case_images: PMC11811417_01
case_images: (A) The X-ray after the first debridement (the generator was removed, and the leads were embedded subcutaneously). (B) The X-ray after the second debridement (the exposed lead on the right subclavian area was cut off). (C) The X-ray after cutting the ventricular lead, removing the bacterial neoplasm under the tricuspid valve and performing the tricuspid valvuloplasty.
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case_images: Subsequently, a pocket infection occurred, leading to the removal of the generator and subcutaneous embedding of the leads (Figure 1A). However, subsequent exposure of the embedded leads at the right subclavian area prompted hospital admission for lead removal and incision debridement (Figure 1B). The cardiac surgeon conducted surgery, involving further cutting of the ventricular lead, removal of the bacterial neoplasm beneath the tricuspid valve, and tricuspid valvuloplasty (Figure 1C). Upon physical examination, her height was 155 cm, weight was 50 kg, and inspection of the chest wall revealed scars and wrinkles on the right subclavian skin (see Supplementary material online, Figure S1).
case_images: (A) The pre-operative electrocardiogram displayed sinus rhythm along with ST-segment depression and T-wave inversion in leads V1-V6. (B) The post-operative electrocardiograms revealed a QRS duration of 110 ms within the normal range.
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case_images: The electrocardiogram (ECG) displayed sinus rhythm, along with QRS duration 110 ms, ST-segment depression, and T-wave inversion in leads V1-V6 (Figure 2A). The generator (Xintong LD300SR) was implanted in the lower-right abdominal pocket (see Supplementary material online, Figure S2). The post-operative ECG revealed a QRS duration of 110 ms within the normal range (Figure 2B).
case_images: (A) The guide wire failed to reach the superior vena cava after puncturing left subclavian vein. (B) Venography showed that the left brachiocephalic vein was occluded (the arrows).
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case_images: However, during the procedure, the guide wire failed to reach the superior vena cava (Figure 3A), revealing occlusion in the left brachiocephalic vein through venography (Figure 3B). The measurement of V6-V1 interpeak interval was 35 ms (see Supplementary material online, Figure S3).
case_images: (A) Medtronic Attain Select II 6248V-130p was used as the inner sheath. (B) The haemostatic valve and 12 cm of the proximal end of the inner sheath was cut for increased usable lead length. (C) Medtronic Attain Command 6250V-MB2X as the outer sheath (a); Medtronic Attain Select II 6248V-130p as the inner sheath (b); and Medtronic 3830-69 cm as the pacing lead (c).
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case_images: The 3830 lead was inserted along the inner sheath, and for increased usable lead length, the haemostatic valve was removed, and 12 cm of the proximal end of the inner sheath was cut (Figure 4A-C). The pacing system continued to function properly, and the ventricular pacing per cent was 36.8% (see Supplementary material online, Figure S4).
case_images: The left bundle branch area pacing lead was screwed into the right ventricular septum (A) under the projection of right anterior oblique 30 view and (B) under the projection of left anterior oblique 30 view. (C) Left bundle branch area pacing threshold testing exhibited an incomplete right bundle branch block pattern in V1, with a width of 103 ms and an left ventricular activation time of 69 ms in V6 at a low output.
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case_images: The lead was screwed into the right ventricular septum until the unipolar QRS complex morphology exhibited an incomplete right bundle branch block pattern in V1, with a width of 103 ms and an left ventricular activation time of 69 ms in V6 at a low output (Figure 5A-C).