A lead extraction procedure commenced to remove three leads: a right atrial (ra), right ventricular (rv) and left ventricular (lv) due to cied system/pocket infection.A spectranetics lead locking devices (lld) were used within each lead to act as a traction platform to aid in extraction.After successful extraction of the ra lead and a partial lv extraction (details of the partial lv lead extraction unknown, but reportedly did not result in an adverse event), the surgeon began attempts to extract the rv icd lead using a spectranetics tightrail rotating dilator sheath in addition to the lld.It was reported that no externalization of the blue high voltage wire was seen on ct scan prior to the extraction.During attempted extraction of the rv lead, the patient''s blood pressure dropped when the coil of the rv lead reportedly came off the ventricular wall and the lead retracted into the tightrail sheath.At the time, the tightrail device was 3 centimeters up the coil of the rv lead when the lead became free.The philips representative, present at the procedure, observed the two electrodes (pacing and sensing) still present in the apex wall.Rescue efforts began immediately, including sternotomy, blood products and bypass.Despite attempts to rescue the patient, the patient died.There was no alleged malfunction of any spectranetics devices during the patient procedure.
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