Lead Salvage Procedure
Prior to the procedure, prophylactic Cephazolin and Vancomycin were administered intravenously. The patient was brought to the electrophysiology laboratory in a post-absorptive state. The right upper quadrant and right sub-costal areas were inspected under fluoroscopy and the location of the previously cut and abandoned leads was marked. Following infiltration with 1% lidocaine/0.5% bupivicane mixture, an incision was made at the right upper abdominal area at the location overlaying the tip of the previously cut and abandoned leads. Using sharp dissection, cautery and blunt dissection, the incision was extended down to the rectus abdominalis fascia, and a pocket was then fashioned caudad and sized to the device. The leads were exposed in the sub-diaphragmatic area. Hemostasis was obtained using cautery.
The two coaxial bipolar atrial epicardial atrial leads were exposed: lead #1 was longer and exposed about 3 cm in the pocket and lead #2 was shorter and exposed about 2.5 cm in the pocket. The distal 3 mm of outer insulation was removed from the end of the cut lead and the outer conductor coil (anode) was identified. The inner coil was not visible in this preparation and considering the short length of the lead a decision was made not to cut the lead more proximally. The lead was inserted, with the anode exposed, into the female end of a bipolar IS-1 lead extender (Oscor, BIS/BIS, 17.4cm, quadrifilar, silicone-covered, connector) such that the conductor coil passed through to the end of the receptacle, passing through both the anodal and cathodal set screws. Both set screws were tightened sufficiently to obtain contact onto the outer conductor coil, but not tightly enough to crush or damage the coil. Good unipolar sensing was confirmed (patient was in atrial fibrillation). Subsequently the patient was cardioverted with a 200J synchronized biphasic shock from atrial fibrillation into junctional rhythm with retrograde atrial conduction and ventricular far-field sensing from Lead #1. Pacing was performed using a unipolar polarity, and capture thresholds were acceptable (1.25 mV at 0.4 ms). The lead extender / prior assembly was then tied with two 0-silk sutures and silicone surgical adhesive was used to seal the lead extender / lead assembly at the lead insertion site. The same process was attempted for Lead #2 but during traction there was a major insulation breach noted on this lead which rendered it unusable for pacing (right atrial capture occurred only at very high thresholds with constant and forceful abdominal muscle capture). Lead #2 was re-capped and abandoned. The pocket was inspected for foreign bodies, irrigated copiously with normal saline solution and inspected again for hemostasis. The lead extender IS-1 pin was inserted into a single chamber pacemaker device, the screws were tightened, and the lead extender was tugged to be sure the connection was secure. The generator was inserted into the pocket with excess lead behind it. The pocket was then closed in multiple layers of absorbable suture, steri-strips were applied, and a sterile dressing was placed over the incision. After implantation the unipolar right atrial lead impendence was 152 Ohms, sensed P-wave was 1.0 mV, and capture threshold were 1.25 V at 0.4 ms. The pacemaker was programmed as AAIR 80-120 bpm. Τhe patient was started on Sotalol 80 mg twice daily and was discharged home in stable condition on post-operative day two. He was seen as an outpatient in follow up one week after discharge. He was in an atrially paced rhythm with consistent atrial capture and intact atrioventricular conduction. His functional status had significantly improved with an obvious decrease in abdominal girth, peripheral edema and improvement of his protein and albumin levels. Approximately 4 months after his procedure, his pro-BNP had decreased from 941pg/mL on the day before the procedure to 102pg/mL. His albumin had increased from 1.5g/dL to normal at 4.6g/dL and his total protein increased from 3.1g/dL to normal at 6.7g/dL. All of this was achieved with routine outpatient Fontan management. This was the longest period of time which the patient had spent out of the hospital in the prior year. His future care plan is to pursue durable atrial pacing (new epicardial or transvenous leads) as he continues to improve by maintaining atrial contraction and atrioventricular synchrony (and thus operative/anesthesia risk improves).