br Practical use of the Sweet Tip screw
Practical use of the Sweet Tip™ screw-in lead
Entrapment of screw-in lead Entrapment is a relatively rare complication that can occur with the Sweet Tip™ screw-in lead as often as with other types of leads [13,14]. In the Sweet Tip™ lead, the helix might become exposed in the atrium and the risk of entrapment may be higher than the risk with a retractable lead. The most common entrapment site is the tricuspid valve, but it also rarely occurs in the vessels, the atrial wall, and intra-cardiac remnant tissues. To prevent entrapment, it is important to apply gentle manipulation and counterclockwise rotation to navigate through the tricuspid valve. The stylet is pulled for several cm to make a loop in the atrium, and then the lead is advanced from the middle of the loop side into the ventricle. After introducing the lead into the ventricle, the loop is released by moving the stylet and directing the lead tip to the desired position. If the lead has become entrapped in the tricuspid valve, it should not be moved forcefully, but gently, with counter-clockwise rotations. If repeated trials are not effective, the surgeon should consider either leaving the lead in place or removing it surgically, depending on the patient׳s background. The author׳s experiences have been similar to the case described by Maruyama et al. , where the entrapped lead could only sense the atrial electrical signals and it was used as an atrial sensing lead with a DDD pacemaker in a patient with atrioventricular block. In similar cases, adapting to the circumstances is necessary.
Conflict of interest
Introduction In recent years, the development of transvenous electrodes and downsized generators has permitted electrophysiologists to implant cardiac implantable electrical devices (CIEDs), including high voltage devices such as implantable cardioverter-defibrillators or cardiac resynchronization therapy devices with defibrillators, using techniques similar to those employed for the methane monooxygenase of permanent pacemakers [1–5]. Implantation of CIEDs by cardiologists in electrophysiology laboratories has several advantages such as support by a specialized staff and availability of appropriate monitoring and radiological equipment. CIEDs can be implanted in pockets created in the prepectoral subcutaneous space. However, subcutaneous pocket creation for lean or small objects thought to lead to pocket erosion, especially in Japanese individuals, beneath the major pectoralis muscle has been recommended [6–8]. Because the creation of such pockets requires deep dissection, traumatic injury of small vessels or nerves, accidental bleeding, or postoperative hematoma may occur. Further, hematomas within the pockets, complicating CIED placement, have been identified as risk factors for pocket infections and have been associated with CIED replacement . Thus, it is desirable to prevent hematoma formation during the procedure. To minimize traumatic pocket complications, prepectoral subfascial implantation has been employed mainly for large devices since the early 1990s . However, there are few data to support this method of implantation. Because we also employ this procedure at our institute, we introduce our method for prepectoral subfascial pocket creation in the present study.
Materials and methods
Discussion For those patients with inadequate subcutaneous tissue for satisfactory closure, creation of deep pockets beneath the major pectoralis muscle has been recommended to avoid pocket erosion. However, because intra- or submuscular pockets are associated with risks of structural trauma or bleeding, an alternative easier method is needed. The current leading method consists of subcutaneous pocket creation directly over the fascia . In this method, the operator must find the proper plane between the fascia and subcutaneous fat. In some patients, an incision within the subcutaneous fat or between the skin and subcutaneous fat will not be much more difficult than in the accurate plane. Inexperienced operators who do not identify the correct insertion plane, may create the pocket incorrectly and perpetuate the error by inserting the device. A subcuticular plane created by sharp dissection leads to device implantation between the skin and its subcutaneous fat. Although not easily created, this plane results from detachment of the skin from its fat. Consequently, device insertion in the subcuticular rather than the subcutaneous space results in chronic pain.