Po-02-056 real-time video assisted thoracoscopic surgery in high-risk transvenous lead extraction

Laceration injury to the superior vena cava (SVC) remains the most feared complication of transvenous lead extraction (TLE). Early recognition is crucial to prevent catastrophic complications. Use of real time video assisted thoracoscopic surgery (VATS) during high risk TLE can potentially be useful for prompt recognition of SVC injury. We describe the use of video assisted thorascopic surgery (VATS) guidance for complex transvenous lead extractions (TLE). We conducted a retrospective analysis of all patients that underwent TLE at our institution from September 2018 to November 2022. Our TLE protocol uses a risk stratification scheme of level 1, 2 and 3 based on perceived risk. Defibrillation leads with a dwell time of >10 years or presence of 3 leads with oldest lead >10 years qualify as level 3 TLE cases. All procedures are performed with surgical back up with the use of VAT via a right thoracoscopic approach in level 3 cases. During single lung ventilation, the surgeon places a camera port to provide visualization of the SVC and right atrium for direct visualization during the laser/mechanical sheath manipulation in the great vessels. Out of 41 patients that underwent TLE during the study period, 10 patients underwent concomitant right VATS. Mean age of cohort was 61.5 + 15.2 years and 70% were males. Mean BMI and LVEF was 28.8 + 7.9 & 28.5 + 5.9 % respectively. Indications for TLE included lead malfunction (50%), infection (40%) and removal of abandoned leads in 1 patient. Mean lead dwell time was 10.4 + 5.6 years. Laser sheath was used in all cases with 2 patients requiring use of additional mechanical sheaths. One case demonstrated externalized ICD coil and extraction was abandoned. A femoral approach with snaring was done in 1 patient. All patients had adequate visualization of the SVC via VATS during TLE. Average procedure duration was 134 + 79.1 minutes. There were no immediate procedural complications. VATS port was removed and a chest drain was placed which was removed on post operative day 1 in all patients. VATS allows for direct visualization of the venous structures, provides real time information regarding impending venous injury, and is feasible with minimal impact on procedural risk and length of stay.