An asymptomatic patient with abandoned leads. Shall we wait decades for class I indications or is it time to consider prophylactic lead extraction?

For the last 20 years scientific guidelines have suggested either lead abandonment or extraction in cardiac implantable electronic device (CIED) patients (class 2b indications). The former strategy, especially in people with longer life expectancy, produces a population of subjects in whom years after device implantation transvenous lead extraction (TLE) becomes a harmful procedure although it appears the only choice in patients with class 1 indications. We describe a female patient with four leads, including two that were abandoned 20 years ago, with pocket infection and lead-related infective endocarditis in whom the sum of the ages of all leads was 100 years (in our opinion the risk associated with removal of old leads is cumulative). The extraction procedure performed in the maximally safe environment was successful. All the leads were removed, and a major complication, cardiac tamponade, was managed surgically by placing sutures over two large perforations in the right atrial appendage (RAA). We discuss the course of the disease and investigate the possible outcomes of TLE if it had been performed 12 years earlier when replacing the device. We also discuss late and very late consequences of lead abandonment on the basis of this case report.