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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 4, July/August 2021
AFRICA
193
Experience of cardiac implantable electronic device lead
removal from a South African tertiary referral centre
Philasande Mkoko, Nicholus Xolani Mdakane, Glenda Govender, Jacques Scherman, Ashley Chin
Abstract
Background:
The rate of cardiac implantable electronic device
(CIED) implantation in low- and middle-income countries
is increasing. Patients recieving these devices are frequently
older and with multiple co-morbidities, which may later lead
to complications requiring CIED removal. CIED removals
are associated with life-threatening complications. However,
high sucesss rates are reported in high-income countries.
The purpose of this study was to report on the experience of
CIED removal in a resource-constrained setting.
Methods:
In this retrospective study, we included consecu-
tive adult patients admitted to Groote Schuur Hospital and
the University of Cape Town Private Academic Hospital for
CIED removal from 1 January 2008 to 31 December 2019.
Results:
During the study period, 53 patients underwent
CIED removal (26 extractions and 27 explants). The patients
had a mean (standard deviation) age of 59.1 (16.0) years. A
history of systemic hypertension was present in 50.9% of
patients, diabetes mellitus in 30.2% and dilated cardiomyopa-
thy in 47.2%. Complete heart block was the leading indication
for CIED implantation (37.7%), and device infection was the
leading indication for removal (69.2%). CIEDs were removed
after a median (interquantile range) of 243 (53–831) days.
There were 40 leads extracted and 35 explants. Lead extrac-
tions were perfomed in the cardiac catheterisation laboratory
under general anaesthesia via a percutaneous transvenous
superior approach. There was one major and one minor
complication related to lead extraction.
Conclusion:
CIED infections were the primary indication for
CIED removal in a tertiary referral centre in South Africa.
Despite being a low-volume centre, we report a high percu-
taneous transvenous extraction success rate with low compli-
cation rate; results which are comparable to high-volume
centres.
Keywords:
cardiac implantable electronic device removal, pace-
maker lead removal, explant and extraction
Submitted 6/11/20, accepted 21/3/21
Published online 19/4/21
Cardiovasc J Afr
2021;
32
: 193–197
www.cvja.co.zaDOI: 10.5830/CVJA-2021-010
Cardiac implantable electronic devices (CIEDs) are a well-
established lifesaving technology for the treatment of
bradycardias, heart failure and ventricular arrhythmias in
susceptible patients.
1-6
Currently, it is estimated that up to
1.4 million CIEDs are implanted globally every year.
7
As the
population ages, the rate of CIED implantation also increases.
4,5
Approximately 70% of CIED recipients are older than 65
years of age, often with co-morbidities that may necessitate
implantation of more complex CIEDs.
5,8,9
The number of
CIED implantations is increasing in low- and middle-income
countries.
10
For example, in South Africa there were 54 per
million population new pacemaker implants in 2005, which
increased to 132 new implants per million population in 2013.
10
At present the main indications for CIED removal include
CIED infection and lead or pacemaker generator malfunction.
7
Percutaneous transvenous lead extraction is now preferred over
surgical lead extraction due to its high success rates and low
risk of complications. However, percutaneous transvenous lead
extraction is associated with a small risk of major complications,
including cardiac avulsion, vascular tears and death.
11,12
In high-
volume extraction centres, the reported clinical success rates
of lead extraction are more than 95%, with low complication
rates.
11,13-15
The purpose of this study was to report the experience
(indications and outcomes) of lead removal (extraction and
explant) from a tertiary South African referral centre.
Methods
We conducted a retrospective review of all patients who
underwent percutaneous transvenous CIED lead removal at
Groote Schuur Hospital (GSH) and the University of Cape
Town Private Academic Hospital (UCTPAH) between 1 January
2008 and 31 December 2019. This study was approved by the
University of Cape Town Human Research Ethics Committee
(HREC number: 591/2019).
All lead extractions and explants were performed in the
cardiac catheterisation laboratory. The extractions were
performed under general anaesthesia, with a transoesophageal
echocardiogram
in situ
to exclude large vegetations and for
monitoring of potential complications. The extraction team
consisted of a cardiac electrophysiologist, a cardiothoracic
surgeon, a cardiac anaesthetist, a clinical cardiology fellow, a
scrub nurse and auxillary catheterisation laboratory staff.
Cardiac Clinic, Groote Schuur Hospital, Cape Town, South
Africa
Philasande Mkoko, MB ChB, MMed (UCT), FCP (SA), Cert Cardio
(SA),
mkkphi002@myuct.ac.zaNicholus Xolani Mdakane, BTech
Glenda Govender, BTech
Chris Barnard Division of Cardiothoracic Surgery, Faculty
of Health Sciences, University of Cape Town, Cape Town,
South Africa
Jacques Scherman, MB ChB, FC Cardio (SA), MMed (UCT)
Division of Cardiology, Department of Medicine, Faculty of
Health Sciences, University of Cape Town; Cardiac Clinic,
Groote Schuur Hospital, Cape Town, South Africa
Ashley Chin, MB ChB, MPhil (UCT), FCP (SA), Cert Cardio (SA),
FHRS