What You Need To Know About Lead Extraction

What is a lead?

A lead is a special wire that delivers energy from a pacemaker or implantable cardioverter defibrillator (ICD) to the heart muscle.

What is a lead extraction?

A lead extraction is the removal of one or more leads from inside the heart. Leads that are placed outside the heart during open heart surgery cannot be removed during this procedure.

Why do I need a lead extraction?

Your doctor has determined that your lead or leads need to be removed for one or more of the following reasons:

• Damage to the inside (called a fracture) or outside of the lead.
• Large amounts of scar tissue forming at the tip of the lead. This causes the lead to need more energy to function than the device (pacemaker or ICD) is able to deliver. This condition is known as exit block.
• An infection at the site of the device and/or lead.
• Blockage of the vein by a clot or scar tissue.

How is the lead extraction performed?

There are two approaches to lead extraction:

Subclavian approach

The subclavian approach is the most frequently used approach. The leads are extracted through an incision in the upper chest over the subclavian vein.

Femoral approach

The femoral approach is used when the subclavian approach is not possible. The leads are removed through a small puncture in the groin over the femoral vein.

Removal of the lead

A special sheath (tube) is placed in the vein. This sheath is threaded over the lead and guided to the tip of the lead (where the lead attaches to the heart).

A laser light or mechanical drill-like tip can often be attached to the sheath to help break up the scar tissue.

The lead is then removed.

Before the procedure

Should I take my medications?

Your doctor may ask you to stop taking certain medications a few days before your procedure (such as blood thinners and aspirin). Do not stop taking any medication before checking with your doctor.

If you must take medications before the procedure, swallow them with only small sips of water.

Can I eat?

Do not eat or drink anything after midnight the night before your procedure.

What happens before the procedure?

The procedure will take place in a special surgical room. You will lie on a bed, and the nurse will start an intravenous (IV) line. This line allows the doctors and nurses to give you fluids and medications during the procedure. You will receive an antibiotic through your IV to help prevent or treat infections.

You may also have an arterial pressure line placed in an artery in your wrist or groin, and an IV will likely be placed in a vein in your groin. This access can be used to:

• Insert a pacemaker wire to keep your heart in rhythm when your pacemaker is removed;
• Insert tools used to remove the leads;
• Give you fluids, if needed;
• or for all of the above reasons if other veins are too small.

The doctor will decide before your procedure if access to your groin is needed and will discuss this with you.

If groin access is needed, the area will be cleaned, draped and numbed. A needle will be inserted in the vein in the same way an IV is started in your arm, only using a larger needle.

Once the line is in place, a catheter used to pace your heart will be inserted into the vein and guided to the right side of your heart. This is done only if your pacemaker/ICD is being replaced during the procedure. If you are receiving a new pacing device at another time, the temporary pacemaker wires may be placed in your neck.

All catheters and temporary pacing equipment are usually removed at the end of the procedure, and the areas are covered with a dressing.

To prevent infection or the spread of any existing infection, it is very important to keep the surgical areas sterile. Your chest and both sides of your groin will be shaved and cleansed with a special soap.

Sterile drapes will cover you from your neck to your feet. As a reminder to keep your hands from coming into contact with the sterile drapes, soft restraints will be placed around your wrists, limiting the movement of your hands.

During the procedure

Will I be asleep?

You will likely be given general anesthesia, which will cause you to sleep through the procedure. General anesthesia can require the use of breathing tube.

If you are not given general anesthesia, you will receive medication through your IV that will make you drowsy throughout the procedure. An anesthesiologist will be present during the entire procedure. If you are uncomfortable when you wake up, please tell the anesthesiologist.

You may feel a pulling as the leads are removed, but you should not feel pain. Your doctor and nurse will be with you throughout the procedure. If you are uncomfortable or need anything during the procedure, let your nurse know. 

Several devices will be used to monitor your condition throughout the procedure.

Monitoring during the procedure

Defibrillator/Pacemaker: Attached to one sticky patch at the center of your back and another on your chest. Allows the doctor and nurse to pace your heart rate if it is too slow or delivers energy to your heart if the rate is too fast.

Electrocardiogram (EKG): Attached to several sticky electrode patches on your chest. Provides a picture on graph paper of the electrical impulses traveling through your heart.

Blood pressure monitor: Connected to a blood pressure cuff on your arm. Checks your blood pressure intermittently throughout the procedure.

Fluoroscopy machine: If you look up, you will see this large X-ray camera above your body. This helps your doctor see the leads as they are removed from your heart.

Oximeter monitor: Attached to a small clip placed on your finger. Checks the oxygen level of your blood.

Will new leads be implanted?

New leads may be placed in your heart (implanted) during this procedure or at a later date. When your leads are replaced depends on the reason the leads are being removed. If they are being removed because you have an infection, you will be treated for the infection before new leads are implanted. If you have any questions or concerns about why your leads are being removed or when they will be replaced, please ask your doctor.

Information about fluoroscopic (X-ray)-guided procedures

During the lead extraction procedure, your doctor will use a fluoroscopy machine to see the leads as they are being removed.

Fluoroscopy uses ionizing radiation (X-rays) to create a constant, moving picture throughout the procedure to help guide small instruments through the blood vessels.

The X-ray beam is typically focused on a relatively small patch of skin. This area of skin receives a higher dose of radiation than any other part of the body. Depending on the X-ray dose you receive, you may receive instructions about how to care for your skin after the procedure.

Although it is rare to have any skin reaction at all after a fluoroscopic procedure, you may experience a mild to moderate skin reaction (sunburn effect) on the skin that received the greatest exposure.

In extremely rare cases and at very high doses of radiation, hair loss and skin damage are possible. The skin reaction may take several days or weeks to develop. Before the procedure, please tell your doctor or nurse if you have ever had a fluoroscopy procedure, and whether you had any skin reaction.

If you have any questions or concerns about fluoroscopy, please discuss them with your doctor during your pre-procedure evaluation.

How long will I stay in the hospital?

The lead extraction procedure takes 2 to 6 hours to complete. Afterwards, you will be transferred to a hospital room as an inpatient. You will stay in the hospital 2 to 10 days. If your leads were removed through your groin (femoral approach), you will need to lay flat in bed for several hours after the procedure. If your new device and leads are implanted at the time your old leads are removed, you may be able to go home the morning after the extraction procedure.

If your device and leads are not replaced at the time of the extraction, you may be hospitalized until they are implanted. Your doctor will be able to tell you how long you should expect to be in the hospital and when your new device and leads will be implanted. While in the hospital, you will be placed on a telemetry monitor. This small box has wires that connect to your chest with sticky electrode patches. The telemetry monitor allows the nurses to observe your heart rate and rhythm on several monitors. Overnight, they will record this information and have your doctor review it in the morning.

You may have stitches (sutures) that will be removed 10 to 14 days after your procedure. Please ask your doctor about this. 

If your leads were removed because of infection, you will likely receive antibiotics after the procedure, either by mouth or through an IV. These antibiotics may need to be continued at home, in which case a home health care nurse can help. Please talk to your doctor about any questions or concerns you have.

The morning after the extraction procedure, you will have a chest X-ray to check your lungs and the position of any new leads that were implanted.

Follow-up care

You should look at your incisions every day using a mirror. Call your doctor if you notice:

• Increased swelling near the incision or in your fingers or toes
• Increased bleeding or drainage
• A fever above 38.6 C (101 degrees F)

Before you leave the hospital, your doctor and nurse will talk to you about activity limits, medications and follow-up appointments. If you have questions, please ask.

If you have any questions after you return home, call your doctor's office.

Action checklist

Before the procedure 

• DO NOT eat or drink anything after midnight the night before your procedure.
• Ask your doctor about which medications you should and should not take before the procedure.
• DO NOT bring valuables to the hospital. If you do bring valuables, please leave them with a family member.

After the procedure

• You will be admitted to the hospital.
• Your doctor will talk to you about medications, activity limits and follow-up guidelines.
• If you have any questions, call your doctor's office.