Bontempi Luca , MD

Division and Chair of Cardiology

Electrostimulation and Electrophysiology Laboratory

Brescia – Italy

TLE with video-assistedminithoracotomy

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ASE

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• 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