IMpact of pocKet rEvision on the rate of InfecTion and other CompLications in patients rEquiring pocket mAnipulation for generator replacement and/or lead replacement or revisioN (MAKE IT CLEAN): A prospective randomized study

Clinical impact of capsulectomy during cardiac implantable electronic device generator replacement: a prospective randomized trial

BACKGROUND

The avascular capsule around the generator of the cardiac implantable electronic device (CIED) could be susceptible to bacterial colonization and source of infection. Capsulectomy during CIED generator replacement may be beneficial in preventing device infection, but there is a lack of evidence.

METHODS

This prospective randomized trial, conducted from December 2013 to December 2019, included 195 patients divided equally into two groups. In the intervention group (n = 97), capsule removal was performed on the floor of the pocket, while it was not performed in the control group (n = 98). In both groups, swab culture was performed in the pocket. The primary outcome was the occurrence of device infection requiring pocket revision.

RESULTS

A total of 195 patients were included (mean age 70.2 ± 13.6 years, 55.4% women), with an average follow-up period of 54.3 ± 28.9 months. Among 182 patients undergoing microbiological cultures of pockets, 19 (10.4%) were confirmed positive, and Staphylococcus species were identified most frequently. The primary outcome occurred in 4 (2.1%), and there was no significant difference between the two groups (3.1% vs. 1.0%, p = 0.606). Hematoma has occurred in 10 patients (3.1% vs. 7.1%, p = 0.338), one of them required wound revision. In multivariable analysis, the occurrence of hematoma was the only independent risk factor associated with device infection (HR 13.6, 95% CI 1.02-181.15, p = 0.048).

CONCLUSIONS

In this long-term prospective study, capsulectomy during the replacement of the generator did not reduce the incidence of device infection. There was no association between bacterial colonization in the capsule around the generator and CIED infection.

Lead Management in Patients with Congenital Heart Disease

Pediatric patients with congenital heart disease present unique challenges when it comes to cardiac implantable electronic devices. Pacing strategy is often determined by patient size/weight and operator experience. Anatomic considerations, including residual shunts, anatomic obstructions and barriers, and abnormalities in the native conduction system, will affect the type of CIED implanted. Given the young age of patients, it is important to have an "eye on the future" when making pacemaker/defibrillator decisions, as one can expect several generator changes, lead revisions, and potential lead extractions during their lifetime.

Chlorhexidine gluconate pocket lavage to prevent cardiac implantable electronic device infection in high-risk procedures

BACKGROUND

Infection is the most dreaded complication of cardiac implantable electronic devices (CIEDs), particularly in patients undergoing high-risk procedures (eg, generator change, device upgrade, lead/pocket revision).

OBJECTIVE

The purpose of this study was to describe the impact of chlorhexidine gluconate (CHG) pocket lavage in high-risk procedures.

METHODS

Patients from a prospective multicenter registry undergoing high-risk procedures were included. CHG lavage was performed by irrigating the generator pocket with 20 cc of 2% CHG without alcohol followed by and normal saline (NS) irrigation. Only NS irrigation was performed in the comparison group. The primary efficacy outcome was CIED-related infection at 12 months. The primary safety outcome was any CHG-associated adverse event. The secondary outcome was CIED infection during long-term follow-up. Propensity score matching (PSM) analysis was performed for the primary efficacy outcome.

RESULTS

A total of 1504 patients were included. At 12-month follow-up, the primary efficacy outcome occurred in 4 of 904 CHG (0.4%) and 14 of 600 NS (2.3%) subjects (log-rank P = .005). On multivariate analysis, the use of CHG irrigation was associated with a lower risk of infection at 1-year follow-up (Cox proportional hazard ratio [HR] 0.138; 95% confidence interval [CI] 0.04-0.45; P = .001). This effect persisted during long-term follow-up. PSM demonstrated a significant reduction in CIED-related infection for the CHG group (0.2% vs 2.5%; Cox proportional HR 0.08; 95% CI 0.01-0.59; P = .014). No adverse events were associated with the use of CHG.

CONCLUSION

CHG lavage during high-risk procedures was associated with a reduction in CIED-related infections without any adverse events reported. The benefits of CHG lavage were observed even during long-term follow up and in PSM analysis.

Use of a taurolidine containing antimicrobial wash to reduce cardiac implantable electronic device infection

AIMS

TauroPace (Tauropharm, Bavaria Germany), a taurolidine solution for combating cardiac implantable electronic device (CIED) infection, was compared with a historical control of 3% hydrogen peroxide (H2O2) in a prospective observational study.

METHODS AND RESULTS

The device pocket was irrigated, and all hardware accessible within (leads, suture sleeves, pulse generator) was wiped with H2O2, TauroPace, or taurolidine in a galenic formulation during any invasive CIED procedure at the study centre. Only CIED procedures covered by TauroPace or H2O2 from 1 January 2017 to 28 February 2022 were included for analysis. Patients who underwent >1 procedure were censored for the last treatment group and reassigned at the next procedure. The primary endpoint was major CIED infection within 3 months. The secondary endpoints were CIED infection beyond 3 months, adverse events potentially related to the antimicrobial solutions, CIED system, procedure, and death, till the end of follow-up. TauroPace covered 654 procedures on 631 patients, and H2O2 covered 551 procedures on 532 patients. The TauroPace group had more patient risk factors for infection than the H2O2 group (P = 0.0058) but similar device and procedure-specific risk factors (P = 0.17). Cardiac implantable electronic device infection occurred in 0/654 (0%) of the TauroPace group and 6/551 (1.1%) of the H2O2 group (P = 0.0075). Death occurred in 23/654 (3.5%) of the TauroPace group and 14/551 (2.5%) of the H2O2 group (P = 0.33). Non-infection related adverse events were rarer in the TauroPace (3.8%) than the H2O2 (6.0%) group (P = 0.0802).

CONCLUSION

TauroPace is safe but more effective than H2O2 in reducing CIED infection.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05576194.

Long-Term Generator Replacement Experience in Hypoglossal Nerve Stimulator Therapy Recipients With CPAP-Intolerant Obstructive Sleep Apnea

OBJECTIVE

In the last decade, hypoglossal nerve stimulation (HNS) has emerged as a therapeutic alternative for patients with obstructive sleep apnea. The original clinical trial cohorts are entering the phase of expected battery depletion (8-12 years). This study aimed to examine the surgical experience with implantable pulse generator (IPG) replacements and the associated long-term therapy outcomes.

STUDY DESIGN

Retrospective analysis of patients from the original clinical trial databases (STAR, German post-market) who were followed in the ongoing ADHERE registry.

SETTING

International multicenter HNS registry.

METHODS

The ADHERE registry and clinical trial databases were cross-referenced to identify the serial numbers of IPGs that were replaced. Data collection included demographics, apnea-hypopnea index (AHI), therapy use, operative times, and adverse events.

RESULTS

Fourteen patients underwent IPG replacement 8.3 ± 1.1 years after their initial implantation. Body mass index was unchanged between the original implant and IPG replacement (29 ± 4 vs 28 ± 2 kg/m2 , p = .50). The mean IPG replacement operative time was shorter than the original implant (63 ± 50 vs 154 ± 58 minutes, p < .002); however, 2 patients required stimulation lead replacement which significantly increased operative time. For patients with available AHI and adherence data, the mean change in AHI from baseline to latest follow-up (8.7 ± 1.1 years after de novo implant) was -50.06%, and the mean therapy use was 7.2 hours/night.

CONCLUSION

IPG replacement surgery was associated with low complications and shorter operative time. For patients with available outcomes data, adherence and efficacy remained stable after 9 years of follow-up.

Avoiding implant complications in cardiac implantable electronic devices: what works?

Nearly one in ten patients experience complications in relation to cardiac implantable electronic device (CIED) implantations. CIED complications have serious implications for the patients and for the healthcare system. In light of the rising rates of new implants and consistent rate of complications, primary prevention remains a major concern. To guide future efforts, we sought to review the evidence base underlying common preventive actions made during a primary CIED implantation.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist

Cardiovascular implantable electronic device (CIED) infections are morbid, costly, and difficult to manage. This review explores the pathophysiology, diagnosis, and management of CIED infections. Diagnostic accuracy has been improved through increased awareness and improved imaging strategies. Pocket or bloodstream infection with virulent organisms often requires complete system extraction. Emerging prophylactic interventions and novel devices have expanded preventative strategies and options for re-implantation. A clear and nuanced understanding of CIED infection is important to the practicing electrophysiologist.

Prevention of cardiac implantable electronic device infections: guidelines and conventional prophylaxis

Cardiac implantable electronic devices (CIED) are potentially life-saving treatments for several cardiac conditions, but are not without risk. Despite dissemination of recommended strategies for prevention of device infections, such as administration of antibiotics before implantation, infection rates continue to rise resulting in escalating health care costs. New trials conveying important steps for better prevention of device infection and an EHRA consensus paper were recently published. This document will review the role of various preventive measures for CIED infection, emphasizing the importance of adhering to published recommendations. The document aims to provide guidance on how to prevent CIED infections in clinical practice by considering modifiable and non-modifiable risk factors that may be present pre-, peri-, and/or post-procedure.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially lifesaving treatments for a number of cardiac conditions but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased health care costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well-recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, antibacterial envelopes, prolonged antibiotics post-implantation, and others. When compared with previous guidelines or consensus statements, the present consensus document gives guidance on the use of novel device alternatives, novel oral anticoagulants, antibacterial envelopes, prolonged antibiotics post-implantation, as well as definitions on minimum quality requirements for centres and operators and volumes. The recognition that an international consensus document focused on management of CIED infections is lacking, the dissemination of results from new important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a Novel 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

Surveillance Cultures and Infection in 230 Pacemaker and Defibrillator Generator Changes in Pediatric and Adult Congenital Patients

BACKGROUND

Postoperative infections can occur during surgical replacement of pulse generators for pacemakers and implantable cardioverter-defibrillators. The incidence of infection is poorly documented in children and patients with adult congenital heart disease. The utility of surveillance cultures obtained from device pocket swabs is unknown in this group.

METHODS

We reviewed surgical replacements of cardiovascular implantable pulse generators from 2010 to 2017. Two cohorts were defined. In a surveillance cohort (123 patients), aerobic and anaerobic culture swabs of the device pocket were obtained at the time of generator change. In a nonsurveillance cohort (107 patients), generator change occurred without obtaining cultures.

RESULTS

During 230 generator changes (mean patient age 19 years; 77% with structural congenital heart disease), two clinical infections occurred at the surgical site (0.9% incidence). Neither infection occurred in the surveillance cohort. Cultures were positive in 12 (9.8%) of 123 patients in the surveillance cohort, but 11 of 12 were likely contaminants and none were subsequently associated with clinical disease. There was no association between clinical infection or positive surveillance cultures and the location of pulse generator, the presence of other concurrent surgeries, or a history of prior pocket infection.

CONCLUSIONS

Clinical infection was rare after pulse generator change in children and young adults. No cases required reintervention on the pocket. Surveillance cultures did not improve clinical care. These data extend current recommendations that surveillance cultures are not required during generator change to the pediatric and young adult population.

Effect of fibrotic capsule debridement during generator replacement on cardiac implantable electronic device infection risk

BACKGROUND

Cardiovascular implantable electronic device (CIED) replacement is increasingly common. It has been proposed that capsule removal at the time of CIED replacement may reduce infection rates. In this study, we aimed to assess how pocket capsule removal impacted infection rates in patients undergoing CIED replacement.

METHODS

We retrospectively reviewed the medical records of patients who underwent CIED replacement from 2006 to 2016 at a single centre. We retrieved patient data, procedure details, and clinical outcomes. To evaluate the relationship between capsule removal and CIED infection, we used the Cox proportional hazard model, with adjustment for multiple variables.

RESULTS

During the study period, 773 patients underwent device replacement. Of these patients, 194 (25%) underwent capsule debridement during the replacement procedure. The mean patient age was 75 ± 15 years, and 281 (36.3%) were females. The replaced CIEDs included DDD pacemakers (32%), VDD pacemakers (15%), VVI/AAI pacemakers (13%), defibrillators (22%), and cardiac resynchronization therapy devices (CRT-D/P) (17%). During an average follow-up of 3.6 years, 42 (5%) patients experienced a CIED infection. Multivariate analysis revealed that patients who underwent capsule removal had a significantly lower risk of CIED infection, with a hazard ratio of 0.32 (95% confidence interval, 0.12-0.83; P = 0.019).

CONCLUSIONS

Capsule debridement during CIED replacement was associated with a significant reduction of CIED infection risk. There is a need for randomized controlled studies to confirm these findings.

Real-life outcome of implantable cardioverter-defibrillator and cardiac resynchronization defibrillator replacement/upgrade in a contemporary population: observations from the multicentre DECODE registry

Aims

The benefit of prolonged implantable cardioverter-defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) therapy following device replacement is hindered by clinical and procedure-related adverse events (AEs). Adverse events rate is highest in more complex devices and at upgrades, as per the REPLACE registry experience, but is changing owing to the improvement in device technology and medical care. We aimed at understanding the extent and type of AEs in a contemporary Italian population.

Methods and results

Detect long-term complications after ICD replacement (DECODE) was a prospective, single-arm, multicentre cohort study aimed at estimating medium- to long-term AEs in a large population of patients undergoing ICD/cardiac resynchronization defibrillator replacement/upgrade from 2013 to 2015. We prospectively analysed all clinical and device-related AEs at 12-month follow-up (FU) of 983 consecutive patients (median age 71 years, 76% male, 55% ischaemic, 47% CRT-D) followed for 353 ± 49 days. Seven percent of the patients died (60.6% for cardiovascular reasons), whereas 104 AEs occurred; 43 (4.4%) patients needed at least one surgical action to treat the AE. Adverse events rates were 3.3/100 years lead-related, 3.4/100 years bleedings, and 1.6/100 years infective. The primary endpoint was predicted by hospitalization in the month prior to the procedure [hazard ratio (HR) = 2.23, 1.16–4.29; 0.0169] and by upgrade (HR = 1.75, 1.02–2.99, 0.0441). One hundred and twelve (11.4%) patients met the combined endpoint of death from any cause, cardiac implantable electronic device (CIED)-related infection, and surgical action/hospitalization required to treat the AE. Hospitalization within 30 days prior to the procedure (HR = 2.07, 1.13–3.81; 0.0199), anticoagulation (HR = 1.97, 1.26–3.07; 0.003), and ischaemic cardiomyopathy (HR = 1.67, 95% confidence interval 1.06–2.63; P = 0.0276) were associated with the combined endpoint during FU.

Conclusions

Adverse events following CIED replacement/upgrade are lower than previously reported, possibly owing to improved patients care. Hospitalization in the month prior to the procedure, upgrade, and clinical profile (anticoagulation, ischaemic cardiomyopathy) hint to increased risk, suggesting an individualized planning of the procedure to minimize overall AEs.

Clinical trial registration

URL: http://clinicaltrials.gov/ Identifier: NCT02076789.

Use of MPH hemostatic powder for electrophysiology device implantation reduces postoperative rates of pocket hematoma and infection

BACKGROUND

Surgical site bleeding and infection are potential complications after electrophysiology (EP) device implantation procedures. To date, there is a wide variety of tools for management of intraoperative bleeding but it still remains unclear what methods are preferred.

OBJECTIVE

The aim of our study is to compare the rate of complications in patients who underwent cardiac implantable electronic device (CIED) implantation utilizing MPH hemostatic powder to the rate of complications in those patients who underwent standard procedure protocol without MPH hemostatic powder.

METHODS

In our study, a new plant-derived microporous polysaccharide hemostatic powder (Arista) was used. A total of 283 consecutive patients were retrospectively studied to assess the rate of complications in patients who underwent CIED implantation with MPH hemostatic powder (n = 77, MPH hemostatic powder) and without (n = 206, no MPH hemostatic powder). Patients were followed for 12 months.

RESULTS

The MPH hemostatic powder group of patients had a lower complication rate when compared to no MPH hemostatic powder, 0.3% vs. 1.7% (p < .05), respectively. The rate of device implantation site MPH hematoma in the MPH hemostatic powder group was 0.4%, versus 0.9% in the other group. There were no postoperative infections in the MPH hemostatic powder group versus 3.2% infections in the other group. The main predictor of increased risk of post-procedural complication was the usage of anticoagulation with a hazard ration of 2.7.

CONCLUSION

Using MPH hemostatic powder for post-procedural hemostasis was shown to result in a significant reduction in the rate of overall post-procedural complications (a composite endpoint of hematoma and infections), and a trend in reduction of the infections rates and device implantation site hematoma rates.

Prevention, Diagnosis, and Treatment of Cardiac Implantable Electronic Device Infections

Cardiac implantable electronic device (CIED) infections are complex medical problems that are increasingly encountered. They are associated with significant morbidity and mortality with tremendous economic cost. The current review will emphasize the prevention, diagnosis, and treatment of this clinical entity using the relatively limited evidence that is currently available. Because there is a paucity of high quality evidence regarding prevention, diagnosis, and treatment of CIED infections, this review will attempt to summarize the best evidence as well as to suggest, when possible, paradigms for care. The topic of CIED infections is a dynamic one as the scope of CIED continues to widen. Furthermore, there are promising advancements in CIED technology which may help reduce its occurrence the future. Unfortunately, significant gaps in knowledge remain, and definitive recommendations regarding CIED infections and future studies should be directed at improving our ability to prevent infections.

Prevention of Cardiac Implantable Electronic Device Infections: Update and Evaluation of the Potential Role for Capsulectomy or the Antibiotic Pouch

Cardiac implantable electronic device (CIED) infections can have devastating implications for patient morbidity and mortality. Over the past decade, the infection rate has risen out of proportion to implant rates, and has prompted the development of innovative solutions designed to reduce infections. The first section of this review provides a summary of the contemporary knowledge regarding the incidence, prevalence, microbiology, and risk factors for cardiac implantable electronic device infections. The second section addresses prevention with an emphasis on the potential role of novel procedural approaches, such as capsulectomy and the antibacterial envelope, in reducing CIED infection.

Cardiac Implantable Electronic Device Infection: From an Infection Prevention Perspective

A cardiac implantable electronic device (CIED) is indicated for patients with severely reduced ejection fraction or with life-threatening cardiac arrhythmias. Infection related to a CIED is one of the most feared complications of this life-saving device. The rate of CIED infection has been estimated to be between 2 and 25; though evidence shows that this rate continues to rise with increasing expenditure to the patient as well as healthcare systems. Multiple risk factors have been attributed to the increased rates of CIED infection and host comorbidities as well as procedure related risks. Infection prevention efforts are being developed as defined bundles in numerous hospitals around the country given the increased morbidity and mortality from CIED related infections. This paper aims at reviewing the various infection prevention measures employed at hospitals and also highlights the areas that have relatively less established evidence for efficacy.