Background
       Techniques used to extract chronically implanted permanent pacing leads have evolved over time. These initially consisted of traction and now have evolved into “counter pressure” and “counter traction” with the assistance of specialized sheaths and locking stylets.¹ The procedure has also been assisted greatly by the development of sheaths that deliver pulses of excimer laser (Spectranetics, Colorado Springs, CO) or radiofrequency current (Cook Vascular Inc., Leechburg, PA). These methods have allowed for successful lead removal but, as with any surgical procedure, the possibility of serious complications exists.² Therefore, the decision to extract chronic leads should be made after considerable planning. Several challenges still remain, one of which is venous stenosis, which can interfere with the implantation of new leads after extraction of previously implanted leads. Due to the potential for fatal complications, surgical back up is standard, as is the collaboration with the cardiac surgeons. The recognition of venous stenosis has led to a growing need for a collaborative relationship with interventional cardiologists. Indications for implantable cardiac devices are expanding and the technology behind them is becoming more complex as cardiac resynchronization therapy gains wider acceptance.³ Our case illustrates the importance of collaborative efforts in which the combined skills of different sub-specialists are needed to overcome issues that may arise in the implantation of these devices. We present a case that demonstrates this concept:
       Our patient required explantation with multiple extraction methods for removal of chronic leads and balloon venoplasty to facilitate implantation of a cardiac resynchronization therapy device with defibrillation capability (CRT-D).

Figure 1.

Atrial lead measurements over time.

Case Presentation
       In January 2003, a dual chamber pacing system was implanted in a 76-year-old male for sick sinus syndrome and severe symptomatic bradycardia. The patient’s medical history included a non-ischemic dilated cardiomyopathy with an ejection fraction of 20%. Non-sustained ventricular tachycardia was documented on telemetry, and an electrophysiology study revealed no inducible arrhythmias. The dual chamber pacing system was implanted without complication and the patient was followed for the next two years in the device clinic and monitored remotely through trans-telephonic visits. During this time period, the patient was hospitalized three times for heart failure despite optimal pharmacologic therapy. Echocardiography revealed that the ejection fraction had declined to 10% and the patient was now pacemaker dependent. In January 2005, (27 months post implant) a trans-telephonic evaluation of the pacing system revealed atrial undersensing and loss of atrial capture. Pacemaker evaluation in the device clinic demonstrated low bipolar and unipolar atrial impedance values, P wave amplitude of < 1 mV, and an elevated atrial-pacing threshold (Figure 1). A chest X-ray revealed an insulation breach in the atrial lead (Model 4035, Guidant, St. Paul, MN) and an indentation in the ventricular lead (Model 4063, Guidant, St. Paul, MN) that did not appear to affect lead function (Figure 2). A prolonged QRS width with consequent electrical dysynchrony, severe left ventricular systolic dysfunction and NYHA Class III heart failure qualified the patient for a CRT-D device. A left subclavian venogram preformed prior to the procedure revealed severe stenosis of the left brachiocephalic vein (Figure 3). The risks and benefits of lead extraction and implanting a CRT-D system were discussed with the patient and the decision was made to proceed.

Figure 2.

(A) Atrial insulation breach. (B) Indentation in Ventricular Lead.

Figure 3.

(A) Stenosis of brachiocephalic vein.

       The patient was placed under general anesthesia, and a staged approach to the extraction procedure was begun. A deflectable electrophysiology catheter was placed to mark the coronary sinus, and a quadripolar catheter was placed in the right ventricular apex for pacing. Venography of the left subclavian vein revealed two tandem stenoses in the brachiocephalic vein and the superior vena cava (SVC) (Figure 4).

Figure 4.

(A) and (B) Tandem stenoses of brachiocephalic vein and superior vena cava.

       The pacemaker pocket was opened and the pulse generator was removed. The silk sutures anchoring the sleeves were cut and removed. The leads were dissected from the fibrous tissue and a straight stylet was introduced into the atrial lead. The tined atrial lead was freed from intravascular adhesions with multiple rotations of the lead body, detached from the atrium with gentle traction, removed with moderate difficulty around the stenosis.
       A straight stylet was now introduced into the ventricular lead, and using clockwise and counterclockwise rotations along with gentle traction, the lead was freed from the apex. While the lead could be retracted to the level of the stenosis of the left brachiocephalic vein, it could not be withdrawn past this point despite multiple traction attempts and infusion of intravenous nitroglycerine at the site. A locking stylet was used to secure the ventricular lead and a 14 French laser sheath (Spectranetics, Colorado Springs, CO) was introduced to the level of the stenosis. Following multiple lasing applications, the lead was removed. New leads could not be advanced beyond the point of stenosis, and the assistance of the interventional cardiologist was sought.

Figure 5.

Balloon venoplasty of brachiocephalic vein stenosis.

       A 0.014 guide wire (Balanced Middleweight, Guidant, Santa Clara, CA) was advanced through the subclavian sheath across the stenosis. A 10 x 40 mm balloon (Viatrac, Guidant, Santa Clara, CA) was advanced to the stenosis and sequentially dilated (Figure 5). Post venoplasty, three leads were advanced: 1) a Medtronic model 4574 tined atrial lead was positioned in the atrial appendage; 2) a Guidant model 0175 passive fixation Gortex™ covered dual coil lead was placed in the right ventricular apex; and 3) a Guidant model 4538 passive fixation unipolar LV lead was placed in an anteriolateral vein and connected to a Guidant Renewal 3 HE (model H177) (Figure 6). Defibrillation energy requirements were evaluated and adequate safety margins obtained. The patient did well and was discharged home the following day.

Figure 6.

(A) Atrial lead. (B) Ventricular dual coil shocking lead. (C) Unipolar LV pacing lead.

       Follow up over the last four months have demonstrated an improvement in ejection fraction from 10% to 20% by echocardiography. New York Heart Association classification has improved one class to NYHA II. The patient has expressed a greater feeling of wellness and can now climb one flight of stairs without dyspnea. There has been one hospitalization unrelated to heart failure during which it was noted that the patient was mildly dehydrated requiring a reduction in the diuretic dosage. The patient has developed intermittent diaphragmatic stimulation, which is being managed through reprogramming.

Conclusion
       Our case illustrates the increasing importance of collaboration between different sub-specialists, especially during electrophysiology and implantation procedures in the current era where the indications for resynchronization therapy and ICD implantation are growing.