Key result
Prophylactic ICD lead extraction in young patients lowers procedural mortality but increases overall adverse events.
Why the study?
Does prophylactic serial lead extraction at ICD generator change reduce extraction-related mortality compared to lead reuse in patients with ICDs?
Does prophylactic serial lead extraction at ICD generator change reduce extraction-related mortality compared to lead reuse in patients with ICDs?
Prophylactic lead extraction at ICD generator change may reduce long-term extraction-related mortality in young patients with >40 years of expected lead dwell time, despite higher upfront procedural risks.
Simulation suggests lower long-term mortality with serial extraction in select young patients; leaves open whether practice should change pending prospective data.
BACKGROUND: Current implantable cardiac devices have a finite battery life of ≈3 to 7 years for implantable cardioverter-defibrillators. It is current practice to reuse all properly functioning intravascular leads. We tested the hypothesis that a strategy of prophylactic lead removal at the time of device change would be superior under some conditions to the current practice of lead reuse. METHODS AND RESULTS: Using currently available data and a Monte Carlo microsimulation trial, we calculated the risks of leaving an indwelling lead until extraction is indicated because of malfunction versus an aggressive management strategy of prophylactic serial extraction at time of generator change. With a serial lead exchange strategy of leads at generator change, there is reduced overall extraction-related mortality because of fewer late complications attributable to extraction of leads with high dwell time because of infection, recall, or subsequent lead failure. This finding is limited to young patients or those with high expected indwell time of lead. This trend reverses for leads with <40 years expected dwell time. Sensitivity analysis shows high dependence on extraction performance and device longevity. In all cases, serial extraction would be expected to lead to increased adverse events related to the more complex procedure. CONCLUSIONS: A strategy of serial lead extraction, given best available current parameters, yields a lower procedural mortality risk in the long-term management of indwelling implantable cardioverter-defibrillator leads in young patients (>40-year estimated dwell time) driven by high aggregate anticipated risk of lifetime lead complication.
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Mendenhall et al. (2014) studied Implantable cardioverter-defibrillator generator change. Prophylactic serial lead extraction vs. Current practice of lead reuse was evaluated on Extraction-related mortality. Prophylactic serial lead extraction at ICD generator change yields a lower procedural mortality risk in young patients with >40-year estimated dwell time, but increases adverse events overall.
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