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Removal of Retained Pacing Leads With Vena Caval Inflow Occlusion When Cardiopulmonary Bypass Is Contraindicated
Removal of Retained Pacing Leads With Vena Caval Inflow Occlusion When Cardiopulmonary Bypass Is Contraindicated Jaishankar Raman, MD, PhD, Deepa Bhat, BS, Asad Torabi, BS, and Richard Trohman, MD, MBA Department of Cardiovascular and Thoracic Surgery, and Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois; and Indiana University School of Medicine, Indianapolis, Indiana
Treatment of infected pacing leads ranges from percutaneous extraction to surgical removal with the use of cardiopulmonary bypass (CPB). Vena caval inflow occlusion (VCIO) is an old technique that has been used with success in the pediatric population. We report on the use of inflow occlusion (IO) in removing infected pacing leads from the right side of the heart
in patients in whom endovascular lead extraction failed. VCIO is a safe and simple technique in patients with infected leads who have contraindications for CPB.
L
structures. A standard dose of 5,000 IU heparin was administered systemically before inflow occlusion (IO) in all patients who did not have heparin-induced thrombocytopenia. The steps of the procedure are presented in Fig 1. A portion of the free border of the right atrium was partially occluded using a partial occlusion clamp, and stay sutures were placed at the edges of the clamp. (The schematic diagram does not show the stay sutures within the clamp.) In the early part of our experience, we used angled vascular clamps to occlude the SVC and IVC. In the last 3 patients, caval snares were used in lieu of the vascular clamps. After the clamps were applied, the patient went into the first period of IO. The right atriotomy, which was made between the stay sutures, was opened with release of the partial occlusion clamp. After the blood was suctioned with a cell-saving device and aspirator, the mass/infected material was removed. The leads were followed into the ventricle and freed up using sharp dissection with a fresh No. 11 scalpel blade. A considerable amount of time was spent curetting the area adjacent to the leads and the tricuspid valve when needed. After 2 minutes, flow was restored with a partial occlusion clamp to the free wall of the right atrium, with care being taken to use the stay sutures in the atrium to gather the atriotomy within the clamp. This was done in conjunction with the caval clamps/ snares being released. If necessary, another period of IO was performed to remove retained material or extract remnants of infected tissue after 5 minutes of reperfusion. This technique of repeated IO followed by reperfusion was used in all cases.
Technique Patients were operated on using general anesthesia. The thoracic cavity was accessed through either a median sternotomy or a right minithoracotomy. The superior vena cava (SVC) and inferior vena cava (IVC) were mobilized, and snares were placed around both
Accepted for publication April 30, 2015. Address correspondence to Dr Raman, 1725 W Harrison St, Ste 1156, Professional Building III, Chicago, IL 60612; e-mail: jairaman2462@ gmail.com.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Clinical Details Eight patients with infected leads and vegetations around the leads were treated with surgical extraction. In all these 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.146
FEATURE ARTICLES
ead extraction in the setting of pacing lead–related endocarditis can be challenging and requires complete removal of all hardware. Percutaneous removal of the leads through the endovascular approach is the least invasive and preferred method [1]. In some cases, the percutaneous approach may not be appropriate for removing large vegetations and may not alter the septic trajectory. Patients in whom attempts at percutaneous extraction have failed must undergo a primary surgical approach to extract leads and remove infected material. Surgical extractions typically rely on cardiopulmonary bypass (CPB) and full heparinization. Patients in whom the percutaneous approach has failed and who are poor candidates for CPB can be particularly difficult to treat surgically. CPB can cause inflammation and amplify an already inflammatory state in the patient with endocarditis [2]. In these patients, vena caval inflow occlusion (VCIO) is a useful and successful approach for lead removal. We describe the off-pump technique of lead extraction using VCIO in patients who are ineligible for percutaneous lead removal and in whom CPB is contraindicated.
(Ann Thorac Surg 2015;100:2379–80) Ó 2015 by The Society of Thoracic Surgeons
2380
HOW TO DO IT RAMAN ET AL VICO FOR REMOVAL OF RETAINED PACING LEADS
Ann Thorac Surg 2015;100:2379–80
pacing leads were implanted in 3 patients, and 1 patient had permanent leads implanted endocardially in the right ventricle before extraction of the infected leads. One patient had a repeated VCIO procedure through a sternotomy for a retained deeply embedded pacing lead in the inferior aspect of the right ventricle, with an adjacent area of infection suggestive of a healed abscess. There were no deaths, and the infections resolved in all patients. Inotropic agents were not required in any of these patients. There were no neurologic complications. There was no new onset of renal dysfunction in any of the patients.
FEATURE ARTICLES
Comment
Fig 1. (A) Stay sutures placed on free wall of right atrium so that they can be accommodated within jaws of partial occlusion clamp. (B) Atriotomy opened between stay sutures as soon as clamps are placed on superior vena cava (SVC) and inferior vena cava (IVC). (C) Flow restored after 2 minutes of occlusion by releasing caval clamps and applying side-biter clamp at base of atriotomy.
VCIO was first described by Carrel in 1905 at the University of Chicago and was 1 of the fundamental bases for modern cardiac surgery [3]. This technique is used occasionally in pediatric cardiac surgery, but it can be used in adult patients with cardiac conditions as well. This simple yet flexible approach is a good bailout technique in selected high-risk adult patients who are poor candidates for CPB. The decision to perform IO occurred at the surgeon’s discretion with an aim to minimize procedural risk and avoid further inflammatory responses caused by CPB [2]. The safe limits of IO have to be followed in a disciplined fashion to ensure adequate time for reperfusion, and great care was taken not to exceed 2 minutes of occlusion time [4]. As more patients with multiple pacing leads get evaluated for lead extraction because of lead-related infections, this technique without CPB is a useful and effective approach to facilitate safe removal of leads and infected material. In conclusion, VCIO is a safe and simple surgical technique that enables extraction of infected pacing leads and removal of associated infected material in patients in whom CPB is contraindicated.
References patients, endovascular extraction by electrophysiologists was attempted but was not successful because of a large infective burden or deeply embedded pacing leads, or both. Laser extraction methods were available and were used as indicated by the electrophysiologists. Median sternotomy was performed in 5 patients and right minithoracotomy was carried out in 3 patients. Two of the thoracotomy patients were undergoing a reoperative cardiac procedure. Four of the patients were pacemaker dependent. In these patients, temporary epicardial
1. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010;121:458–77. 2. Edmunds LH Jr. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg 1998;66(5 Suppl):S12–6; discussion S25–8. 3. Edwards WS. Alexis Carrel’s contributions to thoracic surgery. Ann Thorac Surg 1983;35:111–4. 4. Smith JW, Connolly JE. Methods of lengthening the safe time interval of inflow occlusion under hypothermia. Experimental studies. Arch Surg 1960;81:510–3.
Treatment of infected pacing leads ranges from percutaneous extraction to surgical removal with the use of cardiopulmonary bypass (CPB). Vena caval inflow occlusion (VCIO) is an old technique that has been used with success in the pediatric population. We report on the use of inflow occlusion (IO) in removing infected pacing leads from the right side of the heart
in patients in whom endovascular lead extraction failed. VCIO is a safe and simple technique in patients with infected leads who have contraindications for CPB.
L
structures. A standard dose of 5,000 IU heparin was administered systemically before inflow occlusion (IO) in all patients who did not have heparin-induced thrombocytopenia. The steps of the procedure are presented in Fig 1. A portion of the free border of the right atrium was partially occluded using a partial occlusion clamp, and stay sutures were placed at the edges of the clamp. (The schematic diagram does not show the stay sutures within the clamp.) In the early part of our experience, we used angled vascular clamps to occlude the SVC and IVC. In the last 3 patients, caval snares were used in lieu of the vascular clamps. After the clamps were applied, the patient went into the first period of IO. The right atriotomy, which was made between the stay sutures, was opened with release of the partial occlusion clamp. After the blood was suctioned with a cell-saving device and aspirator, the mass/infected material was removed. The leads were followed into the ventricle and freed up using sharp dissection with a fresh No. 11 scalpel blade. A considerable amount of time was spent curetting the area adjacent to the leads and the tricuspid valve when needed. After 2 minutes, flow was restored with a partial occlusion clamp to the free wall of the right atrium, with care being taken to use the stay sutures in the atrium to gather the atriotomy within the clamp. This was done in conjunction with the caval clamps/ snares being released. If necessary, another period of IO was performed to remove retained material or extract remnants of infected tissue after 5 minutes of reperfusion. This technique of repeated IO followed by reperfusion was used in all cases.
Technique Patients were operated on using general anesthesia. The thoracic cavity was accessed through either a median sternotomy or a right minithoracotomy. The superior vena cava (SVC) and inferior vena cava (IVC) were mobilized, and snares were placed around both
Accepted for publication April 30, 2015. Address correspondence to Dr Raman, 1725 W Harrison St, Ste 1156, Professional Building III, Chicago, IL 60612; e-mail: jairaman2462@ gmail.com.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Clinical Details Eight patients with infected leads and vegetations around the leads were treated with surgical extraction. In all these 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.146
FEATURE ARTICLES
ead extraction in the setting of pacing lead–related endocarditis can be challenging and requires complete removal of all hardware. Percutaneous removal of the leads through the endovascular approach is the least invasive and preferred method [1]. In some cases, the percutaneous approach may not be appropriate for removing large vegetations and may not alter the septic trajectory. Patients in whom attempts at percutaneous extraction have failed must undergo a primary surgical approach to extract leads and remove infected material. Surgical extractions typically rely on cardiopulmonary bypass (CPB) and full heparinization. Patients in whom the percutaneous approach has failed and who are poor candidates for CPB can be particularly difficult to treat surgically. CPB can cause inflammation and amplify an already inflammatory state in the patient with endocarditis [2]. In these patients, vena caval inflow occlusion (VCIO) is a useful and successful approach for lead removal. We describe the off-pump technique of lead extraction using VCIO in patients who are ineligible for percutaneous lead removal and in whom CPB is contraindicated.
(Ann Thorac Surg 2015;100:2379–80) Ó 2015 by The Society of Thoracic Surgeons
2380
HOW TO DO IT RAMAN ET AL VICO FOR REMOVAL OF RETAINED PACING LEADS
Ann Thorac Surg 2015;100:2379–80
pacing leads were implanted in 3 patients, and 1 patient had permanent leads implanted endocardially in the right ventricle before extraction of the infected leads. One patient had a repeated VCIO procedure through a sternotomy for a retained deeply embedded pacing lead in the inferior aspect of the right ventricle, with an adjacent area of infection suggestive of a healed abscess. There were no deaths, and the infections resolved in all patients. Inotropic agents were not required in any of these patients. There were no neurologic complications. There was no new onset of renal dysfunction in any of the patients.
FEATURE ARTICLES
Comment
Fig 1. (A) Stay sutures placed on free wall of right atrium so that they can be accommodated within jaws of partial occlusion clamp. (B) Atriotomy opened between stay sutures as soon as clamps are placed on superior vena cava (SVC) and inferior vena cava (IVC). (C) Flow restored after 2 minutes of occlusion by releasing caval clamps and applying side-biter clamp at base of atriotomy.
VCIO was first described by Carrel in 1905 at the University of Chicago and was 1 of the fundamental bases for modern cardiac surgery [3]. This technique is used occasionally in pediatric cardiac surgery, but it can be used in adult patients with cardiac conditions as well. This simple yet flexible approach is a good bailout technique in selected high-risk adult patients who are poor candidates for CPB. The decision to perform IO occurred at the surgeon’s discretion with an aim to minimize procedural risk and avoid further inflammatory responses caused by CPB [2]. The safe limits of IO have to be followed in a disciplined fashion to ensure adequate time for reperfusion, and great care was taken not to exceed 2 minutes of occlusion time [4]. As more patients with multiple pacing leads get evaluated for lead extraction because of lead-related infections, this technique without CPB is a useful and effective approach to facilitate safe removal of leads and infected material. In conclusion, VCIO is a safe and simple surgical technique that enables extraction of infected pacing leads and removal of associated infected material in patients in whom CPB is contraindicated.
References patients, endovascular extraction by electrophysiologists was attempted but was not successful because of a large infective burden or deeply embedded pacing leads, or both. Laser extraction methods were available and were used as indicated by the electrophysiologists. Median sternotomy was performed in 5 patients and right minithoracotomy was carried out in 3 patients. Two of the thoracotomy patients were undergoing a reoperative cardiac procedure. Four of the patients were pacemaker dependent. In these patients, temporary epicardial
1. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010;121:458–77. 2. Edmunds LH Jr. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg 1998;66(5 Suppl):S12–6; discussion S25–8. 3. Edwards WS. Alexis Carrel’s contributions to thoracic surgery. Ann Thorac Surg 1983;35:111–4. 4. Smith JW, Connolly JE. Methods of lengthening the safe time interval of inflow occlusion under hypothermia. Experimental studies. Arch Surg 1960;81:510–3.