A patient with dilated cardiomyopathy (DCM) underwent conventional CRT-D implantation using left subclavian vein access following a successful resuscitation due to ventricular tachycardia. One month later skin necrosis was detected above the device. Our hypothesis was, that burn injury - which he suffered fourty years prior - has damaged the microcirculation of the skin and was accountable for the necrosis. The complete system was explanted, and we utilized negative pressure wound therapy for the treatment of the remaining tissue.
Figure 1. A: 3 weeks after the implantation. B: The complete system was removed, and a large tissue gap remained. C: Negative pressure of 125 Hgmm was applied, to cover the tissue defect and facilitate tissue regrowth D: 3 weeks after the device explantation. With continuous negative pressure wound therapy the absence of skin tissue was almost completely closed.
We decided to perform surgical reimplantation of the device using mini thoracotomy: right atrial and right ventricular leads were introduced through the right atrial appendage and the left ventricular lead was inserted transapically.
For mini-thoracotomy, a vertical right lateral 5.5 cm long skin incision was made over the fourth right intercostal space just anterior to the midaxillary line. Single-lung ventilation was initiated, and the right lung was retracted posteriorly. The pericardium was carefully opened.
A guidewire was inserted with Seldinger’s technique through the puncture of right appendage into the right atrium. The wire was then exchanged to a sheath and a right ventricular shock electrode was introduced. Eventually it was positioned and secured to the right ventricular apex under fluoroscopy guidance with good electrode parameters. The right atrial lead was also introduced with the same method and positioned with a J-shaped stylet into the anterior part of the right auricle. Bleeding was controlled and the electrodes were secured with purse-string sutures around the puncture points Fig 2.A).
Next, the ideal site for the incision to reach the apex of the left ventricle was identified and marked by transthoracic echocardiography guidance at the corresponding intercostal space. A second mini thoracotomy was performed on the left side of thorax. A guidewire was inserted with Seldinger’s technique through the puncture of the apex into the left ventricle. After removal of the guide wire, the pacing electrode was inserted into the LV cavity through the sheath and peel-off sheath was removed. Bleeding from the LV was controlled with purse-string sutures around the puncture point (Fig. 2.B). Fluoroscopy was utilized for the endocardial fixation of the electrode at the lateral wall of the left ventricle (Fig. 2.E).
The device was implanted in the abdominal area, where the skin was almost intact, below the diaphragm and the electrodes were tunneled (Fig. 2.C). Anticoagulation was initiated becouse of the foreign body in the left ventricle. 6 months later there was no sign of complications, and the surgical wounds healed completely.
Figure 2. Surgical CRT-D implantation. A: Right lateral mini thoracotomy. The right ventricular and right atrial leads are positioned and fixed with purse-string sutures. B: Left lateral mini thoracotomy. The left ventricular lead was introduced through the apex of the left ventricle. C: The leads were pulled through tunnels into the abdominal part and attached to the CRT-D device. D: Positioning of the leads was carried out with fluoroscopy guidance. E: Good parameters were recorded at the end of the procedure. F: 6 months after the surgery