looks like the x8
7 is noticeably worse
Yes X8-2t. Our hospital just bought a fleet of epiq's will all the snazzy software. We do a bunch of structural stuff, so a nice machine is quite useful.
Speaking of lead extractions. What do you guys do in terms of pump / CT surgeon backup? Pump in room, pump primed, pump down the hall, no pump at all? CTS on standby or physically in the room?
Perfusion and CT on standby in the OR complex. Pump literally outside the OR doors.
So I really would have no idea how to answer this if it were asked on oral boards or other. I looked it up. There are a couple studies I found that indicated asymptomatic lead thrombi in atrial leads are about 45-50% and ventricular leads about 30-35%
Correct. Lead thrombus is extremely common.
I think I would want to know how necessary the pacemaker is at this point? Is the pt still having problems with SVT or is the pt completely dependent on the device to prevent intractable SVT?
Good thought. He didn't need it anymore, so we were not replacing it. Had to come out though as the battery pocket was eroding through the skin.
Obviously, the concern would be for a pulmonary embolus causing death as well as undiscovered PFO with arterial spread of embolus should the thrombi come loose.
100%. First thing I did when I saw this monster was to check for a PFO which the patient did not have.
Now as to what to do. Well there are no published guidelines as to what to do when you find a thrombus. Options are pull real hard and hope for the best, anticoagulation, tpa, angiovac/percutaneous removal or surgery. All have their own set of risks.
As per this particular patient, the thrombus is a monster and was literally ebb and flowing in and out of the pulmonary valve. There is no doubt in my mind that if this thing were to embolize, it would cause harm. Not only is it large, but certain aspects of it are very well organized and would not be easy to tpa if it ended up in the lungs. That being said, the patient was 30 years old and had no other heart issues (good EF, etc).
If that thing is veg, just given the massive microbe burden and extremely mobile nature of it he would almost certainly be febrile, bacteremic, and throwing septic emboli to the lungs. But youre right that even if he's asymptomatic the possibility of veg does need to be on our radar.
100%. Definitely keep it in mind but very low probability if the patient isn't septic, valves look good, not throwing septic emboli, etc. Also correct in that the proximal end was an organized thrombus that was rock solid with a distal very mobile part to it.
Ultimately, cardioligy struggled getting this thing out (had 20 years to bury itself into a developing heart). Cards became very reluctant to pursue the lead once i showed him what we were dealing with. This particular cardiologist starts to think of surgical intervention once it is 3-4cm in size. TEE demonstrated at least a 7 cm mass which was likely even bigger. Cards persisted in trying to get it out until his lead extender/sheath broke off at which point the solution became obvious. Pump run for lead extraction which in all honesty would have been a good choice from the get-go as we had an otherwise healthy patient/good protoplasm. Downside would be the scar in a young patient. TPA or anticoagulants were not going to dissolve the proximal thrombus and in the meantime he was at risk for a major card/pulm risk.
All in all the case ended up being super easy once we decided on surgical removal of the pacer lead and thrombus.
