New surgical minimally invasive lead explantation due to infective endocarditis with large lead vegetations is superior to conventional approach via median sternotomy

Objectives: Infective rhythm device-related, and particularly lead endocarditis is becoming a significant source of morbidity and mortality with incidence from 1–7% and mortality approaching 33%. The therapy of choice is transcutaneous removal of infected leads using extraction sheaths or excimer laser. However, in the presence of very large and fragile lead vegetations the potential hazard of pulmonary embolism increases substantially. Moreover, due to concomitant tricuspid valve endocarditis an open-heart surgery is often necessary. Since the complication rates of standard approach via median sternotomy (MS) are relatively high we evaluated the impact of new minimally invasive lead explantation technique (MI) on outcome of these patients.

Methods: In 24 patients with infective endocarditis and large lead-vegetations (fragile, >20mm) an open-heart surgical lead explantation was performed. Conventional MS was performed in 17 patients, video-assisted right lateral mini-thoracotomy (6cm, 4th intercostal space, video-port, cardiopulmonary bypass: femoral artery and vein or combination of femoral and right jugular vein) in 9 patients. If necessary, concomitant tricuspid valve surgery in both groups, or CABG in MS were additionally performed.

Results: Preoperative patient characteristics were similar in both groups (median age 68y in MS vs. 62 in MI, body-mass-index 26.2 vs. 26.3kg/m2, median lead age 5.3y vs. 5.5). Preoperative ejection fraction in MS was 44%, in MI 58%. In all cases leads were completely removed (37 in MS –2.5/patient; 24 in MI –2.7/patient). Concomitant tricuspid valve repair/replacement was performed in 6 patients (3 MS an 3 MI). Single CABG was additionally performed in 3 patients from MS. The operation time was 232 vs. 196 and bypass time 99 vs. 115min. One patient in MS died postoperatively due to sepsis, no deaths in MI were recorded. ICU-stay was 7.3 vs. 2.2 days. Re-thoracotomy due to bleeding was necessary only in MS (5 patients, 29.4%). MS received in median 3.7 blood units in comparison to 1.8 in MI.

Conclusions: New minimally invasive lead explantation technique, even in combination with tricuspid valve surgery is safe and effective. If there are no additional reasons for median sternotomy (e.g. CABG), the minimally invasive approach seems to be superior in term of bleeding reduction, reduced ICU and hospital stay, pain reduction and improved cosmesis, and might be more than an alternative to conventional procedure.