1Otto-von-Guericke-Universität Magdeburg Medizinische Fakultät Klinik für Herz- und Thoraxchirurgie Magdeburg, Deutschland; 2Otto-von-Guericke-Universität Medizinische Fakultät Klinik für Herz- und Thoraxchirurgie Magdeburg, Deutschland
Background:
Laser lead extraction in high risk patients is associated with increased frequencies of superior vena cava lacerations. We report a case where intraoperative video assisted thoracotomy revealed mechanical distortion of the superior vena cava (SVC).
Case Summary:
A 65-year-old male patient presented with a pocket infection of a left sided single chamber defibrillator implanted prophylactically in 2014 for dilated cardiomyopathy, featuring a dual-coil electrode. Due to the prolonged dwell time of the lead and the cachectic general condition of the patient, the procedure was classified as a high-risk intervention, and the extraction was performed using an excimer laser with accompanying right-sided video thoracoscopy (VATS) to visualize the superior vena cava and apply pressure to control bleeding in case of SVC laceration. During the advancement of the laser catheter, a significant deformation with hematoma of the superior vena cava was observed (Figure 1, video). The extraction was immediately stopped, but an intraoperative transesophageal echocardiography revealed an unremarkable finding, and the patient remained hemodynamically stable. VATS ruled out bleeding into the pleura. The extraction was cautiously completed under direct visualization of the deforming SVC. A postoperative CT angiography ruled out hematoma or injury to the SVC and rather confirmed that the observed significant deformations of the SVC resulted from the release of intravascular adhesions with the defibrillator lead.
Conclusion:
This is the first case report documenting the mechanical stress on the superior vena cava (SVC) during a laser extraction of cardiac leads in a video. The use of video monitoring resulted in a more cautious extraction, thereby possibly preventing perforation of the SVC.
Figure 1:Thoracoscopic view of the mediastinum from the right before (A), during (B ) and after completion (C) of lead extraction. The mechanical distortion of the superior vena cava (SVC) is indicated by dashed lines in B and C. IVC: inferior vena cava; RA: right atrium; RV: right ventricle