Features August 2018 Issue

Abandoned Leads Can Cause Major Problems Later On

If your pacemaker or other cardiac device needs to be replaced, be sure the extra wires are removed, too.

Unused wires left inside a body when a cardiac implantable electronic device (CIED) is changed can cause big problems later on. These wires, known as leads, are magnets for infection. The longer they stay in the body, the more dangerous it is to remove them.

“Untreated, infected CIED systems carry up to a 66 percent mortality rate. Even when the leads are removed and the patient is given antibiotics, the risk of death may remain as high as 33 percent at one year,” says Bruce Wilkoff, MD, Cleveland Clinic’s Director of Cardiac Pacing and Tachyarrhythmia Devices.

An Unnecessary Problem

More than 300,000 patients in the U.S. receive CIEDs every year, and this number is growing. So is the number of infections in leads left behind.

Making sure all unused leads are removed when a CIED is switched out would significantly cut the number of lead-related infections. But this isn’t happening.

“Most electrophysiologists are trained in lead implantation, but significant extraction is more uncommon. Many never perform the procedure often enough to become comfortable with it. Some may do uncomplicated extractions, but hesitate when the lead is older or damaged, for fear of causing harm,” says Dr. Wilkoff.

“This thinking gambles on the patient’s future,” he says. “These physicians may question why they should expose a patient to potential complications, when it’s easier to simply add a new lead. But they are not considering that the lead may need to be removed at a future date, when infection leaves no choice.”

How Lead Infections Occur

pacemaker

Various types of CIEDs are used to restore a normal rhythm when a heart starts beating too slowly, too fast or irregularly. They range in sophistication from a simple, single-chamber pacemaker with one lead to a biventricular pacemaker with defibrillator, which has three leads. Regardless of the number of leads, all CIEDs have a battery that sends electrical impulses down the wires into the heart muscle to make it contract.

When a CIED battery begins to wear out, the device is simply switched out for a new one. Because CIEDs are implanted in a small pocket under the skin, the exchange is simple and quick. However, opening the pocket opens the door for germs to enter the body and attach themselves to devices or leads. The risk of infection is higher when a patient has abandoned leads.

Weighing Risk

After about one year in the body, leads become firmly attached to surrounding muscle tissue and veins. Releasing them without causing damage to the heart becomes increasingly difficult. For this reason, it has been customary for old leads to be disconnected and left in the body.

“No one thought they were going to be a problem. We thought we could easily take them out, if necessary, but we were wrong,” says Dr. Wilkoff.

“Extracting leads is a slow, tedious process with inherent risks. However, people don’t understand how serious lead infection is, and how low the risk of extraction is in comparison,” he says.

Some Leads Better Left Alone

Not every unused lead needs to be extracted. Leads in patients who are frail—especially if they are also elderly or have a serious heart disease or other comorbid condition—may be best left alone. In these patients, the extraction procedure may be too difficult to tolerate.

infectedLead

Images courtesy of Cleveland Clinic

Abandoned leads (above) can become infected with bacteria (right) and may be fatal, even with antibiotic therapy.

But these are exceptions to the rule. There is growing recognition that abandoning leads complicates the management of CIED infections and puts patients at risk.

“Most times, we extract leads that would otherwise become redundant. However, the decision to abandon or remove unwanted leads is not always an easy one to make. For this reason, the final decision should be made after a careful discussion involving the patient, family and physician,” Dr. Wilkoff says.

“If a physician is not comfortable removing an unwanted lead, the patient should be referred to a center that specializes in the procedure.”

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