Lead fragment characteristics and detection by radiographic imaging after heart transplant

During orthotopic heart transplant (OHT), removal of a cardiac implantable electronic device involves traction from the device pocket, frequently leaving behind lead fragments.

This study aimed to determine fragment locations, risk factors, chest radiograph (CXR) sensitivity of fragment detection, and risk of fragment-related sequelae.

Among consecutive OHT patients with cardiac implantable electronic devices (2017-2024) at our institution, the prevalence and location of fragments were determined by CXR and computed tomography (CT) scan. Using a CT scan as the gold standard, the sensitivity of CXR and radiology reports for lead fragments was determined. Regression identified factors associated with fragments, bacteremia, and fragment-related sequelae.

Of 116 patients, 20.7% (n = 24) had fragments (79% by CXR, 21% visible on CT scan only), mostly in the innominate vein (75%). CXR sensitivity for fragments was 79%. Only 7 of 19 fragments (37%) visible by initial post-OHT CXR were reported. Of 20 initial post-OHT CTs, 13 noted fragments (65%). Incremental 5-year lead dwell time (odds ratio [OR] 1.9; 95% confidence interval [CI] 1.1-3.1; P = .017), dual-coil implantable cardioverter-defibrillator (OR 4.4; 95% CI 1.4-13.8; P = .011), and increasing number of leads (OR 1.9; 95% CI 1.1-3.6; P = .023) were associated with fragments. Bacteremia occurred in 23% (33% with fragments vs 21% without; OR 1.9; 95% CI 0.7-5.2; P = .19). Magnetic resonance imaging was deferred in 21% of patients (n = 5) with fragments. Neither deep vein thrombosis nor fragment embolization occurred.

At least 20% of OHT patients have retained lead fragments, usually in the innominate vein. CXR is insensitive in identifying fragments. Bacteremia is common after OHT, and longer lead dwell time, dual-coil defibrillator leads, and an increasing number of leads were associated with fragment retention.