br Discussion The excimer laser

Discussion The excimer laser generator and the laser sheath allow for the extraction of leads while freeing them from the site of adhesion by making use of photoablation induced by the energy of ultraviolet rays. Since its approval in 1997 by the US Food and Drug Administration, the use of excimer laser sheaths for the extraction of implanted leads has rapidly increased throughout the world, yielding high success rates and excellent safety [4]. This technique was approved in 2008 in Japan. However, serious and potentially fatal complications, such as vascular injury, hemothorax, and pneumothorax, have been reported with this technique, although their incidences have been relatively low [3]. Thus, care is needed when applying this technique. In 1999, Wilkoff et al. compared lead extraction using the conventional mechanical sheaths with that using laser sheaths. They found that the success rate and safety were both higher for lead extraction using laser sheaths [5]. In 2009, the LExICon study reported the outcomes of lead extractions using excimer laser sheaths at 13 facilities in North America [6]. In that study, the success rate was as high as 97.7%, while the incidence of adverse events was 1.4%, and the VX-765 was 0.27%. The risk for complications tended to be higher at facilities where lead extraction had been used in fewer than 60 cases. The study did not identify any preoperative findings useful for predicting complications from this technique. In the present case, the patient had previously undergone the Senning operation, and lead extraction by open surgery with the use of cardiopulumonary bypass was thought to be dangerous due to severe adhesion. Indications for lead extraction with excimer laser sheaths are determined based on the American Heart Association and Heart Rhythm Society (AHA/HRS) joint guidelines [7,8]. The present case was classified as class IIa according to this guideline, since he complained of unendurable pain caused by the residual leads but had no fatal complications, such as sepsis. Because the preoperative CT scans revealed intense adhesion of the lead to the SVC, continuous intraoperative monitoring of the SVC during the procedure with a thoracoscope was considered extremely useful. Injuries to the lower SVC and the right atrium can result in cardiac tamponade, which can be diagnosed by TEE, whereas upper SVC injury is likely to be ruptured in the intrathoracic cavity. A thoracoscope is useful for monitoring complications in such cases. Thus, thoracoscopic assistance may be indicated particularly in the cases with where severe adhesion of a lead to the upper SVC is found during preoperative examination. In the present case, vascular injury did not occur during the operation, but we had planned to perform open surgery through a median sternotomy to achieve hemostasis immediately upon onset of vascular injury while maintaining percutaneous cardiopulmonary support (PCPS). In the present case, a one-port system was employed for insertion of the thoracoscope. If the thoracoscope is to be used for hemostasis upon onset of vascular injury, a two-port system is needed. The two-port system can control sudden bleeding in the upper SVC without opening the chest.
Conflict of interest
Introduction Percutaneous catheter ablation is a valuable tool for the management of atrial fibrillation (AF). However, this technique requires access to the left atrium (LA), which is obtained by transseptal puncture. Real-time three-dimensional (3D) transesophageal echocardiography (RT3D-TEE) is a recently developed technique that provides 3D images of the heart [1]. Here, we report the case of a patient who required a high-risk transseptal puncture due to a “pancake” deformity of the LA and a displacement of the aorta; our results show that RT3D-TEE is very useful for this procedure.
Case report A 78-year-old man was referred to our hospital for pulmonary vein isolation (PVI) for symptomatic paroxysmal AF. He had a history of pulmonary tuberculosis for which he had undergone a right upper lobectomy. Before the procedure, a “pancake” deformity of the LA was observed using a 64-slice multislice computed tomography (CT). This deformity was believed to be a complication of the right upper lobectomy. The descending aorta was in direct contact with the center of the posterior LA wall. The esophagus had descended to the level of the LA along the left side of the descending aorta. CT revealed an anteroposterior LA diameter of 16mm (Fig. 1). This deformity could not be observed by transthoracic echocardiography. Transesophageal echocardiography revealed the “pancake” LA sandwiched by the ascending aorta and the descending aorta (Fig. 2A). Chest radiography revealed the displacement of the descending aorta (Fig. 2B). In most patients, we use only a fluoroscopically guided approach to the LA for a transseptal puncture. However, in this patient, we thought it would be difficult to approach the LA using our typical method due to the small atrial septum and the displacement of the aorta. After a detailed assessment, we planned to use RT3D-TEE in combination with fluoroscopic imaging for transseptal puncture. Before catheter ablation, the patient gave written informed consent for the procedure. We excluded the existence of a thrombus in the LA and appendage by transesophageal echocardiography.