Cardiac devices: When it's time to get the lead out
Anthony Garvey, M.D.
Providence St. Vincent Cardiac Device and Monitoring Clinic
Providence St. Vincent Heart Clinic-Heart Rhythm Consultants
Published February 2012
The need to remove implanted cardiac device leads has increased as the number of implanted devices has grown. In 2009 more than 1 million pacemakers and 330,000 ICDs were implanted worldwide – more than a quarter of them in the United States.
Although the reliability of cardiac devices remains high, some conditions still require removal of the leads – the wires that follow the blood vessels into the heart – or sometimes the entire system. The primary indications for lead removal are infection, pain, lead malfunction or recall, and venous occlusion.
Removing leads can be difficult because over time they become surrounded by vascular tissue and eventually are endothelialized into the luminal surface of the large veins, portions of the tricuspid valve, and cardiac tissue. Leads often can be removed without laser assistance up to a year after implantation, but if they have been in place longer, removal can be more dangerous and the chances of success are low.
For many years few tools were available for removing cardiac device leads. Systems using manual traction or cutting sheaths were not very successful and were associated with significant risk.
When these less invasive approaches were unsuccessful, cardiac surgeons were called in to remove the leads surgically.
Extraction techniques improve
In the mid- to late-’90s, newer extraction techniques became available. These used special stylets to provide traction within the lead, and laser sheaths to free up tissue around the lead. Current techniques use a laser sheath that passes over the lead, delivering energy that vaporizes tissue through photoablation and freeing the lead for removal. Tissue ablation occurs at a depth of only 50 microns, which focuses the energy just over the lead and decreases the risk of perforation.
Laser lead extraction now is performed with a success rate of nearly 98 percent and a major adverse event rate of only 1.4 percent, according to clinical studies.
The most recent consensus statement regarding lead extraction was published in July 2009 and was a collaboration between the Heart Rhythm Society, American College of Cardiology and the American Heart Association. The statement recommends that lead extraction should be performed in patients with device-related infections and should be strongly considered in selected patients with lead malfunction, venous thrombosis or pain.
Providence St. Vincent Medical Center performed the first laser lead extraction in 1998. Today a multidisciplinary team that includes members from cardiac surgery, infectious disease and cardiac electrophysiology provides the best procedural outcomes for this growing patient population. Providence St. Vincent continues to perform the most chronic laser lead extractions in Oregon and serves as the regional referral center for patients who require this procedure.
To learn more about lead extraction or to refer patients for evaluation, contact Providence St. Vincent Cardiac Device and Monitoring Clinic at 503-216-2188.