Author + information
- Received April 25, 2016
- Revision received May 18, 2016
- Accepted May 26, 2016
- Published online August 3, 2016.
- George H. Crossley, MD∗ (, )
- Sam Aznaurov, MD,
- Matthew R. Danter, MD and
- Christopher Ellis, MD
- ↵∗Reprint requests and correspondence:
Dr. George H. Crossley, Heart and Vascular Institute, Vanderbilt University, 1215 21st Avenue North, Nashville, Tennessee 37232-8802.
The patient presented in 2008 for follow-up of her implantable cardioverter-defibrillator, which had reached its elective replacement indicator. The ventricular lead was a Medtronic 6949 lead (Minneapolis, Minnesota), which was electively replaced with the current Medtronic 6947. There was distortion of the superior vena cava coil prior to extraction, at the same position seen in Figure 1. The new lead displayed some distortion of the coil on the post-operative film. Gradually the abnormality seen here developed, with increased distortion and fractures of the proximal coil. Eventually, noise was seen on the pace/sense component and high impedance was noted on the SVC coil.
It is clear that the proximal coil extends out of the vein and through the subclavius muscle. Soft tissue mobility has led the pulse generator to migrate, putting force on the lead at the point of intravascular adhesions. The free metal pieces are elements of the SVC coil that have fractured.
The extraction was exceedingly difficult. The lead locking stylet did not pass beyond the SVC coil. Eventually, a 16-F laser sheath was advanced over the shredded coils, freeing up the binding site at the proximal end of the SVC coil. The lead was then easily withdrawn. The lead was replaced with a single coil lead, which was placed via a separate, more lateral axillary vein access, avoiding contact with the severed elements of the coils.
The likely mechanism of this fracture is the action of connective tissue on the coils. The fractured elements then serve to disrupt other elements of the lead. Once the integrity of the coil is lost, a fulcrum mechanism may cause fracture of the pace/sense elements. This provides yet another reason not to use dual coil leads and likewise not to use a very central venous access site.
Dr. Crossley has received speaking and consulting fees from Medtronic and Boston Scientific. Dr. Ellis has received consulting fees from Spectranetics; has received research support and consulting fees from Medtronic and Boston Scientific; and has served on the advisory boards of Medtronic and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 25, 2016.
- Revision received May 18, 2016.
- Accepted May 26, 2016.
- American College of Cardiology Foundation