부산대학교 도서관

Device–related infection remains a potentially fatal complication in patients with cardiac implantable electronic devices (CIEDs). Current guidelines recommend complete system extraction in such cases. Moreover, lead extraction of multiple leads implanted in the same CS tributary can be challenging. We describe a case of 71–year–old male with dilated cardiomyopathy. He underwent an implantable cardioverter defibrillator (ICD) implantation in secondary prevention in the year 2005, after a previous cardiac arrest. Subsequently, an upgrading to a cardiac resynchronization therapy defibrillator (CRT–D) in 2018 was performed with a unipolar coronary sinus lead implanted in an anterolateral branch of the coronary sinus (CS). Two months a new active fixation lead was implanted in CS for an elevated impedance of the previous CS catheter. In February 2022, the patient presented signs of pocket infection and was referred to our center for transvenous lead extraction (TLE). For the coronary sinus leads, a locking stylet was first positioned in each lead, then mechanical sheaths were advanced over the passive lead and subsequently on the active lead. Afterwards, a hand–powered mechanical sheath was advanced sequentially over each lead up to the coronary sinus ostium. Contrast injection through the sheath revealed extensive fibrosis of the CS ostium. Midline sternotomy was done and through a right atrial incision, the proximal parts of the CS leads were externalized. A 7.5 Fr mechanical dilator sheath was then advanced over the passive lead, allowing the removal of both the CS leads. Upon resolution of the infection, a new CRT–D device was implanted with two leads in the right ventricle (one in the right ventricular apex, and the other on the interventricular septum), following a multisite right ventricular pacing approach. We present the first case in literature to undergo lead extraction of two leads in the same coronary coronary sinus. The presence of two leads induced extensive fibrosis inside the CS. A combination with surgical approach was needed in order to avoid any possible tear of the coronary sinus. The unusual implantation of more than one lead in the same CS tributary can increase the procedural risk when the need for extraction arises. In that case, a surgical approach combined with the utilization of transvenous lead extaction tools can provide a way to extract the leads with minimal surgical manipulation.