Lead Extraction

Lead Extraction - What it is

The number of pacemaker devices and implantable cardioverter defibrillators (ICD) implanted is expected to grow tremendously with an ageing population and an expanded indication in patients at risk for sudden cardiac death.

The patients with these implanted devices are also now surviving longer and a small portion of these patients develop complications, which requires these devices to be removed.

Occasionally leads are also removed if they are infected.

What is lead extraction?

The solution to such patients with pacemaker and ICD complication is lead extraction. When the leads are initially inserted through the veins of the chest and connected to the heart, they can be easily removed. However, there is often progressive growth of fibrous tissues around the lead body and electrode tip that creates a major barrier to the removal of these leads. Simple traction is not successful and may result in not removing the lead completely. This can potentially result in life threatening arrhythmias, thromboembolism or other problems. Hence, lead extraction is used to remove one or more leads from the inside of the heart and veins with special tools that safely release the lead from the scar tissue.

The success of lead extraction depends on the duration that the lead has been implanted prior to removal and presence of multiple leads.

Lead extraction is however technically difficult and not without complications. Women, older patients and patients with multiple leads in place are at higher risk than others. The procedure is done in the operating room under general anaesthesia together with a cardiothoracic surgeon so that all emergency complications can be treated immediately.

In conclusion, lead extraction though technically difficult can be safely and successfully performed in up to 95% of patients.

Lead Extraction - Causes and Risk Factors

Risk Factors

The complications could arise from:

a) Infection: When a patient develops an infection of the pacemaker or ICD device, the leads* and the pacemaker or ICD must be completely removed to cure the infection.

b) Damage: Sometimes it is discovered that the leads no longer provide reliable connections to the heart. When this happens, the damaged leads need to be replaced, but there may not be enough room in the veins to allow more leads to be added. This necessitates the removal of the damaged leads. However, leads may sometimes be replaced without removing the damaged leads. These damaged leads, however, may send electrical signals that interfere with the pacemaker or ICD.

c) Blockage: Damaged leads that have not been previously removed sometimes block veins entering the heart. In such cases, the damaged leads must be removed in order to allow access to the heart.

Lead Extraction - Preparing for surgery

If I decide to have my leads removed, when will I be admitted for the implantation procedure? How long can I expect to be admitted for?

Your doctor will arrange a date for you to be admitted to the hospital. Usually you are admitted on the day of the procedure; occasionally, you will be admitted the day before. Most patients can expect to be discharged the following day; occasionally, your hospital stay may be longer if the procedure is difficult or complicated.

Do I continue to take my medications till the day of the procedure?

Your doctor should already have instructed you on what to do before the procedure.

Please check before discontinuing any medications. The following information is a general guide only.

If you are on warfarin, this will normally need to be discontinued around 5 days prior to the procedure, and a blood test (“INR”) taken to confirm that your blood clotting is normal prior to implantation.

If you are taking aspirin or clopidogrel (Plavix), you may be asked to discontinue one or both of these prior to implantation; however, please confirm this with your doctor.

You can normally continue taking your other medications as usual.

Can I eat before the procedure?

In most cases, you will be told to eat a normal meal the evening before your procedure. However, do not eat, drink or chew anything after 12 midnight before your procedure. This includes gum, mints, water, etc. If you must take medications, only take them with small sips of water. When brushing your teeth, do not swallow any water.

What should I wear?

When getting ready, please do not wear makeup and remove nail polish. Wear comfortable clothes when you come to the hospital. You will change into a hospital gown for the procedure. Please leave all jewelry (including wedding rings), watches and valuables at home.

What happens before the procedure?

Before the procedure begins, a nurse will help you get ready. You will be given a hospital gown to change into. You may keep your clothes in a locker or you may give them to a family member.

You will lie on a bed and the nurse will start an IV (intravenous) line in a vein in your arm or hand. The IV is used to deliver medications and fluids during the procedure.

To prevent infection and to keep the device insertion site sterile:

An antibiotic will be given through the IV at the beginning of the procedure
The left or right side of your chest will be shaved
A special soap will be used to cleanse the area
Sterile drapes are used to cover you from your neck to your feet
A soft strap may be placed across your waist and arms to prevent your hands from touching the sterile area

Lead Extraction - Post-surgery care

What can I expect immediately after a new lead is implanted?

You will return from the Electrophysiology Laboratory with pressure dressing over the site of the AICD implant. If you have any pain, please inform your nurse so you can be given enough painkillers.

You will stay overnight in the hospital and usually will be able to go home the day after the device is implanted.

What tests will be done after the procedure?

A chest x-ray will be done after the device implant to check your lungs as well as the position of the device and lead(s).

The following day, an Electrophysiology Technician will confirm your AICD and leads are working properly; this is done on the ward, from outside the body.

If there are no problems, you can expect to be discharged the following day.

You will be given outpatient appointment for device check and monitoring.