Lead Extraction/St Jude Battery Replacement - Long post

• by Ababbitt
• 2016-12-05 15:53:14
• Batteries & Leads
• 1913 views
• 3 comments

Because this forum has been so helpful to me, I'd like to give back as much information as I have/know on the subject. I have posted twice before recently and some of this is repetitive.

In 1988, at the age of 34, my father had a pacemaker/defribillator put in his abdominal cavity (he was the 90th person in the US to have the defribillator lead (you have to brag where you can)). At that point in time, the plates were actually attached to your heart. At 40, those leads were disconnected (because they didn't go through a vein ((no blood supply, so no risk of endocardiatis) and they were attached directly to the heart they were left in his body) and a new system (the system most of you have) was placed on the left pocket of his chest with a pacer and defribrillator. Approximately 5 years later, he got the BiV ICD, which has a third lead to synchronize your left and right chamber. Optimally this lead is attached through a branch in the coronary sinus. Getting into the coronary sinus is easy; however, once in there dye is used to find a small branch in the CS to place the lead. There is an optimal location for the branch. The placement of this lead is very difficult (For those of you who don't have this now, you may need it at some point in the future bc it greatly improves your heart function if you have heart failure.) The lead was successfully placed. At some point later, one of the leads fractured and they capped it and put in a fourth lead.

Between the first pacemaker implant, until now, my father has had approximately 6 battery replacements. Most were without any issues. The surgery and recovery were minimal.

In 2014, however, my father had his battery replaced and it became infected. The risk of infection on battery replacements is 1-2%. I was terrified. I was convinced (based on online research and talking to my cousin who is an electrophysiologist at Harvard) that the leads had to be removed, otherwise he would get endocardiatis (the reasoning behind lead removal for infection is that because the device is battery operated and it is in a pocket, antibiotics can never totally clear the infection. Since, the leads go from the battery to your heart, the bacteria can go straight to your heart and cause your heart to become infected). Nevertheless, my father's EP wanted to try antibiotics first and sent my dad to see an infectious disease specialist.  He was on IV antibiotics for a couple months and then oral antibiotics for a couple months. It beat the hell out of him, but he survived and the infection cleared. We were thrilled.

A year later, in 2015, we were all sitting at the dinner table, when his chest started beeping (this had never happened before). We got worried and because we didn't know what the issue was or why it was beeping, we called the EP and my father and I went to see him. It turns out that one of his leads was fractured and the threshold was much higher than it should be (what this means is that the lead drains the battery more quickly - so, instead of replacing the battery every 5 years, it becomes every 3 years, 6 months, etc. - to the point, where you have no choice but to cap the lead and insert a new lead or extract the lead and insert a new lead). His EP told him that since he was going to have one lead extracted, he should have all three (the capped lead they left in place) extracted as well. This was very scary because the leads have been there for almost 15 years, he needs them, and it was unclear how much scar tissue had accumulated around the leads (the more scar tissue, the more difficult it is to extract).  He also happened to have the recalled St Jude device (for those of you with a recalled device, you get a free new one. You also may want to look into the Boston Scientific Device, it is supposed to be excellent). His EP also told him that the extraction did not need to happen right away. He had about a year and that they would monitor his device and the EP would tell my dad when to do the surgery.

Any EP can do the lead extraction. However, it is important to go to someone that only does lead extractions. Because you are extracting the leads, there is a risk of puncturing your lung, vein or heart. The risk greatly reduces when you go to someone who only does lead extractions. You also need a heart team available to do open heart surgery if that becomes necessary. So, my father's EP sent him to a specialist - a cardiothoracic surgeon who only does lead extractions and can do open heart surgery if necessary. My father's cardiologist who is at Cedar Sinai also recommended the same specialist. 

On October 31, my father and I met with the cardiothoracic surgeon. The surgeon suggested that because there had previously been infection (albiet there were no signs of infection), he thought it would be most prudent to do the extraction on Monday and implant the device two days later, just to be sure there was no undetected bacteria. Because my father's blood tests came back clear of infection, the surgeon changed his mind and decided to try and extract the leads and implant the device in one surgery.

With any surgery, there are risks. None of the risks we expected occurred - the lead extraction went smoothly. This is what we were most worried about. The doctor was also able to implant the pacemaker/defribillator lead. He spent 2.5 hours in the coronoary sinus trying to find an optimal branch for BiV lead, but couldn't. It should be noted that my father has chronic kidney disease (dye can cause damage to your kidneys) and over the last few years has also developed an allergy to dye. So, the surgeon had to be very conservative in his use of dye, which could have been part of the reason that he couldn't find a branch in the CS.

Nevertheless, there were unexpected risks. Apparently, throughout the surgery, my father's blood pressure dropped very low and stayed low (anesthesia causes your blood pressure to drop a little, but they normally are able to maintain a healthy blood pressue throughout the surgery and this had never been an issue for my father before (low blood pressure is 90/60 - he was at about 70/50 - and despite the use of Vasopressers, they couldn't keep his blood pressure stable.)) The risk of hypotension (low blood pressure) is that it can lead to septic shock and all your organs failing bc they are not receiving blood.

 After surgery, he was extubated too soon and couldn't breathe so they had to reintubate him. He was kept on a ventilator and was given the maximum dosage of 4 vasopressers. They didn't think he was going to make it through the night. But he did. We needed him to remain stable enough to do the second surgery and get the BiV lead implanted. He did stabilize and the surgeon wanted to keep him sedated and on the ventilator until friday and do the surgery on friday. The pulmonologist, however, felt that we should extubate him (take him off the ventilator), let his body recover, and do the surgery monday. 

They extubated him Wednesday, by Friday (because he didn't have all the leads and he was laying down and he was not given a mild diuretic, which he takes daily) his lungs had filled with fluid, he felt like he was drowning (bc he basically was) and they had to reintubate him. Needless to say, we were all terrified. He did, however, stabilize and the surgeon was able to perform the surgery monday. 

This time the surgeon did a thoracotomy. Basically, they cut into his chest, deflated his lung, moved it aside, and attached the lead directly to his heart (the studies on this approach are mixed - some say this leads to a more optimal location/placement and is just as effective if not superior than going through the CS; others say, that it is a major surgery and because the lead is directly attached to the heart, there is a greater chance of it becoming dislodged).

The surgery went without any hiccups. It lasted 45 minutes. To be safe and because of what happened after the first surgery, they kept him on a ventilator for 24 hours. They extubated him the next day. The kept him in the hospital for 5 days and yesterday he came home. He is incredibly weak. He currently needs a walker to walk and help getting up and sitting down. However, this is not permanent. He will start doing therapy three days a week to build back his strength and muscle loss and he should go back to being fully independent in a month or two. 

The silver lining - his heart is working better than before. His ejection fraction went from 35% presurgery to 45% postsurgery. As a result, the blood flow to his kidneys has increased and while he still has chronic kidney disease, his kidneys are functioning better than they were before.  Hopefully, he will have a smooth and speedy recovery.