Percutaneous extraction of inadvertently placed left‐sided pacemaker leads with complete cerebral embolic protection

Abstract

Lead wire malposition is a known, but rare complication of permanent pacemaker or defibrillator implantation. The actual incidence and prevalence is unknown and management options for inadvertent left ventricular lead malposition have not been uniform. Current recommendations include systemic anticoagulation with warfarin or surgical lead removal with circulatory arrest for compelling clinical scenarios. Percutaneous left-sided lead extraction is contraindicated due to the potentially increased risk of thromboembolic complications associated with this procedure. To our knowledge, this is the first report of percutaneous extraction of inadvertently placed left ventricular and left atrial endocardial pacemaker leads with flow-preserving complete cerebral embolic protection. We also review the current literature regarding the incidence, management, and percutaneous extraction of left-sided cardiac leads.

Successful percutaneous extraction of malpositioned pacemaker lead in the left ventricle after proper dabigatran treatment

“…In our case, dabigatran treatment pre‐ and post‐operation; immediate pre‐operative TEE to rule out thrombosis; lowering the head side and giving heparin during operation; and no extraction sheath over the atrial septum to the left heart side, may have contributed the successful transvenous lead extraction without complications. If the pacing lead in the LV has been in place for a long time and a mechanical extraction sheath is needed to get into the left heart, we suggest an arterial cerebral protection system should be used 2,3,13 …”

“…Surgical removal of the lead was often considered to avoid the risk of left‐sided endocarditis, ventricle perforation and systemic thromboembolism. Although there have been reports describing transvenous extraction of inadvertently placed LV leads, 1,2 it remains a debatable approach due to the risk of thromboembolic events during lead removal 3 . Direct oral anticoagulants are attractive alternatives for warfarin to treat left atrial (RA) and LV thrombosis 4 .…”

Left ventricular endocardial pacing in the real world: Five years of experience at a single center

“…Infective complications requiring extraction of the LV endocardial lead are of particular concern because a surgical procedure is recommended to avoid possible embolic complications. Notably, Bahadorani et al reported a case in which two leads, wrongly located in left‐sided cardiac chambers, were extracted without complications using a complete cerebral embolic protection system.…”

Chronic lead malposition diagnosis and management: discussion of two cases and literature review

“…However, few cases of percutaneous pacemaker and ICD lead extraction for leads accidently placed in the left ventricle have been reported, some of which had been in place for up to 8 years . Embolization prevention devices have been used in the internal carotid and vertebral arteries in at least one reported case , but the literature is sparse in regard to left atrial lead extraction.…”