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.