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Active-fixation coronary sinus pacing lead extraction: A hybrid approach
International Journal of Cardiology 156 (2012) e51–e52
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Active-fixation coronary sinus pacing lead extraction: A hybrid approach Antonio Curnis a, Luca Bontempi a, Giuseppe Coppola b,⁎, Manuel Cerini a, Francesca Gennaro b, Francesca Vassanelli a, Alessandro Lipari a, Najat Ashofair a, Carlo Pagnoni a, Gianluigi Bisleri c, Claudio Munaretto c, Livio Dei Cas a a b c
EP Lab, Department and Chair of Cardiology, Spedali Civili, University of Brescia, Italy O.U. of Cardiology, EP Lab, A.O.U. Policlinico P. Giaccone, Post Graduate School of Cardiology, University of Palermo, Italy Department and Chair of Cardiac Surgery, Spedali Civili, University of Brescia, Italy
a r t i c l e
i n f o
Article history: Received 12 August 2011 Accepted 15 August 2011 Available online 9 September 2011 Keywords: Infection Lead extraction Laser sheath
Cardiac resynchronization therapy (CRT) can be considered as the standard treatment for patients suffering from heart failure (NYHA III–IV), severely reduced left ventricular (LV) function, and wide QRS complexes. Over the past years, the lead systems used to stimulate the left ventricle have evolved technically from epicardial approaches to a transvenous access accompanied by a significant reduction of procedure-related complication rates [1]. However, even today, LV dislodgement rates ranging 5–10% and the instability of thresholds over time remain the greatest challenges with transvenous LV leads in CRT. Therefore, a special LV lead utilizing active fixation (the Attain StarFix® active fixation unipolar lead, Model 4195) was developed. At the target location, three lobes at the distal end of the lead can be deployed, which compress gently against the vein wall and thereby provide enhanced fixation of the LV lead [1]. This lead is safe and highly efficacious. It affords the physician more choices in lead placement location and has a remarkably low dislodgement rate [2,3]. We describe the case of a patient implanted in 2008 with a cardiac resynchronization therapy-defibrillator (CRT-D) device and an “active-fixation” coronary sinus lead (Attain StarFix®, Model 4195 Medtronic Inc., Minneapolis, MN, USA), who underwent transvenous lead
⁎ Corresponding author at: U.O.C. di Cardiologia, A.O.U.P. “P. Giaccone”, Università degli Studi di Palermo, Via del Vespro 127, 90100 Palermo, Italy. Tel.: + 39 0916554303; fax: + 39 0916554301. E-mail address: [email protected] (G. Coppola).
0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.08.016
removal for lead infection. Using an Excimer Laser system emitting energy at the tip of a flexible fiber-optic 12 F sheath (Spectranetics Inc., Colorado Springs, CO) we completely extracted the double coil lead from the right ventricle apex as well as the atrial lead. Then we tried to deflate the fixing mechanisms of the left ventricle lead but we found that something was retaining the lobe at the distal part of the lead. Using an 8.5 F Byrd dilator sheath (Cook Medical Inc. Bloomington, IN, USA) we removed the tissue adhesions as far as the ostium of the coronary sinus and then we tried again to pull the lead manually, but it was not successful. Angiography with contrast agent showed a coronary sinus fibrotic occlusion, so we positioned a delivery system as far as the distal pole of the StarFix device; and attempted traction again, but without success (Fig. 1). After that, using an ablation catheter (curve A) through the femoral vein, we reached the lead at the CS ostium. Then we cut the proximal side of the lead at the level of the collar-bone and we brought the lead into the inferior vena cava (together with the ablation lead). After positioning of a SR0 FastCath introducer (St. Jude Medical, Minnetonka, MN, USA) into the femoral vein, we used a bioptome to catch and pull the lead, but during the traction a break in the lead insulation was observed and a piece of the internal coil remained in the atrium. An echo exam during and after the procedure did not show any pericardial effusion. We therefore decided to check if it would be possible to complete the procedure using a surgical approach. The patient underwent general anesthesia with selective intubation (with bronchial excluders) in order to achieve exclusion of the left lung. The patient's position was supine with a 30° rightward rotation achieved using an inflatable bag. Three ports were positioned in the 4th, 5th and 6th intercostal spaces (ICS) respectively, with the camera port (5th ICS) on the anterior axillary line and the remaining two instrument ports at the level of the mid-axillary line. Once the pericardium was opened, and following a careful visual inspection of the cardiac surface in the lateral region, an area of hematoma was clearly depicted close to the left atrial appendage (Fig. 2), thereby suggesting the area where the percutaneous attempt at lead extraction had failed. The tip of the lead could be clearly identified and confirmed with the use of endoscopic instruments. The coronary vein was then opened and the remaining part of the lead was easily retrieved (Fig. 2). However, the tip of the catheter was tightly fibrosed and removal was achieved only following debridement of the tight adhesions with a scalpel (see video
e52
A. Curnis et al. / International Journal of Cardiology 156 (2012) e51–e52
Fig. 1. Coronary sinus angiography.
file). The coronary vein was then sutured with 5/0 polypropylene, and conventional closure of the ports was then achieved. The patient was extubated and, following the surgical procedure, had an uneventful recovery in the post-operative period. The Attain StarFix® lead (Medtronic, Minneapolis, Minnesota) was designed with a novel active fixation mechanism. The goal of this design was to minimize lead dislodgement and to give the implanter more choices in implantation location. This was achieved with a fixation mechanism using deployable lobes that enable implantation at any suitable location along a given cardiac venous branch [2,3]. Although experience with coronary sinus lead extraction is limited, especially with regard to chronic leads; based on experience that is available, most passive fixation coronary sinus leads can be successfully extracted with direct traction alone. This can be explained by the poor fixation mechanisms and the low propensity to fibrosis within the coronary sinus and in its tributaries, particularly for leads implanted for a short period of time [4]. With only few previously described cases [3,5], the main implications of the present one were the infected, and therefore mandatory device removal indication, the lead implantation time (2 years) and, in our case, the necessity to adopt a hybrid approach in order to complete lead extraction successfully. In conclusion, the Attain StarFix® lead should be used carefully as the last resort in CRT and probably avoided in patients with a long life expectancy or in patients at high risk of potential device infection [4]. Supplementary materials related to this article can be found online at doi:10.1016/j.ijcard.2011.08.016.
Fig. 2. Area of hematoma depicted close to the left atrial appendage and lead exposure during coronary sinus opening.
None. We would like to thank Dr. Federico Marcia for his support during manuscript preparation. References [1] Luedorff G, Kranig W, Grove1 R, Wolff E, Heimlich G, Thale J. Improved success rate of cardiac resynchronization therapy implant by employing an active fixation coronary sinus lead. Europace 2010;12:825–9. [2] Crossley GH, Exner D, Hardwin R, et al. For the Medtronic 4195 Study Investigators. Chronic performance of an active fixation coronary sinus lead. Heart Rhythm 2010;7:472–8. [3] Bongiorni MG, Di Cori A, Zucchelli G, et al. A modified transvenous single mechanical dilatation technique to remove a chronically implanted active-fixation coronary sinus pacing lead. PACE 2010;33:1376–81. [4] Nagele H, Azizi M, Hashagen S, Castel MA, Behrens S. First experience with a new active fixation coronary sinus lead. Europace 2007;9:437–41. [5] Baranowski B, Yerkey M, Dresing T, Wilkoff BL. Fibrotic tissue growth into the extendable lobes of an active fixation coronary sinus lead can complicate extraction. PACE 2010:1–3.
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Active-fixation coronary sinus pacing lead extraction: A hybrid approach Antonio Curnis a, Luca Bontempi a, Giuseppe Coppola b,⁎, Manuel Cerini a, Francesca Gennaro b, Francesca Vassanelli a, Alessandro Lipari a, Najat Ashofair a, Carlo Pagnoni a, Gianluigi Bisleri c, Claudio Munaretto c, Livio Dei Cas a a b c
EP Lab, Department and Chair of Cardiology, Spedali Civili, University of Brescia, Italy O.U. of Cardiology, EP Lab, A.O.U. Policlinico P. Giaccone, Post Graduate School of Cardiology, University of Palermo, Italy Department and Chair of Cardiac Surgery, Spedali Civili, University of Brescia, Italy
a r t i c l e
i n f o
Article history: Received 12 August 2011 Accepted 15 August 2011 Available online 9 September 2011 Keywords: Infection Lead extraction Laser sheath
Cardiac resynchronization therapy (CRT) can be considered as the standard treatment for patients suffering from heart failure (NYHA III–IV), severely reduced left ventricular (LV) function, and wide QRS complexes. Over the past years, the lead systems used to stimulate the left ventricle have evolved technically from epicardial approaches to a transvenous access accompanied by a significant reduction of procedure-related complication rates [1]. However, even today, LV dislodgement rates ranging 5–10% and the instability of thresholds over time remain the greatest challenges with transvenous LV leads in CRT. Therefore, a special LV lead utilizing active fixation (the Attain StarFix® active fixation unipolar lead, Model 4195) was developed. At the target location, three lobes at the distal end of the lead can be deployed, which compress gently against the vein wall and thereby provide enhanced fixation of the LV lead [1]. This lead is safe and highly efficacious. It affords the physician more choices in lead placement location and has a remarkably low dislodgement rate [2,3]. We describe the case of a patient implanted in 2008 with a cardiac resynchronization therapy-defibrillator (CRT-D) device and an “active-fixation” coronary sinus lead (Attain StarFix®, Model 4195 Medtronic Inc., Minneapolis, MN, USA), who underwent transvenous lead
⁎ Corresponding author at: U.O.C. di Cardiologia, A.O.U.P. “P. Giaccone”, Università degli Studi di Palermo, Via del Vespro 127, 90100 Palermo, Italy. Tel.: + 39 0916554303; fax: + 39 0916554301. E-mail address: [email protected] (G. Coppola).
0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.08.016
removal for lead infection. Using an Excimer Laser system emitting energy at the tip of a flexible fiber-optic 12 F sheath (Spectranetics Inc., Colorado Springs, CO) we completely extracted the double coil lead from the right ventricle apex as well as the atrial lead. Then we tried to deflate the fixing mechanisms of the left ventricle lead but we found that something was retaining the lobe at the distal part of the lead. Using an 8.5 F Byrd dilator sheath (Cook Medical Inc. Bloomington, IN, USA) we removed the tissue adhesions as far as the ostium of the coronary sinus and then we tried again to pull the lead manually, but it was not successful. Angiography with contrast agent showed a coronary sinus fibrotic occlusion, so we positioned a delivery system as far as the distal pole of the StarFix device; and attempted traction again, but without success (Fig. 1). After that, using an ablation catheter (curve A) through the femoral vein, we reached the lead at the CS ostium. Then we cut the proximal side of the lead at the level of the collar-bone and we brought the lead into the inferior vena cava (together with the ablation lead). After positioning of a SR0 FastCath introducer (St. Jude Medical, Minnetonka, MN, USA) into the femoral vein, we used a bioptome to catch and pull the lead, but during the traction a break in the lead insulation was observed and a piece of the internal coil remained in the atrium. An echo exam during and after the procedure did not show any pericardial effusion. We therefore decided to check if it would be possible to complete the procedure using a surgical approach. The patient underwent general anesthesia with selective intubation (with bronchial excluders) in order to achieve exclusion of the left lung. The patient's position was supine with a 30° rightward rotation achieved using an inflatable bag. Three ports were positioned in the 4th, 5th and 6th intercostal spaces (ICS) respectively, with the camera port (5th ICS) on the anterior axillary line and the remaining two instrument ports at the level of the mid-axillary line. Once the pericardium was opened, and following a careful visual inspection of the cardiac surface in the lateral region, an area of hematoma was clearly depicted close to the left atrial appendage (Fig. 2), thereby suggesting the area where the percutaneous attempt at lead extraction had failed. The tip of the lead could be clearly identified and confirmed with the use of endoscopic instruments. The coronary vein was then opened and the remaining part of the lead was easily retrieved (Fig. 2). However, the tip of the catheter was tightly fibrosed and removal was achieved only following debridement of the tight adhesions with a scalpel (see video
e52
A. Curnis et al. / International Journal of Cardiology 156 (2012) e51–e52
Fig. 1. Coronary sinus angiography.
file). The coronary vein was then sutured with 5/0 polypropylene, and conventional closure of the ports was then achieved. The patient was extubated and, following the surgical procedure, had an uneventful recovery in the post-operative period. The Attain StarFix® lead (Medtronic, Minneapolis, Minnesota) was designed with a novel active fixation mechanism. The goal of this design was to minimize lead dislodgement and to give the implanter more choices in implantation location. This was achieved with a fixation mechanism using deployable lobes that enable implantation at any suitable location along a given cardiac venous branch [2,3]. Although experience with coronary sinus lead extraction is limited, especially with regard to chronic leads; based on experience that is available, most passive fixation coronary sinus leads can be successfully extracted with direct traction alone. This can be explained by the poor fixation mechanisms and the low propensity to fibrosis within the coronary sinus and in its tributaries, particularly for leads implanted for a short period of time [4]. With only few previously described cases [3,5], the main implications of the present one were the infected, and therefore mandatory device removal indication, the lead implantation time (2 years) and, in our case, the necessity to adopt a hybrid approach in order to complete lead extraction successfully. In conclusion, the Attain StarFix® lead should be used carefully as the last resort in CRT and probably avoided in patients with a long life expectancy or in patients at high risk of potential device infection [4]. Supplementary materials related to this article can be found online at doi:10.1016/j.ijcard.2011.08.016.
Fig. 2. Area of hematoma depicted close to the left atrial appendage and lead exposure during coronary sinus opening.
None. We would like to thank Dr. Federico Marcia for his support during manuscript preparation. References [1] Luedorff G, Kranig W, Grove1 R, Wolff E, Heimlich G, Thale J. Improved success rate of cardiac resynchronization therapy implant by employing an active fixation coronary sinus lead. Europace 2010;12:825–9. [2] Crossley GH, Exner D, Hardwin R, et al. For the Medtronic 4195 Study Investigators. Chronic performance of an active fixation coronary sinus lead. Heart Rhythm 2010;7:472–8. [3] Bongiorni MG, Di Cori A, Zucchelli G, et al. A modified transvenous single mechanical dilatation technique to remove a chronically implanted active-fixation coronary sinus pacing lead. PACE 2010;33:1376–81. [4] Nagele H, Azizi M, Hashagen S, Castel MA, Behrens S. First experience with a new active fixation coronary sinus lead. Europace 2007;9:437–41. [5] Baranowski B, Yerkey M, Dresing T, Wilkoff BL. Fibrotic tissue growth into the extendable lobes of an active fixation coronary sinus lead can complicate extraction. PACE 2010:1–3.