Transvenous Extraction and Removal of Pacing Leads Placed after Cardiac Transplantation

Case Reports in Cardiology
15 Mar, 2019 ,

A 75-year-old man with p/h/o IHD who had undergone orthotopic heart transplantation (OHT) in 1997 (biatrial anastomosis) was referred for pacemaker system extraction. Medtronic 3830 lead, was extracted using laser energy application, following this the pocket was debrided, and the incision was closed using vertical mattress sutures. The patient was readmitted six months later due to sepsis and died due to multiorgan failure. 

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A 75-year-old man with a past medical history of ischemic cardiomyopathy who underwent orthotopic heart transplantation (OHT) in 1997 (biatrial anastomosis) was referred for pacemaker system extraction. His initial posttransplant course had been complicated by sinus node dysfunction with a slow junctional escape rhythm, and he underwent implantation of a single chamber AAI Medtronic 8088B pacemaker with a Medtronic 4068 lead placed in the right atrium shortly after his transplantation. In 2007, the atrial lead had low impedance and impending failure, so a Medtronic 3830 lead was added in the right atrial appendage at the time of generator change.

He developed end-stage renal disease (ESRD) secondary to calcineurin inhibitor toxicity, and hemodialysis was started in 2012. He developed recurrent infections in his left upper extremity fistula site (initially methicillin-sensitive Staphylococcus aureus but later polymicrobial) in 2016 with eventual pacemaker pocket infection requiring full CIED system extraction.

The Medtronic 3830 lead, which had been indwelling for nine years, was extracted using laser energy application along the proximal portion of the lead. The older Medtronic 4068 lead, indwelling for 19 years, required extensive application of laser energy at multiple points along the lead for removal. The pocket was debrided, and the incision was closed using vertical mattress sutures. There was no temporary pacemaker placed, as he was not pacemaker-dependent. The patient was readmitted within 30 days due to concern that the pacemaker pocket site infection had not been fully cleared. This was ultimately treated by drainage of a complex fluid collection associated with the previous pacemaker site. The patient was admitted six months later due to sepsis secondary to disseminated histoplasmosis and ultimately died secondary to multiorgan failure.