tle with video-assisted e...
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Bontempi Luca , MD
Division and Chair of Cardiology
Electrostimulation and Electrophysiology Laboratory
Brescia – Italy
TLE with video-assistedminithoracotomy
MO
NST
ER C
ASE
MO
NSTER
CA
SE
• Male
• 61 years old
• BMI 23.3 Kg/m2
• SSS, No structural heart disease
• PM-DDDR implant (1998): - RA passive fixation lead
- RV passive fixation lead
Patient presentation
Indication:RV lead malfunctioning
• High stimulation threshold (3.9 V)
• Low sensing (1.4 mV)
• Impedence reduction (< 200 Ω)
Procedure
• TLE procedure
•New RV Lead implant
BLOOD TEST:
• WBC 5.820• RBC 4.150.000• Hb 13.6 g/dL• PTL 218.000• PCR 3.2 mg/L• ESV (VES) 10 mm/1h• Creatinine 0.87 mg/dL
Patient presentation
TLE
dec
isio
np
roce
du
re
LEADS MOVEMENT – VENOUS OCCLUSION – COLLATERAL CIRCULATION
Strong fibrosis/adherence between leads and anatomic structures
Difficult TLE tools advancement over leads
High risk of venous rupture
TLE decisio
n p
roced
ure
• RV passive fixation lead (`98)
• Venous occlusion
•Hard fibrosis
• LED index: 20
HYBRID APPROACH TLE
+video-assisted
minithoracotomy
TLE decision procedure
•General anesthesia
• Surgical minithoracotomy (right side - 4° intercostal space) and
video real-time monitoring
• TLE Tools:
Looling stylet (Cook Liberator)
Byrd dilator polypropylene sheath 8.5 Fr – 10 Fr – 11.5 Fr (Cook)
Controlled-rotation dilator sheath 13 Fr (Cook)
Laser sheath 80 Hz; 12 Fr – 14 Fr – 16 Fr (Spectranetics GlideLight)
Hybrid Procedure
VIDEO REAL TIME MONITORING
RAA
RA
SVC
AO
INN. V.Direct visualizationof anatomicalstructures
Controlled-rotation dilator sheath and
oversheath advancement over RV lead
in left subclavian vein
RV Lead TLE
Controlled-rotation dilator sheath and
oversheath advancement over RV
lead in innominate vein
RV Lead TLE
Controlled-rotation dilator sheath
push and lead traction through SVC
RV Lead TLE
RV Lead TLEFurther advancement of
controlled-rotation dilator sheath
SVC HEMATOMA
RV Lead TLEHematoma stability → Procedure continued & Successfull accomplished
Transitorial severe tricuspid rigurgitation (Laser sheath through tricuspid valve), and RV Lead complete removal
• The correct evaluation of hight risk TLE procedures is crucial to choose the
right procedural method
• The video assisted minithoracotomy can reveal the real perception of
what we are doing, helping to face promptly also life-threatening
complications
• Difficult TLE procedures, can be successful accomplished when realized
with video real-time monitoring, also in place of adverse events (as SVC
hematoma)
Take home message
Bontempi Luca , MD
Division and Chair of Cardiology
Electrostimulation and Electrophysiology Laboratory
Brescia – Italy
Thank you foryour attention