When Not to Extract: Navigating Clinical and Ethical Boundaries

Interview With Raymond Schaerf, MD
 

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EP LAB DIGEST. 2026;26(3).

Interview by Isabel Vega 

In this interview, we speak with Dr Raymond Scharf from the Smidt Heart Institute at Cedars-Sinai in Los Angeles to discuss his presentation from the recent Virtual Lead Extraction Experts Meeting titled, "When Not to Extract: Navigating Clinical and Ethical Boundaries."

Raymond Schaerf, MD: Hi, I'm Dr Raymond Scharf, I'm a cardiothoracic surgeon at the Smidt Heart Institute at Cedars-Sinai in Los Angeles. I've been doing extractions since 1972. I'm here today to talk about when not to do extractions, which I presented on at the recent VLEEM meeting. We perform about 180 extractions per year at Cedars-Sinai, but we also turn down about 10 to 20 patients each year, depending on the situation. Turning them away doesn't mean they don't receive an extraction, it means they have a different procedure performed, such as an open-heart procedure.

With today’s powerful extraction tools and advanced support options, what are the key factors that tell you an extraction should not be performed—even when it’s technically feasible?

Raymond Schaerf, MD: I think the most important issue is the goal of the extraction, and the benefit, if there is one for the patient. There are some things that are quite simple. If someone is infected and they have a life expectancy that is at least several months, then we go ahead and do it no matter what the risks are. 

There are some patients, however, who may be better served with a different kind of procedure, or no procedure at all. If we see a patient who has other cardiac anomalies or a condition such as valve disease, and the patient needs to have something else performed besides the lead extraction, then we usually refer them to cardiac surgery. An example of this is a patient with wide-open tricuspid insufficiency. There are ways of repairing this, but sometimes that is better done with surgery, because not all cases can be treated percutaneously. 

For example, if we have a patient who has experienced a massive stroke and we don't expect them to recover, then they are better treated medically and not with surgery, because the surgery itself can pose a risk to the patient. We perform all these cases under general anesthesia. We don't want to expose someone who is already frail to something that may not help them.

You emphasize the importance of learning to say “no.” What patient population or procedural red flags should EP teams recognize early on when considering lead extraction?

Raymond Schaerf, MD: Some of it has to do with the experience of the team and the complexity of the case. This may include patients with multiple lead fragments in the body or if a patient has an infected or malfunctioning pacemaker, but they also have wide-open valvular disease, severe valve disease, or a severely impaired myocardium. Those patients should either be referred elsewhere or not undergo the procedure, because the anticipated benefit is unlikely to outweigh the risks.

How should EP labs balance guideline-based indications for extraction with real-world issues like limited life expectancy, severe comorbidities, or do-not-resuscitate status?

Raymond Schaerf, MD: The key is to have a team that is multifactorial. It involves not only the EP lab, but cardiology, ethics, social work, and all the things that come into play with a program such as ours. A decision must be made based on the patient’s preference—if the patient has decision-making capacity—or the wishes of the family. Most importantly, there must be a clear understanding of what the expectations are. It is important to ensure that patients have realistic expectations, as surgery may offer only limited benefits and may not meaningfully address the problem.

What risks do you think EP teams most often underestimate when planning complex lead extractions, especially in patients with challenging anatomy or prior surgeries?

Raymond Schaerf, MD: I think the concern is always what is going to happen to the patient if it is not an easy extraction, and I don't think that's underestimated. Often, we'll see things when we do our workup that may not be visible to the average eye. For example, we perform a gated cardiac computed tomography for every case, and sometimes we find that a lead that we're going to extract has gone through the myocardium, and the risk of a tamponade after that is very high. On other occasions, we may see dense calcification or scarring in the superior vena cava, which makes extraction more challenging, but this can be addressed by using a Bridge balloon (Philips) if necessary.

As extraction volumes and expectations continue to rise, how can EP labs maintain strong clinical judgment and ethical decision-making while still advancing in the field?

Raymond Schaerf, MD: I believe that the more you do, the more you learn. Reviewing the cases, including a broad-based review of the department, is important. You learn by doing, including what not to do. Keeping this in mind as you progress through your surgeries and evaluations will enable you to speak more honestly with patients and their families about your experience. 

Is there anything else you'd like to share with our readers?

Raymond Schaerf, MD: Lead extraction has come a long way. I've been performing these procedures for many years, and it is remarkable to see how companies have not only advanced education in this field but also developed excellent tools, with even more innovations coming in the future. For some clinicians, using extraction tools can be challenging, but based on current developments, the process is likely to become more streamlined and easier in the future. 

It is essential that patients receive appropriate treatment. For example, infection is a Class I indication for infection and should be addressed promptly. However, global data show that fewer than 25% of patients with this indication undergo extraction. That is an issue, as failure to treat appropriately can significantly affect both survival and quality of life.

The transcripts were edited for clarity and length.