Introduction

This patient information gives general advice about removal of your Implantable Loop Recorder (ILR). It does not replace advice from a healthcare professional but is intended to let you know why this might have been recommended, as well as outlining the benefits and risks, how to prepare for your appointment, what the procedure itself involves and what the aftercare will be. This has been written to help you understand each stage so that you know what to expect and hopefully feel more comfortable about your procedure.

What is an ‘explant’?

You may hear healthcare professionals refer to you having an ‘explant’. This simply means the procedure to remove the ILR from under your skin once it is no longer needed or has reached the end of its battery life. Removing the device is very similar to the procedure to implant it and is done under local anaesthetic so that you don’t feel any pain⁽¹⁾. Removing your device will likely take a little longer than your implant. This is still done as a day-case, meaning that you go home the same day.

Why is the ILR being removed?

There are a few reasons why your doctor/clinician might recommend your ILR be removed:

• The device has completed its monitoring purpose – it has recorded your heart’s activity during your symptoms, and sufficient information has been gathered to make a diagnosis. Once the cause of your symptoms has been identified (or ruled out), the device is no longer needed and can be removed. For example, if it turns out that your blackouts were not due to a heart rhythm problem, or if an alternative diagnosis has been confirmed, then the ILR’s job is finished.
• Battery life is ending/has ended – The LINQ II ILR (the current generation of device that we implant) runs on a small battery that typically lasts between 4 and 5 years. When the battery is depleted, the device can no longer record data. It is safe for the device to remain in your chest after the battery is depleted, but it won’t be working, so removal is generally recommended.
• Moving to a different treatment – In some situations, the ILR findings may indicate that you need another type of device of treatment, for instance, if a cardiac cause for your symptoms has been found (such as a slow heart rhythm), your doctor/clinician might recommend a pacemaker. In that case, the ILR will be removed (sometimes this is done during the procedure to implant the pacemaker, rather than two separate procedures).
• Device issues – less commonly, the ILR might be removed early if there is a problem with the device or the implant site – for example if the ILR causes persistent skin irritation or if there is an infection.

If it is not clear to you why your doctor has recommended this, you are encouraged to contact them to discuss this further, prior to attending your appointment – your referring doctor/clinician will not be available on the day, though there will be an appropriately trained clinician present with whom to discuss the procedure itself.

Removal and New Implant

Very occasionally, there is an indication for monitoring to continue beyond your current ILR’s battery life. In this scenario it may be recommended for you to have your device removed, followed by the insertion of a new device as one procedure. In this scenario the procedure of removing the old device is the same, but a new ILR will be placed in the old pocket under the skin, before the cut is closed with skin glue.

Rarely, a new cut may need to be made if the old site is not felt to be appropriate, due to anatomy, infection, or other concerns about positioning.

What are the benefits of having the device removed?

Having the device removed has several benefits:

• No more device under the skin – once the ILR is out, you won’t have a device under the skin anymore. Many patients are barely aware of their ILR, while others may occasionally feel or see a lump where it was implanted. After removal, there will be no device protrusion under the skin, which might be more comfortable for you, especially if the implant had been particularly sensitive or if you were self-conscious about it.
• Avoid unnecessary risks – an ILR is generally considered to be safe to leave in place after it has served its purpose, but there is no evidence for this over the long term, as standard practice is to have them removed. Any implanted device carries a small risk of infection or irritation over the long term.

Manufacturers advise removing the device out once it is no longer needed and by doing so you eliminate any ongoing risk of device-related skin issues.

• End of monitoring responsibilities – when the ILR is removed, you will no longer need to carry the patient activator or bedside monitor for it, and you won’t have to transmit data or keep track of a device battery.
• Peace of mind – finally, many patients simply feel better once an unnecessary device is taken out. The ILR doesn’t cause any significant issue by itself, but it’s normal to feel relieved that you no longer need a device that is not serving any purpose. You’ll have a small scar, but otherwise your chest will be back to normal. If the ILR did not find any dangerous heart rhythm issues, having it removed can psychologically mark the end of that investigative journey.

What are the potential risks and complications?

• Infection – this is rare (less than 1% risk) and may need antibiotics.
• Haematoma (a collection of blood under the skin) – this is also rare (less than 1% risk).
• Bruising or discomfort – this is common and will settle within days. You can take simple over-the-counter pain killers such as paracetamol and ibuprofen⁽⁶⁾.
• Skin reaction – this is uncommon.
• Scarring – there will be a slightly larger scar than before, but it will still be small.
• Mild sensitivity around the removal site – this is common and may last for a few weeks.

What do I need to know before the procedure?

• You should eat and drink normally on the day of your procedure. If you are particularly prone to fainting – when you have your blood taken etc – you are advised to drink plenty of fluid and make sure you eat before attending⁽⁴⁾.
• Take your medications as usual – this includes blood thinning drugs (anticoagulation or antiplatelets)⁽⁵⁾.
• Wear loose, comfortable clothing.
• Bring a list of your medications and allergies.
• Please inform a team member on the day if you have had any heart valve surgery in the past.
• Please inform the team if you are pregnant, have any bleeding disorders, or any other specific concerns or needs that you believe to be relevant.
• The procedure is carried out in our cardiac catheter laboratory as a day-case, with the appointment taking 30 to 45 minutes including the pre and post procedural care.
• If you feel unwell in the days leading up to the procedure (vomiting, diarrhoea, cough, cold or flu-like symptoms, with or without a fever), you should contact the cardiology booking team before attending, or the cardiac catheter lab, if on the day of the procedure.
• If you have large breast size (cup size over C), a sports (or other sufficiently supportive) bra is recommended for 7 days following the procedure to reduce wound traction and ensure that the wound has the opportunity to properly heal.
• We recommend that you arrive in plenty of time for your appointment. Information about parking (including how to use your blue badge for free parking) can be found on our website: https://www.ulh.nhs.uk/hospitals/lincoln-county/parking/ or scan the QR code below:
• Call 0300 300 3434 if you believe you are eligible for patient transport.

If you are unable to keep your appointment

Please contact the booking team immediately, if it becomes apparent that you cannot attend your appointment. This allows us to:

• Organise a new appointment with you, rather than simply remove you from the waiting list for failing to attend without explanation.
• Offer another patient your appointment to use our time efficiently and keep our waiting lists down.

If you are running late on the day, please contact the cardiac catheter lab on 01522 582 648 to notify them of your arrival time.

What happens in the procedure?

If you have had heart valve surgery in the past, then you will receive a single dose of an intravenous antibiotic before the procedure, to reduce the risk of infection on your heart valve (known as endocarditis)⁽⁶⁾.

• Preparation – you will lie on your back either on a trolley or a specific procedural table. Your chest will be fully exposed. It will be necessary to inspect the site of the device implant, to judge where best to make the cut in the skin, to access the device. Once the operator is satisfied, the left side of the chest is cleaned with a surgical cleaning solution. A sterile drape will then be placed over the chest, which may partially obscure your face.
• Anaesthetic – local anaesthetic is injected to numb the skin. Time will be allowed for this to be effective, and you will not be rushed. You will remain awake throughout.
• Incision – a cut is made using a scalpel, which will be slightly larger than that made when the device was implanted. This is to allow for forceps to grasp the device through the opening in the skin. Sometimes this takes a few moments, sometimes longer.
• Removal – you may be aware of some pressure or tugging, but should not feel any pain, and we will talk to you throughout to reassure you and confirm that you are comfortable as we are working. Once we have hold of the device it will be slid out from under the skin. This may be a strange sensation but will not be painful.
• Closure – as with an implant, the cut is closed with skin glue and covered with a water-proof clear dressing, which remains in place for 7 days.
• Duration – the removal procedure can be quick and simple – sometimes it can be more challenging. Sometimes devices that have been in place for longer are more difficult to tease out, but this is not always true.

What happens after the procedure?

• You will be able to go home at this point.
• You may feel some mild tenderness at the removal site for a few days.
• Keep the dressing dry for 48 hours; after that you can shower normally (avoid fully submerging whilst the dressing remains in place for 7 days).
• Avoid strenuous activity, stretching, or heavy lifting for 3 to 5 days.
• If you have large breast size (cup size over C), a sports (or other sufficiently supportive) bra is recommended for 7 days following the procedure to reduce wound traction and ensure that the wound has the opportunity to properly heal.
• There is no limitation on when you can return to work.
• Avoid tight clothing or pressure directly over the implant site until healed.
• It might be tempting to feel where the device was, but poking at the area can disturb healing. There may be a little bruising or a lump under the skin initially – this is normal and will resolve. Let your body heal without interference.
• If needed for soreness, you can take over the counter painkillers such as paracetamol or ibuprofen⁽⁶⁾.

When to seek medical advice

You should present to your local urgent treatment centre (UTC) or emergency department if you experience:

• Redness, swelling, or pus from the wound.
• Feeling unwell with a fever (temperature).
• Significant bleeding from the site that won’t stop.

Frequently asked questions

Can I shower or swim after?

Shower, yes – provided you keep the dressing in place, you can shower after 48 hours.

Swimming/bathing, no, not straight away – avoid soaking the wound until fully healed (7 days), at which time the dressing can be removed.

Can I drive after?

There are no restrictions on driving related to the procedure itself, but there may be restrictions on the basis of your symptoms – blackouts⁽⁷⁾, for example. Your doctor/clinician should advise you regarding this, and advice regarding this falls outside the scope of your ILR appointment. Further information can be found on the DVLA website: https://www.gov.uk/driving-medical-conditions/ or scan the QR code below:

Do I need any special tests or checks after the explant procedure?

No. The wound will heal on its own, and you don’t need any x-rays or blood tests simply because of the device removal.

Do I need to do anything with the home monitor?

Once the ILR is explanted, you will no longer need the home monitor or the patient activator and can bring these with you to your procedure. Alternatively, you can return them to the pacing team at Lincoln, Grantham or Pilgrim hospitals.

Can I travel after?

You will be safe to travel after your procedure. However, you should check with your doctor/clinician before making travel arrangements and ensure you have adequate travel insurance.

If you have any questions or concerns about your removal procedure not covered in this patient information, there will be an opportunity to discuss these on the day.

For any questions about your diagnosis or clinical management, you are encouraged to contact your doctor/clinician to discuss this separately, as they will not be available on the day.

Please keep this document so that after you have been to visit us for your ILR explant, you can scan the QR code below and complete a very short patient feedback questionnaire.

https://docs.google.com/forms/d/e/1FAIpQLSd75dStaoYRB0giFtOhg6LO3rceV6TxAckT8DmVmSDE_ofWTw/viewform?usp=sharing&ouid=104476154605656483068

We greatly value your feedback. We will use this information to adapt our services to better address your concerns and align with your needs and expectations. Thank you!

Contacts

Monday to Friday 9.00am to 5.00pm unless otherwise stated

Cardiology booking team (about your appointment):    01522 597 716 and 573 575

or email: [email protected]

Cardiology secretaries (general queries):                        01522 597 875 (Lincoln)

                                                                                                01522 446 282 (Pilgrim)

Cardiac catheter laboratory: (on the day)                                    01522 582 648

Cardiac physiology team:                                                   01476 464 160 – Lincoln and Grantham areas

01205 446 565 – Boston area

Medtronic ‘Be Connected’:                                                 00800 266 632 82

(Monday to Friday 8.00am to 4.00pm, free of charge)

Patient transport:                                                                  0300 300 3434

                                                                                                (7 days a week)