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EP LAB DIGEST. 2026;26(6).

Edited by Jodie Elrod

Bradley Knight, MD: Hi, I’m Brad Knight, editor of EP Lab Digest. We’re here in Chicago at the annual Heart Rhythm conference, and I have the pleasure of speaking with Dr Mikhael El-Chami at Emory, who is Vice Chair of the updated consensus document on cardiovascular implantable electronic device lead management and extraction. Thanks for taking a few minutes to talk with us. Maybe we can start with the highlights of the consensus document and what’s new.

Mikhael El-Chami, MD: Thank you so much for inviting me to talk about this. As you know, the last expert consensus statement was in 2017, so it’s been almost 10 years. There are a lot of newer technologies now being used, like leadless devices, the S-ICD, EV-ICD, and vegetation aspiration tools used in lead extraction. There are many new developments that we felt warranted updating the document.

Bradley Knight, MD: Let’s talk about that a little. There are a lot of newer extraction tools and approaches. I stopped doing extractions a few years ago. How did this influence the document and the levels of recommendation?

Mikhael El-Chami, MD: It’s true that there are many extraction tools on the market. Newer ones include lithotripsy and vibration tools. But these technologies don’t yet have a lot of data behind them. There’s not much in the document specifically about these tools. However, there’s a lot in the document about what to do with leadless pacing, S-ICD, and EV-ICD systems. I’ll give you some highlights. The best lead management strategy is to avoid leads whenever possible. So we now have a recommendation that if a patient presents for a pacemaker, there should be shared decision-making about choosing the best device based on the patient’s comorbidities and conduction system disease. For instance, if the ejection fraction is normal and there’s little chance of a high right ventricular pacing burden, consider a leadless pacemaker to avoid transvenous leads early on.

Bradley Knight, MD: I think the shared decision-making process really wasn’t present before, when we had fewer options. It was basically: you need a pacemaker, you get a pacemaker. And people have raised the question of whether, if you’re doing conduction system pacing, you really have that discussion with the patient or simply proceed with that approach. It’s not directly related to extraction, but it is related to lead management.

Mikhael El-Chami, MD: Exactly. The same applies to ICDs. For patients with novel primary prevention ICD indications, no pacing requirement, and no CRT requirement, we now have a Class I recommendation for shared decision-making. We also have a Class I recommendation for S-ICDs in patients with prior infections or vascular access limitations. For EV-ICDs, we have a Class IIa recommendation because the committee felt the EV-ICD has only been on the market for a couple of years, whereas the S-ICD has been available for 11 or 12 years, so the level of recommendation differs somewhat. There was some controversy among committee members, but ultimately we reached consensus.

Bradley Knight, MD: I’ll come back to how you approached those situations. Let’s go back to the S-ICD because, in the previous guidelines, I think the only Class I indication was for patients with limited access or prior infections. The vast majority of patients I implant with a subcutaneous ICD really only have a IIa indication. How did that change?

Mikhael El-Chami, MD: The previous guidelines didn’t include randomized trial data. Now we have the PRAETORIAN results, which showed that the S-ICD is noninferior to transvenous ICDs in a randomized controlled trial. So we now have stronger evidence supporting S-ICD use. The Class I recommendation came through shared decision-making, which I think is reasonable. 

Bradley Knight, MD: Even though these documents emphasize they’re guidance for physicians, they often end up being used almost verbatim by insurance companies for preauthorization, so wording matters. Can you talk a little more about some of these newer extraction tools? What’s your opinion on technologies like lithotripsy?

Mikhael El-Chami, MD: I was actually in a session today where a speaker discussed her experience with lithotripsy. It seems promising, although I personally haven’t tried it. The challenge with the data is that people say, “This looked like it would be a very difficult case, but after using lithotripsy it became easier than I expected.” But we don’t know what would have happened without lithotripsy. We need randomized data and more safety data because, at the end of the day, you’re inflating a balloon in areas with calcification. It appears safe, but we don’t really know yet. That’s why the guidelines didn’t focus heavily on these technologies—we just mentioned them.

Bradley Knight, MD: Historically, most acceptance of extraction has related to infected devices. Everyone understands that the whole system usually has to come out. Sterile leads are much more controversial. What’s your perspective—and what do the guidelines say—regarding a patient with a 10-year-old pacemaker coming in for an upgrade to an ICD?

Mikhael El-Chami, MD: That’s a good question. We have several recommendations addressing this. One is shared decision-making regarding abandonment versus extraction. We include a couple of clinical scenarios. For example, an 85-year-old with an abandoned pacing lead—in that situation, we suggest leaving the lead alone. On the other hand, for a 40-year-old with an abandoned lead, the risk-benefit discussion is different. The decision has to be individualized.

Bradley Knight, MD: The guidelines are balanced. They’re not recommending extraction of every lead in every patient. A newer situation we’re encountering involves transcatheter tricuspid valves trapping leads. We published data at Northwestern showing that among about 54 jailed leads, only around 3 had failures. Your group reported a somewhat higher incidence of problems. We’ve become more aggressive about extracting these leads because of increased experience. What’s your approach?

Mikhael El-Chami, MD: The guidelines include a substantial section on TTVR. Remember, recommendations require at least 70% agreement. Across all the TTVR data, including your center’s, the lead malfunction rate after jailing is around 6% to 10%. Our data was somewhat higher because it included many non-EVOQUE valves. We now have a Class I recommendation to avoid jailing leads whenever possible, with the caveat that patients at high extraction risk are excluded. One reason is that we already have a Class I recommendation against jailing leads during venous stenting.

Bradley Knight, MD: That’s a good analogy.

Mikhael El-Chami, MD: A 5% to 10% malfunction rate over 6 months to 1 year is not low risk.

Bradley Knight, MD: Right. It depends if the patient becomes dependent.

Mikhael El-Chami, MD: Many patients aren’t dependent beforehand but can become dependent afterward or move into a borderline situation. So we wanted to make a strong and consistent recommendation to avoid jailing leads whenever possible. We recommend evaluation by a lead extraction specialist. I often hear EPs say a patient is “high risk” for extraction even when the lead is only 5 years old or the patient has had a prior sternotomy. We wanted these cases evaluated by physicians who perform extractions regularly.

Bradley Knight, MD: At our institution, all of these patients are seen by one of the 2 physicians who perform most of the lead extractions. One final scenario: TAVR. I thought we were moving past this, but there’s a lot more pressure to reduce hospital length of stay, so we’re seeing very high-risk patients before TAVR to potentially implant pacemakers the same day if needed. There’s even some discussion of preemptively placing pacemakers. What’s your take? Are there any patients who should get a pacemaker before TAVR?

Mikhael El-Chami, MD: The only reason to place a pacemaker before TAVR is to make the interventional cardiologist feel better. So my answer is no.

Bradley Knight, MD: All right. 

Mikhael El-Chami, MD: We did not address preemptive pacing in TAVR patients in the document.

Bradley Knight, MD: Anything else you’d like to highlight?

Mikhael El-Chami, MD: Yes. One totally new section focuses on implant technique and minimizing leads. We now have a Class I recommendation to minimize leads, especially in younger patients. We also recommend avoiding an atrial lead during ICD implantation for primary prevention when it’s not necessary, because we don’t want to place redundant leads. And we have a Class I recommendation to avoid a medial subclavian stick. The idea is to proactively minimize future extraction problems.

Bradley Knight, MD: Thank you for your insight.

Mikhael El-Chami, MD: Thank you so much. 

The transcripts have been edited for clarity and length.