A Mobile Tubular Mass Visualized by Transesophageal Echocardiography After Successful Lead Extraction
A 29-year-old woman with a dual-chamber defibrillator previously implanted for congenital long QT syndrome was found to have a fractured Medtronic 6949 defibrillator lead. A lead extraction was recommended because of her young age and her aversion to the presence of multiple redundant nonfunctional leads. Her lead extraction was performed in the operating room under general anesthesia with the use of intraoperative transesophageal echocardiograpy. With gentle traction after the screw was retracted, the right ventricular lead was only adherent to the right ventricle at the tip of the right ventricular lead. This lead was not adherent to the subclavian vein, superior vena cava, or tricuspid annulus. Therefore, the right ventricular lead was removed with gentle traction without use of a lead extraction sheath. After extraction of the right ventricular defibrillator lead, a long, thin, tubular mobile structure became evident within the right atrium and right ventricle, crossing the tricuspid valve. This structure appeared to be anchored in the right atrium near the tricupid annulus, and it freely prolapsed back and forth across the tricuspid valve with each cardiac cycle (Figure 1 and Movie I in the online-only Data Supplement). Examination of the extracted lead showed that it was completely intact. A new dual-chamber implantable cardioverter-defibrillator was placed without incident, and the patient had an uncomplicated postextraction and reimplant hospital course.
The luminal and tubular shape of the mass as seen on echocardiography indicates that this structure was the fibrous sheath that covered the extracted defibrillator lead, and was sheared off during extraction. Although a clot could not be excluded, the echocardiographic characteristics of the lead were more consistent with a fibrous sheath. Because there was concern of thrombus formation, anticoagulation with aspirin was initiated. Repeat transesophageal echocardiograpy at 4 weeks demonstrated that the fibrous sheath was still present (Figure 2). At the 3-month follow-up, the patient has done well, with no embolic symptoms.
Fibrosis surrounding defibrillator leads is well described in autopsy studies,1 and is occasionally observed after surgical or percutaneous lead extraction. This is the first case where this remnant fibrous sheath has been visualized. Although embolization of this remnant structure could be a potential explanation for pulmonary embolism observed after lead extraction, the majority of embolisms described are due to retained lead remnants.2,3
This finding raises important questions regarding the frequency of this event and appropriate management. Based on this observation, we recommend the use of a long outer sheath over the lead to capture this fibrous material at the time of lead extraction. Furthermore, a long sheath and a locking stylet may reduce the risk of cardiac perforation by decreasing the tension at the tip of the lead. Intraoperative transesophageal echocardiograpy may help to guide lead extractions, because fibrous sheaths surrounding leads may be more common than is currently recognized.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/123/19/e590/DC1.
- © 2011 American Heart Association, Inc.
- Epstein AE,
- Kay GN,
- Plumb VJ,
- Dailey SM,
- Anderson PG
- Calvagna GM,
- Evola R,
- Valsecchi S
- Robinson T,
- Oliver J,
- Sheridan P,
- Sahu J,
- Bowes R