Left persistent superior vena cava lead extraction using a femoral approach.

A 27-year-old man with a congenital heart disease consisting of a double inlet left ventricle s/p a classic Fontan palliation and oversewing of a regurgitant tricuspid valve in 1991 with enlargement of a bulboventricular foramen in 1997, transposition of the great arteries, subaortic stenosis, a left persistent superior vena cava (LSVC), and a hypoplastic mitral valve was followed up in an adult congenital clinic. He had a single-chamber pacemaker implanted via the LSVC (Capsurefix 4068, Medtronic) for sinus node dysfunction in 1997 with the lead screwed directly into the ostium of the coronary sinus due to the inability to find an acceptable site for right atrial capture. In 2001, this lead was found to have a high capture threshold and was capped. A St Jude Medical Tendril 1388T lead was placed via the LSVC and screwed into the coronary sinus near the first lead (Panel A). In 2008, an epicardial right ventricular lead (MyoPore 511212, St Jude Medical) was implanted to serve as a backup because of gradually increasing thresholds on the RA lead. In 2015, the patient underwent a generator exchange. Two weeks later, he developed an methicillin sensitive Staphylococcal aureus pocket infection and bacteraemia. He subsequently was referred for system extraction. A 14and then 16-Fr Excimer laser sheath (GlideLight, Spectranetics) were used to free both endocardial leads proximally. The laser sheaths could not be passed further than the proximal LSVC nor could a mechanical cutting sheath (TightRail, Spectranetics) due to the right angle of the LSVC take off. With further attempts, lead integrity proximally