Should Lead Explantation Be the Practice Standard When a Lead Needs to Be Replaced?

Twenty years ago, lead explantation was reserved for those patients with pacemaker lead endocarditis and continued septicemia because extraction, whether it be accomplished using manual traction, mechanical traction as with pulleys, or openchest surgery, was associated with significant operative morbidity and even mortality. A lead that merely malfunctioned was typically capped and abandoned in place. Newly developed extraction devices combined with improvements in extraction techniques and an increased number of physicians experienced in lead removal warrant a reconsideration ofthe prior practice standard. Presenters at many pacing and electrophysiology conferences often give the impression that there is no longer any reason to leave a nonworking lead in situ. Have we reached the time where the practice standard should be the routine explantation of any lead that needs to be replaced for any of the multiple reasons in addition to infection? Clearly, the risks associated with lead extraction have decreased dramatically as physicians and medical device companies continue to improve lead extraction technologies. However, reduced risk is not the same as no risk. Experience with the Accufix J lead (Telectronics, Englewood, CA, USA) advisory bears witness to the need for caution even with the newer lead extraction systems. The number of major complications, including death, far exceeds the incidence of spontaneous complications from the lead itself.^ Further study of the data reveals that the incidence of major complications is inversely proportional to the physician's experience in lead explantation, while the morbidity associated with the explantation process increases in a direct relationship to the number of years that the lead has been implanted.