Pacemaker and Defibrillator Extraction & Revision
BACKGROUND
A lead is a special wire that delivers energy from a pacemaker or implantable cardioverter defibrillator (ICD) to the heart muscle.
A lead extraction is the removal of one or more leads from inside the heart. Many people have surgically implanted cardiac devices which include pacemakers and implantable cardioverter defibrillators [ICD].
What are the components of pacemakers/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.
What is Lead Extraction?
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.
Why might I need a lead extraction?
Leads usually stay in the body permanently, but you may need to have them removed in certain cases.
- 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
PROCEDURE INFORMATION
How Is Lead Extraction Performed, and What Should I Expect From the Procedure?
- Usually, the lead-extraction procedure is performed with patients under general anaesthesia, but sometimes, sedating medications may be used instead.
- A team of medical professionals, including a Cardiac Electrophysiologist, Cardiac surgeon, anaesthesiologist, nurses, and technicians, is required to perform the operation safely.
- Facility and equipment requirements include a wide array of lead-extraction tools, high-quality x-ray and Echo, and a well-equipped operating room. Because of these complex technical requirements, lead extraction is usually performed in specialized centers.
- This procedure is more likely to be successful when performed by operators and medical centers with more experience. The overall success rate of procedures was >90%, but this depends on many factors, such as the condition of the leads and the amount of time the leads have been implanted.
Will new leads be implanted?
New leads may be placed in your heart (implanted) during this procedure or at a later date. When your leads are replaced depends on the reason the leads are being removed. If they are being removed because you have an infection, you will be treated for the infection before new leads are implanted.
PRE/POST PROCEDURE
You will be admitted a day prior to the procedure and evaluated by an anaesthetist. Certain medications, such as blood thinners, might be stopped before the procedure. You will be asked not to eat or drink 6-8 hours prior to the procedure.
How long will I stay in the hospital?
The lead extraction procedure takes 2 to 6 hours to complete. Afterwards, you will be transferred to a room or ICU. You will stay in the hospital 2 to 7days depends on clinical condition.
If your device and leads are not replaced at the time of the extraction, you may be hospitalized until they are implanted. If your leads were removed because of infection, you will likely receive antibiotics after the procedure, either by mouth or through an IV.
Your doctor will be able to tell you how long you should expect to be in the hospital and when your new device and leads will be implanted.
If your new device and leads are implanted at the time your old leads are removed, you may be able to go home in few days after the extraction procedure.
RISKS/BENEFITS
What are the risks for lead extraction?
Lead extraction is a complex surgical procedure with some unavoidable risks. Each time the lead is separated from scar tissue; there is a small chance of tearing the surrounding blood vessel or perforating the heart, which can result in major bleeding in the chest or around the heart. In some cases, this requires blood transfusion or even immediate open heart surgery to save the patient’s life.
Other major complications of lead extraction include a blood clot dislodging into the lung and stroke.
Less severe problems that have been reported include fluid accumulation around the heart or lung (not requiring drainage), bleeding under the skin, swelling of the arm, and a small amount of air entry into the vein.
The rate of major complications was 1.6% to 2.0%, or approximately 1 in 50 patients.
Benefit includes complete and early treatment of pacemaker infection, avoiding repeated hospitalisation for infection and its complications.
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