[181086673]
A lead extraction procedure commenced to remove a right ventricle (rv) lead due to bacteremia, pocket/device erosion, and the patient was positive for a staph infection. Prior to the procedure, the patient's not for resuscitation (nfr) was discussed and the decision was made with the patients? Medical power of attorney and the patient that no surgical rescue was to be performed in the event of major bleeding. As such, against the centers standard procedure, surgical back up and bypass was not available in the room. Lead extraction was performed. A temporary pacing wire was paced through a 6fr right femoral sheath into the rv. Initial difficulty was experienced while placing the temporary wire, however, reliable capture was obtained and pacing was controlled through the temporary wire. The 5076 rv lead helix was retracted and the lead was unable to be removed through simple traction. A spectranetics lead locking device was placed in the lead and lead remained stuck. A spectranetics 14fr glidelight laser sheath was then used. The initial advancement into the innominate vein and under the clavicle was challenging. The outer sheath was then utilized. The glidelight appeared to progress over the lead from the innominate/superior vena cava (svc) interface down to the tricuspid valve with minimal lasing and force. The extraction at this point appeared unremarkable. As the glidelight advanced around tricuspid valve (approximately 2-3 cm from the tip of the rv lead) the anesthesiologist reported a 1 cm pericardial effusion around the apex of the heart. The patients? Blood pressure dropped over the next few minutes. The lead was extracted while the other operator inserted a pericardial drain and approximately 900ml of blood was removed. The glidelight and the drain were kept in place and fluid was added. The patient's blood pressure was stabilized and improved slightly for a few minutes. The blood pressure then dropped again and the pericardial drain was unable to remove any further blood. The echo suggested no rv filling and the effusion was 1. 5 cm. At this point, the decision was made to stop treating the patient as per the previously established medical directive (nfr). The patient expired. Upon further discussion with the philip's representative, the physicians were unclear whether the injury may have been caused by the temporary pacing wire or extraction sheath. The location of the injury was suspected to be somewhere within the pericardium, due to the observed pericardial effusion. There was no reported malfunction of any spectranetics products used during the procedure.
Patient Sequence No: 1, Text Type: D, B5