Complete removal as a routine treatment for any cardiovascular implantable electronic device-associated infection

Regional Disparities in Transvenous Lead Extraction for Cardiac Implantable Electronic Device Infection in Japan - A Descriptive Study Using the National Database Open Data

BACKGROUND

Because the penetration of transvenous lead extraction (TLE) for cardiac implantable electronic device (CIED) infection has not been investigated in Japan, we conducted a population-based, retrospective, descriptive study to evaluate regional disparities in the use of TLE for CIED infection and the potential undertreatment of CIED infection using a nationwide insurance claims database.Methods and Results: Patients who underwent CIED implantation or generator exchange and TLE between April 2018 and March 2020 were identified. Moreover, the penetration ratio of TLE for CIED infection in each prefecture was estimated. CIED implantation and TLE were most prevalent in the age categories of 80-89 years (40.3%) and 80-89 years (36.9%), respectively. There was no correlation between the number of CIED implantations and that of TLE (rho=-0.087, 95% confidence interval -0.374 to 0.211, P=0.56). The median penetration ratio was 0.00 (interquartile range 0.00-1.29). Of the 47 prefectures, 6, comprising Okinawa, Miyagi, Okayama, Fukuoka, Tokyo, and Osaka, showed a penetration ratio ≥2.00.

CONCLUSIONS

Our study data indicated great regional disparities in the penetration of TLE and potential undertreatment of CIED infection in Japan. Additional measures are needed to address these issues.

Cost-effectiveness of an antibacterial envelope for infection prevention in patients undergoing cardiac resynchronization therapy reoperations in Denmark

AIMS

Use of an absorbable antibacterial envelope during implantation prevents cardiac implantable electronic device infections in patients with a moderate-to-high infection risk. Previous studies demonstrated that an envelope is cost-effective in high-risk patients within German, Italian, and English healthcare systems, but these analyses were based on limited data and may not be generalizable to other healthcare settings.

METHODS AND RESULTS

A previously published decision-tree-based cost-effectiveness model was used to compare the costs per quality-adjusted life year (QALY) associated with adjunctive use of an antibacterial envelope for infection prevention compared to standard-of-care intravenous antibiotics. The model was adapted using data from a Danish observational two-centre cohort study that investigated infection-risk patients undergoing cardiac resynchronization therapy (CRT) reoperations with and without an antibacterial envelope (n = 1943). We assumed a cost-effectiveness threshold of €34 125/QALY gained, based on the upper threshold used by the National Institute for Health and Care Excellence (£30 000). An antibacterial envelope was associated with an incremental cost-effectiveness ratio (ICER) of €12 022 per QALY in patients undergoing CRT reoperations, thus indicating that the envelope is cost-effective when compared with standard of care. A separate analysis stratified by device type showed ICERS of €6227 (CRT defibrillator) and €29 177 (CRT pacemaker) per QALY gained.

CONCLUSIONS

Cost-effectiveness ratios were favourable for patients undergoing CRT reoperations in the Danish healthcare system, and thus are in line with previous studies. Results from this study can contribute to making the technology available to Danish patients and align preventive efforts in the pacemaker and ICD area.

Rate of Cardiovascular Implantable Electronic Device-Related Infection at a Tertiary Hospital in Saudi Arabia: A Retrospective Cohort Study

Introduction

Cardiovascular implantable electronic devices (CIEDs) are long-term cardiac treatments that address a variety of cardiac diseases. In the recent years, a steady growth has been noticed in CIEDs, mainly due to expanding indications for their usage. Possible device-related infection, whether pocket or systemic, which leads to high morbidity and mortality, is one of the most worrying complications. In addition, there are limited studies conducted on the topic of CIED infection rate and their clinical presentation both regionally and locally.

Methods

In this retrospective cohort study, we reviewed the medical records of all patients with CIEDs who presented to our medical center (implanted, followed up, or referred to our hospital) between January 2016 and January 2019.The medical records were extracted from the BestCare electronic medical records system (ezCaretech Co, Seoul, Korea). All consecutive patients were included as we had no exclusion criteria.

Results

During the three years of the study period, a total of 612 patients with CIEDs were identified at our medical center. Among this cohort, 436 subjects (71.2%) were male and 176 (28.8%) were female. Thirty-four patients experienced device-related infections from among the total patient population (n = 612) who presented with CIEDs between January 2016 and January 2019, for a total rate of 5.6%. Of the infected patients, 29 (85%) presented with local infections and five (15%) presented with systemic infections.

Conclusion

The infection rate of 5.6% observed in this study was higher than expected. Therefore, we conclude that action should be taken to reduce infection rates at our medical center to at least that seen in prior studies or below that, if possible. Moreover, we found that CIED infections were often caused by Staphylococcus species and commonly affected the elderly and patients with chronic diseases such as diabetes and hypertension. Most of the identified cases were local infections, although systemic infections were common in those with renal disease. Further studies are needed to control the risk factors and to better understand the role of antibiotics, antiseptic prophylaxis, and other methods in avoiding CIED infection and associated complications.

Delayed Improvement of Left Ventricular Function in Newly Diagnosed Heart Failure Depends on Etiology—A PROLONG-II Substudy

In patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF), three months of optimal therapy are recommended before considering a primary preventive implantable cardioverter-defibrillator (ICD). It is unclear which patients benefit from a prolonged waiting period under protection of the wearable cardioverter-defibrillator (WCD) to avoid unnecessary ICD implantations. This study included all patients receiving a WCD for newly diagnosed HFrEF (n = 353) at our center between 2012 and 2017. Median follow-up was 2.7 years. From baseline until three months, LVEF improved in patients with all peripartum cardiomyopathy (PPCM), myocarditis, dilated cardiomyopathy (DCM), or ischemic cardiomyopathy (ICM). Beyond this time, LVEF improved in PPCM and DCM only (10 ± 8% and 10 ± 12%, respectively), whereas patients with ICM showed no further improvement. The patients with newly diagnosed HFrEF were compared to 29 patients with a distinct WCD indication, which is an explantation of an infected ICD. This latter group had a higher incidence of WCD shocks and poorer overall survival. All-cause mortality should be considered when deciding on WCD prescription. In patients with newly diagnosed HFrEF, the potential for delayed LVEF recovery should be considered when timing ICD implantation, especially in patients with PPCM and DCM.

Impact of Timing of Transvenous Lead Removal on Outcomes in Infected Cardiac Implantable Electronic Devices

BACKGROUND

Cardiovascular implantable electronic device (CIED) infections are associated with increased mortality and morbidity.

OBJECTIVE

This study sought to evaluate the impact of early versus delayed transvenous lead removal (TLR) on in-hospital mortality and outcomes in patients with CIED infection.

METHODS

Using the nationally representative, all-payer, Nationwide Readmissions Database, we evaluated patients undergoing TLR for CIED infection between January 1, 2016, to December 31, 2018. The timing of the TLR procedure was determined based on hospitalization days after initial admission for CIED infection. The impact of early (≤ 7 days) versus delayed (> 7 days) TLR on mortality and major adverse events was studied.

RESULTS

Of 12,999 patients who underwent TLR for CIED infections, 8,834 patients underwent early TLR versus 4,165 patients who underwent delayed TLR. Delayed TLR was associated with a significant increase in in-hospital mortality (8.3% vs. 3.5%, adjusted odds ratio:1.70; 95% confidence interval, 1.43-2.03; P value<0.001). Subgroup analysis of patients with CIED infection and systemic infection showed that delayed TLR in patients with systemic infection was associated with a higher rate of in-hospital mortality compared with early TLR (10.4% vs. 7.5%, adjusted odds ratio:1.24; 95% confidence interval, 1.04-1.49; P value<0.019). Delayed TLR was also associated with significantly higher adjusted odds of major adverse events and post-procedural length of stay.

CONCLUSIONS

These data suggest that delayed transvenous lead removal in patients with CIED infections is associated with increased in-hospital mortality and major adverse events, especially in patients with systemic infection.

Therapy and outcomes of cardiac implantable electronic devices infections

Cardiac implantable electronic device (CIED) infection causes significant morbidity and mortality without appropriate treatment. It can present as incisional infection, pocket infection, systemic CIED infection, or occult bacteraemia. Complete percutaneous CIED extraction (excepted in case of incisional infection) and appropriate antibiotic therapy are the two main pillars of therapy. Device reimplantation, if needed, should be delayed sufficiently to allow control of the infection. Here, we address the differences in prognosis according to the clinical scenario and the different treatment options.

Salvage of Threatened Cardiovascular Implantable Electronic Devices: Case Series and Review of Literature

BACKGROUND

The treatment of infected or exposed cardiac pacing and defibrillator devices is controversial. The conservative and widely accepted management calls for removal of the device and leads with immediate or delayed replacement of new components in a new site. Lead extraction carries a 2% major complication risk. In this article, we describe our experience with device salvage techniques and review the current literature.

METHODS

This is a retrospective case series of consecutive patients with infected, exposed, or at-risk implanted cardiac devices that were treated with aggressive surgical debridement, local pocket irrigation, and revision. A comprehensive review of the literature regarding device infection management was performed.

RESULTS

Ten patients with threatened devices were identified. Surgical revision with the aim to salvage the device was successful in 8 (80%) of 10 cases. Seventeen retrospective publications were reviewed. All indicate success with attempted salvage surgery, but heterogeneity of data limits formal meta-analysis and prevents management recommendations.

CONCLUSIONS

Cardiac pacing and defibrillator devices with low-grade infection or threatened exposure may be salvaged without explantation. Despite the lack of clear management guidelines or data, plastic surgeons may be asked to assist in the management of threatened cardiac devices. Further prospective trials are required to evaluate the safety, efficacy, and cost-effectiveness of attempted implant salvage.

Prolonged Catheter Use and Infection in Regional Anesthesia: A Retrospective Registry Analysis

BACKGROUND

Prolonged catheter use is controversial because of the risk of catheter-related infection, but the extent to which the risk increases over time remains unknown. We thus assessed the time-dependence of catheter-related infection risk up to 15 days.

METHODS

Our analysis was based on the German Network for Regional Anesthesia, which includes 25 centers. We considered 44,555 patients who had surgery between 2007 and 2014 and had continuous regional anesthesia as well as complete covariable details. Cox regression analysis was performed and adjusted for confounding covariables to examine the relationship between catheter duration and probability of infection-free catheter use.

RESULTS

After adjustment for confounding factors, the probability of infection-free catheter use decreases with each day of peripheral and epidural catheter use. In peripheral catheters, it was 99% at day 4 of catheter duration, 96% at day 7, and 73% at day 15. In epidural catheters, it was 99% at day 4 of catheter duration, 95% at day 7, and 73% at day 15. Only 31 patients (0.07%) had severe infections that prompted surgical intervention. Among these were five catheters that initially had only mild or moderate signs of infection and were left in situ; all progressed to severe infections.

CONCLUSIONS

Infection risk in catheter use increases over time, especially after four days. Infected catheters should be removed as soon as practical.

VISUAL ABSTRACT

An online visual overview is available for this article at http://links.lww.com/ALN/B683.

Unusual conservative treatment of a complicated pacemaker pocket infection: a case report

Background

For patients with complicated generator pocket infection, expert consensuses universally advocate complete device and leads removal followed by delayed replacement on the contralateral side. We cured our patient by partial generator removal and reimplantation of sterilized pulse generator on the ipsilateral side. We also performed a literature review about incomplete removal therapy for the management of cardiac implantable electronic device infection.

Case presentation

An 86-year-old Chinese Han man was diagnosed as having third-degree atrioventricular block and received a permanent double-chamber pacemaker in his left prepectoral area 15 years ago. Nine years later, the entire system was removed because of confirmed infection, and a new device was reimplanted in the contralateral area. He developed skin necrosis around the pacemaker pocket after 1 year, and his generator was renewed without leads extraction at another medical center. He was subsequently admitted several times for surgical tissue debridement at another institution due to extended skin necrosis. At the time of the new admission, he had severe infection, heart failure, and hypoalbuminemia. He was diagnosed as having complicated pacemaker pocket infection. Our preferred treatment strategy was for complete removal of both the generator and transvenous pacing leads, and we intended to implant an epicardial pacemaker in our patient if necessary. However, he rejected the treatment strategy and firmly refused to replace his generator. We had to attempt a novel pacemaker-preserving strategy considering our patient’s severe comorbidities. Finally, we cured him by partial generator removal and reimplantation of the sterilized pulse generator on the ipsilateral side. There was no sign of wound dehiscence or infection during a 6-month follow-up.

Conclusions

We would posit that partial removal of infected generators combined with conservative treatment may be a proper treatment of complicated generator pocket infection, especially for those who are susceptible to cardiac complications. Reimplantation of a sterilized pulse generator on the ipsilateral side may be an option if patients reject a new device and contralateral vascular condition is not really suitable. Opting for such treatment should be at the consideration of the primary care physician based on the condition of the patient.

Outcomes of repeated transvenous lead extraction

INTRODUCTION

The outcomes of repeated cardiovascular implantable electronic device (CIED) lead extraction have not been well studied. We sought to determine the indications, outcomes, and safety of repeated lead extraction procedures.

METHODS

This retrospective study was conducted using data from two medical centers, including 38 patients who had undergone two or more lead extraction procedures compared to 439 patients who had a single procedure. The electronic medical records and procedural databases were reviewed to determine the indications, procedural characteristics, and outcomes. The outcomes of the first procedure were compared to the outcomes of subsequent procedures.

RESULTS

The 5-year cumulative probability of a repeated extraction procedure was 11% (95% confidence interval, 7%-15%). In 439 patients who underwent single lead extractions, 72% had device and lead related infections as the procedure indication compared to 39% for 38 patients who underwent repeated extraction (P < 0.001). The mean duration from device reimplant to repeated extraction procedures was 63 ± 48 months. Ninety-eight percent of the leads were removed completely in repeated procedures, similar to the 95% success rate of the first procedure (P = 0.51). There was no significant difference in major complication rate in the first or repeated extractions (2.6% vs 5.2%, P = 0.79).

CONCLUSIONS

Repeated transvenous lead extraction is not uncommon. It had a high success rate comparable to that of the initial procedure and was not associated with an increased incidence of adverse events.

Primary Cardiac B-Non-Hodgkin Lymphoma Disguised as a Pacemaker Endocarditis

Background  Pacemaker infections rates are high compared with the incidence of primary malignant cardiac tumors. However, they can look alike in diagnostics and patient presentation. Case Description  We hereby report a rare case of a suspected pacemaker endocarditis which in fact turned out to be a primary cardiac B cell lymphoma. The lymphoma was removed surgically. Conclusion  Sometimes we encounter the unexpected. Suboptimal preoperative diagnostics certainly lead to the faulty conclusion of an endocarditis. Nonetheless, even such an enhanced primary cardiac tumor can be resected with good clinical outcome and long-term survival.

Percutaneous Lead Extraction in Infection of Cardiac Implantable Electronic Devices: a Systematic Review

INTRODUCTION

In the last two decades, the increased number of implants of cardiac implantable electronic devices has been accompanied by an increase in complications, especially infection. Current recommendations for the appropriate treatment of cardiac implantable electronic devices-related infections consist of prolonged antibiotic therapy associated with complete device extraction. The purpose of this study was to analyze the importance of percutaneous extraction in the treatment of these devices infections.

METHODS

A systematic review search was performed in the PubMed, BVS, Cochrane CENTRAL, CAPES, SciELO and ScienceDirect databases. A total of 1,717 studies were identified and subsequently selected according to the eligibility criteria defined by relevance tests by two authors working independently.

RESULTS

Sixteen studies, describing a total of 3,354 patients, were selected. Percutaneous extraction was performed in 3,081 patients. The average success rate for the complete percutaneous removal of infected devices was 92.4%. Regarding the procedure, the incidence of major complications was 2.9%, and the incidence of minor complications was 8.4%. The average in-hospital mortality of the patients was 5.4%, and the mortality related to the procedure ranged from 0.4 to 3.6%. The mean mortality was 20% after 6 months and 14% after a one-year follow-up.

CONCLUSION

Percutaneous extraction is the main technique for the removal of infected cardiac implantable electronic devices, and it presents low rates of complications and mortality related to the procedure.

Attempted salvage of infected cardiovascular implantable electronic devices: Are there clinical factors that predict success?

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.

Lead extractions in patients with cardiac implantable electronic device infections: Single center experience

Background

Lead extraction using laser sheaths is performed mainly for cardiac implantable electronic device (CIED) infections. However, there are few reports concerning the management of CIED infections in Japan.

Methods and results

Lead extraction procedures were performed in 183 patients targeting 450 leads (atrial leads: 170, ventricular: 181, implantable cardioverter-defibrillators (ICDs): 79, and coronary sinus: 20). One hundred twenty patients (65.6%) presented with pocket infections without the presentation of an endovascular infection. Blood cultures were positive at least once in 63 patients (34.4%). Complete procedure success was achieved for 437 leads (97.1%) while partial removal occurred in nine, and failure in four leads. Major complications directly related to the procedure occurred in five patients (2.7%). Two of the four patients with a cardiac tamponade required a surgical repair. All patients received intravenous antibiotics, at least, one week after the procedure. Pocket or systemic infections were successfully controlled in 181 patients (98.9%). Coagulase-negative staphylococci (30.1%) and Staphylococcus aureus (37.1%) were the most common causes of CIED infections.

Conclusion

The current status of CIED infections in Japan seems to be similar to that previously reported from foreign countries. The optimal treatment of CIED infections involves the complete explantation of all hardware, followed by antibiotic therapy.

Management of Cardiac Electronic Device Infections: Challenges and Outcomes

Cardiac implantable electronic device (CIED) infection is an increasing problem. Reasons for this are uncertain, but likely relate to an increasing proportion of implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices implanted, as well as implantations in 'higher risk' candidates, i.e. patients with heart failure, diabetes and renal failure. Challenges within the field of CIED infections are multiple with prevention being the most important challenge. Careful prescription of CIED treatment and careful patient preparation before implantation is important. Diagnosis is often difficult and delayed by subtle signs of infection. Treatment of CIED infection includes complete system removal in centres experienced in CIED extraction and prolonged antibiotic therapy. Meticulous planning and preparation before system extraction and later CIED re-implantation is essential for better patient outcome. Future strategies for reducing CIED infection should be tested in sufficiently powered, multicentre, randomised controlled trials.

Fistula Formation 6 Years after Removal of Infected Pacemaker Leads

We describe a case of a male patient who presented with a chronic ulcer below the left clavicle. Six years before the present admission a permanent pacemaker, including leads, was explanted related to endocarditis. The initial working hypothesis suspected an infected sebaceous gland as the cause of ulceration. After two periods of unsuccessful surgical treatment of the gland, further examination identified a small pacemaker lead fragment underneath the articulation between sternum and clavicle as a possible reason.

Complete removal of infected devices and simultaneous implantation of new devices for infective endocarditis after pacemaker implantation

Two cases of infective endocarditis after pacemaker implantation were reported. Complete removal of infected devices was performed under cardiopulmonary bypass, and simultaneous implantation of new devices was performed using epicardial leads and generator on the abdominal wall. The postoperative course was uneventful and recurrence was not recognized. These procedures may be suitable for the patients who depend on the pacemaker or who have repeat bacteremia with other infectious disease or conditions.

Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE)

Infections related to implantable cardiac electronic devices (ICEDs), including pacemakers, implantable cardiac defibrillators and cardiac resynchronization therapy devices, are increasing in incidence in the USA and are likely to increase in the UK, because more devices are being implanted. These devices have both intravascular and extravascular components and infection can involve the generator, device leads and native cardiac structures or various combinations. ICED infections can be life-threatening, particularly when associated with endocardial infection, and all-cause mortality of up to 35% has been reported. Like infective endocarditis, ICED infections can be difficult to diagnose and manage. This guideline aims to (i) improve the quality of care provided to patients with ICEDs, (ii) provide an educational resource for all relevant healthcare professionals, (iii) encourage a multidisciplinary approach to ICED infection management, (iv) promote a standardized approach to the diagnosis, management, surveillance and prevention of ICED infection through pragmatic evidence-rated recommendations, and (v) advise on future research projects/audit. The guideline is intended to assist in the clinical care of patients with suspected or confirmed ICED infection in the UK, to inform local infection prevention and treatment policies and guidelines and to be used in the development of educational and training material by the relevant professional societies. The questions covered by the guideline are presented at the beginning of each section.

Prevention of pacemaker infections with perioperative antimicrobial treatment: an in vitro study

AIMS

The antimicrobial treatment of pacemaker casings with antiseptics (povidone-iodine or octenidine dihydrochloride) or antibiotics (vancomycin, daptomycin, cefuroxime, Tazobac, or nebacetin) was analysed in vitro for its biocompatibility and efficacy in preventing the bacterial adhesion of Staphylococcus epidermidis, Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli to cardiac-implantable electrophysiological devices (CIEDs).

METHODS AND RESULTS

Titan platelets (0.4 cm&sup2;) cut from pacemaker casings were impregnated with seven different antimicrobial solutions: two antiseptics and five antibiotics. Subsequently, they were challenged with bacterial contamination by four test strains over a 24 h incubation period. Bacterial adherence was quantified using the colony-forming-unit method after cell recovery with sonication and examined with confocal laser scanning electron microscopy. Simultaneously, the biocompatibility of the antimicrobial impregnation was assessed using pre-treated titan platelets in a culture of human fibroblasts, skeletal myoblasts, and microvascular endothelial cells. After a 48 h incubation, cell vitality was measured using the 2-(2-methoxy-4-nitrophenyl)-3-(4-nitrophenyl)-5-(2,4-disulfophenyl)-2H/tetrazolium monosodium (WST-8) assay. The immersion of pacemaker casings in antiseptic or antibiotic solutions applies an antimicrobial coating that can significantly reduce bacterial adhesion. The studied impregnations differed in their antimicrobial efficacy and toxicity.

CONCLUSION

Compared with the two antiseptics and the other tested antibiotics, nebacetin showed the best ratio of efficacy to toxicity. Nebacetin showed good in vitro antibacterial activity against both Gram-positive and Gram-negative pathogens without impairing human cell vitality. It is a safe and effective candidate for CIED impregnation.

Transcutaneous lead implantation connected to an externalized pacemaker in patients with implantable cardiac defibrillator/pacemaker infection and pacemaker dependency

AIMS

Systemic cardiac implantable electronic device (CIED) infection is a serious complication, especially in patients with pacemaker (PM) dependency. In those patients after infectious device removal temporary pacing is necessary, to obtain adequate haemodynamics. In this study, a new therapy option with temporary pacing by ipsilateral implantation of a new active-fixation right ventricular (RV)-lead was evaluated.

METHODS AND RESULTS

Between September 2009 and November 2011, infectious lead removal was performed in 17 patients with systemic CIED infection. Temporary pacing was achieved by simultaneous implantation of a new active-fixation RV-lead, which then was connected extracorporally to the old CIED device. Antibiotic therapy was initiated. When laboratory infection parameters were in normal range and blood culture samples showed negative results, new CIED was implanted on contralateral side and temporary RV-lead was removed. Mean patients' age was 71.3 ± 9.1 years. Mean C-reactive protein values were 79.3 mg/dL, and mean leucocytes counts were 12.6 × 10(3). After lead extraction, temporary pacing was necessary in all patients due to severe bradycardia. Mean duration of temporary pacing was 12.7 (6-24) days. No major procedure-related peri- or post-operative adverse events occurred. Mean time of hospitalization was 20.8 (10-48) days. Mean follow-up time was 21.1 months (12-36), showing survival rate of 100% and freedom from reinfection in all patients.

CONCLUSION

Ipsilateral implantation of a temporary active-fixation RV-lead connected to an externalized PM and pursued antibiotic therapy seems to be a good option for patients with CIED infection and PM dependency, showing no temporary pacing-related complications and no reinfection after mean follow-up time of 21.1 months.

Long-term outcome of complete cardiovascular implantable electronic device removal with cardiopulmonary bypass

Definitive endovascular techniques have been developed for pacemaker lead extraction; however, a few patients require immediate secondary open heart surgery because of incomplete transvenous lead extraction. This study examined the safety, effectiveness, and long-term outcome of the removal of cardiovascular implantable electronic device (CIED) via median sternotomy under cardiopulmonary bypass. The removal of CIED was performed in 6 patients (mean age 57 ± 16 years, 5 males and 1 female), from September 2000 to April 2011. The reasons for removal included eradication of an infection in 5 patients and elimination of pacemaker component allergy in 1. Positive culture results, including methicillin-sensitive Staphylococcus aureus (MSSA, n = 2), methicillin-resistant S. aureus (MRSA, n = 1), coagulase-negative staphylococci (CNS, n = 1), and methicillin-resistant S. epidermidis (MRSE, n = 1) were observed in all 5 infected patients. Mitral annuloplasty (n = 1), mitral valvuloplasty (n = 1), tricuspid annuloplasty (n = 3). Implantation of myocardial pacing leads (n = 5) were performed concomitantly (n = 4), or secondarily (n = 1). All 6 patients were alive in good condition at 72 ± 55 months following CIED removal. New device infection occurred in 1 patient during long-term follow up. Complete surgical removal of pacing systems via median sternotomy with cardiopulmonary bypass is, therefore, considered to be safe and feasible with acceptable long term results.

Complications of cardiac implants: handling device infections

Managing patients with cardiac implantable electrophysiological devices (CIED) infections can be challenging. The first step should be prevention, which involves patient selection, timing of implantation, and the procedure itself. After implantation, a high degree of suspicion should be applied in order to correctly diagnose patients with infected implanted devices. It is necessary to recognize that patients can present with a wide variety of signs and symptoms. Once diagnosed, the next step is determining if it is a local pocket infection or system infection. In almost every patient, in addition to antibiotics, complete removal of ALL hardware is required. Transvenous lead extraction is now safe and effective, but should only be performed at experienced centres with a practiced extraction team, all possible needed equipment, and cardiothoracic surgical backup. After extraction, the indication for CIED therapy should be re-evaluated to determine re-implantation is warranted. Timing of re-implantation depends on a variety of factors such as type of infection or valvular involvement and should be made in concordance with an infectious disease specialist. This review is aimed at introducing the steps needed to manage patients with infected cardiac devices.