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PP-158 NEW TRANSVENOUS LEAD EXTRACTION TECHNIQUE TO OVERCOME FIBROUS ADHESION SITES: CASE REPORT
Cardiology Posters / International Journal of Cardiology 140, Supplement 1 (2010) S1–S93
S85
native to surgical closure. Although excellent results have been reported for transcatheter occlusion with devices, concerns have arises about peri-interventional complications. Despite implanting an intracardiac, potentially thrombogenic foreign body, reports on thromboembolic complications related to an interatrial device are rare. This case report illustrates that periprocedural thrombus formation occur at transport catheter. Methods: A 45 years old man presented emergency service with cerebrovascular accident. He had no past medical history except smoking (30 pocket/year). During his evaluation at emergency service, complete blood count, biochemical tests including renal-liver function tests and thyroid function tests, thrombophilia panel parameters (prothrombin time, activated partial thromboplastin time, international normalized ratio, protein C activity, protein S (total and free), antithrombin III, anticardiolipin antibodies, homocysteine, factor V Leiden mutation, and prothrombin gene PCR) were in normal limits. The ECG was in sinus rhytm, incomplete RBBB and telecardiogram was normal. Imaging with cranial MR and MRA revealed milimetric acute ischemic lesions in left precentral gyrus, superior temporal and frontal areas. Transcranial doppler ultrasound showed right to left shunt like waterspout pattern. So PFO or ASD were suspected in differential diagnosis. Interatrial septal aneurysm was detected with TTE. TEE revealed ASD with 10mm diameter in bicaval position, was relevant for percutaneous closure. There was no any other pathology. Patient was taken for transcatheter closure of ASD with TEE control under general anesthesia. Amplatzer® Septal Occluder device in 13mm diameter prepared for closure. After passing through the left atrium, there was thrombus formation at the tip of transport catheter of device. The occluder device deployed under TEE imaging and thrombus was taken in between arms of the device. The patient was anticoagulated with UFH infusion immediately during procedure. Results: Control TEE after implantation of device revealed no thrombus around occluder device. Patient was asypmtomatic after procedure with no neurological signs. Patient was discharged with oral anticoagulation. Control TTE before discharging showed that the device was positioned flat against the septum and appeared to be in complete contact with the septum. Patient was asymptomatic at 4th week control with normal TTE. Conclusions: Although percutaneous ASD closure is associated with low complication rate, it is not risk free. Patients shoul be followed closely and over a long term after closure. It is essential that the cardiology community should be aware of these rare complications.
lead extraction technique has been made. A number of different type equipments are used for extraction with their different safety, efficacy and cost. We report a case of a faulty DDD-ICD ventricular leads extraction by mechanical sheath. Methods: A 80 years old man, after an anterior myocardial infarction, in July 2002 received an DDD-ICD according to guidelines. Due to lead failure, another right ventricular (RV) lead positioned after an unsuccessful old lead extraction. After 2 years, patient developed acute decompansated heart failure and sustained ventricular tachycardia. He was hospitalized in another center for stabilization. During pacemaker control, increased ventricular lead impedance (>5000Ω) and pacemaker generator end of life were seen. So, patient was referred for lead extraction. After external revision of pocket and leads, lead extraction was attempted. Manual traction was performed, but there was no removal of leads. A locking stylet (Liberator™, Universal Locking Stylet, Cook medical) was positioned in one of the RV lead, manual traction applied showing adhesion at the level of subclavian-brachiocephalic vein. A stainless steel mechanical sheath (Byrd™ Dilator sheaths, Cook medical) was used in both leads as a dilator to permit an easier venous access, the Evalution™ sheath is polymer sheath with a stainless steel bladed tip connected to the handle that allows the physician to exert a rotational force in order to overcome fibrous binding sites and to run over the lead length. The cutting tip of the Evalution™ was covered by an outer telescoping polymer sheath so as to protect venous wall from damage while advancing over the lead in the tracts free from adherences. After removal of both RV leads, new RV ICD lead was positioned to the RV apex with no complication. Also pacemaker generator was exchanged. Results: In this case, we used the new Evalution™ mechanical dilator sheath; its rotational mechanism let the sheath advance cutting the fibrous adhesions; to reduce the possible risk of damaging venous wall. In this way no complication developed, procedure was successfully performed. Conclusions: Many techniques have been described to perform pacemaker/ICD lead extraction, choice of technique depends on patient’s clinical presentation, physicians preferences, available material.
PP-157 TRANSCATHETER CLOSURE OF A BLALOCK-TAUSSIG SHUNT WITH THE AMPLATZER DUCT OCCLUDER-II
Mine Durukan, Kazim Baser, Umit Guray, Yesim Guray, Burcu Demirkan, Tolga Aksu, Sule Korkmaz Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
Ali Baykan, Sadettin Sezer, Sertac Hanedan Onan, Kazim Uzum, Nazmi Narin Paediatric Cardiology, University of Erciyes School of Medicine Paediatric Department, Kayseri, Turkiye
Objective: Permanent pacemakers and implantable cardioverterdefibrillators (ICD) are becoming increasingly used for the treatment of cardiac rhythm disturbances worldwide and early and long term complications related to these devices are also becoming more common. Despite the advances in the intracardiac electronic device technology, these devices are still prone to electromagnetic interferences (EMI). EMI with a variable strength may be encountered in everyday life or in the hospitals in the form of litotripsy, transcutaneous nerve stimulation, radiation therapy or magnetic resonance imaging (MRI). Methods: In this report, we present a patient with a four year old DDD pacemaker who had subjected to the inadvertent cranial magnetic resonance imaging (MRI) with 1.5 T strength for stroke. Results: After MRI examination, pacemaker interrogation showed significantly increased ventricular lead impedance (above the detectable limits) with a loss of ventricular lead function. Other battery parameters and atrial lead function were normal. Since both in radiographic examination and direct examination during lead revision, no lead abnormality compatible with lead fracture was found, microfracture within lead was held responsible for the lead dysfunction. Due to normal battery and lead functions during routine controls before MRI, EMI caused by the MRI was thought to be the underlying mechanism for the lead malfunction. The ventricular lead was extracted and replaced appropriately. Conclusions: Although significant increases in lead impedance were reported previously after MRI scanning, to the best of our knowledge, this is the first report describing an acute lead dysfunction with a resultant failure to capture after MRI examination. Noticing the probability of acute lead malfunction as described in our case, clinicians should be aware of a possible lead dysfunctions associated with MRI scanning particularly in pacemaker dependent patients.
Central aortopulmonary shunts and Blalock–Taussig (BT) shunts are wellknown palliative procedures in cyanotic congenital heart disease. After corrective operations, these shunts do not need to maintain and are therefore ligated. To occlude these shunts, coils and other transcatheter devices have been used with varying results. Herein we described a case of Fallot tetralogy (TOF) with modified BT shunt, was successfully occluded by using Amplatzer duct occluder-II (ADO-II). In conclusion, ADO-II will be appropriate especially for the closure of a BT shunt. We want to emphasize on the catheter closure of BT palliative shunts because this procedure is feasible, safe and effective and so can be an alternative to surgery.
PP-158 NEW TRANSVENOUS LEAD EXTRACTION TECHNIQUE TO OVERCOME FIBROUS ADHESION SITES: CASE REPORT Ugur Canpolat, Hikmet Yorgun, Hamza Sunman, Gorkem Fatihoglu, Banu Evranos, Ergun Baris Kaya, Kudret Aytemir, Ali Oto Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: The number of pacemakers and implantable cardioverter defibrillators (ICD) is increasing each year due to expansion of clinical indications. Besides implantation of devices, there is a need for effective method for lead extraction. For the last 10 years, progression in the
PP-159 VENTRICULAR LEAD MICROFRACTURE AFTER AN INADVERTENT CRANIAL MAGNETIC RESONANCE IMAGING IN A PATIENT WITH PERMANENT DDD PACEMAKER
S85
native to surgical closure. Although excellent results have been reported for transcatheter occlusion with devices, concerns have arises about peri-interventional complications. Despite implanting an intracardiac, potentially thrombogenic foreign body, reports on thromboembolic complications related to an interatrial device are rare. This case report illustrates that periprocedural thrombus formation occur at transport catheter. Methods: A 45 years old man presented emergency service with cerebrovascular accident. He had no past medical history except smoking (30 pocket/year). During his evaluation at emergency service, complete blood count, biochemical tests including renal-liver function tests and thyroid function tests, thrombophilia panel parameters (prothrombin time, activated partial thromboplastin time, international normalized ratio, protein C activity, protein S (total and free), antithrombin III, anticardiolipin antibodies, homocysteine, factor V Leiden mutation, and prothrombin gene PCR) were in normal limits. The ECG was in sinus rhytm, incomplete RBBB and telecardiogram was normal. Imaging with cranial MR and MRA revealed milimetric acute ischemic lesions in left precentral gyrus, superior temporal and frontal areas. Transcranial doppler ultrasound showed right to left shunt like waterspout pattern. So PFO or ASD were suspected in differential diagnosis. Interatrial septal aneurysm was detected with TTE. TEE revealed ASD with 10mm diameter in bicaval position, was relevant for percutaneous closure. There was no any other pathology. Patient was taken for transcatheter closure of ASD with TEE control under general anesthesia. Amplatzer® Septal Occluder device in 13mm diameter prepared for closure. After passing through the left atrium, there was thrombus formation at the tip of transport catheter of device. The occluder device deployed under TEE imaging and thrombus was taken in between arms of the device. The patient was anticoagulated with UFH infusion immediately during procedure. Results: Control TEE after implantation of device revealed no thrombus around occluder device. Patient was asypmtomatic after procedure with no neurological signs. Patient was discharged with oral anticoagulation. Control TTE before discharging showed that the device was positioned flat against the septum and appeared to be in complete contact with the septum. Patient was asymptomatic at 4th week control with normal TTE. Conclusions: Although percutaneous ASD closure is associated with low complication rate, it is not risk free. Patients shoul be followed closely and over a long term after closure. It is essential that the cardiology community should be aware of these rare complications.
lead extraction technique has been made. A number of different type equipments are used for extraction with their different safety, efficacy and cost. We report a case of a faulty DDD-ICD ventricular leads extraction by mechanical sheath. Methods: A 80 years old man, after an anterior myocardial infarction, in July 2002 received an DDD-ICD according to guidelines. Due to lead failure, another right ventricular (RV) lead positioned after an unsuccessful old lead extraction. After 2 years, patient developed acute decompansated heart failure and sustained ventricular tachycardia. He was hospitalized in another center for stabilization. During pacemaker control, increased ventricular lead impedance (>5000Ω) and pacemaker generator end of life were seen. So, patient was referred for lead extraction. After external revision of pocket and leads, lead extraction was attempted. Manual traction was performed, but there was no removal of leads. A locking stylet (Liberator™, Universal Locking Stylet, Cook medical) was positioned in one of the RV lead, manual traction applied showing adhesion at the level of subclavian-brachiocephalic vein. A stainless steel mechanical sheath (Byrd™ Dilator sheaths, Cook medical) was used in both leads as a dilator to permit an easier venous access, the Evalution™ sheath is polymer sheath with a stainless steel bladed tip connected to the handle that allows the physician to exert a rotational force in order to overcome fibrous binding sites and to run over the lead length. The cutting tip of the Evalution™ was covered by an outer telescoping polymer sheath so as to protect venous wall from damage while advancing over the lead in the tracts free from adherences. After removal of both RV leads, new RV ICD lead was positioned to the RV apex with no complication. Also pacemaker generator was exchanged. Results: In this case, we used the new Evalution™ mechanical dilator sheath; its rotational mechanism let the sheath advance cutting the fibrous adhesions; to reduce the possible risk of damaging venous wall. In this way no complication developed, procedure was successfully performed. Conclusions: Many techniques have been described to perform pacemaker/ICD lead extraction, choice of technique depends on patient’s clinical presentation, physicians preferences, available material.
PP-157 TRANSCATHETER CLOSURE OF A BLALOCK-TAUSSIG SHUNT WITH THE AMPLATZER DUCT OCCLUDER-II
Mine Durukan, Kazim Baser, Umit Guray, Yesim Guray, Burcu Demirkan, Tolga Aksu, Sule Korkmaz Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
Ali Baykan, Sadettin Sezer, Sertac Hanedan Onan, Kazim Uzum, Nazmi Narin Paediatric Cardiology, University of Erciyes School of Medicine Paediatric Department, Kayseri, Turkiye
Objective: Permanent pacemakers and implantable cardioverterdefibrillators (ICD) are becoming increasingly used for the treatment of cardiac rhythm disturbances worldwide and early and long term complications related to these devices are also becoming more common. Despite the advances in the intracardiac electronic device technology, these devices are still prone to electromagnetic interferences (EMI). EMI with a variable strength may be encountered in everyday life or in the hospitals in the form of litotripsy, transcutaneous nerve stimulation, radiation therapy or magnetic resonance imaging (MRI). Methods: In this report, we present a patient with a four year old DDD pacemaker who had subjected to the inadvertent cranial magnetic resonance imaging (MRI) with 1.5 T strength for stroke. Results: After MRI examination, pacemaker interrogation showed significantly increased ventricular lead impedance (above the detectable limits) with a loss of ventricular lead function. Other battery parameters and atrial lead function were normal. Since both in radiographic examination and direct examination during lead revision, no lead abnormality compatible with lead fracture was found, microfracture within lead was held responsible for the lead dysfunction. Due to normal battery and lead functions during routine controls before MRI, EMI caused by the MRI was thought to be the underlying mechanism for the lead malfunction. The ventricular lead was extracted and replaced appropriately. Conclusions: Although significant increases in lead impedance were reported previously after MRI scanning, to the best of our knowledge, this is the first report describing an acute lead dysfunction with a resultant failure to capture after MRI examination. Noticing the probability of acute lead malfunction as described in our case, clinicians should be aware of a possible lead dysfunctions associated with MRI scanning particularly in pacemaker dependent patients.
Central aortopulmonary shunts and Blalock–Taussig (BT) shunts are wellknown palliative procedures in cyanotic congenital heart disease. After corrective operations, these shunts do not need to maintain and are therefore ligated. To occlude these shunts, coils and other transcatheter devices have been used with varying results. Herein we described a case of Fallot tetralogy (TOF) with modified BT shunt, was successfully occluded by using Amplatzer duct occluder-II (ADO-II). In conclusion, ADO-II will be appropriate especially for the closure of a BT shunt. We want to emphasize on the catheter closure of BT palliative shunts because this procedure is feasible, safe and effective and so can be an alternative to surgery.
PP-158 NEW TRANSVENOUS LEAD EXTRACTION TECHNIQUE TO OVERCOME FIBROUS ADHESION SITES: CASE REPORT Ugur Canpolat, Hikmet Yorgun, Hamza Sunman, Gorkem Fatihoglu, Banu Evranos, Ergun Baris Kaya, Kudret Aytemir, Ali Oto Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: The number of pacemakers and implantable cardioverter defibrillators (ICD) is increasing each year due to expansion of clinical indications. Besides implantation of devices, there is a need for effective method for lead extraction. For the last 10 years, progression in the
PP-159 VENTRICULAR LEAD MICROFRACTURE AFTER AN INADVERTENT CRANIAL MAGNETIC RESONANCE IMAGING IN A PATIENT WITH PERMANENT DDD PACEMAKER