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Pacemaker Lead Extraction

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Pacemaker and Defibrillator Lead Extraction: An Overview

Surgical cardiac devices, such as implantable cardioverter-defibrillators (ICDs) and pacemakers, play a crucial role in maintaining a healthy heart rhythm for countless individuals. At the heart of these devices are two key components: an array of leads and a pulse generator.

Leads are specialised wires that effectively convey energy from the device to the heart muscle. They are designed to be permanently affixed to the heart. However, certain scenarios may necessitate their removal, such as in the event of infection or damaged leads. This procedure is referred to as pacemaker lead extraction and involves the careful and strategic removal of one or more leads from inside the heart.

Lead extraction is a complex and nuanced procedure. One of the main challenges encountered during this process is the traversal through the tough scar tissue that secures the leads in place. When it comes to procedures as intricate as lead extraction, entrusting your health to an experienced specialist is paramount. With an impressive track record and a deep-rooted passion for cardiac health, Dr Karthigesan exemplifies expertise and dedication in the field of cardiac lead extraction. Opt for the best care for your heart. Book an appointment today!

Image during the Pacemaker and Defibrillator Lead Extraction. The elements seen are labelled.
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Image of an eroded device, a major cause of Pacemaker Lead Removal.
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Pacemaker Lead Removal: Why It is Necessary

Lead extraction from cardiac devices, such as pacemakers or ICDs, often becomes indispensable due to several factors. Predominantly, infection of the device is the leading cause of lead extraction. Should any part of the ICD or pacemaker harbour bacterial infection, either on the lead or around the device itself, it becomes imperative to perform an extraction. The infection may cause the device to erode through the skin, making extraction the only effective way to eliminate the infection completely. Despite the use of antibiotics for temporary suppression, the body cannot fully eradicate the infection until all artificial material has been removed.

Another primary cause of lead extraction pertains to their functionality. Leads might necessitate removal if they are not functioning optimally or if they are deemed unnecessary. Broken leads, often resulting from wire fractures, also significantly contribute to the need for extraction. In some instances, the implanting physician may decide to keep the broken lead inside the heart while placing a new one adjacent to it. However, due to spatial constraints, this may not always be feasible. In younger patients, who are likely to require additional leads at some point in the future, elective lead removal might be preferred, given that extraction becomes more challenging over time.

While these reasons are most common, there are several other medically valid reasons to extract lead, albeit less frequent. These include:

  • Leads with malfunctioning or dangerous characteristics, such as protruding wires.
  • Recall the model of a specific ICD lead or pacemaker.
  • The formation of a clot on a lead, causing vein obstruction.
  • Other complications or abnormal heart rhythms caused by retained lead.
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Assessment Prior to Pacemaker Lead Extraction

Before undergoing a lead extraction procedure for your pacemaker or defibrillator, an extensive evaluation process is typically carried out. This involves a series of diagnostic tests:

  • Electrocardiogram (ECG), a test for heart rhythm analysis.
  • Blood tests, which serve as a baseline for the procedure to follow.
  • Venogram, used to evaluate vein anatomy around the device.
  • CT scan of the chest, used to evaluate the heart
  • Echocardiography (Echo), a procedure for evaluating the anatomy and functioning of the heart.
Wires used in the Pacemaker Lead Extraction procedure.
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Image of a TightRail, Mechanical rotating dilator sheath used for Laser Sheath assisted lead extraction.
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Procedure for Pacemaker and Defibrillator Lead Extraction

The process of lead extraction is executed using one of two main approaches, depending on your unique circumstances and anatomical considerations. One is the subclavian approach, and the other is the femoral approach. The subclavian approach is commonly used. The femoral approach is used when the subclavian approach fails. There are three main types of lead extractions:
Mechanical sheath-assisted lead extraction
Operating manually, the Rotational Mechanical Dilator sheath incorporates a metal blade or tip that rotates. This tool assists in dissecting adhesive fibrotic tissues, whether between leads and vessel walls or within different cardiac structures. Additionally, it proves valuable for extracting leads or wires from the body.
Laser Sheath assisted lead extraction
Excimer Laser System uses a specially designed Laser Sheath, which has an unprecedented ability to customise the laser settings throughout the procedure in order to remove the infected or abandoned leads safely and efficiently by breaking the adhesions. It can be used to extract every infected pacemaker, and ICD leads with different sizes under general anaesthesia. It can also be used to remove unwanted leads while upgrading the pacemaker into advanced heart failure devices. Interventional Cardiologist and Electrophysiologist Dr A.M Karthigesan performed the first-ever invasive lead extraction procedure using the latest PLS Excimer laser system in a 72yrs male patient in India.
Femoral or inferior approach to lead extraction
The femoral or inferior approach utilising snares via femoral venous access is an important part of any lead extraction program, especially when the superior approach fails, or it is not feasible to use mechanical or Laser-assisted methods. In the Femoral approach, a large Sheath is extended from the groin into the heart. Through that sheath, a snare will be introduced to hold and apply traction to the lead.

Pacemaker Lead Removal:  Before, During, and After the Procedure

  • A multidisciplinary team headed by cardiac electrophysiologist and assisted by cardiac surgeons, nurses, technicians, and anesthesiologists will be prepping for the procedure to ensure a safe operation.
  • You will have the opportunity to meet the members of your anaesthetic and surgical teams, undergo a chest x-ray, and complete some blood tests.
  • You will be admitted to the hospital early on the day of the procedure. Some patients may be directly admitted to the hospital before the procedure or transferred from another hospital.
  • You will be placed under general anaesthesia, ensuring you are asleep and free from any sensation throughout the procedure.
  • A temporary pacemaker will be inserted as your coronary pacemaker will be removed during the surgery.
  • A special leisure/mechanical sheath (tube) will be inserted from your pacemaker region, which will be manoeuvred to reach the lead.
  • Real-time imaging (fluoroscopy) will guide the sheath to the precise location.
  • Instruments attached to the sheath tip will break up the scar tissue, freeing a small section of the lead.
  • The sheath will be advanced to the next portion of the lead still in place.
  • Once the lead is free from scar tissue, it will be removed along with the sheath.
  • The small bruise will be closed and covered with a bandage.
  • The lead extraction procedure typically takes between 2 to 3 hours. Following the procedure, you will be transferred to a room or ICU for recovery.
  • Depending on your clinical condition, you may stay in the hospital for a period of 2 to 7 days.
  • If your device and leads are not replaced during the extraction, you may remain hospitalised until they are implanted.
  • Should your leads have been removed due to an infection, you will likely receive antibiotics after the procedure, and new devices will be implanted before your discharge.

The Benefits of Pacemaker and Defibrillator Lead Extraction

The advantages of undertaking a lead extraction procedure are manifold and heavily depend on your individual health situation. Here's how the procedure can enhance your cardiac health:

  • If the lead of your pacemaker is infected, you can control the spread of infection quickly by removing the lead at an early stage. This can help save your life.
  • If the lead of your pacemaker or ICD has been malfunctioning or fractured, lead extraction can restore the device to full functionality, ensuring it works optimally to maintain your heart rhythm.
  • If your irregular heart rhythms, or arrhythmias, are caused by interactions with the abundant lead, extraction can alleviate these symptoms, leading to a more regular and comfortable heart rhythm.
  • Blood clots or scar tissue from the lead can cause a blockage in your blood flow. Removing the lead can restore blood flow, improving overall heart function and reducing the risk of potential complications.
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Whether you're grappling with a device infection, dealing with malfunctioning leads, or in need of in-depth answers to your queries, Dr Karthigesan is here to provide expert assistance.

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Pacemaker and Defibrillator Lead Extraction -  Your Questions Answered

The primary causes of lead extraction include device infection, which is the most prevalent cause, and broken leads, which is another significant factor leading to the procedure.

The device is comprised of a pulse generator and leads. The pulse generator, a small computer equipped with electric circuits and a battery, is usually located beneath the collarbone. The leads are wires that connect the pulse generator to the heart. For swift and comprehensive management of the infection, it's crucial to remove all device components. Any residual parts could perpetuate local infection, which risks spreading to the bloodstream.

New leads may be implanted during the extraction procedure or at a later date. If your leads are being removed due to an infection, Dr Karthigesan will ensure you receive treatment for the infection prior to implanting new leads.

Reach out to your healthcare provider immediately if you experience symptoms such as difficulty in breathing, a fever exceeding 101°F, swelling at the bruise site or in your fingers or toes, or unusual bleeding or drainage.

Like any invasive procedure, lead extraction carries certain risks, which include complications from anaesthesia, breaking the lead, major bleeding that necessitates a blood transfusion, perforation of the heart with the lead tip, tearing a blood vessel, or blood leakage around the heart.

Patients are typically required to stay in the hospital overnight or, in some cases, longer. Post-procedure, you may need to lie down if your leads were removed via your femoral vein. Additionally, if your device and leads were not replaced during extraction, you may need to remain in the hospital until your provider can perform the new implantation. If the lead extraction was necessitated by an infection, you'll likely receive antibiotics post-procedure. The morning after the extraction, a chest X-ray will be conducted to check the positioning of any newly implanted leads.

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