A Team Approach to Lead Extraction: The UCSD Experience

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EP LAB DIGEST. 2024;24(12):16-18. 

Stephanie H Yoakum, RN, MSN, ACNP-BC; Travis Pollema, DO; Andrew Y Lin, MD; Niki Aramburo, AA; Ulrika Birgersdotter-Green, MD, FHRS
University of California, San Diego, La Jolla, California 

As the number of cardiac implantable electronic devices (CIED) increases, the population lives longer, and patients are receiving biventricular devices, more leads may need to be extracted due to infection, malfunction, and other indications. 

Lead extraction is a complex procedure and should not be performed at every institution. At UC San Diego Health (UCSD), we have developed a lead management program utilizing an experienced, multidisciplinary team that has resulted in safe and effective patient outcomes and high levels of satisfaction among patients and their families.

Our Team

At UCSD, the multidisciplinary team is comprised of electrophysiologists, a cardiac surgeon, cardiac anesthesiologists, perfusionists, 2 nurse practitioners, nurses and technicians specialized in electrophysiology (EP), and administrative staff (Figure 1). We are fortunate to have strong institutional support and work closely with our industry representatives. We partner with our infectious disease colleagues to provide comprehensive care for patients with infections and sepsis. 

Patient Referral and Evaluation 

UCSD is a tertiary lead management referral center. Patient referrals come from a broad region, including southern California, Hawaii, and various other locations along the west coast. Referrals are received from various sources, including cardiologists, electrophysiologists, and hospital admissions.

Evaluation Prior to Extraction 

A standardized approach is utilized to evaluate patients for lead extraction based on factors such as lead characteristics (age, type, and number of leads in place), patient comorbidities, and procedural risks. 

Initial consultations for lead extraction in the outpatient setting are seen by the EP nurse practitioner and electrophysiologist. Hospitalized patients are evaluated by the EP consult team and attending electrophysiologist. The indication for extraction as well as alternatives to lead extraction are discussed with cardiothoracic (CT) surgery, including additional leads, tunneling, epicardial leads, or abandoning leads if necessary. The type of device to be implanted after extraction is discussed, including that in some cases, the same type of device may not be implanted and that leadless technology may be considered. If patients appear to no longer have an indication for the type of CIED initially implanted, an insertable cardiac monitor is often implanted for ongoing monitoring and evaluation. For patients with right ventricular implantable cardioverter-defibrillator lead malfunction, tachycardia therapies are turned off and outpatients are fitted with a wearable cardiac defibrillator. 

The lead extraction procedure is explained step by step, and patients and families are provided with a patient guide developed at UCSD that explains the lead extraction program and process. Two lead extraction videos created by UCSD are also available on YouTube.¹ 

Workup Prior to Extraction

All patients being evaluated for lead extraction have a device interrogation, posteroanterior and lateral chest x-ray, and laboratory work (complete

blood count, comprehensive metabolic panel, procalcitonin, C-reactive protein test, sedimentation rate, type and screen) to initially evaluate for antibodies and blood cultures if the patient has an infection. 

For patients experiencing pocket pain with no obvious cause, a tagged white blood cell scan is ordered to assess for potential pocket infection.

UCSD has developed a computed tomography angiography protocol (CTA Chest and Lead Extraction) for patients undergoing lead extraction to determine how the leads course through the body, any areas of binding or heavy calcification, lead perforation, and patency of venous anatomy (Figure 2). All patients with leads older than 1 year have a chest CTA unless they have a creatinine greater than 2; otherwise, they have a noncontrast CTA.

Once patients have completed their pre-extraction workup and are evaluated by the EP team in clinic, a preliminary recommendation for extraction is made and a discussion takes place of what device, if any, will likely be implanted post extraction. The patient is then seen in clinic by the cardiac surgeon and CT surgery nurse practitioner, where the CT scan is reviewed and surgical risk is discussed in detail. The data is evaluated by all parties and shared decision-making is used to decide whether to proceed with lead extraction and finalize the device to be implanted post extraction. The final recommendation is communicated with the patient over the phone. Our administrative team schedules the patient for a surgery date once patients are deemed appropriate for extraction.

Lead Extraction Procedure

Lead extractions at UCSD are performed in a hybrid operating room (OR) (Figure 3). There is dedicated block time in the hybrid OR one day per week. The hybrid OR is difficult to access outside of our block time, which can be a challenge when scheduling inpatient procedures. Outpatient procedures are occasionally rescheduled to accommodate inpatients or for urgent procedures by other services that require the hybrid OR. 

A cardiac anesthesia team who performs preprocedural transesophageal echocardiography (TEE) is utilized as well. TEE imaging is utilized if

hypotension occurs or if there is a change in the patient’s status. We do not routinely perform a postprocedural TEE. Technicians from our EP laboratory who are trained in extractions also work in the hybrid OR on extraction days. The hybrid OR also provides cardiac nurses and scrub technicians to assist with the extractions. 

Tools required for extraction, including lasers, mechanical rotational sheaths, and a femoral workstation, are kept on a cart that is maintained by EP laboratory personnel. The OR staff ensure a heart surgical tray and sternotomy saw are available for all extraction procedures. 

During the procedure, the patient will be draped to cover the femoral groin area and chest. For patients with a history of sternotomy, a 5 French (F) sheath is placed in both the left femoral vein and artery. A 12F sheath will be placed in the right femoral vein for a superior vena cava (SVC) occlusion balloon, with specific guidelines based on the age of the leads being extracted:

• Less than 1 year old: No occlusion balloon.

• 1-3 years old: Confirm with the CT surgeon if an occlusion balloon or prep kit is required.

• 3-5 years old: Drop the prep kit to the scrub technician and confirm with the CT surgeon about the occlusion balloon.

• Over 5 years old: Drop both the occlusion balloon and prep kit to the scrub technician.

If the patient is pacemaker dependent, a temporary wire will be inserted via a 6F sheath in the right femoral vein. The SVC occlusion balloon is inflated in cases of hypotension that do not respond to corrective measures.

We have standardized protocols for intraoperative management, including protocols for anesthesia management, hemodynamic monitoring, and infection prevention.  

After lead extraction without an infection, patients are admitted to the Procedure and Treatment Unit (PTU) with the plan to discharge the following day. Patients undergo a device interrogation and chest x-ray prior to discharge. 

Patients with infection are admitted to the hospital or return to their hospital bed. If the patient is pacemaker dependent or has a temporary pacemaker placed, they are managed by EP. If a wound vac or drain was placed, this is managed by CT surgery. The infectious disease team is consulted, if not already involved, and a time in the EP laboratory is scheduled to reimplant the CIED based on infectious disease recommendations. Hospitalized patients are seen daily by CT surgery and EP. 

Discharge and Follow-up

Once patients are deemed safe for discharge, education is provided by the EP nurse practitioners and nurses. Patients are scheduled for a wound check in 10-14 days. If patients have been referred from outside our institution, a wound check visit is completed and ongoing follow-up is ensured with the referring provider. Communication with the referring provider is maintained throughout patient care. 

Best Practice Alert for Infection

Infection is one of the primary reasons patients are referred to our center for extraction. Patients with CIEDs and infection are at increased risk for morbidity and mortality. Early lead extraction in patients with infection and sepsis has been associated with an increase in 1-year survival and reduced adverse outcomes.²

UCSD has developed and implemented an automated best practice alert (BPA) in our electronic medical record (EMR) that provides notifications when patients are admitted with infections or sepsis with CIEDs (Figure 4). The automated alert is generated when an admitted patient has a positive blood culture and presence of a CIED as determined by a chest x-ray report within 10 days of the positive blood culture. The BPA is sent to a predetermined electrophysiologist and an infectious disease specialist when these 2 criteria are met. The BPA enables early detection of patients as well as quick and effective evaluation of the need for lead extraction.

Extraction Database

UCSD maintains a custom, home-grown lead extraction database utilizing the Patient Analysis and Tracking System (PATS), developed by Axis Clinical Software. Over 200 data points are collected for each lead extraction procedure, including reason for extraction, type and age of leads extracted, preprocedure laboratories, CTA data, antibiotics given for infection, length of stay, and outcomes. This database is maintained by a cardiovascular data manager who also helps maintain other mandated registries and databases. The electrophysiologist will provide data related to the case on a form that is kept in the hybrid OR. Other data is obtained by chart review. Our data manager will occasionally utilize cardiovascular nurses on light or limited duty to help extract data from the EMR. The database allows for tracking and evaluation of procedural outcomes, helping to identify trends, successes, and areas of improvement. The database is used for research and clinical studies, and helps to enhance patient care and decision-making about the lead extraction program. 

Lessons Learned

The lead management program is regularly assessed to identify both successes and areas for improvement. Valuable insights have been gained over time, including the following:

• It takes a team. Lead management is definitely a team effort and is most successful when there is a dedicated and skilled team in place that consistently works together. Also, having institutional buy-in is crucial to ensure adequate resource allocation and support.

• Having a point person for referrals is important. Our electrophysiologists receive all referrals and are responsible for communicating with the team and referring providers. 

• Time spent with the patient and their family prior to lead extraction is time well spent. A comprehensive explanation of the procedure, including risks versus benefits as well as what to expect before, during, and after the procedure, is imperative. 

• Lead extraction is not always the best option. Sometimes less really is more. 

• Imaging helps. We find the CT scan to be invaluable to preprocedural planning as it allows us to visualize the patient’s specific anatomy and any variations that might affect the procedure, assessment of lead condition and placement including adhesions which helps with surgical risk stratification, and surgical planning. 

• Track your data. Data tracking allows for identification of trends and evaluation of outcomes, which improves the program. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Lin and Aramburo report no conflicts of interest regarding the content herein. Ms Yoakum is a speaker for Abbott and Medtronic, and is a consultant for Biotronik. Dr Pollema reports honoraria from Philips. Dr Birgersdotter-Green reports honoraria from Abbott, Biotronik, Boston Scientific, Medtronic, and Philips. 

References

1. Pacemaker and lead extractions. UC San Diego Health. YouTube. Published June 8, 2017. Accessed October 15, 2024. https://youtu.be/_PvSqgYW1y0?si=f6Suaf_o4gWuN_mA

2. Lin Ay, Saul T, Aldaas OM, et al. Early versus delayed lead extraction in patients with infected cardiovascular implantable electronic devices. JACC Clin Electrophysiol. 2021;7(6):755-763. doi:10.1016/j.jacep.2020.11.003