Simultaneous suction debulking of lead vegetation prior to percutaneous lead extraction

The infection rates of implanted cardiac devices have increased disproportionate to the dramatic increase in implantation rates, possibly related to rising patient comorbidities. Optimum strategy in cases with larger size vegetations, however, remains to be ascertained. In the absence of an effective and less invasive alternative, such patients usually undergo open thoracotomy for lead extraction. We describe the case of a 50-year-old female presenting with recurrent methicillin-resistant Staphylococcus aureus bacteremia found to have 3 cm highly mobile vegetation on the right ventricular lead of her implanted defibrillator. While being intermediate-to-low surgical risk, she underwent AngioVac-directed suction debulking (AngioDynamics, Latham, NY, USA) of the vegetation simultaneously preceding percutaneous laser lead extraction in a single session. This less invasive alternative to open thoracotomy has been described in high surgical risk patients, but its widespread role remains unexplored. <Learning objective: Complete lead extraction is recommended in all cases of lead infection. However in the presence of large-size lead vegetation, the optimum management strategy is still controversial, especially among high-risk surgical patients. AngioVac system (AngioDynamics, Latham, NY, USA) has a centrifugal suction cannula which can offer a safer and less invasive percutaneous alternative to open thoracotomy approach, with a possibility of large-scale application due to faster recovery.>.