Features January 2012 Issue

Laser Removal of Heart Device Wires Safe for Older Patients

Recent research suggests this less-invasive procedure is an option for most patients who need to have device leads extracted and replaced.

Implanted cardiac devices (ICDs) such as pacemakers and defibrillators are connected to the heart with wires called “leads.” Information travels to and from the heart via the leads, allowing the ICDs to perform their function of keeping the heartbeat regular. But sometimes, these leads need to be removed.

At one time, lead removal required invasive surgery, but now, it is more often performed via a percutaneous (meaning “under the skin”) procedure that threads a small tube, or sheath, into the veins in which the leads are located. During this procedure, a laser is sometimes used to facilitate the extraction. For older patients, laser lead extraction was considered more risky than for younger patients.

But a new study found that laser lead extraction is as safe for people in their 80s as it is for younger patients. The study, published in the October 11, 2011 issue of Circulation: Arrhythmia & Electrophysiology, also found that there was no difference in the rate of infection between older and younger patients.

“These study results are not surprising to me,” says Bruce Wilkoff, MD, director of cardiac pacing and tachyarrhythmia devices in the department of cardiovascular medicine at Cleveland Clinic. “The conventional view is that older adults are less able to tolerate procedures than younger adults, but there’s nothing about being older that makes this procedure more dangerous. In fact, the majority of patients needing lead removal are candidates for laser extraction, regardless of their age.”

Reasons for Lead Removal
The most common reason for lead extraction is infection, according to Dr. Wilkoff.

The leads also can break or malfunction, or the vein in which the lead is placed may become closed off. ICDs need to be replaced periodically, usually because the battery has worn out.

“Sometimes, when the ICD is replaced, the leads appear to be fine, but following the replacement, an infection develops, and we need to go back in and remove the leads,” says Dr. Wilkoff.

The infection is treated with antibiotics, and, once it has resolved, new leads are implanted into the veins and restore the connection between the ICD and the heart.

How Laser Extraction Works
“During laser lead extraction, we go into the vein through a small incision and slide a sheath equipped with a laser over the lead. The laser breaks up scar tissue that has formed around the lead and makes it easier to remove the lead,” says Dr. Wilkoff.

Lead extraction also can be done without the use of a laser. The risks associated with both types of extraction are very low, but Dr. Wilkoff says the laser extraction is preferable because it reduces the forces that potentially cause tears of the vein wall, leading to internal bleeding, making it a “gentler” procedure.

When Lasers Aren’t the Answer
There are situation and conditions in which percutaneous laser lead extraction is not appropriate.

“If the lead has crossed through either the walls of a vein or of the heart, or if there are vegetations—growths on the leads from infection­—which could break off when the sheath is threaded through the vein and travel to the lungs, which can cause a potentially fatal pulmonary embolism (blood clot in the lung), we don’t use this procedure,” explains Dr. Wilkoff.

If there is a defect in the heart wall separating the top two chambers of the heart, a transvenous (through the vein) extraction can result in a clot, called a paradoxical embolus, that passes from the veins to the arteries and travels to the brain, possibly causing a stroke. If any of these conditions are present, lead extraction is performed by accessing the heart and veins through a surgical opening in the chest.

A small number of patients cannot undergo a lead extraction procedure, even if there is an infection.

“If a person is very ill due to other comorbidities (e.g., end-stage cancer) and has a short life expectancy, then the leads are left in place and the infection is treated with antibiotics,” explains Dr. Wilkoff. “However, this is not a long-term solution, and it raises the risk of being infected with Clostridium difficile and other types of bacteria that can have potentially serious consequences.”