances of success in the extraction itself. Further large scale studies are needed.