Lead extraction 28 year old leads

Hi all,

Congenital complete heart Block patient, 46 years old, female. I am currently on my 3rd device, a medtronic crt-p. Currently have estimated 9 months left on device. Original implant for this one was 2014. I am paced 100% in ventricle and between 50-60% in atria- so very dependent. 

My Original right ventricular lead had to be switched from bipolar to unipolar about 4-5 years ago due to "zapping" feelings. General feeling was that it was due to age wearing the outer casing of the lead. So to buy time until the device battery wore out, we switched it to unipolar.  

So, likely to have lead replaced with this change. Has anyone here had 28 year old leads removed? Important notes, I tend to keloid scar externally- not sure if that means it's possible to have keloiding around the lead? I also have a bleeding disorder which hasn't been an issue for standard replacements. However it has caused major issues in cardiac cath and post- partum, leading to massive hemorrhage. 

Needless to say the idea of extraction terrifies me. So, experiences? Have they ever just removed 2 old ones at the same time- to prevent having to do it again? Will they keep you several days/in cicu if complication risk is higher?

They had a hell of a time getting the 3rd lead in last time for the crt-p, so there's definitely no more room at the inn to just disconnect the lead and add a new one.


7 Comments

Not 28 years, but 11 years for me..

by USMC-Pacer - 2024-02-16 00:05:26

I had one defective lead that need replacing. But, when the DR. got in there, they were scarred and entangled so both of them were removed and replaced with new leads without incident. I think they do it better now than years ago. My DR. didn't get into detail but said: "it wasn't easy but went without any issues." As far as my hospital here in Boston, they had numerous staff in the room to include a cardiothorasic surgeon "just in case." Thankfully that wasn't needed. I'm not saying that to make you nervous, but to say that you are safe in case something happens which I am condident is rare nowadays. They have lots of technology today that they didn't have years ago. Others will chime in with their experiences too.. Good luck :)

extraction

by Tracey_E - 2024-02-16 12:22:05

Good Dog and I are both in the same situation, haven't had the extraction yet but have deteriorating very old leads. We are both still doing research while the clock ticks down on the current battery. My leads will be 30 yrs old this year, one is showing wear, and I have less than a year on this battery.

Some thoughts...

If they extract, they might as well do all of them and not just the bad one. Newer leads are thinner and stronger and have better technology. If you're going to the trouble to extract, start with a clean slate. 

You want a surgeon who specializes in extraction. This is very important and is worth traveling for if there is no one local who does them at least weekly and has done other very old leads. Think places like Cleveland or Mayo. My EP does extractions, but he has another surgeon he consults with on higher risk extractions and they do it together. My guy is in Miami and I think the other is in Naples (he travels to Miami to do the surgeries).

When it's closer to time, I will meet with this guy and he can do tests to evaluate the condition of the leads and the condition of my veins. Once we have that information, that will help me make a decision. I'd like to have the old hardware out, but if the risk is too high I'll live with leaving it in. I've got reduced circulation in my left arm now and it stays swollen, so if I get it all out we can get a vascular surgeon to fix that at the same time. 

They always have a cardiothoracic surgeon in the OR as a back up. It's rare to need it, but when they need it, it's an emergency. You can ask your team  how many times they've needed that surgeon and survival rate. In all the years his team has been doing extractions, my EP has needed that surgeon 3 times, and all 3 patients survived. He's never needed the cardiac surgeon with the specialist.  

There is a balloon sheath (I'm probably calling it by the wrong name) that came out a couple of years ago. They can have it on standby on lower risk extractions, or in place on higher risk. If there is a rupture, they can deploy it in seconds to create a tampon which buys them time (30 min) to fix it. This brings down the risk substantially on more complicated extractions. 

Abbott's 2 chamber leadless was approved last summer and has been used in a very few patients so far that have existing old leads like we do. I know of one person who has this, and she was out running a race less than 2 months later. She was the first in the UK to get this. My EP has never done one of these but said he'd be learning all he can about it and it is a possibility for me. He offered to refer me out if we go that direction as he has not done leadless yet outside of a dummy in a seminar situation. I'm hoping he'll have done one or two by the time I need it.

He likes the Abbott over the Medtronic leadless because the Medtronic is intended to be left in while the Abbott is intended to be retrieved when they replace it. He said I'm too young (at 57) and will have too many replacements in my lifetime to leave two of them in each time. They do 2 devices for 2 chamber pacing.

So, if we go leadless, we can extract or not extract.

If we stay with traditional leads, we can extract, or they can leave the old ones in and run the new ones from the other side. 

As a last resort, if they can't extract, there is no room on other side, they can do epicardial (outside of the heart rather than in veins)

You'll want someone who specializes in the bleeding disorder consulting every step of the way. If you are at risk of hemorrhage, that may take extraction off the table.

My EP is an adult congenital specialist. I switched to him a few years ago. My last doc was terrific and I still happily refer people to him, but he didn't have anyone else like me. Every year he'd tell me I was doing great. Which was fine, but I want to continue to do great, to be proactive. I went to the specialist for a consult and never looked back. He sees people like us all day long so has a different perspective. The Adult Congenital Heart Association has a list of clinics, which grows all the time as technology allows more of us thrive well into adulthood. Most larger cities have at least one now. That's where I found mine. 

Hope this helps! Good luck and stay in touch. 

me too

by dwelch - 2024-02-17 03:07:37

I have 36 year old leads one broken one I am using and a 29 year old lead I am using.  Doc mentioned we will talk about leads on the next replacement.   So have not had  them removed yet but I have four, using three, and most are decades old.

I guess it may be a race between the handful of us to see who does this first.  Supposedly the surgeon here is "the one" you want in this part of the country, but I wonder if every office says that.

My 2 Lead Extractions

by Buzbuz9 - 2024-02-18 12:37:56

I have had two lead extractions at this point. One in 2016 and one just this past January 2024. I am on the very young side for a pacemaker patients, 24 years old currently (first lead extraction at 17), so the leads from my extractions weren't nearly as old as yours but I can talk about my experience getting it done twice.

 

I will say my recent lead extraction had a much easier recovery than my previous one because there have been huge improvements to the technology of lead extractions in the last 10 years. My first extraction was for 8 year old leads because I had broken my atrial lead(dual chamber pacemaker). It was a pretty risky surgery, with a reported 1/100 chance of death,  at the time and my surgeon flew out a lead extraction specialist to do the extraction. They used a drill technique to remove the leads and it was a 15+ hour surgery. The recovery was very difficult and I couldn't do much of anything for weeks. The pain was really strange because I swear I felt it inside the veins for weeks afterward. I didn't really feel fully recovered for months. 

My lastest extraction was far easier in comparison. My leads were about 10 years old. I did get it done at the largest heart center in my region, Duke Hospital in NC, by someone who does them frequently (that is important!) I highly recommend getting it done by someone well versused in the procedure. Though the risk of complications was reported to me to be about the same the risk of death was WAY lower. They used a combined laser and drill technique for the procedure and it was only about 5 hours. The recovery took about a week and a half before I was back to doing my normal stuff and most of my issues were around my new leadless pacemaker and not the extraction. Though the pain and recovery may have been less because I did not get new leads put in. I had to switch to a leadless pacemaker because I probably need to have a tricuspid valve replacement this year.

Other Notes:

On the good side it is a general anesthesia procudure so you won't have to deal with the scariness of an awake one. They always freak me out worse. This means you will be intubated meaning your throat will hurt for a few days as well. I recommend hospital jello to help. Not sure about Keloids (definitely something to ask your doc) but I do have some bleeding issues related to liver failure(from tricuspid regurgitation) and it didn't have any major affects on how my surgery went. Over all the laser lead extraction I had was a easy fast procedure that had a decently easy recovery time :)

Tips:

-recovery will likely be harder and more painful than you doctor will probably indicate(everyone is different though) - just like a normal PM/ICD surgery ice can be super helpful

-if they try to send you home without proper pain managment, fight them about it

-plan to take it easy for at least several weeks

-day 2 and 3 are normally the worst

-get soft front button up shirts to wear while recovering 

-both times i only spent one night in the hospital, but it could be a couple depending on your initial recovery 

-I was kepts in the PICU/ICU for about 4 hrs at my last lead extraction I believe and I am also have bleed issues that have caused problems with cath procudures before

 

Good luck with your extraction!

Buzbuz

by Tracey_E - 2024-02-19 10:21:13

Great information! How are you doing with the Micra? Do you have one or two chamber? 

Tracey_E

by Buzbuz9 - 2024-02-19 23:11:21

I am doing alright with my Mirca, it is a single chamber one.

I am planning on making a larger post about it soon for the folks here who are considering switching from traditional to leadless(since I may be the first one)

But generally it is okay, the pacing isn’t quite as good in my opinion but I was also not a perfect candidate for it due to my tricuspid regurgitation, which is loud and affects how my heart beat sounds which is what the Micra uses to judge when to pulse your heart. It isn't terrible though. The base setting when I first got it were really bad, like walk 5 steps and be out of breath bad but i got into my EP and spent 4 hrs working with a Micra team making adjustments and I am back to normalish now. It definitely feels a bit different than my dual chamber one did, so I tend to notice it more which is odd. The recovery was way easier though. Ive also got a lot of other health stuff going on at the moment so my opinion is probably a bit skewed at the moment. I'll make a post in the next month or so talking about the it in more detail, but feel free to message me if you have any specific questions in the meantime :)

Buzbuz

by Tracey_E - 2024-02-20 11:26:08

Thanks for the info! And yes I believe you are the first here to go from traditional to leadless. A few of us (me, Good Dog, dwelch) will be anxiously awaiting your updates. Sounds like you've got a really terrific EP. It's hard to find one that is expert at programming the Micra since there are so few. Sorry to hear you are dealing with other issues, too. 

You know you're wired when...

Titanium is your favorite metal.

Member Quotes

Your anxiety is normal. It takes some of us a little time to adjust to the new friend. As much as they love you, family and friends without a device just cannot understand the adjustment we go through. That is why this site is so valuable.