Pacemaker and ICD leads: Strategies for long-term management



Pacemaker and defibrillator therapy is on the rise as a result of expanding indications. Unfortunately, this trend is associated with an increased number of cardiac device-related complications. Lead failure, device infection and vascular complication are not uncommon and may cause significant patient morbidity and mortality. Furthermore, the considerable variability in the approach to dealing with device-related complications not infrequently leads to additional problems and complications. This review is intended to provide general guidelines and strategies for long-term management of cardiac devices. Proper implantation techniques that focus on primary prevention of complications, as well as, planning for future procedures are essential. The use of sterile techniques and implementation of peri-operative antibiotics are well supported in clinical trials. Additionally, minimizing the amount of implanted hardware and limiting the procedure length have also been shown to decrease the rates of infectious complications. Once device infection is confirmed, the primary objective, short of a few exceptions, should consist of the entire system removal via open surgery or percutaneously and antibiotic therapy before reimplantation. Vascular occlusions are not uncommon; however, in the majority of cases they are asymptomatic. Nonetheless, they pose a significant problem with device reimplantation, especially in the younger patients who will require multiple generator exchanges in the future. Site preservation should, therefore, become the primary objective. This can also be accomplished with the open surgical or percutaneous device removal. The latter is very safe and effective when performed in experienced centers. Finally, lead follow-up must be routinely conducted to identify problematic leads, prevent further reimplantations, and guide future research.


Strategies for cardiac device management Lead complications Infectious complications Vascular complications Device extraction 


  1. 1.
    Josephson, M., & Wellens, H. J. (2004). Implantable defibrillators and sudden cardiac death. Circulation, 109, 2685–2691.PubMedCrossRefGoogle Scholar
  2. 2.
    Hauser, R. G. (2005). The growing mismatch between patient longevity and the service life of implantable cardioverted-defibrillators. Journal of the American College of Cardiology, 45, 2022–2025.PubMedCrossRefGoogle Scholar
  3. 3.
    The Antiarrhythmic Versus Implantable Defibrillators (AVID) Investigators (1997). A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. New England Journal of Medicine, 337, 1576–1583.CrossRefGoogle Scholar
  4. 4.
    Moss, A. J., Zareba, W., Hall, W. J., et al. (2002). Multicenter Automatic Defibrillator Implantation Trial II Investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. New England Journal of Medicine, 346, 877–833.PubMedCrossRefGoogle Scholar
  5. 5.
    Buxton, A. E., Lee, K. L., Fisher, J. D., Josephson, M. E., Prystowsky, E. N., & Hafley, G. (2000). A randomized study of the prevention of sudden death in patients with coronary artery disease. New England Journal of Medicine, 342, 1300.CrossRefGoogle Scholar
  6. 6.
    Kadish, A., Dyer, A., Daubert, J. P., et al. (2004). Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. New England Journal of Medicine, 350, 2151–2158.PubMedCrossRefGoogle Scholar
  7. 7.
    Bardy, G. H., Lee, K. L., Mark, D. B., et al. (2005). Sudden Cardiac Death in Heart Failure Trial. (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. New England Journal of Medicine, 352, 225–237.PubMedCrossRefGoogle Scholar
  8. 8.
    Abraham, W. T., Fisher, W. G., Smith, A. L., et al. (2002). MIRACLE Study Group. Cardiac resynchronization in chronic heart failure. New England Journal of Medicine, 346, 1845–1853.PubMedCrossRefGoogle Scholar
  9. 9.
    Linde, C., Braunschweig, F., Gadler, F., Bailleul, C., & Daubert, J. C. (2003). Long-term improvements in quality of life by biventricular pacing in patients with chronic heart failure: results from the Multisite Stimulation in Cardiomyopathy Study (MUSTIC). American Journal of Cardiology, 91, 1090–1095.PubMedCrossRefGoogle Scholar
  10. 10.
    Bristow, M. R., Saxon, L. A., Boehmer, J., et al. (2004). Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac resynchronization therapy with or without an implantable defibrillator in advanced heart failure. New England Journal of Medicine, 350, 2140–2150.PubMedCrossRefGoogle Scholar
  11. 11.
    Cleland, J. G., Daubert, J. C., Erdmann, E., et al. (2005). Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators: The effect of cardiac resynchronization on morbidity and mortality in heart failure. New England Journal of Medicine, 352, 1539–1549.PubMedCrossRefGoogle Scholar
  12. 12.
    Page, C. P., Bohen, J. M. A., Fletcher, J. R., McManus, A. T., Solomkin, J. S., & Wittmann, D. H. (1993). Antimicrobial prophylaxis for surgical wounds: Guidelines for clinical care. Archives of Surgery, 128, 79.PubMedGoogle Scholar
  13. 13.
    Da Costa, A., Kirkorian, G., Cucherat, M., et al. (1998). Antibiotic prophylaxis for permanent pacemaker implantation. A meta-analysis. Circulation, 97, 1796–1801.PubMedGoogle Scholar
  14. 14.
    Klug, D., Balde, M., Pavin, D., Hidden-Lucet, F., Clementy, J., Sadoul, N., PEOPLE Study Group, et al. (2007). Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation, 116(12), 1349–1355 Sep 18.PubMedCrossRefGoogle Scholar
  15. 15.
    Bertaglia, E., Zerbo, F., Zardo, S., Barzan, D., Zoppo, F., & Pascotto, P. (2006). Antibiotic prophylaxis with a single dose of cefazolin during pacemaker implantation: incidence of long-term infective complications. Pacing and Clinical Electrophysiology, 29, 29–33.PubMedCrossRefGoogle Scholar
  16. 16.
    Anonymous (1992). Antibiotic prophylaxis in surgery. Medical Letter on Drugs and Therapeutics, 34, 5–8, Medline.Google Scholar
  17. 17.
    Accorti, P. R. (1994). Leads technology. In I. Siner (Ed.) Implantable Cardioverter Dfibrillator. Armonk, NY: Futura.Google Scholar
  18. 18.
    Mouchawar, G. A., Wolsleger, W. K., Doan, P. D., Causey III, J. D., & Kroll, M. W. (1997). Does an SVC electrode further reduce DFT in a hot-can ICD system? Pacing and Clinical Electrophysiology, 20, 163–167.PubMedCrossRefGoogle Scholar
  19. 19.
    Kay, G. N., Brinker, J. A., Kawanishi, D. T., et al. (1999). Risks of spontaneous injury and extraction of an active fixation pacemaker lead: report of the Accufix Multicenter Clinical Study and Worldwide Registry. Circulation, 100, 2344–2352.PubMedGoogle Scholar
  20. 20.
    Accufix Research Institute. Englewood, CO. Retrieved November 26, 2007 from
  21. 21.
    Dorwarth, U., Frey, B., Dugas, M., et al. (2003). Transvenous defibrillation leads: High incidence of failure during long-term follow-up. Journal of Cardiovascular Electrophysiology, 14, 38–43.PubMedCrossRefGoogle Scholar
  22. 22.
    Gold, M. R., Peters, R. W., Johnson, J. W., & Shorofsky, S. R. (1997). Complications associated with pectoral implantation of cardioverter defibrillators. World-Wide Jewel Investigators. Pacing and Clinical Electrophysiology, 20, 208–211.PubMedCrossRefGoogle Scholar
  23. 23.
    Tullo, N. G., Saksena, S., Krol, R. B., Mauro, A. M., & Kunecz, D. (1990). Management of complications associated with a fist-generation endocardial defibrillation lead system for implantable cardioverter defibrillators. American Journal of Cardiology, 66, 411–415.PubMedCrossRefGoogle Scholar
  24. 24.
    Wilkoff, B. L., Belott, P. H., Love, C. J., et al. (2005). Improved extraction of ePTFE and medical adhesive modified defibrillation leads from the coronary sinus and great cardiac vein. Pacing and Clinical Electrophysiology, 28, 205–211.PubMedCrossRefGoogle Scholar
  25. 25.
    Ellenbogen, K. A., Wood, M. A., Shepard, R. K., et al. (2003). Detection and management of an implantable cardioverter defibrillator lead failure: incidence and clinical implications. Journal of the American College of Cardiology, 41, 73–80.PubMedCrossRefGoogle Scholar
  26. 26.
    Chua, J. D., Wilkoff, B. L., Lee, I., Juratli, N., Longworth, D. L., & Gordon, S. M. (2000). Diagnosis and management of infections involving implantable electrophysiologic cardiac devices. Annals of Internal Medicine, 133, 604–608.PubMedGoogle Scholar
  27. 27.
    Wilkoff, B. L. (2007). How to treat and identify device infections. Heart Rhythm, 11, 1467–1470.CrossRefGoogle Scholar
  28. 28.
    Sticherling, C., Chough, S. P., Baker, R. L., et al. (2001). Prevalence of central venous occlusion in patients with chronic defibrillator leads. American Heart Journal, 141, 813–816.PubMedCrossRefGoogle Scholar
  29. 29.
    Byrd, C. L., Wilkoff, B. L., Love, C. J., et al. (1999). Intravascular extraction of problematic or infected permanent pacemaker leads: 1994–1996. U.S. Extraction Database, MED Institute. Pacing and Clinical Electrophysiology, 22, 1348–1357.PubMedCrossRefGoogle Scholar
  30. 30.
    Bracke, F., Meijer, A., & Van Gelder, B. (2002). Extraction of pacemaker and implantable cardioverter defibrillator leads: Patient and lead characteristics in relation to the requirement of extraction tools. Pacing and Clinical Electrophysiology, 25, 1037–1040.PubMedCrossRefGoogle Scholar
  31. 31.
    Kennergren, C., Schaerf, R. H., Sellers, T. D., et al. (2000). Cardiac lead extraction with a novel locking stylet. Journal of Interventional Cardiac Electrophysiology, 4, 591–593.PubMedCrossRefGoogle Scholar
  32. 32.
    Gilligan, D. M., & Dan, D. (2001). Excimer laser for pacemaker and defibrillator lead extraction: Techniques and clinical results. Lasers in Medical Science, 16, 113–121.PubMedCrossRefGoogle Scholar
  33. 33.
    Wilkoff, B. L., Byrd, C. L., Love, C. J., Hayes, D. L., Sellers, T. D., Schaerf, R., et al. (1999). Pacemaker lead extraction with the laser sheath: Results of the pacing lead extraction with the excimer sheath (PLEXES) trial. Journal of the American College of Cardiology, 33, 1671–1676.PubMedCrossRefGoogle Scholar
  34. 34.
    Byrd, C. L., Wilkoff, B. L., Love, C. J., Sellers, T. D., & Reiser, C. (2002). Clinical study of the laser sheath for lead extraction: the total experience in the United States. Pacing and Clinical Electrophysiology, 25, 804–808.PubMedCrossRefGoogle Scholar
  35. 35.
    Ellenbogen, K. A., Wilkoff, B. L., Kay, G. N., & Lau, C. P. (2007). Clinical cardiac pacing, defibrillation, and resynchronization therapy. Philadelphia, PA: Saunders.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Department of CardiologyCleveland Clinic FoundationClevelandUSA

Personalised recommendations