Proximal end of 15-year-old ventricular electrode penetrating pulmonary tissue – a source of infection and a challenge for transvenous lead extraction

We report a case of a 56-year-old man with a DDD pacemaker implanted in 1998 followed by additional ventricular lead implantation in 2000 due to lead dysfunction and battery replacement in 2006 (proximal end of the abandoned lead already observed in the pulmonary artery), with currently present clinical signs of lead-dependent infective endocarditis (LDIE). In March 2013 he was diagnosed with recurrent episodes of shortness of breath, cough and fever. Initially the patient was hospitalized in the pneumology ward and underwent a series of diagnostic examinations, including computed tomography (CT) and bronchoscopy. Chest CT revealed localized signs of inflammation (which could be differentiated from neoplastic lesions) in the mid-right pulmonary lobe. Given the vicinity of the migrated lead to the lung inflammatory process, penetration of the lead in the lung tissue was confirmed. Blood cultures were positive for Staphylococcus epidermidis (MSS). After cardiologist consultation the patient was transferred to the Cardiology Clinic with LDIE diagnosed. The patient was qualified for a transvenous lead extraction (TLE) procedure. Pre-operative transthoracic echocardiography (TTE) revealed dilatation of the right atrium and ventricle with very high pulmonary artery systolic pressure (PASP = 80 mm Hg) calculated from tricuspid regurgitation. There were no signs of vegetations in transesophageal echocardiography (TEE) examination. The TLE procedure was performed in the cardiovascular operating room with on-site surgical standby. General anesthesia was used; invasive blood pressure, ECG, and ventilation parameters were monitored. At the beginning both functional leads were removed (using a Byrd dilator mechanical sheath). After unsuccessful grasping of the non-functional lead at the level of the right ventricle (due to adherences to the wall), it was successfully captured in the pulmonary artery using a pig-tail catheter; afterwards the proximal end was grasped in the right atrium lumen with a lasso catheter and the lead was finally extracted using the left subclavian approach and dilator sheaths (Figure 1). There were no procedural or post-procedural complications. Full radiological and clinical success was achieved. Postoperative TTE/TEE showed no signs of lead fragments or vegetations and reduction of PASP (60 mm Hg). As the patient was not pace-dependent, system reimplantation was delayed.
According to the current guidelines, indications for TLE of a...


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