lTroubleshooting Pacemaker and Defibrillator Malfunctions
What is a Lead?
A lead is a thin, flexible wire that travels through a vein and delivers energy to the heart muscle from a pacemaker or implantable cardioverter defibrillator (ICD) – special devices implanted under the skin that help a patient’s heart beat in a regular rhythm. Two, or sometimes, three leads are used to connect the patient’s heart to the pacemaker or ICD.
What is Lead Extraction?
When the leads are initially inserted through the veins of the chest and connected to the heart, they can be easily removed. However, eventually the leads are held in place by scar tissue. Lead extraction is the removal of one or more leads from the inside of the heart and veins with special tools that safely release the lead from the scar tissue.
Why is Lead Extraction Necessary?
A lead must be removed when it becomes infected or damaged or causes a mechanical problem.
- Infection. When a patient develops an infection of the pacemaker or ICD system, the leads and the pacemaker or ICD must be completely removed to cure the infection.
- Damage. Sometimes it is discovered that the leads no longer provide reliable connections to the heart. When this occurs, the damaged leads need to be replaced, but there may not enough room in the veins to permit the addition of more leads. This necessitates the removal of the damaged leads. However, leads may sometimes be replaced without removing the damaged leads. Damaged leads, however, may send electrical signals that interfere with the pacemaker or ICD.
- Blockage. Damaged leads that have not been previously removed sometimes block veins entering the heart. In such cases, the damaged leads must be removed in order to allow access to the heart.
How is Lead Extraction Performed?
The patient receives general anesthesia before the surgery. The extraction is performed by hooking a special wire onto the inside of the lead, or by placing a snare through a vein to grasp the outside of the lead. The physician then pushes a plastic tube with a laser over the lead to help separate it from the scar tissue in the veins and the heart. The plastic tubes, or sheaths, break the scar tissue to prevent tearing the veins or heart. The new leads and pacemaker or defibrillator are implanted during the same surgery. At Providence Saint Joseph Medical Center (PSJMC), more than 150 cases of infected systems have also been implanted during the same surgery, with only a 2% re-infection rate in 14 years. This has saved many patients multiple surgeries or prolonged hospital stays. Patients usually leave the hospital the day after the procedure. If everything goes as planned, the patient should be able to resume normal activities relatively soon after the surgery.
What Are the Outcomes of Lead Extraction Surgery?
Lead extraction was not consistently performed until 1988 when better tools became available to safely release the lead from the scar tissue. A registry of lead extraction procedures has been carefully maintained since that time. Usually the complete lead is removed; however, sometimes a small segment is left behind. This is usually not a problem and may be enough to allow the patient to continue living with no further interference from the partially removed lead. Approximately 90% of all leads are completely removed with current techniques.
What Are the Complications of Lead Extraction Surgery?
Complications are uncommon, in experienced hands, and may include bleeding from the vein or heart. Since 1988, the mortality at PSJMC has been less than 0.25%, but this varies throughout the U.S. The risk and success of lead extraction depends on having the best tools, taking appropriate precautions and utilizing an experienced physician and team.
Lead Extraction at Providence Saint Joseph Medical Center
Raymond Schaerf, MD, NASPEExAM Testamur, Chief of Staff at Providence Saint Joseph Medical Center in Burbank, is one of only a handful of physicians in the world who routinely performs lead extraction surgery. Dr. Schaerf was among the first in the world to perform lead extraction surgery using an excimer laser. To date, he has removed more than 1,000 leads, which makes him one of the most experienced lead extraction specialists not only in the U.S., but also in the world.
For more information about lead extraction surgery at Providence Saint Joseph Medical Center, call 818-843-2334 or 1-888-HEALING.
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Providence Expertise with Cardiac Care leads the way for PACEMAKER patient
A few months after 62-year-old Era Butler retired from a celebrated teaching career in her hometown of Perris, California, she had surgery to replace the battery in a pacemaker system used to regulate her heartbeat. The pacemaker – which uses a small, battery-powered generator to deliver timed, electrical impulses to the heart muscle through tiny wire leads – had been implanted 12 years earlier when complications from an illness caused Butler’s heartbeat to become irregular.
Less than a week after the pacemaker battery replacement, Butler began suffering from fever, chills and body aches. “I thought it was a flu virus,” says Butler’s daughter, Gloria Woolridge. “I didn’t suspect it was the pacemaker until three weeks later.”
Physicians at the hospital near Butler’s home, where the procedure had been performed, ordered a series of tests and subsequently re-hospitalized Butler. After determining that she had an infection, her doctors prescribed antibiotics. Butler still failed to improve. Her local physicians then determined that Butler’s pacemaker leads had been infected and transferred her to a tertiary healthcare facility in Los Angeles specializing in cardiac care.
Woolridge remembers the desperation both she and her mother felt. “My mother said, ‘Gloria, it feels like something is munching on me right here,’ and then she pointed to her chest area near her heart and shoulder. My mother said ‘There is something eating on me. Honey, you’re my last hope.’ I knew that she needed help.”
However, physicians at the hospital told Butler they did not have the expertise or the technology to remove the leads and that the risk of surgery was prohibitive. They planned to continue to treat Butler with antibiotics. Butler’s daughter worried about this approach. “I had done the research, and I thought, that’s not going to work. She’s going to die,” says Woolridge. Butler had developed an infection inside her heart.
Not willing to accept the death of her mother as a possible outcome, Woolridge began searching the Internet for treatment options. “I felt as though I was in the midst of solving a puzzle, and I needed to find the missing piece,” explains Woolridge.
She soon discovered the “missing piece” for her mother was lead extraction surgery, a specialized procedure required when the pacemaker leads become damaged, infected or blocked by scar tissue. Only a handful of physicians in the world perform the surgery. Fortunately for Butler, one of those surgeons is Raymond Schaerf, MD, NASPEExAM Testamur, Chief of Staff at Providence Saint Joseph Medical Center in Burbank.
“Each case can be an adventure because you can never be sure exactly what’s going on inside the heart,” says Dr. Schaerf. “Some of the patients have complex anatomy, including congenital heart disease, and some have actually had heart transplants. Many of the defibrillator patients who require extractions have very weak hearts and require extensive monitoring. They absolutely can’t tolerate having even a minor complication.”
Dr. Schaerf was among the first in the world to perform lead extraction surgery using an excimer laser. To date, he has removed more than 1,000 leads, which makes him one of the most experienced lead extraction specialists not only in the U.S., but also in the world. He is one of only a few physicians in California who routinely performs the procedure.
During the procedure, Dr. Schaerf uses a special wire to hook onto the inside of the lead, or places a snare through a vein to grasp the outside of the lead. He then pushes a plastic tube with a laser over the lead to help separate it from the scar tissue connecting the lead to the veins and the heart. The procedure is a very complex and high-risk operation that, on occasion, requires emergently opening the chest.
“When I first started doing lead extractions in 1979, the only operation available was an open heart procedure,” notes Dr. Schaerf. “With the development of the new tools and advanced technology available at Providence Saint Joseph Medical Center (PSJMC), patients can often go home in one to two days and only have a standard pacemaker incision.”
But Dr. Schaerf is quick to point out that it is not only the technology that enables him to offer this state-of-the-art care to his patients. “I’ve been very fortunate not only to have the available technology, but also a very strong team of nurses, surgery and radiology technicians, anesthesiologists, cardiologists, and infection disease experts,” he adds.
Gloria Woolridge considers all of it “a gift”: the technology, the staff and Dr. Schaerf’s leadership, expertise and compassion.
“My mother is the center of our family. She has a husband, two children, five grandchildren, many siblings. She had just retired. She wanted to live. For her to go from no hope to surgery overnight… we’re still coming down from it.”
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