Troubleshooting during a challenging high-risk pacemaker lead extraction: a case report and review of the literature

BACKGROUND: The use of cardiac implantable electrical devices continues to increase with the validation of new beneficial indications. While the risks of device implantation decreased significantly over time, significant risk remains associated with their extraction when indicated. A high-risk pacemaker lead extraction case is described, wherein a chronically implanted lead that had perforated the right atrium was successfully removed without the need for cardiopulmonary bypass. In this report we share our approach to this challenging extraction case and describe an infrequently utilized off-pump hybrid technique that we term the “lead-inverting stitch”. CASE PRESENTATION: A 74 year-old Caucasian woman with complete heart block and remote pacemaker implantation presents with a swollen and erythematous infected pacemaker pocket necessitating device extraction. Chest computerized tomographic imaging revealed a chronically perforating right atrial lead tip approximately 2 cm within the pericardial space. A successful hybrid transvenous and open surgical extraction approach was undertaken without the need for cardiopulmonary bypass; this was made possible due to a successfully positioned “lead-inverting stitch”. CONCLUSION: Implantable cardiac electrical device infections are amongst the most dreaded post implant complications. Risks of device extraction are further complicated in cases of chronic lead perforations. Extraction strategies that avoid cardiopulmonary bypass initiation are preferred.