17165 Lead Extraction

Overview

A pacemaker or an implantable cardioverter defibrillator (ICD) is a small device placed under the skin of the chest. It connects to your heart through thin, flexible wires called leads. The leads carry electrical signals to and from the heart. 'Lead extraction' means removing one or more of these wires, usually because they are infected, broken, or no longer needed. It is done by a specially trained heart team, often in a specialist centre, because the wires can become stuck to the inside of veins and the heart over time. The team uses special tools passed through a vein, usually in the groin or the chest, to free and gently pull out the wire.

Lead extraction is much less common than putting a device in, but it is a routine specialist procedure in heart centres. Thousands are done each year, and the numbers are growing as more people live longer with pacemakers and ICDs.

It affects people who already have a pacemaker, ICD, or a similar heart device. This includes older adults who have had a device for many years, younger adults who may need several device changes over their lifetime, and some children and teenagers born with heart rhythm problems. People with a device infection, a damaged lead, or a blocked vein in the arm or chest are the most likely to be offered extraction.

Symptoms

Common symptoms

• Redness, warmth, swelling, or fluid leaking from the skin pouch (pocket) where the device sits
• Fever or feeling generally unwell with no clear cause
• A device alert, beeping, or a message from the clinic that a lead is not working properly
• Pacing symptoms such as dizziness, fainting, or a return of the slow heartbeat the device was treating
• Hiccups, twitching of the chest or diaphragm, or a 'shock' feeling that is not normal for your device
• Swelling of the arm or shoulder on the side of the device, which can mean a vein is narrowed or blocked

Symptoms in children

• Irritability, poor feeding, or poor weight gain in babies with a device
• Tiredness or fainting during play or sport
• Redness or swelling over the device site, which can be harder for a child to describe
• A device that feels loose under the skin or pushes against the skin

Symptoms in older adults

• Confusion or sudden tiredness, which can be the first sign of infection
• Fever that comes and goes, or a wound that heals slowly
• Falls or dizziness caused by the heart rhythm not being controlled
• Thin skin over the device that looks shiny, stretched, or close to breaking open

Causes

Main causes

• Infection of the device, the pocket of skin around it, or the leads themselves — this is the most common reason for extraction
• A lead that has cracked, worn through its covering, or stopped working properly
• A vein in the arm or chest becoming narrowed or blocked by one or more leads
• A lead that is no longer needed, for example after a device upgrade or a change in your heart rhythm treatment
• A lead that was the subject of a safety notice from the manufacturer, or a lead that is very old and no longer reliable
• Extra or abandoned leads left in place that are causing problems or blocking the vein
• Needing a magnetic resonance imaging (MRI) scan, when the older leads are not safe for MRI

Risk factors

• Having had the leads in place for many years — the longer they stay, the more firmly they can stick to the vein and heart
• Having more than one lead, or more than one device over your lifetime
• A previous device infection or a previous pocket infection
• Diabetes, kidney disease, or a weakened immune system
• Having a device implanted at a young age, meaning the leads must last many decades
• Bleeding or a collection of blood around the device soon after implantation
• Long-term use of steroid medicines or other treatments that lower the body's infection defences

When to see a doctor

See a doctor urgently if:

• Any fever, redness, or fluid leaking from the device site — contact your device clinic or doctor the same day
• The device or a wire becomes visible through the skin
• Repeated or unexpected shocks from an ICD
• New dizziness, fainting, or a return of the slow heartbeat the device was treating
• Swelling of the arm, shoulder, or face on the side of the device

Book a routine appointment if:

• Your device clinic has told you a lead is not working well, even if you feel fine
• You have been invited for a device check or a lead review
• You are due to have an MRI scan and want to know whether your device is safe for it
• You have questions about an old or abandoned lead
• You are planning travel or surgery and want advice about your device

Diagnosis

The decision to remove a lead is made by a heart team after looking at your history, examining you, checking how your device is working, and doing tests. They will confirm the reason for extraction — such as infection or a broken lead — and plan the safest way to do it. You will usually be seen in a specialist device or heart rhythm clinic before the procedure.

Tests that may be done

• A device check (interrogation): a computer reads the stored information from your pacemaker or ICD to see how the leads are working
• Blood tests, including tests for infection and for blood counts
• Blood cultures, where a small sample of blood is tested to see if germs are growing — important if infection is suspected
• An echocardiogram (ultrasound scan of the heart) to look at the leads, the heart valves, and the heart muscle
• A chest X-ray or a CT scan to see the path of the leads and check for problems
• Sometimes a scan of the veins (venogram) to check whether a vein is narrowed or blocked

What to expect at your appointment

You will normally have a full conversation with the heart team before anything is booked. They will explain why extraction is being recommended, what the alternatives are, and what the risks and benefits are for you. You will be asked to give consent. If infection is suspected, you may be started on treatment and the procedure may be arranged quite quickly. Your team will tell you how to prepare, including which medicines to take on the day.

Treatment

Lead extraction is done in a specialist heart centre, usually under sedation with local anaesthetic or under a general anaesthetic. The team makes a small cut, usually in the groin or the upper chest, and passes a thin tube into the vein. Special tools gently free the lead from the vein wall and the heart, and then the lead is removed. In some cases a new lead or a new device is put in during the same stay, or later once any infection has cleared. Sometimes open heart surgery is needed, but this is much less common.

Self-care at home

• Keep the wound clean and dry until your team says it is safe to wash or bathe
• Follow your team's advice about how long to avoid lifting, heavy pushing, or raising the arm on the treated side
• Check the wound each day for redness, swelling, warmth, or discharge, and tell your team if anything changes
• Take any prescribed treatment exactly as directed — never stop it on your own
• Wear your device identification card or bracelet, and tell any doctor or dentist that you have a heart device
• Go to all your follow-up appointments, including device checks and wound checks
• Ask before driving again — your team will tell you when it is safe, and this can depend on whether a new device was fitted

Medical treatments

If infection is the reason for extraction, you will be given treatment for infection through a drip in hospital, and often for a period after you go home. The exact choice and length of treatment is decided by your medical team based on the germs found and how you respond. You may need a temporary pacing wire or a temporary device while the old system is out and a new one is being planned. Pain relief and support for your heart rhythm are also part of the care. Your team will monitor you closely during and after the procedure.

When is surgery considered?

Open heart surgery is needed only in a small number of cases — for example, if a lead is very firmly stuck, if a lead breaks during the procedure, or if there is damage to the heart or a vein that cannot be repaired from inside. Your team will discuss this possibility with you beforehand, so you know what to expect.

Living with this condition

Most people recover well over a few weeks. You may feel tired for a while, and the wound site can be sore and bruised. You may have a scar, usually small. If a new device was fitted, you will need to get used to it and attend device checks. If no new device was fitted, your heart rhythm will be watched carefully. Many people find they feel better than before, especially if an infection or a faulty lead was making them unwell.

Lifestyle tips

• Build activity back up slowly, following your team's advice about lifting and arm movement
• Keep the wound area out of swimming pools, baths, and hot tubs until it is fully healed and your team agrees
• Avoid tight clothing or straps rubbing on the wound while it heals
• Carry your device information with you at all times
• Tell airport security staff about your device before you go through screening
• Keep phones and strong magnets at a safe distance from the device, as advised by your clinic

Diet and exercise

Eat a balanced diet with plenty of vegetables, fruit, whole grains, and protein to help healing, and keep salt and highly processed foods to a moderate level. Gentle walking is usually encouraged soon after the procedure. More vigorous exercise, swimming, and heavy lifting can start once your team confirms the wound has healed and the leads are secure. If you have other heart conditions, ask your team what exercise is right for you.

Mental health and emotional wellbeing

It is very common to feel anxious before and after lead extraction. You may worry about the procedure, about infection, or about whether your device will work properly. Some people feel low for a while after time in hospital. These feelings are normal. Talk to your team — they can explain things again, involve a specialist nurse, or arrange extra support. If low mood or worry is affecting your sleep, appetite, or daily life, please tell your doctor. If you ever feel unable to cope or have thoughts of harming yourself, contact your local emergency number or a crisis support service in your area straight away.

Prevention

Not all lead extractions can be prevented, because leads can fail or become infected even with the best care. But some things lower the risk. Good care of the device site, keeping the wound clean and dry after implantation, and reporting any redness or fever early all help. Careful planning at the time of the original implant — such as using the fewest leads needed — can reduce problems later. Keeping your follow-up appointments means small problems are spotted before they become big ones.

Vaccines

There is no vaccine for lead problems. But staying up to date with recommended vaccinations, including flu and pneumonia vaccines if your doctor advises them, helps you stay well and lowers the risk of infections generally.

Screening programmes

There is no screening programme for lead problems. Instead, your device is checked regularly at a device clinic, which reads the stored information and can spot a failing lead early. Attend these checks even if you feel well.

Complications

If left untreated

• An infection can spread from the device site into the bloodstream and to the heart valves, which is serious
• A broken or damaged lead can give wrong signals, cause unnecessary shocks, or fail to treat a dangerous heart rhythm
• A blocked vein can cause arm swelling and make future device treatment harder
• A lead can, rarely, push through the heart wall and cause bleeding or fluid around the heart
• An old, unnecessary lead can make later procedures more difficult

Long-term outlook

For most people, lead extraction goes well and symptoms improve. Serious complications are uncommon in specialist hands, and teams plan carefully to keep risks as low as possible. Recovery usually takes a few weeks, and many people get back to normal activities with a working device or a plan for a new one. Your team will talk you through your own risks honestly, and support you at every step.

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