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DP45: AICD LEAD EXTRACTION RESULTING IN CATASTROPHIC CARDIAC TAMPONADE AND ARREST
Justin Miranda, Dr; Samantha Arzillo-Garner, MD
HCA Westside Hospital
Introduction/Background: Surgically implanted cardiac devices are commonly used for the management of cardiac rhythm disorders. These devices have two main components: a pulse generator and cardiac leads connect directly into the myocardium. There are many indications for lead extraction, most commonly device-related infections or malfunctioning leads. Extraction procedures are generally safe, however they are technically complex and come with risks. Advanced lead age represents the most significant risk factor for catastrophic complications like myocardial perforation and cardiac arrest.
Case Presentation: Patient was a female in her late 70s who presented for extraction of multiple AICD leads due to klebsiella endocarditis and recurrent bacteremia. Notably, the patient had several lead revisions and replacements previously, with the oldest lead being about 20 years-old. Prior to induction, two large bore IV’s, an arterial line were placed, and a cardiothoracic surgeon was on standby. Induction was rather uneventful and pre-incision TEE was notable for an EF of 40%, moderate tricuspid regurgitation, diastolic dysfunction and a mild pericardial effusion.
The first lead was extracted without issue. However, the second lead was noticeably more calcified and more difficult to extract. Using TEE, we helped eventually retrieve the lead, which was adhered to the right ventricle. At that point, the blood pressure dropped drastically and the patient went into asystole. Chest compressions were immediately performed and epinephrine was administered. At that time a massive pericardial tamponade was seen on TEE; and the cardiothoracic surgeon performed a sternotomy, drained the effusion and closed the hole in the right ventricle. A central line was placed, and the patient received a total of 10 pRBCs, 6 platelets, 2 FFP, 250mL’s of cryoprecipitate, 3000 units of PCC, 9L of crystalloid. She also received 2g of epinephrine, 5g of calcium, 7 ampules of sodium bicarbonate and 1g of TXA. At the end of the operation, she was hemodynamically stable on no vasopressors with the great improvement on serial ABGs.
The patient was transferred to the ICU at which point she went into multi organ failure and progressively deteriorated. Given the lack of clinical improvement, the family made the decision to withdraw care, and she subsequently expired on postoperative day five.
Discussion: This case highlights the critical role of an anesthesiologist in the management of high-risk cardiac lead extractions. Patients with old, calcified intracardiac leads represent a population of elevated risk for catastrophic complications. Adequate care begins in the preoperative setting with a comprehensive assessment of the patient’s history and prior device-related surgical procedures. Notably, it is crucial to understand the age of each cardiac lead. Adequate vascular access, continuous invasive hemodynamic monitoring and the use of intraoperative TEE were imperative for the immediate recognition of tamponade physiology and facilitation of immediate intervention. This case highlights the necessity of preoperative planning with large-bore vascular access, arterial blood pressure monitoring, quick availability of blood products and surgical standby for patients undergoing cardiac lead extraction. As anesthesiologists, we must maintain a high suspicion for complications and be prepared for rapid diagnosis and intervention.