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Maintaining Normal Heart Rhythms

Johns Hopkins electrophysiologist Charles Love excels at replacing the wires that regulate your heartbeat.

A version of this story appeared in Cardiovascular Report.

Whether designing electronic circuit boards or repairing cars, Charles Love has always enjoyed tinkering. Over time, that passion extended to repairing and replacing implantable cardiac devices. In 1994, Love became the first cardiac electrophysiologist in the world to remove a pacemaker wire from a person’s heart, using a laser catheter. To date, the Pittsburgh native has inserted more than 9,000 pacemakers and has extracted nearly 3,000 wires, also known as leads.

Since joining Johns Hopkins in 2017 as director of cardiac rhythm device services, Love says he feels empowered to help a growing number of patients with infections or problems caused by faulty leads. “As people live longer, they’re more likely to end up with a broken wire that might need to be replaced,” he says. Or, they may need an upgrade of their devices, he adds, because most last between 10 and 15 years.

The Johns Hopkins Hospital remains a high-volume leads extraction center and is, by far, the busiest in the region, says Love. Experts at the hospital’s Heart and Vascular Institute will perform well over 100 extractions this year. Most patients are in their 60s or 70s and arrive with malfunctioning or infected devices.

Leads must be removed when the pacemaker or defibrillator system becomes infected. In addition, there may be a manufacturer’s recall that requires that a lead be replaced.

“It can be a challenge to remove them,” says Love, “and one must always be careful not to tear a hole in a blood vessel or heart. But our success rate — 99.5 percent — and low complication rate — under 1 percent — bode well for patients.”

On hand to assist is a team that includes cardiac surgeons, infectious disease experts, interventional radiologists, cardiac anesthesiologists and imaging experts.

Removal procedures take place in a hybrid operating room, which can serve as both a well-equipped minimally invasive electrophysiology lab and a cardiac operating room. In the rare event that heart tissue is torn, surgeons can immediately perform open-heart surgery without losing valuable time.

Most of these replacement surgeries, says Love, are routine, and the hospital’s cardiac team performs many without incident, using general anesthesia. The lead extraction procedure is typically performed through a small incision in the chest, where the pacemaker has been implanted.

Once the leads are surgically exposed, the surgeon places a sheath (tube) over the lead that needs to be removed and advances it inside the vein. Using laser or mechanical energy, the surgeon frees the wire from the scar tissue in the vein and heart. The wire is then removed through the sheath. The process usually takes only a few minutes. Typically, patients stay in the hospital just one night from the time the leads are removed, depending on the reason for their extraction. Patients with infections will stay longer.

Misconceptions about the need for wire removal persist, he says. One fallacy is that an infection, other than a superficial skin infection, can be cured using antibiotics. Not true. “It is critical that a patient with an infected device have the system removed as soon as possible,” he says.

Another mistaken notion is that extracting leads is extremely dangerous. “Actually,” says Love, “there’s only a 0.3 percent mortality, and that number is getting lower with new techniques that we recently adopted.”

The electrophysiologist also offers consultation on other implant device issues. One patient recently arrived at the clinic feeling miserable because the timed settings between the chambers of the heart were not ideal. “We were able to adjust the algorithms and make her feel normal again and return her to her regular activities without operating,” recalls Love.

Read more stories in Cardiovascular Report.

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