What is a Pacemaker or ICD Lead?
A Pacemaker or Implantable Cardioverter Defibrillator consists of the device placed under the skin and one or more leads connecting it to the heart. A lead is a device that measures the passage of electrical signals. Leads are used in electrocardiograms to record the electrical activity of the heart. Leads are also used with pacemakers or Implantable Cardioverter Defibrillator devices (ICDs) to detect abnormal beating of the heart, and to deliver electrical impulses to the heart, in order to correct the abnormal heartbeat, or rhythm.
Why does a pacemaker or defibrillator lead need to be removed?
The most common reason is infection with bacteria, either on the lead itself or around the pacemaker or defibrillator. The infection may be associated with erosion of the pacemaker or defibrillator through the skin. Until all artificial material has been removed, the body is not able to completely clear the infection even though antibiotics may temporarily suppress the infection. A lead may also need to be removed because it is not working properly or is unnecessary.
How are leads removed?
Scar tissue grows around the lead within the veins and the heart. This holds the lead in place and can make difficult to remove. The procedure is usually performed under general anaesthesia so the patient is asleep. An incision is made through the old pacemaker implant scar and the pacemaker is removed. A metal or plastic tube (called a sheath) is inserted over the lead and pushed along its length. The sheath breaks up the scar tissue and allows the lead to be removed. Special sheaths can be connected to a laser, which is very effective in breaking up the scar tissue. Sometimes a tube is inserted into a vein in the neck or leg so that the lead can be snared and pulled out. In some circumstances the only way to remove the leads is by open heart surgery.
Is lead removal successful?
More than 95% of all leads can be completely removed. In a small number of patients the tip of the lead is left behind in the heart and this usually does not cause any further problem. In rare cases a large portion of the lead cannot be removed and further treatment depends on the particular situation.
What are the risks of lead removal?
This procedure carries a 2% risk of major complications including death, serious bleeding, stroke, brain damage, heart valve damage and the need to perform emergency open-heart surgery. These complications happen because of tearing the heart or a vein, which can cause sudden severe bleeding. 2% means that: out of 100 patients undergoing a lead removal procedure, 2 will have a serious complication. The risk of death from the procedure is small – about 3 in 1000. The risk of complications at the Royal Melbourne Hospital is similar to the risk at other major hospitals in Australia and overseas and is similar to the risks involved in open-heart surgery such as bypass surgery. The longer the lead has been implanted, the greater the risk of complications.
If problems occur during lead removal the only treatment may be emergency heart surgery. Lead removal is usually performed in an operating theatre with a cardiac surgeon and team standing by, who can immediately perform emergency surgery.
Will a blood transfusion be necessary?
Blood is taken for cross-matching before the procedure and a blood transfusion may be required during or after the procedure.
Who performs lead removal?
While many cardiologists in Australia implant pacemakers and defibrillators, there are only a few who remove them. That is because it is not required very often and only a few doctors have acquired the necessary experience. In Victoria, Dr Neil Strathmore at the Royal Melbourne Hospital has extensive experience in this procedure. Patients are referred to the Royal Melbourne Hospital from all over Victoria, South Australia and Tasmania. Dr Strathmore works with a team of cardiologists, cardiac surgeons, anaesthetists and nurses. The success and complication rates at the Royal Melbourne Hospital are similar to other Australian and overseas hospitals. Dr Strathmore performs most of these procedures at the Royal Melbourne Hospital because it is the only hospital in Victoria with the laser lead removal equipment.
When is another pacemaker or defibrillator implanted to replace the one removed?
This depends on the reason for removal and the dependence of the patient on the pacemaker. Some patients cannot live without a pacemaker so a “temporary pacing wire” has to be inserted through a vein in the groin or the neck, before the permanent pacemaker and leads can be removed. A new pacemaker is then implanted several days later. Some other patients can get by without a pacemaker for several days or weeks and so the new pacemaker implant can be delayed. Sometimes a pacemaker or defibrillator is no longer needed.
How will I be admitted to hospital?
You will receive information from the hospital about the admission. Usually you will attend the pre-admission clinic on Ward 2 East at the Royal Melbourne Hospital one or two days before the procedure. You will meet members of the surgical and anaesthetic team as well as having a chest x-ray and some blood tests. You will then be admitted to hospital early on the day of the procedure. Some patients are directly admitted to the hospital before the procedure, or are transferred directly from another hospital. You will have the opportunity to ask questions to the doctors at the time of admission.
How long is the stay in hospital?
This depends on the need for antibiotics to control infection and the timing of a new pacemaker implant. Most patients are up and about on the day following the procedure and go home 24 or 48 hours later.