Surgical lead-preserving procedures for pacemaker pocket infection

Soft Bioelectronics Based on Nanomaterials

Recent advances in nanostructured materials and unconventional device designs have transformed the bioelectronics from a rigid and bulky form into a soft and ultrathin form and brought enormous advantages to the bioelectronics. For example, mechanical deformability of the soft bioelectronics and thus its conformal contact onto soft curved organs such as brain, heart, and skin have allowed researchers to measure high-quality biosignals, deliver real-time feedback treatments, and lower long-term side-effects in vivo. Here, we review various materials, fabrication methods, and device strategies for flexible and stretchable electronics, especially focusing on soft biointegrated electronics using nanomaterials and their composites. First, we summarize top-down material processing and bottom-up synthesis methods of various nanomaterials. Next, we discuss state-of-the-art technologies for intrinsically stretchable nanocomposites composed of nanostructured materials incorporated in elastomers or hydrogels. We also briefly discuss unconventional device design strategies for soft bioelectronics. Then individual device components for soft bioelectronics, such as biosensing, data storage, display, therapeutic stimulation, and power supply devices, are introduced. Afterward, representative application examples of the soft bioelectronics are described. A brief summary with a discussion on remaining challenges concludes the review.

Salvage of Infected Cardiac Implantable Electrical Devices with Subpectoral Plane Pocket Revision

Introduction Infection of cardiac implantable electrical devices (CIEDs) may lead to serious complications. Complete CIED explantation is expensive, requires expertise, not free from complications, and may not be an option in patients with device dependence.

Aim To highlight that carefully selected infected CIEDs can be salvaged by placing the device in a subpectoral pocket below the pectoralis major muscle. We conducted a retrospective descriptive observational study.

Material and Methods Twelve patients (10 male and two female) with erosion, exposure or infection of infraclavicular, subcutaneously placed CIED were treated over a 30-month period between July 2018 and December 2020. The technique involved debridement and excision of a peridevice capsule, creating a subpectoral pocket beneath the pectoralis major muscle, and placing the CIED in a new pocket with total muscle coverage and closure of skin without tension.

Results Twelve patients ( m = 10; f = 2) with a mean age of 65 years (range, 46–82 years) presented with infection of CIED within 9 months of implantation. None had sepsis or endocarditis. In nine patients, CIEDs were successfully salvaged with relocation to subpectoral pocket. Mean follow-up was 20 months (range, 8–30 months). Three out of 12 developed reinfection that ultimately required CIED explantation. There was no mortality.

Conclusion In the absence of sepsis or endocarditis, infected CIEDs may be attempted at salvage by subpectoral pocket placement. This obviates the need for potentially risky explantation or replacement of expensive CIEDs.

Erosion of Cardiovascular Implantable Device: Conservative Therapy or Extraction?

The standard of care for device infection is normally a complete removal of the implantable system, including lead extraction in local or systemic infection cases. Despite the importance of lead extraction techniques, these techniques are complex and have some major risks. Success rates were high, but they are less favorable in patients with several comorbidities. An 80-year-old male presented for device erosion. The patient is known to have several cardiac comorbidities: a transcatheter aortic valve replacement (TAVR), mitral clips for severe aortic stenosis, mitral regurgitation, dual-chamber implantable cardioverter defibrillators (ICD) for secondary prevention. Several weeks ago, he noted tenderness and redness at the site of his device pocket, and his physician, after checking his wound, suggested a possible skin irritation with no systemic infection and started antibiotics treatment. Two weeks later, he noted thinning of the skin around the device with a hematoma and ecchymosis, and slight skin erosion. Strategies for assessment of the wound and pocket cleaning were taken. The strategy was to remove the left-sided device and keep the leads since the patient lately has no elevated inflammatory labs, negative cultures, no fever, nor signs of vegetation on transesophageal echocardiography (TEE) and refused any additional examination as positron emission tomography (PET) scan, and reimplant a new system on the contralateral side. The procedure was divided into two sequences: extracting the device and after one-week implantation of a right-sided new system. In this case, chronic antibiotics were discussable to decrease the recurrence rate, but they did increase the severity of the patient's thrombocytopenia. Despite extraction being the gold standard of treatment in most cases of devices with local and systemic infection, there are some frail patients with several comorbidities where extraction is unbearable due to its major risks and complex procedure. In these specific cases with local infection and device erosion with no signs of any systemic infection, conservative therapy could be a viable option.

Low-budget, single-session elimination of CIED pocket infection

BACKGROUND

The dramatic increase in the use of cardiovascular implantable electronic devices (CIED) was associated with an increased rate of CIED infection, which has a high management cost.

AIM OF THE STUDY

To test the safety and efficacy of a single-session protocol, aiming to reuse the infected pocket side and the same device and leads in patients with CIED pocket infection.

PATIENTS AND METHODS

We included patients with isolated pocket infection between January 2015 and November 2019. The Patient was prepared by taking a swab for culture and sensitivity before the procedure. The pocket was debrided and the capsule was removed, the pocket was rinsed with povidone-iodine and hydrogen peroxide mixture, then packed with gauze sponge soaked with povidone-iodine. The device was debrided using ultrasonic irrigation and sterilized using gas plasma. The device was reimplanted and the wound was closed in layers.

RESULTS

During the period of the study, we had 12 patients with isolated pocket infection. Nine presented with erosion, two with impending erosion, and one with a chronic sinus. Patient's age was 61.5 ± 7.64 years. The infection was diagnosed 14.2 ± 8.22 weeks post device implantation. They were admitted for 7.6 ± 1.54 days postprocedure. The follow-up duration was 26.5 ± 15 (1.7-52) months. Only one patient (8%) had a recurrence of the infection after 50 days of the procedure.

CONCLUSION

Our protocol was successful in treating 92% of device-related pocket infection without the need to replace the device or the pocket side.

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.

Safe and Simplified Salvage Technique for Exposed Implantable Cardiac Electronic Devices under Local Anesthesia

Background

Skin erosion is a dire complication of implantable cardiac pacemakers and defibrillators. Classical treatments involve removal of the entire generator and lead systems, however, these may result in fatal complications. In this study, we present our experience with a simplified salvage technique for exposed implantable cardiac electronic devices (ICEDs) without removing the implanted device, in an attempt to reduce the risks and complication rates associated with this condition.

Methods

The records of 10 patients who experienced direct ICED exposure between January 2012 and December 2015 were retrospectively reviewed. The following surgical procedure was performed in all patients: removal of skin erosion and capsule, creation of a new pocket at least 1.0–1.5 cm inferior to its original position, migration of the ICED to the new pocket, and insertion of closed-suction drainage. Patients with gross local sepsis or septicemia were excluded from this study.

Results

Seven patients had cardiac pacemakers and the other 3 had implantable cardiac defibrillators. The time from primary ICED placement to exposure ranged from 0.3 to 151 months (mean, 29 months. Postoperative follow-up in this series ranged from 8 to 31 months (mean follow-up, 22 months). Among the 10 patients, none presented with any signs of overt infection or cutaneous lesions, except 1 patient with hematoma on postoperative day 5. The hematoma was successfully treated by surgical removal and repositioning of the closed-suction drainage.

Conclusions

Based on our experience, salvage of exposed ICEDs is possible without removing the device in selected patients.

Aging might increase the incidence of infection from permanent pacemaker implantation

Aim. The elderly are the major population receiving the implantation of a permanent pacemaker (PPM). Infection is a devastating complication. The present study is to verify the relationship between age and PPM implantation infection. Methods. All patients (162 adult and 292 elder patients) received the implantation of PPM. Subcutaneous tissue samples solution was collected in three time points, the first sample was got at skin incision, and the second sample was got when the PPM had been implanted. And the third sample was got after 0.9% NaCl quick rinse. And the tissue solutions were cultured. If culture results are positive, it is considered as evidence of the presence of bacteria in pocket in operation of PPM implantation. Results. The data demonstrated that compared with that in the adult patients, subcutaneous bacterial survival rate was higher significantly in the elderly. Staphylococcus epidermidis is the major bacterial strain. The rinse decreased subcutaneous bacterial survival rates in the adult group. Conclusion. With the age increasing, PPM implantation might be easier to result in infection. Simple rinse can prevent implantation infection significantly. However, age alleviated the protective effects of rinse. Therefore, we should pay more attention to post implantation infection in the elderly.

Analysis of extracted cardiac device leads for bacteria type: clinical impact

The use of cardiac implantable electronic devices (CIED) increased over time, followed by rise of CIED-related complications, mainly infections and malfunctions. A clear diagnosis of CIED infection is of pivotal importance. When infection is confirmed, transvenous lead extraction (TLE) becomes mandatory, with associated risks and mortality. Local lesions at the device pocket often return negative swabs and tissue specimens, but conservative interventions are inconclusive, raising risks of systemic dissemination of infection and difficulties of subsequent TLE any more. When local bacteriological analyses are positive, once again, a contamination effect cannot be excluded. So traditional local swabs and tissue specimens exhibit low sensitivity and specificity for diagnosis of CIED infection. On the contrary, in cases sepsis, blood samples show high specificity, while the sensibility remains low, due to possible negative results in patients on antibiotics. In this scenario, the analysis of extracted device leads seems more appropriate for diagnostic purposes.

Salvage of Exposed Implantable Cardiac Electrical Devices and Lead Systems With Pocket Change and Local Flap Coverage

Erosion and exposure of pacemaker (PPM) and implantable cardiac defibrillator (ICD) devices are potentially dire complications, which have classically required the removal of the entire generator and lead systems. This study evaluates a series of cases wherein debridement, irrigation, pocket change, and local flap coverage were used for the successful salvage of indwelling leads after exposure and infection of implantable cardiac defibrillator devices. Patients with skin erosion, infection, and/or exposure of prepectoral infraclavicular cardiac defibrillator devices were treated over a 23-month period between June 2004 and April 2006. The surgical technique involved wide excision of the exposure site with a rhombic incision pattern, followed by removal of the generator unit and complete debridement of the peridevice capsule. Subclavian atrioventricular (AV) leads were preserved. The pocket was irrigated with antibiotic solution. A new pocket plane was selected and developed, and a new generator unit was implanted. A rhombic flap was developed and transposed to achieve tension-free closure over closed suction drains. Data were reviewed retrospectively. Six patients were treated, all male, mean age 66 years (range, 50 to 83 years). All patients presented with "new" exposure of the implantable generator within 48 hours. None demonstrated gross purulence, sepsis, or endocarditis. Initial gram stain was negative for bacteria in all cases, 1 (17%) grew sensitive Staphylococcus epidermidis species. Mean follow-up is 22 months (range, 8 to 31 months). One patient (17%) developed a hematoma, successfully treated by aspiration. Five patients (83%) were treated successfully, with no wound dehiscence, generator or lead exposure, or recurrence of infection. One patient (17%) developed drainage and exposure at a separate site (AV lead) at 10 months postoperative and required generator and lead explantation and site change to the contralateral anterior chest wall. In conclusion, in the absence of sepsis or gross infection, skin excision, pocket change, generator change with lead preservation, closed-suction drainage, and flap coverage for tension-free closure should be considered in the treatment of early ICD and PPM exposure.

Laser Assistance for Extraction of Chronically Implanted Endocardial Leads: Infectious versus Noninfectious Indications

BACKGROUND

Powered sheaths, including Excimer laser sheaths, were introduced for the removal of transvenous pacing and defibrillator leads. The purpose of this study was to develop an algorithm to better predict which patients are likely to benefit from these devices.

METHODS

We reviewed 283 consecutive patients in whom a total of 500 leads (302 pacing and 198 defibrillator leads) were extracted over a 5-year period at our operative facilities. Laser assist was utilized whenever moderate traction failed.

RESULTS

In 128 patients, 203 leads were removed for noninfectious indication. In 155 patients, 297 leads for infectious indications, including sepsis 22% (111), pocket infection 23% (115), and erosion 14% (71). Laser assistance was required for 6%+/- 5% (+/- 95% confidence interval) of septic leads, 51%+/- 7% of leads associated with erosion or pocket infection and 60%+/- 7% of noninfected leads (P = 0.001). Laser assistance was necessary more often for leads implanted >12 months (53%+/- 5%) than 12 months or less (6%+/- 5%) (P = 0.001) and for ventricular (52%+/- 6%) compared to atrial (35%+/- 7%) leads (P = 0.001).

CONCLUSIONS

Chronically implanted leads (>12 months), especially noninfected leads and leads associated with erosion or pocket infection, should be referred for extraction with powered sheaths to ensure successful removal. However, leads that are associated with systemic sepsis can generally be removed without powered sheaths.

Deep brain stimulation for Parkinson's disease: Surgical issues

Numerous factors need to be taken into account when implanting deep brain stimulation (DBS) systems into patients with Parkinson's disease. The surgical procedure itself can be divided into immediate preoperative, intraoperative, and immediate postoperative phases. Preoperative considerations include medication withdrawal issues, stereotactic equipment choices, imaging modalities, and targeting strategy. Intraoperative considerations focus on methods for physiological confirmation of a given target for DBS electrode deployment. Terms such as microelectrode recording, microstimulation, and macrostimulation will be defined to clarify inconsistencies in the literature. Advantages and disadvantages of each technique will be addressed. Furthermore, operative decisions such as staging, choice of electrode and implantable pulse generator, and methods of device fixation will be outlined. Postoperative issues include imaging considerations, including magnetic resonance safety, device-device interactions, and immediate surgical complications pertaining to the DBS procedure. This report outlines answers to a series of questions developed to address all aspects of the DBS surgical procedure and decision-making with a systematic overview of the literature (until mid-2004) and by the expert opinion of the authors. This is a report from the Consensus on Deep Brain Stimulation for Parkinson's Disease, a project commissioned by the Congress of Neurological Surgeons and the Movement Disorder Society. It outlines answers to a series of questions developed to address all surgical aspects of deep brain stimulation.

Local symptoms at the site of pacemaker implantation indicate latent systemic infection

BACKGROUND

To determine whether local complications at the site of pacemaker implantation indicate infection of the intravascular part of the lead as well as of the pacemaker pocket.

METHODS

105 patients admitted for local inflammatory findings, impending pacemaker or lead exteriorisation, frank pacemaker or lead exteriorisation, or overt infection were studied prospectively. After systematic lead extraction, the initial clinical presentation was related to the results of lead cultures.

RESULTS

Regardless of the initial presentation, the intravascular parts of the leads gave positive cultures in 79.3% of patients. Additionally, 91.6% of the cultures of the extravascular lead segments were positive, in contrast to 38.1% positivity for wound swab cultures. No clinical observations or laboratory investigations permitted identification of patients with negative lead cultures. In a subgroup of 50 patients with manifestations strictly limited to the pacemaker implantation site, cultures of intravascular lead segments were positive in 72%. Infection recurred in 4/8 patients without complete lead body extraction (50%) v 1/97 patients (1.0%) whose leads were totally extracted (p < 0.001).

CONCLUSIONS

Local complications at the site of pacemaker implantation are usually associated with infection of the intravascular part of the leads, with a risk of progressing to systemic infection. Such local symptoms should prompt the extraction of leads even in the absence of other infectious manifestations.

Candida infections of medical devices

The number of indwelling medical devices is escalating, and an increasing proportion of device-related infections are being caused by Candida spp. Candida spp. produce biofilms on synthetic materials, which facilitates adhesion of the organisms to devices and renders them relatively refractory to medical therapy. Management of device-related Candida infections can be challenging. Removal of the infected device is generally needed to establish cure of Candida infections of medical devices. However, since the pathogenesis of Candida bloodstream infection is complicated, more studies are necessary to determine the role of catheter exchange in patients with both gastrointestinal tract mucositis and indwelling catheters. The medical and economic impact of these infections is enormous.