Taking the Lead: Removing Pacemaker and ICD Leads

An aging population and expanding indications for implantable cardiac support devices mean that more and more patients rely on pacemakers and implantable cardioverter-defibrillators (ICDs) to treat heart rhythm problems. With their growing use, however, comes concerns about extracting fragile leads that connect to the devices when they fail or need replacement. In fact, it is estimated that up to 25% of leads fail within eight years.

“Lead extraction requires a great deal of finesse,” said Graham Adsit, MD, electrophysiologist and Medical College of Wisconsin faculty member. “We have to take precautions to avoid damage to the heart muscle wall or blood vessels.” Froedtert Hospital is one of a small number of centers in the region performing this intricate procedure.

Reasons for Lead Removal

In most cases, leads remain in the body permanently. Some circumstances, however, require leads to be removed. These can include:

• Infection where the lead or device is implanted
• Damage to the inside or outside of the lead
• Electrical malfunction of the lead
• An ICD or pacemaker device upgrade

A Painstaking Procedure

Lead extraction is most often performed as a minimally invasive procedure. “We typically use a subclavian approach, with a small incision over the subclavian vein,” Dr. Adsit said. “If that isn’t possible, we approach through a puncture in the femoral vein.”

The lead extraction team places a sheath around the lead and advances it to the tip of the lead. “Scar tissue naturally develops where the lead attaches to the heart, and the longer the lead has been in, the more likely that is the case,” Dr. Adsit said. “We gently have to free the lead from that tissue.” The team uses a tiny laser or drill-like instrument at the tip of the catheter surrounding the lead, carefully teasing the lead from the heart wall to avoid tears.

If patients are having new devices or leads implanted, this may take place at the same time as the lead extraction. If leads are being removed due to infection, the medical team will treat the infection prior to implanting new leads. Following the lead extraction, patients stay in the hospital one or two days.

The Expertise of a Team

The Froedtert & MCW team brings years of experience to the lead extraction process. The team includes experts from electrophysiology, cardiac surgery, anesthesiology and radiology.

“Lead extraction is a delicate procedure,” Dr. Adsit said. “We have all the resources to do it expertly and to help keep pacemakers and ICDs performing at their peak for patients.”