Letter to the Editor--Extraction of nonfunctional leads at the time of device upgrade: Still unproven benefit compared to abandoning leads

I am concerned with the suggestion of Huang et al that because of their high success and low complications rates, lead extraction is preferred over abandoning nonfunctional leads at the time of device upgrade. It is not the success or complication rate that determines whether a procedure is recommendable but the net health gain for the patient. As of yet, the health profit of extracting nonfunctional leads is unproven. Even if complications are observed after leads are abandoned, this does not imply a causal relationship. Infection is not related to abandoning leads but to the surgical procedure. Venous obstruction does not suddenly result from leads that have been indwelling for years but from the insertion of new leads. Furthermore, it is unlikely that lead extraction prevents infection; it actually increases the risk by adding to the complexity of the procedure. Similarly, venous occlusion is a known complication of lead extraction, and there is no proof that the incidence is less frequent than with abandoning leads. Although the authors argue correctly that future extractions have a higher procedural risk because of longer dwell times, only a minority of patients with abandoned leads will ever need future mandatory extraction for device-related infection. Therefore, the absolute mortality and cost still will be lower than with early extraction of all nonfunctional leads. Finally, the claim that experienced centers have no extraction-related deaths is surprising. For example, The Cleveland Clinic reported 2 deaths in 429 extraction procedures of recalled leads. Thus, despite the excellent results reported by the authors, the article provides no arguments to advocate extraction of nonfunctional leads at the time of device upgrades.