Cardiac Rhythm Management
Articles Articles 2014 May

Temporary Occlusion of an Atrial Septal Defect to Prevent Paradoxical Embolization During Extraction of Infected Defibrillator Leads

SETH J. RIALS, MD, PhD, ARNOLD P. GOOD, MD and DAVID J. NICHOLSON, DO

Department of Cardiology, Grant Medical Center, Columbus, OH, USA

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The authors report no conflicts of interest for the published content.
Manuscript received March 5, 2015, final version accepted April 3, 2014.

Address correspondence to: Seth J. Rials, MD, PhD, Medical Director, Arrhythmia Services, Grant Medical Center, Department of Cardiology, 111 South Grant Ave, Columbus, OH 43215. E-mail: Seth.Rials@ohiohealth.com

Introduction

Treatment of patients with infected cardiac implanted electrical devices (CIEDs) almost always requires complete extraction of the generator and leads. A potential complication associated with lead extraction is embolization of fibrous, thrombotic, or infectious material that is adherent to the lead, or embolization of lead fragments. Usually, embolization of this material is well tolerated as the leads are not in the systemic circulation and the pulmonary vascular bed has the capacity to absorb large emboli without acute clinical deterioration. Small studies have reported uneventful transvenous lead extraction in the setting of large vegetations without long-term sequelae. 1,2 Patients with atrial septal defect (ASD) or patent foramen ovale (PFO) present a special challenge, however, because of the risk of paradoxical embolization to the systemic circulation. 3,4 We describe a means to temporarily occlude an ASD during lead extraction to prevent systemic embolization.

Case report

A 78-year-old man with an ischemic cardiomyopathy, a secundum ASD, and persistent left ventricular dysfunction underwent implant of a transvenous defibrillator system for primary prevention. The patient had refused closure of the ASD on multiple occasions. Three years later, the patient developed persistent Staphylococcus aureus bacteremia. A transthoracic cardiac echo showed a 1.4×0.5 cm vegetation on the defibrillator lead in the right atrium and a 1.2-cm secundum ASD. A transesophageal echo (TEE) confirmed the presence of the vegetation and demonstrated pulmonary hypertension with bidirectional shunting across the ASD ( Figure 1 ). Extraction of the defibrillator system was planned. The patient's ongoing infection and multiple comorbid conditions made open surgical lead extraction and concomitant closure of the ASD prohibitively risky. Because of concern that the vegetation could embolize across the ASD during transvenous extraction, provision was made to temporarily occlude the ASD while extracting the defibrillator leads.

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Figure 1: Transesophageal color flow echocardiogram showing bidirectional shunting across the atrial septal defect (arrow).

After induction of general anesthesia, the chest, abdomen, and groin were prepped and draped. A TEE probe was placed and the ASD visualized. An atrial septal occluder balloon (25 mm×3 cm, PTS Sizing balloon catheter, B. Braun Interventional Systems, Bethlehem, PA) was inserted transvenously using femoral access and positioned across the ASD using a Boston Scientific Magic Torque guidewire and Cordis MPA2 guide sheath. The balloon was inflated until flow across the ASD was occluded as assessed by TEE color Doppler ( Figure 2 ). Stability of the balloon was assessed during the case using fluoroscopy ( Figure 3 ) and TEE. Extraction of the defibrillator leads was then performed using standard techniques. The atrial lead (Medtronic 5076, Minneapolis, MN) was removed with gentle traction after retraction of the fixation screw. The ventricular lead (Medtronic Model 6935) was fibrosed in place and required use of a lead locking stylet, and 14F Spectranetics (Colorado Springs, CO) laser sheath for extraction. After complete removal of the extraction hardware from the left subclavian site, the ASD sizing balloon was left inflated for an additional 5min. The sizing balloon and guide were then removed in their entirety. Inspection of the extracted leads showed adherent fibrous tissue but no evidence of the vegetation, which was presumed to have been sheared off and to have embolized to the lungs. The ASD was not closed during the extraction due to ongoing infection. The patient tolerated the procedure well and showed no evidence of systemic embolization during more than 6 months of follow-up.

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Figure 2: Transesophageal echocardiogram showing balloon across the atrial septal defect (arrow) and vegetation on lead (triangle).


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Figure 3: Anterior-posterior fluoroscopic image showing balloon positioned across the atrial septal defect (ASD). A “waist” is seen where the balloon straddles the ASD.

Discussion

Paradoxical embolization from the leads of implanted devices in patients with ASD or PFO can lead to stroke and other complications. 4,5 Embolization is especially likely to occur in the setting of known vegetation and lead extraction where a close-fitting sheath is advanced in a telescoping fashion over the body of the lead. Any adherent vegetation or thrombus will be sheared off, as there is no room for this material within the sheath. To our knowledge, this is the first report of a method to temporarily occlude an ASD during lead extraction to prevent paradoxical embolization. The technique uses equipment that is likely to be readily available at centers that perform lead extraction, and appears to be both safe and effective. To reduce the risk that a clot would form on the balloon and/or guidewire and embolize, the dwell time of the sizing balloon and guidewire in the left atrium was minimized. The nature of lead extractions precludes concomitant anticoagulation. Careful consideration of the risk of embolization from the added hardware used for this technique versus the risk of embolization of the vegetation across an ASD is necessary in each case.

We performed temporary occlusion of an ASD during CIED lead extraction using a balloon that straddled the ASD. This concept of temporary occlusion could conceivably be applied to patients with PFO as well, although the balloon would likely need to be advanced entirely into the left atrium, inflated, and then pulled back against the left atrial side of the septum to prevent right to left embolization.

We did not perform permanent occlusion of this patient's ASD because of persistent infection and concern that any implanted septal occlusion device would itself become infected. In patients with either an ASD or PFO who are not infected but require extraction of a CIED lead, it may be prudent to consider permanent closure prior to extraction so as to prevent paradoxical embolization of thrombus, fibrotic material, or lead fragments.

References

  1. Meier-Ewert HK, Gray ME, John RM. Endocardial pacemaker or defibrillator leads with infected vegetations: a single-center experience and consequences of transvenous extraction. Am Heart J 2003; 146:339–344.
  2. Perez Baztarrica G, Gariglio L, Salvaggio F, Reolón E, Blanco N, Mazzetti H, et al. Transvenous extraction of pacemaker leads in ineffective endocarditis with vegetations >20 mm: our experience. Clin Cardiol 2012; 35:244–9.
  3. Dieuzaide P, Savon N, Chalvidan T, LeTallec L, DeHaro JC, Djiane P. Complication of pacemaker lead extraction: Paradoxical Embolism of a lead fragment in a leg artery. Pacing Clin Electrophysiol 1998; 21:2699–2700.
  4. DeSimone CV, DeSimone DC, Hagler DJ, Friedman PA, Asirvatham SJ. Cardioembolic stroke in patients with patent foramen ovale and implanted cardiac leads. Pacing Clin Electrophysiol 2013; 36:50–54.
  5. DeSimone CV, Friedman PA, Noheria A, Patel NA, DeSimone DC, Bdeir S, et al. Stroke or transient ischemic attack in patients with transvenous pacemaker or defibrillator and echocardiographically detected patent foramen ovale. Circ 2013; 128:1433–1441.

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