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Pseudo-tamponade during transvenous lead extraction Mouhannad M. Sadek, MD, Andrew E. Epstein, MD, FAHA, FACC, FHRS, Albert T. Cheung, MD, Robert D. Schaller, DO From the Electrophysiology Section, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania.
A 37-year-old woman with a history of untreated polycythemia vera suffered cardiac arrest secondary to coronary thrombosis. She underwent stent insertion followed by implantation of an implantable cardioverter-defibrillator with a Sprint Fidelis lead (Medtronic, Minneapolis, MN) in 2004. Implantable cardioverter-defibrillator shocks secondary to lead fracture required insertion of a new pace-sense lead shortly thereafter. The patient developed recurrent pulmonary emboli despite systemic anticoagulation. A transesophageal echocardiogram (TEE) showed multiple thrombi attached to the leads and tricuspid valve (TV). Transvenous lead extraction was performed using a combination of a
locking stylet (LLD EZ, Spectranetics, Colorado Springs, CO) and a 14-F outer diameter SLS II Excimer laser powered sheath (Spectranetics). First, the pace-sense lead was removed without complication. Thereafter, while applying tension to the defibrillator lead through the laser sheath, the patient developed persistent hypotension with a decrease in mean blood pressure from 71 to 33 mm Hg. The thrombi on the lead were still present with no evidence of embolization. Hypotension persisted despite releasing traction from the lead, as the vascular binding sites maintained tension on the right ventricular (RV) apex. The TEE showed a large echolucent space adjacent to the RV
Figure 1 KEYWORDS Lead extraction; Right ventricular prolapse; Hypotension ABBREVIATIONS ICE ¼ intracardiac echocardiography; RV ¼ right ventricular; TEE ¼ transesophageal echocardiogram; TV ¼ tricuspid valve (Heart Rhythm 2015;12:849–850) Address reprint requests and correspondence: Dr Robert D. Schaller, Electrophysiology Section, Cardiovascular Division, University of Pennsylvania, 3400 Spruce St, 9 Founders, Philadelphia, PA 19104. E-mail address: [email protected].
1547-5271/$-see front matter B 2015 Heart Rhythm Society. All rights reserved.
with evidence of RV collapse (Figure 1A), suggesting cardiac tamponade secondary to RV wall avulsion. An 8-F phased-array AcuNav intracardiac echocardiography (ICE) catheter (Acuson Corporation, Mountain View, CA) was advanced into the right atrium. ICE imaging revealed the RV apex to be bound to the defibrillator lead and prolapsed into the TV, suggesting that the echolucent http://dx.doi.org/10.1016/j.hrthm.2014.12.016
850 space was caused by pulling the RV wall off the pericardium, creating a visible space (Figure 1B). Hemodynamic compromise was not due to cardiac tamponade secondary to compression, but rather due to tension on the RV apex with embarrassment of RV preload. Further sheath dissection and tension on the lead resulted in successful extraction and return of blood pressure to normal. The TEE now showed only the baseline trace pericardial effusion with no evidence of the large echolucent space (Figure 1C). The thrombi remained affixed to the TV. Lead extraction may result in intraprocedural hypotension due to multiple complications, including RV avulsion with resultant cardiac tamponade, superior vena cava laceration, damage to the TV and pulmonary emboli.1 We describe a reversible cause of hypotension during lead extraction due to persistent RV apical eversion. Although the TEE showed an echolucent space indicative of possible tamponade, ICE imaging was conclusive in showing tension on the RV apex caused by the lead, avoiding unnecessary emergent cardiac
Heart Rhythm, Vol 12, No 4, April 2015 surgery. Extreme caution should be exercised when pulling on leads without access to extraction tools, such as sheaths and femoral snare tools, in an attempt to “see if it will come.” Inability to relieve RV apical tension with such tools may result in persistent hypotension.
Appendix Supplementary data Supplementary material cited in this article is available online at http://dx.doi.org/10.1016/j.hrthm.2014.12.016.
Reference 1. Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH III, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Wazni OM. Heart Rhythm Society; American Heart Association. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009;6:1085–1104.
Pseudo-tamponade during transvenous lead extraction Mouhannad M. Sadek, MD, Andrew E. Epstein, MD, FAHA, FACC, FHRS, Albert T. Cheung, MD, Robert D. Schaller, DO From the Electrophysiology Section, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania.
A 37-year-old woman with a history of untreated polycythemia vera suffered cardiac arrest secondary to coronary thrombosis. She underwent stent insertion followed by implantation of an implantable cardioverter-defibrillator with a Sprint Fidelis lead (Medtronic, Minneapolis, MN) in 2004. Implantable cardioverter-defibrillator shocks secondary to lead fracture required insertion of a new pace-sense lead shortly thereafter. The patient developed recurrent pulmonary emboli despite systemic anticoagulation. A transesophageal echocardiogram (TEE) showed multiple thrombi attached to the leads and tricuspid valve (TV). Transvenous lead extraction was performed using a combination of a
locking stylet (LLD EZ, Spectranetics, Colorado Springs, CO) and a 14-F outer diameter SLS II Excimer laser powered sheath (Spectranetics). First, the pace-sense lead was removed without complication. Thereafter, while applying tension to the defibrillator lead through the laser sheath, the patient developed persistent hypotension with a decrease in mean blood pressure from 71 to 33 mm Hg. The thrombi on the lead were still present with no evidence of embolization. Hypotension persisted despite releasing traction from the lead, as the vascular binding sites maintained tension on the right ventricular (RV) apex. The TEE showed a large echolucent space adjacent to the RV
Figure 1 KEYWORDS Lead extraction; Right ventricular prolapse; Hypotension ABBREVIATIONS ICE ¼ intracardiac echocardiography; RV ¼ right ventricular; TEE ¼ transesophageal echocardiogram; TV ¼ tricuspid valve (Heart Rhythm 2015;12:849–850) Address reprint requests and correspondence: Dr Robert D. Schaller, Electrophysiology Section, Cardiovascular Division, University of Pennsylvania, 3400 Spruce St, 9 Founders, Philadelphia, PA 19104. E-mail address: [email protected].
1547-5271/$-see front matter B 2015 Heart Rhythm Society. All rights reserved.
with evidence of RV collapse (Figure 1A), suggesting cardiac tamponade secondary to RV wall avulsion. An 8-F phased-array AcuNav intracardiac echocardiography (ICE) catheter (Acuson Corporation, Mountain View, CA) was advanced into the right atrium. ICE imaging revealed the RV apex to be bound to the defibrillator lead and prolapsed into the TV, suggesting that the echolucent http://dx.doi.org/10.1016/j.hrthm.2014.12.016
850 space was caused by pulling the RV wall off the pericardium, creating a visible space (Figure 1B). Hemodynamic compromise was not due to cardiac tamponade secondary to compression, but rather due to tension on the RV apex with embarrassment of RV preload. Further sheath dissection and tension on the lead resulted in successful extraction and return of blood pressure to normal. The TEE now showed only the baseline trace pericardial effusion with no evidence of the large echolucent space (Figure 1C). The thrombi remained affixed to the TV. Lead extraction may result in intraprocedural hypotension due to multiple complications, including RV avulsion with resultant cardiac tamponade, superior vena cava laceration, damage to the TV and pulmonary emboli.1 We describe a reversible cause of hypotension during lead extraction due to persistent RV apical eversion. Although the TEE showed an echolucent space indicative of possible tamponade, ICE imaging was conclusive in showing tension on the RV apex caused by the lead, avoiding unnecessary emergent cardiac
Heart Rhythm, Vol 12, No 4, April 2015 surgery. Extreme caution should be exercised when pulling on leads without access to extraction tools, such as sheaths and femoral snare tools, in an attempt to “see if it will come.” Inability to relieve RV apical tension with such tools may result in persistent hypotension.
Appendix Supplementary data Supplementary material cited in this article is available online at http://dx.doi.org/10.1016/j.hrthm.2014.12.016.
Reference 1. Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH III, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Wazni OM. Heart Rhythm Society; American Heart Association. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009;6:1085–1104.
