Abandoning a Pacemaker or Defibrillator Lead — When Less is More

In this case-based discussion, author Kathy Glatter, MD will discuss lead management issues in an interesting patient, as well as look at the pros and cons of lead extraction versus abandoning the lead. Case Report A 46-year-old male prisoner with a long history of pacemaker implantation was referred to our institution for pacemaker interrogation. Old records were not available for review, but the patient reported that he had received his first single-chamber pacemaker implanted in his left subclavian vein at age 30 for “passing out spells.” The lead had fractured, was abandoned, and a new right ventricular lead was placed at age 40 in the right subclavian vein. Pacemaker interrogation revealed a fractured right-sided pacemaker lead with lead impedance over 2,000 ohms and inability to capture. Holter monitoring documented multiple 6-10 second pauses while awake, and the patient said he felt dizzy during those episodes. The patient was extremely muscular. He admitted that he lifted heavy weights as his hobby to pass the time in prison, which was felt to be the etiology of the lead fractures. Echocardiogram showed a normal heart with moderately severe tricuspid regurgitation. With two fractured pacemaker leads in place, what should we do now with this patient? Background There has been an explosion of new device implants worldwide over the past two decades. Increasing ease of placing devices, broader indications for placement, and technology advances with CRT (cardiac resynchronization or biventricular) devices have all led to more implants. There was an increase in the implantation rate of cardiac devices (from a Medicare database) from 1990 to 1999 by 42%.1 Patients are also living longer. The average lifespan for a person born in the United States today is 78 years, and longer for women. Since sick sinus syndrome is often age-dependent, it is not surprising that we have seen (and will continue to see) growth in the number of pacemaker implantations over time. Even patients in their 80’s or 90’s may benefit from placement of a pacemaker.2 Defibrillator therapy has enjoyed an equally successful period of growth. Unless someone is expected to die within the next six months, most patients with an LVEF (ejection fraction) less than 35% should be offered an implantable cardioverter-defibrillator (ICD).3 Additionally, physicians are more aggressive about offering ICDs to patients with genetic conditions like long QT syndrome (at least 1 in 5,000 have long QT syndrome), Brugada syndrome, or hypertrophic cardiomyopathy.3 It has become relatively easy to place ICDs, and the downside to not offering one is sudden cardiac death, which is unacceptable for these often young and otherwise healthy patients. Thus, many more cardiac devices are being placed. However, along with greater numbers of device placements comes the added headache of managing the complications of these procedures. In particular, what should we do with unwanted device leads? The most common indication for removing device leads has been infection. However, a recent review article from the Mayo Clinic published in the January 2009 edition of the HeartRhythm journal looked at the larger issue of removing abandoned (or unused) device leads.4 Therefore, we will look at the pros and cons of lead extraction, including briefly outlining the extraction procedure, followed by an analysis of the excellent Mayo Clinic article. Lead Extraction The Heart Rhythm Society defines extraction as removing any lead in place for over a year or using tools beyond the standard stylets to remove the lead.5 There are published guidelines as to which leads should be removed (Table 1).6 Class I indications mean that there is literature supporting its use, Class II are reasonable, and Class III means that the extraction should not be done (contraindication). Lead extraction is generally done only at institutions with back-up, on-site cardiac surgery that is immediately available, in the event that ventricular perforation occurs during the procedure. A locking (or other type of) stylet is placed into the lead to be removed. A sheath is advanced over the lead, to free up any adhesions which are present. If needed, an Excimer laser (Spectranetics) assisted lead extraction can be performed. The success rate and associated risk of complications depend on several factors. First, leads that have been in longer are obviously more difficult to remove intact. Such leads can break, requiring further procedures (even surgery) to remove fragmented lead pieces. The U.S. Extraction Database indicates that the risk of failed extraction doubles for every three years the lead has been in.7 Next, the lead type plays a role in ease of removal. Active fixation leads are more likely to be removed intact than passive leads. Operator experience plays an important role in successful lead extraction. Finally, ICD leads can be more difficult to remove than pacemaker leads, due to their greater size and the fact that the SVC defibrillator coil in particular triggers dense fibrosis. Large studies from institutions that do a high volume of lead extractions have shown a success rate of over 90% at removing leads entirely, with another 3-5% at partial removal of the leads.5-7 The risk of complication is around 5%, including rare cases of death, tamponade requiring surgical intervention, or vascular damage. Clearly, lead extraction is a major undertaking that carries significant risks for morbidity (and even mortality). It is not a trivial procedure. Thus, given the possible risks of lead extraction, why not just leave old device leads in place? Few studies have examined this question in a systematic fashion. However, Glikson et al recently undertook a retrospective study looking at this issue using the Mayo Clinic database from August 1993 to May 2002.4 Their elegant paper was published in the January 2009 issue of HeartRhythm. They reported on 78 defibrillator patients with 101 leads. Their patients were mainly male (81%) and were on average 63 years of age. Each patient had on average 1.5 abandoned leads (range of 1-3 leads per patient). The study followed the patients for over three years. The leads were abandoned for a variety of reasons, including a desire to upgrade from a pacemaker to an ICD lead, lead failure, and oversensing issues. During the follow-up period of the study, there were no obvious complications attributable to leaving the leads in place. There were no obvious cases of thromboembolic venous complications. The abandoned leads did not obviously affect the DFTs (defibrillation threshold) of new ICD placements, and there were no clear cases of infection attributable to leaving old leads in place. The Mayo Clinic study has several important limitations. First, it was a retrospective study from one institution. Second, no children were included in the study, so information on abandoning leads in the pediatric population is lacking. Finally, the follow-up period is relatively short, so it is not known if the authors would see a similarly low rate of complications for leads left in 20 years or more. Still, given the risks (including death) at removing device leads, this interesting study supports the idea of leaving non-functional leads in place. Clearly, more work needs to be done in this area. Conclusion As for our prisoner with the two abandoned pacemaker leads: we offered him different options including placing a third pacemaker lead, removing the non-functional leads via extraction, or even putting in an epicardial lead. He wanted a third pacemaker lead placed transvenously, which was done successfully. We counseled him to stop weight-lifting, which likely contributed to his pacemaker lead fractures. After one follow-up visit, the prisoner stopped coming. He got parole and moved out of state.