Pacemaker Lead

Pacemaker Lead | The inpatient cardiology market has been slowly but steadily shrinking in recent years. Yet University of Colorado Hospital has bucked that trend, increasing its market share the past four years. While the introduction of innovative procedures, notably transaortic valve replacement, ablation for atrial fibrillation, and a sharp rise in the number of vascular surgeries helped fuel the surge, smaller-volume procedures have also played a role.

One example is removal of infected pacemaker leads, a procedure that requires a multidisciplinary team that includes specialists in cardiac electrophysiology, cardiothoracic surgery, cardiac anesthesiology and ultrasound imaging, as well as skilled nursing. Infectious disease specialists are also involved to manage the infection and prepare the patient for reimplantation.

The number of infected pacemaker lead removal procedures at UCH, while still relatively small, has risen notably the past two years, said Ryan Aleong, MD, a cardiologist with the Electrophysiology Lab at UCH’s Cardiac and Vascular Center and director of the Lead Extraction Program. In all of 2010, the lab performed 13 such procedures, Aleong said. The number rose to 20 in 2011; during the first five months of fiscal year 2013 alone (July 1 to Nov. 30, 2012), the number was 22.

Aleong, who performs the majority of the procedures – Paul Varosy, MD, and Duy Nguyen, MD, also handle some – said the increase is partially attributable to more referrals from community physicians throughout Colorado and surrounding states. But Aleong said the team’s track record of success has also been a factor.

“We’ve done a good job of making sure the procedure is safe as possible,” he said.
Infected leads scar major blood vessels and the heart. If left unchecked, the infection may spread to the heart valves, causing further complications, Aleong explained.

Many hands on deck. Because of the risk, Aleong and his colleagues perform the procedure in the OR with cardiothoracic surgeons, including Brett Reece, Ashok Babu and Joseph Cleveland, backing them up. The team often uses the hospital’s hybrid suite, which allows them to switch quickly to an emergency open-heart procedure if complications develop.

The basic approach involves opening the old incision over the pacemaker or defibrillator generator, removing it, then using special sheaths to cut scar tissue around the pacemaker leads and extracting them. Patients typically recover overnight in the ICU, then spend several days in the hospital while providers monitor heart function and ensure no damage occurred during the procedure.

The delicate work requires providers who have perfected their techniques through repetition, Aleong said. He learned lead extraction during a Cardiovascular Disease fellowship at the University of Pittsburgh Medical Center before coming to UCH in 2009.

“Experience is important because lead extraction involves careful dissection of the leads from the major blood vessels,” he explained. “It requires a certain tactile ability that takes time to develop.” Because of that, he added, the Heart Rhythm Society recommends that medical centers perform a minimum number of lead-extraction procedures.

“As we build volumes, we get used to the procedures and the precautions we need to take,” Aleong said. “That helps to improve patient outcomes. We’re also doing a lot to decrease risk with our team approach.”

Peter Buttrick, MD, who heads the CU School of Medicine’s Division of Cardiology, said the infected lead removal procedure illustrates the advantages an academic medical center can offer patients.

“It’s a very complicated undertaking that requires sophisticated equipment,” he said, “and cardiology and surgical partners working together in the OR setting. The infrastructure is complex.” That makes it impractical for most private practices to take on the procedure or build the volume necessary to develop the expertise that leads to good outcomes, he added.

Aleong stressed, however, that his program also helps patients and providers make treatment decisions together. He meets with them one-on-one in the clinic or hospital to discuss treatment options.

“It’s important to help them understand it’s one of the more high-risk procedures in cardiac electrophysiology,” he said. “We help them understand the risks and benefits of the procedure.”