Author + information
- Received January 22, 2019
- Accepted January 31, 2019
- Published online May 20, 2019.
- Serkan Cay, MD∗ (, )
- Ozcan Ozeke, MD,
- Firat Ozcan, MD,
- Serkan Topaloglu, MD and
- Dursun Aras, MD
- Division of Arrhythmia and Electrophysiology, Department of Cardiology, University of Health Sciences, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey
- ↵∗Address for correspondence:
Dr. Serkan Cay, Division of Arrhythmia and Electrophysiology, Department of Cardiology, University of Health Sciences, Yuksek Ihtisas Heart-Education and Research Hospital, 06100 Sihhiye, Ankara, Turkey.
A 44-year-old male patient with end-stage renal failure receiving chronic hemodialysis and ischemic cardiomyopathy underwent an epicardial defibrillator device implantation for secondary prevention 2 years ago. Epicardial implantation was due to a totally occluded right subclavian vein from previous venous access attempts for dialysis and a permanent dialysis catheter on the left side. During follow-up, the device detected a lead warning regarding high defibrillation impedance. The fluoroscopic image showed a fractured epicardial defibrillator lead (Figure 1). The subcutaneous defibrillators are not eligible for reimbursement in the country. Therefore, a challenge from the right side was chosen. A deep right subclavian puncture and contrast injection showed a well-developed sharply angulated collateral between the patent proximal part of the right subclavian vein and the left innominate vein (Figure 2A). A 9-F peel-away sheath was introduced over a guidewire in the proximal part of the subclavian vein and adjacent collateral. A single-coil DF1 defibrillator lead (Sprint Quattro MRI SureScan, Medtronic, Inc., Minneapolis, Minnesota) without an inner stylet was advanced into the collateral up to the sharp angle. However, no further advancement from that point was achieved. A steerable 8.5-F catheter (Agilis, Abbott, Abbott Park, Illinois) was introduced over a guidewire from the right femoral vein up to the left innominate vein (Figure 2B). A 4-F snare catheter with a loop diameter of 5 mm (AndraSnare, Andramed GmbH, Reutlingen, Germany) was advanced through the steerable catheter to grasp the distal portion of the lead (Figure 2C). When grasped, the entire system was pulled back from the collateral to the low right atrium near the tricuspid valve with simultaneous advancement of the lead from the pectoral region (Figures 2D and 2E, Online Video 1). The steerable catheter and the snare were used for the orientation of the lead to the valve. Finally, the lead was advanced into the right ventricle using an inner soft stylet offering more backup force (Figure 2F). Proximal pins were attached to the pulse generator, and the generator was placed in the pocket conventionally (Figure 3, Online Video 2). Sensing, pacing, and impedance values were detected in normal ranges during and at 6 months after implantation. A successful 35 J cathodal shock delivery for a fast ventricular tachycardia episode was also detected during the device interrogation.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received January 22, 2019.
- Accepted January 31, 2019.
- 2019 American College of Cardiology Foundation