Letter to the Editor Superior vena cava obstruction as late complication of biventricular pacemaker implantation: Surgical replacement of the malfunctioning previous leads Fabrizio Ceresa a , Fabrizio Sansone a , Salvatore Patanè b , Giuseppe Mario Calvagna b, ⁎, Francesco Patanè a a Cardiochirurgia Ospedale Papardo Messina, Azienda Ospedaliera Ospedali Riuniti Papardo Piemonte, 98158 Messina, Italy b Cardiologia Ospedale San Vincenzo - Taormina (Me) Azienda Sanitaria Provinciale di Messina, Contrada Sirina, 98039 Taormina (Messina), Italy article info Article history: Received 31 May 2014 Accepted 26 July 2014 Available online 3 August 2014 Keywords: Cardiac surgery Endocarditis Extraction Implantable defibrillator Lead Pacemaker Introduction: The use of implantable cardiac devices has increased in the last 30 years. The evolution of devices in serious cardiac rhythm pathology management has led progressively to the development of devices for the treatment of bradycardia, ventricular arrhythmia, and heart failure and for the prevention of sudden cardiac arrest leading to delivery of pacemakers, implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT) plus ICD (CRT-D) [1–22] and to the recent subcutaneous implantable cardioverter-defibrillator (S-ICD) [23–25]. Infectious complications also lead to endocarditis [1, 8,26–33] and non-infectious complications [9,21,23,34–37] often neces- sitate removal [1,2,8,37–43] and affect patients' wellbeing which also leads to an increase in psychological difficulties [23,44–50]. In addition, the improved patients' survival [51–65] with the burden of concomitant diseases, the progressively younger implanted population and the increase in device and procedure complexity have raised the risk of system component structural failures [51–65]. Lead extraction is being the cornerstone of the modern clinical cardiac electrophysiology as well as efficacious cardiac device implantation and management. Transvenous lead extraction and venous occlusion: Since 2002, our institution (Cardiologia Ospedale San Vincenzo — Taormina (Me), Azienda Sanitaria Provinciale di Messina, 98039 Taormina (Messina), Italy) has been a referral center in Sicily for PM and ICD lead extraction, using the Bongiorni's multiple entry-site approach [66] and non-powered sheats [40]. Central venous occlusion in patients with pre-existing devices is often asymptomatic and optimal management of such patients in need of device revision/upgrade/extraction [67] may represent a serious chal- lenge. Pre-procedure venography to assess venous patency [67] should be performed. Research suggests a venous occlusion incidence closer to 30% [67–69]. Nevertheless, the complete occlusion of superior vena cava occurs only in about 1% of the cases [67]. Various strategies to overcome venous occlusion exist including contralateral lead or device implanta- tion, venoplasty, lead extraction and surgical epicardial lead implantation [67]. We usually search to remove the preexisting electrodes with a percutaneous approach [66] but if the adhesions between the leads and the venous wall cannot be gone over, in our mind, the surgical strategy is often mandatory. Clinical case: We describe a case of 54 year old male affected by obesity, diabetes mellitus and idiopathic dilated cardiomyopathy who underwent cardiac resynchronization therapy through a transvenous ap- proach 5 years ago. After an ineffective try to remove the malfunctioning leads through a percutaneous extraction procedure, contrast venography was performed and showed a complete occlusion of the SVC (Fig. 1) and an anastomotic circle between SVC and inferior vena cava (IVC) through the azygos vein that was dilated. He has been referred to our center for surgical replacement of the leads. Given that the patient has a high risk of major sternal wound complication, we have decided to perform the operation through both an inferior ministernotomy and left minithoracotomy to avoid it. We choose to implant the leads through two different minimally invasive surgical approaches that have been performed to reduce his risk of sternal wound complication, mainly depended on the diabetes and severe obesity. The right and left ventricu- lar leads have been screwed into the wall using a sutureless electrode and obtaining the very low thresholds. We have performed the pacemaker's pocket in the right upper abdominal quadrant given that a subcutaneous ICD could be afterwards implanted in a left pectoral pocket. Thereby, the distance between the two generators should be enough to avoid any in- terference. After having checked the thresholds, the electrodes were tunneled and connected to the pacemaker (PM) in a right upper abdom- inal pocket. We placed a chest and pericardial tubes that were removed after 24 h. The patient was extubated in the operating room. He was discharged after 3 days and he enjoys good health. Considerations: Clinical practice has always been needed for lead ex- traction, but never more so than now [57,70]. The growing implanted International Journal of Cardiology 176 (2014) e83–e85 ⁎ Corresponding author. Tel.: + 39 3474800260. E-mail address: gicalvagna@tiscali.it (G.M. Calvagna). http://dx.doi.org/10.1016/j.ijcard.2014.07.164 0167-5273/© 2014 Published by Elsevier Ireland Ltd. 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