Lead Extraction

What is lead extraction?

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

Both these devices have two main parts: a pulse generator and one or more 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. This burst of energy can cause the heart to beat more quickly (as with a pacemaker), or it can stop dangerous, rapid heart rhythms (as with an ICD). To do this, the leads need to make contact with the heart itself. Most leads travel through a vein to enter the right side of the heart. They often connect to the inside of the heart directly into the muscle of the heart wall. The body forms scar tissue around the lead. This anchors it firmly to the heart.

The design of the leads allows them to stay attached to the heart permanently. Sometimes, however, it's needed 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 scar tissue and heart muscle. This allows the leads to be removed safely from the body.

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. Your healthcare provider will only do lead extraction if the benefits outweigh the risks.

Device infection is the most common reason for lead extraction. This is often necessary if any part of the pacemaker or ICD becomes infected. It's likely 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 may also need generator and lead extraction.

Broken leads are another major reason for lead extraction. This might happen when there's a break in the wire, for example. Broken leads may not need to be removed. Sometimes, a surgeon can leave the broken lead inside the heart and place a new lead beside it. But this isn't always possible because space may be limited. Even if there's space available for the new lead, people sometimes have the lead removed. For instance, a young person who would likely need more leads in the future may choose to have a broken lead removed. That's because the longer a lead has been in place, the harder it is to remove. Lead removal may also be done if you may need MRI at a later date. Abandoned leads would prevent you from getting the MRI.

Some people get a pacemaker, but later need an ICD. In such cases, one of the pacemaker leads is often removed and a new ICD lead is placed. This is done because pacemaker leads are unable to deliver a shock, so an ICD lead is needed.

There are a number of other reasons for lead extraction, but they're less common. These include:

• Dangerous or malfunctioning leads, such as 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

• An upgrade to a newer system that's MRI compatible

What are the risks of lead extraction?

Lead removal is successful in most people, but it's a complex procedure with risks. It has some real risks that will be reviewed with you in detail. There's 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 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

• Fragments of the lead being dislodged

• Death (rare)

Certain factors make complications a little more likely. These include being female, having a small body size, and having chronic kidney disease. Leads that are older or hardened (calcified) or needing more than one lead removed can also raise your risk for complications. Your specific risks will depend on your health conditions. Talk with your healthcare provider about your concerns before your lead extraction.

How do I get ready for a lead extraction?

Talk with your healthcare provider about what you should do to prepare for your lead extraction. Follow any directions you're given for not eating or drinking before the procedure.

Often this is 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 provider tells you to do so. If you take medicines that affect your blood's ability to clot (blood thinners), you may need to stop taking them before the procedure. Talk with your provider about what medicines you should and shouldn't take and when to stop taking them.

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

• Electrocardiogram (ECG) to analyze the heart rhythm

• Echocardiogram (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 provider know if you're pregnant before having the procedure. The imaging used during the procedure uses radiation. This may be a risk to the unborn baby. If you're of childbearing age, your provider may want you to have a pregnancy test to make sure you aren’t pregnant.

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

What happens during a lead extraction?

The procedure takes 2 to 4 hours. A cardiologist and a special team of nurses and technicians will do the extraction. Generally, during the procedure:

• You'll be given anesthesia before the procedure starts. General anesthesia is used. This will help you sleep deeply and painlessly through the procedure.

• An IV (intravenous) line is placed in the arm and possibly in the groin area.

• A transesophageal ultrasound probe may be placed in the esophagus. This allows real time visualization of the heart and surrounding structures.

• An incision is made over the device and the device is removed.

• Next, the leads are removed from the heart using the sheath inserted through the blood vessel. 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 the sheath was inserted.

What happens after a lead extraction?

In the hospital after the procedure:

• You'll spend several hours in a recovery room.

• The team will watch your vital signs, such as your heart rate and breathing. They'll also watch your heart rhythm.

• If the extraction involved using a vein in your leg, you'll need to lie flat for several hours after the procedure. You shouldn't bend your legs. This will help prevent bleeding.

• You may get pain medicine if you need it.

• Time in the hospital varies. But you'll likely spend at least one night.

• You'll need a follow-up chest X-ray to check your heart and lungs after the procedure and to make sure that any new leads placed are in the right position.

At home after the procedure:

• You'll likely be able to return to light activity relatively soon.

• You may have stitches (sutures) that will need to be removed after the procedure. Talk with your healthcare provider about when these should be removed.

• Call your provider if you have increased swelling, increased bleeding or drainage, or a fever.

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

Next steps

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

• The name of the test or procedure

• The reason you're 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're 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 didn't have the test or procedure

• Any alternative tests or procedures to think about

• When and how you'll get the results

• Who to call after the test or procedure if you have questions or problems

• How much you'll have to pay for the test or procedure