A 63 year old male with history of ischemic cardiomyopathy and single chamber ICD with a dual coil active fixation lead implanted twelve months prior to presentation, underwent routine echocardiography identifying the lead localized in the aortic root and crossing the aortic valve. The proximal coil was adjacent to the right coronary cusp. The patient had recurrent gastrointestinal bleeding prohibiting long term anticoagulation therapy. Considering the thromboembolic risk of arterial lead placement and concern for adhesion near the ostium of the right coronary artery, we opted to proceed with transarterial lead extraction. Under general anesthesia and in the hybrid operating room, the subpectoral pocket was exposed. Thoracic aortic arch and carotid angiography was performed, and distal embolic filter wires were deployed in the right and left internal carotid arteries following anticoagulation with unfractionated heparin. Intravascular ultrasound of the left subclavian artery was performed to localize the lead entry point at the left subclavian artery and determine appropriate reference vessel sizing for stent graft placement. As the lead was withdrawn, a covered stent was deployed at the entry site as described previously. There were no neurological or vascular complications following the procedure. Reimplantation of a cardiac resynchronization device was performed electively via the left subclavian vein without any complications.
A 23-year-old female with Ebstein's anomaly of tricuspid valve underwent one and half ventricular repair with tricuspid valve annuloplasty, atrial septal defect closure and cavopulmonary anastamosis of right superior venacava to the right pulmonary artery. She also needed dual chamber pacing for symptomatic bradycardia secondary to sinus nodal and atrioventricular nodal disease. There was no pre-excitation or tachyarrhythmias. Left atrial and left ventricular epicardial leads were connected to a pulse generator that was implanted in epigastric subcutaneous pocket. There was synchronous atrioventricular pacing with acceptable pacing thresholds during the time of implantation. Three months later, new onset symptomatic diaphragmatic pacing was observed from atrial lead. So the pacemaker was reprogrammed to pace ventricle alone. After another two months, diaphragmatic pacing was observed from ventricular lead too. The threshold voltage for ventricular capture was more than that of the diaphragm. The reasons for delayed onset diaphragmatic pacing through both leads almost five months after the epicardial lead placement and pacemaker implantation was not understood. Her symptoms related to bradycardia warranted permanent dual chamber pacing. Since extensive dissections will be needed through the previous surgical scars and adhesions in midline sternotomy and left thoracotomy, a second epicardial lead repositioning was not considered. A minimal incision right anterolateral thoracotomy was made and two introducer sheaths were inserted through two pursestring sutures placed on the right atrial free wall.() Two screw-in endocardial leads were inserted through the sheaths under transesophageal echocardiographic guidance into the right atrial appendage tip and right ventricular apex to achieve atrioventricular pacing. On a follow up of nine months, the patient was asymptomatic, pacing was synchronous and chest X-ray showed both the new and old leads. ()