St. Louis specialists facilitate laser lead extraction for heart device patients
ST. LOUIS, MO. – Cardiac surgeons and electrophysiologists (EPs) at Saint Louis University (SLU) Hospital are now offering a less invasive, safer way to remove pacemaker leads, using lasers to break up scar tissue built up around them.
The timing for the newest option by specialists at SLU’s new Center for Comprehensive Cardiovascular Care (“C4”) comes soon after Riata/Riata ST defibrillation leads and Medtronic’s Sprint Fidelis® defibrillation leads were recalled, accounting for roughly 500,000 patients worldwide.
“There are many reasons to take out leads – infection, too many leads blocking off veins, or breakage, which is the reason for the Riata and Fidelis leads being recalled,” said “C4” co-director and cardiac surgeon Richard Lee, MD, MBA. “Laser lead extraction is the best way to take care of the recalled leads for those patients in particular.”
Lee brought the new procedure to SLU from Northwestern Memorial Hospital and the Center of Heart Rhythm Disorders at the Bluhm Cardiovascular Institute, where he served as attending cardiac surgeon and surgical director, respectively, for five years before returning to St. Louis.
“The laser lead extraction procedure itself isn’t brand new, but the technology continues to evolve,” he explained. “It was dangerous when it first came out, but now it’s very, very low-risk. It provides the best option for patients rather than leaving these leads in place. For example, after a year or so, scar tissue starts building up around the leads and becomes strongly adhered to the body’s vessels. Therefore, the leads can’t simply be pulled out of the vein. Historically, physicians used to just leave them in place; this increased the risk of blocking the patient’s major vein to the arm and also infection. The laser provides a safe option to remove these leads and prevent the complications.”
Lee explained that when a pacemaker or implantable cardioverter defibrillator (ICD) is implanted in the chest to treat patients with irregular heartbeats, leads run from the device through veins to the heart’s chambers, allowing rhythm monitoring and the ability to deliver energy if the heart gets out of rhythm. If a device needs to be removed, new leads need to be inserted as veins only have so much capacity. Replacing them is challenging; many physicians who implant devices prefer not to remove them because of inherent risks.
“Why was it not so safe with the lead extraction before? Maybe every two times of 100 or so early on, the laser made a hole in the heart,” explained Lee. “The laser just burns and doesn’t discriminate, and instead of around the lead, it would burn a hole in the heart. That sets up an emergency situation.”
The laser lead extraction procedure calls for cardiac surgeons and EPs to work in tandem to insert and remove leads. Leads are inserted via a sheath wrapped in laser fiber optics through the targeted vein and over the lead. Laser energy breaks up the scar tissue and frees the lead, which is then easily removed.
“The cardiac surgeon needs to be actively involved in every case,” insisted Lee, who primarily performs the procedure with SLU Hospital EP chief Ali Mehdirad, MD. “At SLU, I do all the extractions and the EPs do all the implants. It’s a great partnership because I do what I do all the time; they do what they do all the time, and it works really well. The best outcomes (according to the Heart Rhythm Society guidelines) require a strong collaboration between surgery and cardiac EP.”
Patients undergoing the laser lead extraction are put under anesthesia for the surgical procedure and usually have an evening hospital stay. According to a 2011 study published in the journal Circulation, the national success rate with laser lead extraction exceeds 90 percent.
“I’ve never lost a patient to lead extraction,” said Lee. “With the EP and cardiac surgeon working together on every case, if a potentially fatal problem occurs, it’s recognized immediately and fixed before it’s too late.”