Surgical Removal of Entrapped Endocardial Leads Without Using Extracorporeal Circulation* JUAN DUBERNET, MANUEL J. IRARRAZAVAL, GUILLERMO LEMA, GUSTAVO MATURANA, JORGE URZUA, SERGIO MORAN, MIGUEL NAVARRO, and ALEJANDRO FAJURI From the Department of Cardiovascular Diseases, Clinical Hospital, Catholic University of Chile DUBERNET, J., ET AL.: Surgical removal of entrapped endocardial leads without using extracorporeal circulation. 0/ 267 patients having a tined endocardial lead implanted from 1978 to December 1983, three (1.1%) developed pulse generator pocket infection. Proper treatment of this complication involves removal of the pulse generator, continued external pacing via the implanted lead, pocket drainage and administration of specific antibiotics until the infected area clears. In two patients, the electrode could not be removed by traction. A sternotomy was performed, the pericardium was opened, the endocardia! electrode was located by palpation, and a purse string suture (PSS) was prepared around it on the right ventricular wall. A new myocardial electrode with its corresponding generator was then implanted to reestablish pacing. Through the PSS the myocardium was incised, the distal end of the endocardial lead was exteriorized and severed, and the PSS was tied. The remaining lead was withdrawn proximally and the surgicaJ wounds were closed. The results of this procedure have been been excellent, allowing the removal of the entrapped leads, with continuous pacing and without the need for extracorporeal cir- culation. (PACE, Vol. 8, March-April 1985] entrapped endocardial lead removal, pulse generator pocket infection Introduction At present, endocardial leads are preferred for permanent pacing in over 95% of the cases.' The improved design, quality of materials, and ease of implantation has made them the leads of choice, particularly those with the newer tined electrodes. The older endocardial leads had complications such as displacement, perforation, and infection, in about 10-20% of the patients.^ With the tined leads, dis- placement has been reduced to less than 2%, but threshold increase and infection continue to be a problem.^'' In our experience, the infection of the pulse gen- erator pocket is usually complicated by sepsis due 'Supported by the Gildemeister Foundation. Address for reprints: Dr. Juan Dubernet, Marcoleta 347, San- tiago, Chile. Received February 16. 1984; revision received June 27, 1984; accepted on July 17. 1984. to progression of the infection through the fibrotic lead sleeve. The only consistently effective ther- apeutic procedure is to remove the generator and electrode completely in addition to specific anti- biotic therapy. Hou^ever, the distal end of the tined lead, due to its design, is usually entrapped by the fibrotic sleeve or adherences to the trabeculae and sometimes cannot be withdrawn by traction alone. Various techniques have been described to re- move this entrapped lead; one of them is the use of extracorporeal circulation (ECC), which in- volves an important additional risk. We have de- veloped a procedure that allows the removal of the entrapped portion of the lead through the ven- tricle without ECC. Clinical Experience From 1978 to December 1983 we implanted 267 pacemakers with tined endocardial leads (Med- PACE. Vol. 8 March-April 1985 175