Lead Management Across a Lifetime: Pediatric and Congenital Heart Disease Challenges in the Extraction Era

Interview With Douglas Y Mah, MD, FHRS, CEPS-P

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EP LAB DIGEST. 2026;26(9).

Interview by Jodie Elrod

EP Lab Digest sits down with Douglas Y. Mah, MD, FHRS, CEPS-P, to discuss long-term consequences of lead management decisions in pediatric and congenital heart disease patients, leadless pacing and nonvascular implantable cardioverter-defibrillator (ICD) technologies for younger patients, and the unanswered questions that remain around extraction safety and lead durability in this patient population.

The consensus statement repeatedly emphasizes thinking about lead management across a patient's lifetime. In pediatric and congenital heart disease patients, what decisions made during the first implant can have the biggest impact decades later?
I think how you phrased the question is perfect. When we implant devices in this population, we’re not just thinking about how it will affect them over the next 10-15 years, but really over a lifetime. What decisions can we make today that will set these patients up for success over the next 50-70 years?

The consensus statement addresses this quite well. Our goals are to limit the number of procedures the patient undergoes over their lifetime and to make future device revisions as straightforward as possible. Some procedural choices are well established, such as avoiding subclavian access to reduce lead malfunctions from subclavian crush syndrome and minimizing the amount of implanted hardware to limit venous obstruction. 

But I think the most important decision is choosing the right lead at the time of implant. That means selecting a lead with a good track record in terms of longevity, while also considering how well it will maintain its integrity if extraction becomes necessary. In young patients, abandoning leads over a lifetime is not really an option. So when you implant a lead, you should do so with the expectation that it will need to be removed at some point. I’m partial to lumenless leads for this reason. Their smaller caliber limits venous obstruction and interference with the tricuspid valve, and their tensile strength can make them relatively easier to extract when needed.  

How are leadless pacing and nonvascular ICD technologies changing the conversation for younger patients?
There have been great advancements in device technology, but in my mind, the impact on young patients remains relatively limited. Leadless devices are great for adult-sized pediatric patients with structurally normal hearts. However, the 27 French sheath for implant makes them less desirable for younger patients. The patient’s right ventricle also has to be large enough to accommodate the device without interfering with the AV valve function. As with conventional leads, we also need to make sure we are implanting hardware that can be readily explanted in the future. With no large-scale data on extractability after 10 or more years, I’m still hesitant to recommend these devices as first-line options for my patients.  

Size considerations also play a role with ICDs. The generator for the subcutaneous ICD remains somewhat bulky for many younger patients. The extravascular ICD has helped address that, but the inability to implant it in patients with a prior sternotomy makes it contraindicated for many congenital patients. Young patients with cardiomyopathies or channelopathies may benefit the most from these technologies. Congenital heart patients, however, are still often left with more conventional transvenous or epicardial devices, especially since many of them have pacing needs as well. 

What unanswered questions remain around extraction safety and lead durability in congenital heart disease populations?
I think the biggest questions regarding lead extractions in congenital heart patients are:

1. Will extracting left bundle leads be an issue down the road? With the leads burrowed deep into the septum, it is unclear to me whether their removal will be more difficult, potentially leading to more advanced extraction techniques being used and more lead fragments left behind.
    
2. How can we make lead extraction safer in patients who received their devices at a young age? Leads implanted in young patients often develop more extensive fibrosis and stronger lead binding over time, making extraction more challenging. Again, picking the right lead at implant is imperative in making future extractions easier. For congenital heart patients specifically, there remains a higher incidence of tricuspid valve injury following lead extraction. We need more data on to better understand why this occurs and how it can be prevented. Transesophageal and intracardiac echocardiography can help, but image quality is often insufficient to fully evaluate how the lead is interacting with the tricuspid valve, especially the subvalvular apparatus. There is still a great deal to learn.