Implanted cardiac devices such as pacemakers and implantable cardioverter defibrillators play an integral part of clinical care in the United States, with over 400,000 being implanted each year. Lead extractions for pacemakers and Implantable Cardioverter Defibrillators (ICD) are undertaken when leads become infected or malfunction. Lead extractions are high-risk surgical procedures performed by cardiac electrophysiologists and cardiac surgeons. Leads are extracted either using a subclavian approach in which an incision is made in the upper chest over the subclavian vein or through a femoral approach in which access is gained through a small incision in the grown over the femoral vein. These leads are then removed using simple traction, laser sheaths, mechanical sheaths, an open thoracotomy approach or a combination of these. Minor complications of these procedures include bleeding, hematomas, thrombosis, arrhythmias, while major complications include vascular tears, cardiac perforation, stroke, and cardiac tamponade.
In this research project, we reviewed 200 patients who underwent lead extraction procedures performed at UCLA for an eleven-year period from 2007 to 2018. Risk factors, procedure details, management of patients, and outcomes were evaluated for all patients. Data included clinical characteristics, lab values, type of organism for infections, device characteristics, procedure details, and patient outcomes.
The median patient age was 60 years old and 69% were male. Infection was the cause of 52% of these extractions while lead malfunction resulted in 39%. In total, 409 leads were extracted of which 61% were extracted using a laser approach and 29% with simple traction. 95% of the total leads were completely extracted while 5% were partially extracted. Major complications occurred in 5% of the procedures and 7% of patients experienced minor complications. A better understanding of risk factors for adverse events will allow us to improve patient outcomes and management.
Over the eleven-year period, the proportion of extraction patients with infection decreased, while lead malfunction increased. The majority of the leads were extracted using an excimer laser system. These lead extraction surgeries were a safe and effective procedure, but overall one in fifty patients required emergency open chest surgical repair.