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Gabriels JK, Schaller RD, Koss E, Rutkin BJ, Carrillo RG, Epstein LM. Lead management in patients undergoing percutaneous tricuspid valve replacement or repair: a 'heart team' approach. Europace 2023; 25:euad300. [PMID: 37772978 PMCID: PMC10629975 DOI: 10.1093/europace/euad300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 09/30/2023] Open
Abstract
Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads.
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Affiliation(s)
- James K Gabriels
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY, USA
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elana Koss
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | - Bruce J Rutkin
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | | | - Laurence M Epstein
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY, USA
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Salvage of Cardiac Implantable Electronic Device Pocket Infection with Skin Erosion in Frail 92-Year-Old. J Cardiovasc Dev Dis 2022; 9:jcdd9030081. [PMID: 35323629 PMCID: PMC8955956 DOI: 10.3390/jcdd9030081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 02/01/2023] Open
Abstract
We reported the novel use of a taurolidine-containing antimicrobial solution in the successful salvage of a partially exposed and polymicrobially infected cardiac implantable electronic device pulse generator in a frail patient unfit for lead extraction. The old, salvaged device was entirely internalized, and there were no signs of recurrent infection at 9 months follow-up.
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Borov S, Baldauf B, Lau EW, Bonnemeier H. Salvage of infected cardiac implantable electronic device with taurolidine—a case report. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00068-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cardiac implantable electronic devices (CIEDs) are commonly used to treat cardiac arrhythmias and prevent sudden cardiac death. Complications of CIED therapy include component malfunction, lead dislodgement, skin erosion and infection. Infection can result in significant morbidity and even mortality. The recommended treatment of CIED skin erosion and infection is urgent complete device extraction. When this is infeasible due to patient or resource factors, an attempt could be made to salvage the exposed or infected CIED system by debridement of all the infected necrotic tissues and irrigation of the pocket and contaminated hardware with anti-septic/antibiotic solutions. Taurolidine, when dissolved in an aqueous solution, produces a broad spectrum of antimicrobial actions and may be used as a novel irrigation agent during CIED salvage.
Case presentation
This report describes the first use of a taurolidine-containing solution for pocket irrigation and in situ hardware sterilisation that resulted in the successful salvage of a CIED infected with multi-resistant Staphylococcus epidermidis.
Conclusions
A taurolidine-containing antimicrobial solution can be a safe and effective alternative to traditional antiseptic/antibiotic solutions for pocket irrigation and in situ hardware sterilisation during CIED salvage, and may produce better clinical outcomes by some unique mechanisms of action such as inhibition of biofilm formation and neutralisation of endotoxins, with little risk of inducing and encountering resistance.
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Bisignani A, De Bonis S, Mancuso L, Ceravolo G, Bisignani G. Pacemaker pocket infection: Innovative conservative treatment in elderly patients with no signs of systemic infection. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1340-1346. [PMID: 31429949 DOI: 10.1111/pace.13787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/02/2019] [Accepted: 08/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The gold standard to treat cardiovascular implantable electronic devices (CIEDs) infections is the complete system removal. The aim of this retrospective analysis is to assess the feasibility and safety of an alternative conservative surgical system revision approach, to be applied in elderly patients who refused the extraction procedure, in case of no signs of systemic infection. METHODS Between May 2009 and January 2019, we performed system revision of 25 patients (15 men and 10 women, median age 81 [IQ: 75-85] years) with negative blood culture, no signs of vegetation, who experienced CIED infections. RESULTS In all patients the following surgical procedure was applied: the pocket was opened, the wound's necrotic tissue was dissected en bloc; fibrotic tissue was excised. The pocket was washed with hydrogen peroxide and saline solution. The pocket was then closed without implanting the device and left with a continuous infusion of antibiotics and normal saline for 4 days. Subsequently the new generator was implanted, possibly in a different pocket than the previous one. All patients underwent a median follow up of 24 [IQ: 14-34] months. In 24 patients out of the 25 observed the procedure was safe and effective, except for one patient who needed the extraction. CONCLUSIONS The two-stage surgical revision technique is feasible and safe. It may be considered for elderly patients who refused extraction and presented no signs of systemic infection or in some categories of patients. In case of failure of the procedure, subsequent treatment with complete extraction of the system would not be precluded.
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Affiliation(s)
- Antonio Bisignani
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Silvana De Bonis
- Department of Cardiology, Ospedale "Ferrari", Castrovillari, Cosenza, Italy
| | | | | | - Giovanni Bisignani
- Department of Cardiology, Ospedale "Ferrari", Castrovillari, Cosenza, Italy
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Nagel SJ, Frizon L, Maiti T, Machado AG, Gillies GT, Helland L, Woodroffe RW, Howard MA, Wilson S. Contemporary Approaches to Preventing and Treating Infections of Novel Intrathecal Neurostimulation Devices. World Neurosurg 2019; 128:e397-e408. [DOI: 10.1016/j.wneu.2019.04.165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 02/04/2023]
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Love CJ. Palliation and Nonextraction Approaches. Card Electrophysiol Clin 2018; 10:681-687. [PMID: 30396583 DOI: 10.1016/j.ccep.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Although definitive therapy for infected cardiac implantable electronic device systems requires removal of all hardware in the infected areas with extraction of intravascular components as well, there are situations where extraction is not available or appropriate. Palliative procedures and chronic suppressive antibiotics may be used in these cases. There are also options that may in some cases result in long-term freedom from infection.
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Affiliation(s)
- Charles J Love
- Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 592B, Baltimore, MD 21287, USA.
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Peacock JE, Stafford JM, Le K, Sohail MR, Baddour LM, Prutkin JM, Danik SB, Vikram HR, Hernandez-Meneses M, Miró JM, Blank E, Naber CK, Carrillo RG, Greenspon AJ, Tseng CH, Uslan DZ. Attempted salvage of infected cardiovascular implantable electronic devices: Are there clinical factors that predict success? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018. [PMID: 29518265 DOI: 10.1111/pace.13319] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Published guidelines mandate complete device removal in cases of cardiovascular implantable electronic device (CIED) infection. Clinical predictors of successful salvage of infected CIEDs have not been defined. METHODS Data from the Multicenter Electrophysiologic Device Infection Collaboration, a prospective, observational, multinational cohort study of CIED infection, were used to investigate whether clinical predictors of successful salvage of infected devices could be identified. RESULTS Of 433 adult patients with CIED infections, 306 (71%) underwent immediate device explantation. Medical management with device retention and antimicrobial therapy was initially attempted in 127 patients (29%). "Early failure" of attempted salvage occurred in 74 patients (58%) who subsequently underwent device explantation during the index hospitalization. The remaining 53 patients (42%) in the attempted salvage group retained their CIED. Twenty-six (49%) had resolution of CIED infection (successful salvage group) whereas 27 patients (51%) experienced "late" salvage failure. Upon comparing the salvage failure group, early and late (N = 101), to the group experiencing successful salvage of an infected CIED (N = 26), no clinical or laboratory predictors of successful salvage were identified. However, by univariate analysis, coagulase-negative staphylococci as infecting pathogens (P = 0.0439) and the presence of a lead vegetation (P = 0.024) were associated with overall failed salvage. CONCLUSIONS In patients with definite CIED infections, clinical and laboratory variables cannot predict successful device salvage. Until new data are forthcoming, device explantation should remain a mandatory and early management intervention in patients with CIED infection in keeping with existing expert guidelines unless medical contraindications exist or patients refuse device removal.
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Affiliation(s)
- James E Peacock
- Section on Infectious Diseases, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeanette M Stafford
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Katherine Le
- Division of Infectious Diseases, Department of Medicine, and the Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Muhammad Rizwan Sohail
- Division of Infectious Diseases, Department of Medicine, and the Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, and the Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Jordan M Prutkin
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Stephan B Danik
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Holenarasipur R Vikram
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Marta Hernandez-Meneses
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José M Miró
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Elisabeth Blank
- Ärztin im Studienzentrum Kardiologie, Contilia Heart and Vascular Center, Essen, Germany
| | - Christoph K Naber
- Klinik für Kardiologie und Angiologie, Contilia Heart- and Vascular Center, Elisabeth-Krankenhaus, Essen, Germany
| | - Roger G Carrillo
- Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Arnold J Greenspon
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, CA, USA
| | - Daniel Z Uslan
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, CA, USA
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