A cardiac implantable electronic device (CIED), which includes implantable cardioverter defibrillators (ICDs) and pacemakers (PCMs), have thin wires called leads that connect the device to a patient’s heart. These leads monitor the electrical activity of the heart, can pace the heart if it is going too slow and, in the case of an ICD, can deliver an electric shock to restore the heart to its normal rhythm. When these leads are not working properly—often due to a mechanical problem known as lead fracture—or if the device/leads become infected, they need to be removed. Surgery to extract and replace leads can be a straightforward procedure. But, if leads have been in place for many years, they can become overgrown with surrounding scar tissue and are much more challenging to remove.
Lead extraction can be performed through these sites on the body:
Cardiac specialists at the Brigham and Women’s Hospital (BWH) Heart & Vascular Center are considered world experts in performing ICD and PCM lead extraction, using a range of tools and techniques, including minimally invasive laser technology.
With 47,000 outpatient visits each year, the Heart & Vascular Center is one of the largest in the United States, treating over 7,000 inpatients and performing more than 8,000 procedures annually at our state-of-the-art Shapiro Cardiovascular Center.
Cardiac specialists in the Heart & Vascular Center are experts in a minimally invasive procedure known as transvenous lead extraction. Patients travel from across the country and around the world to have their procedure performed at BWH. Due to scarring that occurs around the leads, it is often not possible to “just pull them out.” In addition, there is the risk of tearing a blood vessel or the heart with lead removal. Therefore, a variety of specialized tools and techniques have been developed in order to safely “extract” the leads. One such tool is the laser sheath. This device consists of a sheath (long tube) wrapped in laser fiber optics that is advanced through the targeted vein and over the lead. Laser energy cuts through the scar tissue surrounding the lead, allowing it to be safely removed.
Brigham and Women’s Hospital physicians helped test and develop laser lead extraction technology, even before the surgical technique was approved by the Food and Drug Administration. Today, our Cardiac Arrhythmia Service is a regional, national and international referral center for this complex procedure. We perform laser lead extraction in a hybrid operating room, equipped with the latest imaging equipment and staffed by a team of cardiac specialists. The transvenous lead extraction program at Brigham and Women’s Hospital is one of the largest in the world with outcomes second to none.
There are many reasons a patient needs to have a lead removed, including:
Patients can expect to be in surgery for approximately two to four hours and usually stay one night in the hospital for monitoring. After the procedure, patients may experience soreness, swelling and bruising at the site where the device and leads were removed. Recovery from the surgery is approximately one week.
Every medical procedure carries risks to your health. Published data suggest a 1.5% risk of major complication and a 0.3% risk of death. In expert hands, these rates are even lower. Over the past 15 years, in over 2,000 extraction procedures, the major complication rate at Brigham and Women’s Hospital has been 0.6% with only 1 death (0.05%).
The Heart & Vascular Center is located in the Shapiro Cardiovascular Center, across the street from BWH’s main 75 Francis Street entrance. The Heart & Vascular Center brings together the full range of services in one location, fostering seamless and coordinated care for all cardiovascular patients.
Prior to having the procedure, you will be scheduled for a visit to the Watkins Clinic in the Shapiro Cardiovascular Center for preoperative information and tests.
The day of the procedure, your care will be provided by physicians, anesthesiologists, technicians and nurses who specialize in lead extraction. The Heart & Vascular Center is home to one of the most advanced hybrid operating rooms in the country. This procedure is performed in the Hybrid OR because it offers advanced imaging capabilities to help guide the operation and the ability to perform immediate rescue surgery, in the very rare cases it is required. You will recover in the post-surgical care unit (PACU) where you will receive comprehensive care by an experienced surgical and nursing staff.
The procedure is most often done under general anesthesia. You therefore will experience no discomfort after the procedure. Most often, the leads are removed via the implant site (usually the left or right upper chest). On some occasions, the leads need to be removed via the femoral vein (the large vein in your groin area). After you are asleep, a vascular sheath (plastic tube) will be placed in the femoral vein in case we need vascular access for medications, temporary pacing or removal of leads.
Because of this access, you will have to lie flat for 4 hours after the procedure. You may experience soreness at the surgical site. This can be managed with pain medications and is usually short lived. After recovery in the PACU, you will be transferred to one of the private rooms in the Shapiro Cardiovascular Center. In the morning, you will have a chest X-ray and undergo “interrogation” of your device. One of our team will also review everything with you and answer any questions you may have.
During the procedure, family and friends can wait in the Shapiro Family Center where staff members will provide surgery updates.
Patients benefit from the teamwork of surgeons, cardiologists, interventional cardiologists, cardiovascular imaging experts and radiologists, and anesthesiologists, all experts in cardiovascular disease. They work alongside nurses, physician assistants, physical therapists, dietitians and social workers to achieve outstanding outcomes for our patients.
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