DGK Herztage 2025. Clin Res Cardiol (2025). https://doi.org/10.1007/s00392-025-02737-x
1Asklepios Klinik St. Georg Kardiologie & internistische Intensivmedizin Hamburg, Deutschland; 2Asklepios Klinik St. Georg Abteilung für Viszeralchirurgie Hamburg, Deutschland; 3Asklepios Klinik St. Georg Radiologie Hamburg, Deutschland; 4Asklepios Klinik St. Georg Abteilung Herzchirurgie Hamburg, Deutschland
A 68-year-old patient presented in an outward clinic with intermitted thoracal pain three months after undergoing a lead revision for lead dysfunction of the 16-year-old right atrial (RA) lead and an exchange of the dual chamber pacemaker (PM) generator. The pain had a stabbing character and was initially present right after the intervention and restarted two weeks bevor presentation. The PM interrogation showed a regular function. In transthoracic echocardiography a pericardial effusion (PE) of 20 mm was documented. A fluoroscopy and thoracic computed tomography (CT) were conducted for further investigation. These revealed fragments of a BMW guidewire in the right ventricle (RV), with longer sections having perforated the RV and lying intraperitoneally above the liver (Figure 1 and 2).
The BMW guidewire was utilised during the RA-lead revision to navigate the stenosis of the right-sided V. subclavia. It became torn, and the remaining fragments had migrated.
Given the anatomical characteristics of the patient with severe obesity (BMI 54 kg/m2), the wire fragments were likely undetectable. The post-procedural X-Ray after the initial procedure did also not reveal any clear signs of these fragments.
After drainage of 600 ml PE the patient was transferred in our clinic for further therapy.
We planned a two-phase strategy with the involvement of the visceral surgeon. The initial procedure involved the extraction of intracardiac fragments from our heart team. An EN-Snare was utilized to retrieve the fragments. However, maneuvering the selected snare proved challenging due to its stiffness, resulting in the snare dislodging from the RV into the right atrium, making it difficult to reach the fragments initially. After introducing the EN-Snare via an Agilis Catheter for additional support, the two intracardiac fragments were successfully retrieved (Figure 3.). The second procedure was performed from the visceral surgeon, who extracted the two intraperitoneal fragments via laparoscopy (Figure 4). No complications occurred in both procedures. A fluoroscopy was performed to verify the full extraction of the fragments. However, a small fragment was still detected. The location of the remaining fragment was estimated to be either at the RV-bottom or between the RV and diaphragm. The patient was clinically stable and asymptomatic. Therefore, by mutual agreement, we decided to adopt a watch-and-wait strategy and scheduled a follow-up appointment within three months.
Conclusion: This case highlights the importance of having trained teams for clinically difficult cases. When operating on patients with challenging anatomy, it is essential that both the operator and assisting nurse maintain focus to ensure the proper extraction of materials used. In the event of unexpected difficulties, it is necessary to
transfer the patient to a specialised center.