June 23, 2026
A Mayo Clinic cardiovascular specialist is first author and chair of the new cardiovascular implantable electronic device (CIED) practice guidelines, which were published in Heart Rhythm and developed in consensus with key cardiac societies. Internationally recognized experts from five countries in the fields of clinical electrophysiology, pediatric electrophysiology, cardiothoracic anesthesiology, cardiothoracic surgery and infectious diseases served on the writing committee.
Yong-Mei Cha, M.D., a cardiologist and cardiac electrophysiologist at Mayo Clinic in Rochester, Minnesota, steered this expert statement on lead management and extraction. The updated guidelines address changes since the 2017 statement. They cover new evidence on CIED lead management and the growing development of new technologies.
This increase in using the modern technologies of leadless pacing and nonvascular implantable cardioverter-defibrillators (ICDs) has created what the 2026 authors describe as a new paradigm of nonvascular cardiac rhythm management. Today's CIEDs provide the potential to decrease clinical challenges and morbidity that may be associated with intravascular devices.
"The evolving new technologies provide patients with not only transvenous (TV)-CIEDs but also leadless PMs, nonvascular ICDs, which are alternatives and more favorable options for those who lack venous access, have recurrent transvenous lead infections and other limitations," Dr. Cha says.
Future CIED lead management
For more than 70 years, CIEDs have become an established treatment option for certain patients with bradycardia, tachycardia and heart failure. Plus, new cardiac and vascular procedures such as transvenous tricuspid valve (TTV) interventions and central venous stenting have concurrent lead management implications.
"The new document has a significant impact on CIED practice. It addresses the latest CIED technologies and the advantages of transvenous leads over other lead types," Dr. Cha says. "The guidelines also deliver new evidence supporting diagnosis, treatment and prevention of CIED infection. And they offer appropriate lead management in transcatheter tricuspid valve replacement for tricuspid regurgitation and standardization of the transvenous lead extraction approach."
Preventing CIED infection
It's imperative to give careful thought to lead selection implantation techniques. With transvenous leads, consider the risk of lead fracture, infection, pocket complications and the need for future extraction.
The new statement recommends:
- Minimizing the number of leads as appropriate.
- Selecting single versus dual implantable cardioverter defibrillator coils.
- Practicing meticulous techniques for vascular access and lead placement.
"In patients undergoing a CIED procedure, administering preoperative systemic antibiotics prior to incision is recommended to reduce the risk of infection. In high-risk patients with a CIED, immunosuppression or prior device infection, using an antibacterial envelope can help reduce the risk of pocket infection," Dr. Cha says.
Shared decision-making
When patients have indications for lead removal, prompt referral to an experienced center with a multidisciplinary team of specialists is necessary.
Early extraction is recommended for patients with CIED infection. Removing the CIED in less than seven days shows reduced hospital mortality and major adverse events than with delayed extraction.
"Lead management and extraction involve a high-risk procedure, and patient-centered shared decision-making is key," Dr. Cha says. "It's important to assess and discuss the immediate and long-term risks and benefits of each treatment option while taking into account the patient's preference and comorbidities."
The guidelines call for mandatory remote monitoring. "Pacemakers and defibrillators lead failure can present in a variety of clinical scenarios," Dr. Cha says. "They may range from presymptomatic detection on remote monitoring or in-person device interrogation, to symptomatic abnormal performance of the CIED system, to catastrophic failure to pace or defibrillate. Remote monitoring and close clinical follow-up are crucial."
Looking ahead
Due to knowledge gaps, more research is needed about evidence-based management of CIED leads. The information will be critical to guiding future recommendations and optimizing patient outcomes.
"CIED management strategies start from the implant, including device and lead selection, implant techniques and infection prevention. CIED requires lifelong lead management through remote monitoring and in-person clinic follow-up," Dr. Cha says. "These new guidelines will impact clinical practice to improve the outcomes of CIED lead management and extraction for the best of patient care."
For more information
Cha Y, et al. 2026 HRS/AHA/APHRS/EHRA/IDSA/LAHRS/PACES/STS expert consensus statement update on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2026; In press.
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