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).