First-in-the-state heart procedure saves Iowa man’s life

Sherman’s luck didn’t end there. His arrhythmia eventually calmed, and a procedure was scheduled the following day to implant a cardioverter defibrillator to monitor his heartbeat and, if necessary, deliver a shock to restore his heart’s normal rhythm. For more than 20 years, the device hadn’t needed to deliver a shock, although the battery had to be replaced twice. But in 2023, the device shocked Sherman three times within a couple of months.

Luckily, his health care providers at Iowa quickly diagnosed a bacterial infection near the device’s wires — also called leads — and scheduled a lead extraction, a procedure that specialists in the UI Health Care Heart and Vascular Center complete more than 120 times a year — making Iowa one of the highest-volume lead extraction heart centers in the country.

UI cardiac electrophysiologist E. Michael Powers, MD, MBA, who performed the procedure on Sherman in December 2023, says it is not uncommon for an infection to develop around a device implanted in the body and that lead extraction is routine, usually taking a couple of hours to complete. But Sherman’s case presented a challenge.

“When you open the pocket, what you want to find is a little bit of light scar tissue that you can cut through quickly. What I found in Dr. Sherman was a rock-hard shell of calcium three or four millimeters thick surrounding the leads, and there’s only so much you can do with cutting tools,” says Powers, clinical assistant professor of internal medicine–cardiovascular medicine. “I have a laser that will cut through scar tissue but will do nothing on calcium. I have a mechanical cutting tool that is designed to cut without cutting through the blood vessel, and it can sometimes cut the calcium if it’s not too severe, but if it’s a thick chunk, it’s not going anywhere.”

Luckily, Powers had another option: shock wave lithotripsy. Originally developed to treat kidney stones, the procedure uses acoustic shock waves released via a balloon inserted into the blood vessel to break up the calcium. Powers had performed it once before — as a cardiac electrophysiology fellow at Vanderbilt University Medical Center — but it had never been done in Iowa. 

“Without the extraction, Dr. Sherman was absolutely going to die,” Powers says. “To get these kinds of infections under control, you must first put the patient on antibiotics, and then you’ve got to get the hardware out. Once the hardware gets infected, there’s no way to sterilize it. The bacteria form a biofilm that prevents penetration by the immune system, so even if you suppress the infection with antibiotics, the bacteria will still be inside, just waiting to spring out and make the patient sick again when antibiotics are stopped. If the infection goes on long enough, the bacteria can become resistant to the antibiotics, and then the infection slowly kills the patient.”

Before using the shock waves, Powers inserted a vacuum catheter to suck up vegetation comprising chunks of bacteria and clotted blood that was growing on the leads to prevent it from dispersing. While Sherman’s case was about as challenging and as risky as they come — the device was old, the leads were thick, and the patient was older — Powers says that UI Health Care was well equipped to tackle it.

“Anytime you’re dealing with high-risk procedures, volume matters. Because the more you do something, the better you get at it and the more comfortable you are,” Powers says. “This was an extraordinary case, but when you do a couple of high-risk extractions a month, that’s enough volume to identify gaps in care and make sure it is safe. You can foresee opportunities and problems, and that helps you deal with emergent issues rapidly. Plus, there are three of us here doing extractions — we can collaborate to get the best outcomes for our patients. We also have an updated cardiac catheterization lab and great cardiac surgeons who can step in when things do happen.”

Though technology has advanced over the years — Iowa’s cardiac electrophysiologists have provided input to manufacturers to improve the devices — Powers says lead extractions won’t be going away anytime soon.

“Leads will always scar the body and will always need to be extracted, and there will always be risk associated with that,” Powers says.

Since he was of advanced age and not dependent on the cardioverter defibrillator, Sherman opted to have the device and its leads removed and not replaced. He says he feels great today and will accept his fate if his heart stops. Plus, he knows his health is in good hands at Iowa.

“If I had one real wish, it would be for the arthritis in my knees to go away,” he says. “Iowa is a hospital you can trust. You go in expecting the best, and you get the best. There are a lot of hospitals in a lot of cities and all kinds of doctors, but I feel as though the best of the best overall are at UI Health Care. It has a great national reputation, and I’m very happy with it.”