Lead Management Program

Overview

Pacemakers and ICDs are implantable cardiac devices that help patients with abnormally slow or abnormally fast heart rhythms. Most of those systems include “wires” or leads which travel in the veins from the device, usually implanted under the skin at the level of the left or right chest, to the heart and connect the device with the heart electrically.

What Is Lead Management?

Lead extraction occurs when a lead that has been in the body for over a year has to be removed. It is a procedure which requires experience, skill and special tools, as the body develops scar tissue around older leads and someone needs to free the leads from the scar tissue before they are able to remove the lead.

You may need this procedure if you have an old and malfunctioning lead, if you have an infected lead or if your doctor wishes to offer you a different cardiac device. An average life for a lead is 10–15 years.

A fracture and disruption of the electrical connection is a common problem for older leads. When this happens, the lead may be extracted to create the space for a new lead to be inserted.

Another common reason to extract a lead is if there is an infection involving the device system or the heart and the blood stream.

Finally, a patient may need a different kind of device, for example an upgrade of a pacemaker to an ICD. In that case, an old lead may have to be removed and a different kind of lead may have to be introduced.

Our Services

At the Mass General Corrigan Minehan Heart Center, all lead extractions are performed in the operating room using a multidisciplinary team. A cardiac electrophysiologist performs the actual lead extraction and possible implantation of a new lead. A cardiothoracic surgeon opens the pocket of the device and remains as a backup in case the patent requires an open chest intervention. An anesthesiologist places the patient under general anesthesia and monitors the patient for the duration of the procedure. Other teams of doctors may occasionally be involved, including a vascular surgery or medicine team, an interventional radiology team, and interventional cardiology team. The patient is monitored in the hospital overnight after the procedure and is discharged the following date in most cases.

To remove the leads from the body we use two main types of tools:

1. LASER sheath, which is a tube which has a LASER ring at its end that frees the scar tissue as we advance it over the lead while we are pulling the lead back
2. Mechanical sheath with a distal revolving portion that frees the lead from the scar tissue surrounding it as we advance it over the lead. After the lead is extracted, we use the space we have created to introduce new leads as needed

What to Expect

There is a small risk for a significant complication as a result of this procedure. The risk for anything serious to occur ranges between 1-2%. Complications may include a venous or cardiac injury with significant internal bleeding requiring an open chest surgery, infection, need for a blood transfusion, a blood clot in the lungs (pulmonary embolism), a stroke, a heart attack or a less than 1% risk for death.

The physicians who perform the procedure are available to discuss with the patient the procedure and answer all their questions. The registered nurse in our service will also be available to organize the schedule and go over the process with the patient.

The patient will receive general anesthesia for the procedure and will recover in the recovery room for a few hours after. The patient will then spend the night on one of the cardiac floors and will typically be discharged the following day. If a new lead is implanted, patients will be asked to restrict arm movements for about a month.

Research

Physicians in the Mass General Lead Management Program are leaders in their field and have long been at forefront of national conferences regarding lead extraction.

Relevant publications:

1. Mela T. Explanting chronic coronary sinus leads. Card Electrophysiol Clin 2019;11(1):131-140
2. Qin D, Chokshi M, Sabeh MK, Maan A, Bapat A, Bode WD, Hanley A, Hucker WJ, Ng C,gt66 Funamoto M, Barrett C, Mela T. Comparison between Tightrail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction. PACE: first published 05 March 2021. https://doi.org/10.1111/pace.14206 
3. Fitzsimons MG, Barrett C, Streckenbach S, Bendapudi PK. Factor V deficiency (Owren’s disease) in a patient at high risk for transfusion-associated circulatory overload and bleeding during laser lead extraction. J Cardiothorac Vasc Anesth 2021;S1053-0770(21)00121