Lead Extraction

Many people have surgically implanted cardiac devices. These devices include pacemakers and implantable cardioverter defibrillators or ICDs. Pacemakers can help treat slow heart rhythms, and ICDs stop dangerous rapid heart rhythms.

Both these devices have 2 main components: a pulse generator and a set of leads. The pulse generator is a small computer with electric circuits and a battery. The leads are wires that run between the pulse generator and the heart. These leads can deliver a burst of energy in both pacemakers and ICDs. This burst of energy can cause the heart to beat more quickly (in a pacemaker), or it can stop dangerous rapid heart rhythms (in an ICD). To do this, the leads need to contact the heart itself. Most leads travel through a vein to enter the right side of the heart. They usually connect to the inside of the heart with a small screw screwed directly into the muscle of the heart wall. The body forms scar tissue around the lead, which anchors it even more firmly to the heart.

The design of the leads allows them to stay attached to the heart permanently. Sometimes, however, it is necessary to remove leads. This is called lead extraction. The surgeon opens the area where the leads are attached to the pulse generator and disconnects the leads. Laser or mechanical sheaths are then placed over the leads to free them from the body. This allows the leads to be removed safely from the body.

Leads usually stay in the body permanently, but you may need to have them removed in certain cases. Your healthcare provider will only perform lead extraction if the benefits outweigh the risks.

Device infection is the most common reason for lead extraction. This is usually necessary if any part of the pacemaker or ICD becomes infected. It is usually impossible to get rid of the infection without doing this. The pulse generator and all the leads must be removed. Infection of a heart valve would also require generator and lead extraction.

Broken leads are another major reason for lead extraction. This might happen from a break in the wire, for example. It is not always necessary to remove broken leads. Sometimes a surgeon can leave the broken lead inside the heart and place a new lead beside it. Because of space limitations, this is not always possible. Sometimes people have lead removal even if there is space available for the new lead. This might be true in a young person who would probably need more leads in the future. Lead removal is more difficult to perform later, so this person might choose to go ahead and have the lead removed.

There are a number of other medically approved reasons for lead extraction, which are less common. The following are examples:

• Dangerous or malfunctioning leads (like a protruding wire)
• Recall on a specific pacemaker or ICD lead
• Clot formation on a lead that obstructs a vein
• Retained lead triggering abnormal heart rhythms or other complications

Lead removal is successful in most people, but it is a complex surgical procedure. As such, it has some real risks that will be reviewed with you in detail. There is a chance of puncturing the heart or tearing a surrounding blood vessel. This can cause major bleeding in the chest. This might require blood transfusion or immediate open-heart surgery. Other possible problems include:

• Blood clot lodging in the lung (pulmonary embolism)
• Stroke
• Damage to the heart valve on the right side of the heart, causing it to leak
• Complications from anesthesia
• Fluid accumulation around the heart or lung
• Bleeding under the skin
• Swelling of the arm
• Infection
• In rare cases, death

Certain factors make complications slightly more likely. These include being female, being younger, if the leads are calcified or needing multiple leads removed. Your specific risks will depend on your specific medical conditions. Be sure to discuss your concerns with your healthcare provider before you have your lead extraction.

Talk with your healthcare provider about what you should do to prepare for your lead extraction. You may need to avoid eating or drinking anything before midnight of the day of your procedure. Follow instructions about what medicines to take before the procedure. Don’t stop taking any medicine unless your healthcare provider tells you to do so. Blood thinners are usually held before the procedure.

You may have some tests before your procedure. These might include:

• Electrocardiogram (ECG), to analyze the heart rhythm
• Echocardiography (Echo), to evaluate heart anatomy and function
• Venogram, to evaluate vein anatomy surrounding the device
• Blood tests, to establish a baseline before the procedure

Let your healthcare provider know if you are pregnant before having the procedure. The imaging used during the procedure uses radiation, which may be a risk to the fetus. If you are a woman of childbearing age, your healthcare provider may want a pregnancy test to make sure you aren’t pregnant.

If needed, skin above the area of operation (in your groin or shoulder) may be shaved.

The procedure takes 2 to 6 hours. A cardiologist and a special team of nurses and technicians will perform the extraction. During the procedure:

• You will be give anesthesia before the surgery starts. Afterwards, you won’t remember it.
• An incision is made.
• Next, the leads are removed from the heart using the sheath. A variety of methods and tools can be used depending on your specific situation.
• The team will carefully monitor you throughout the procedure. If complications arise, you may need to have immediate open heart surgery.
• The team will remove the leads and sheath through the blood vessel. In some cases, they also might place new leads at this time.
• The team will close and bandage the site where they inserted the sheath.

In the hospital after the procedure:

• You will spend several hours in a recovery room.
• The team will monitor your vital signs, such as your heart rate and breathing. They will also monitor your heart rhythm.
• If the extraction involved using a vein in your leg, you will need to lie flat for several hours after the procedure. You should not bend your legs. This will help prevent bleeding.
• You may receive pain medicine if you need it.
• Time in the hospital varies, but you will likely spend a minimum of one night.
• You will need a follow-up chest X-ray to check your heart and lungs after the procedure.

At home after the procedure:

• You will probably be able to return to light activity relatively soon.
• You may have sutures that you will need to have removed after the procedure.
• Call your healthcare provider if you have increased swelling, increased bleeding or drainage, or a fever.

After you leave the hospital, it is important to follow all the instructions your healthcare provider gives you for medicines, exercise, diet, and wound care. Be sure to keep all your follow-up appointments.

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure
• The reason you are having the test or procedure
• What results to expect and what they mean
• The risks and benefits of the test or procedure
• What the possible side effects or complications are
• When and where you are to have the test or procedure
• Who will do the test or procedure and what that person’s qualifications are
• What would  happen if you did not have the test or procedure
• Any alternative tests or procedures to think about
• When and how will you get the results
• Who to call after the test or procedure if you have questions or problems
• How much will you have to pay for the test or procedure