Lead extraction

A lead is a special wire that delivers energy from a pacemaker or implantable cardioverter defibrillator (ICD) to the heart.

A lead extraction is the removal of one or more leads from the heart. This procedure is used to remove pacemaker/ICD leads that have been in place from a few months to many years. It is NOT the same as battery change. This procedure is performed at very few hospitals in Australia and is only performed by a select number of highly trained specialists. Removal of leads that are placed outside the heart during open heart surgery is not possible with this procedure.

Your doctor has determined that your lead or leads need to be removed for one or more of the following reasons:

• An infection at the site of the device and/or lead
• Damage to the inside or outside of the lead (called a fracture)
• Blockage of the vein by a clot or scar tissue
• Inability to insert new leads due to multiple existing leads

Your doctor has determined that your lead or leads need to be removed for one or more of the following reasons:

• An infection at the site of the device and/or lead
• Damage to the inside or outside of the lead (called a fracture)
• Blockage of the vein by a clot or scar tissue
• Inability to insert new leads due to multiple existing leads

Initially an incision is made over the pacemaker or ICD generator (battery) and it is removed. The leads are detached from the device and freed from the scar tissue in the wound. The lead may be removed from the site of the pacemaker, the neck or groin. If the leads have been in place for more than a few months they can become tightly attached by scar tissue to the heart and to the veins through which they pass, making removal more difficult.

Sometimes leads can be removed simply by gently pulling on the lead (traction). In most cases a special sheath (tube) is placed in the vein. This sheath is threaded over the lead and guided to the tip of the lead (where the lead attaches to the heart). A laser light or mechanical cutting tip may be attached to the sheath to help break up the scar tissue around the lead to help with its removal. If this fails, open chest surgery may be required. Alternatively, in some cases, the leads may be detached from the pacemaker/ICD unit and simply left inside the patient.

Depending on your heart problem, a temporary pacemaker may be inserted via the groin or neck. A temporary pacemaker may remain in place after the procedure until a new device is implanted. In some cases of pacemaker or ICD infection implantation of a new device may occur weeks later; to allow healing and completion of antibiotic treatment.

Lead extraction is a complex surgical procedure with some unavoidable risks.

1. Each time the lead is separated from scar tissue, there is a small chance of tearing the surrounding blood vessel or the heart itself, which can result in major bleeding in the chest or around the heart.
2. Blood clots can travel to the lung or brain causing a stroke.
3. Problems can occur rarely related to anaesthesia.
4. Death can occur rarely as a result of any of the above complications.

Less severe problems include fluid accumulation around the heart or lung (not requiring drainage), bleeding under the skin and swelling of the arm. In the large published studies on lead extraction, the rate of major complications is 1.6% to 2.0%, or approximately 1 in 50 patients. The risk of death associated with the procedure has been reported to be between 0.03- 0.8 % (less than 1 in one hundred patients).

In the rare event of a complication other procedures that may be required:

1. Blood transfusion
2. Immediate open heart surgery

In order to perform this procedure you will require a general anaesthetic. General anaesthesia usually requires the use of breathing tube and will allow you to ‘sleep’ for the procedure. A general anaesthetic to allow us to monitor you better and deal with the complications should they arise.

Following removal of the leads, the operator will deal with the wound depending on the circumstances of the extraction.

The wound may be closed on the day or a deferred closure may be warranted with a variety of stitches (sutures).

A wound pack and /or a drain may be left in the wound if deemed clinically necessary.

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.

Lead extraction procedures usually take between 2 to 3 hours to complete. Afterwards, you will be transferred to the coronary care unit and stay there overnight.

If your new device and leads are implanted at the time your old leads are removed, you may be able to go home the morning after the extraction procedure. If your device and leads are not replaced at the time of the extraction, you may be hospitalised until they are implanted. 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 leads were removed through your groin (femoral approach), you will need to lay flat in bed for several hours after the procedure.

After the extraction, you will have a chest X-ray to check your lungs and to check for any remaining lead fragments.