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Tabbah RN, Abi-Saleh B. Erosion of Cardiovascular Implantable Device: Conservative Therapy or Extraction? Cureus 2020; 12:e12032. [PMID: 33457133 PMCID: PMC7797431 DOI: 10.7759/cureus.12032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Randa N Tabbah
- Cardiology, Centre Hospitalier Universitaire Notre Dame de Secours, Beirut, LBN
| | - Bernard Abi-Saleh
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
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2
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Simpson AM, Rockwell WT, Freedman RA, Rockwell WB. Salvage of Threatened Cardiovascular Implantable Electronic Devices: Case Series and Review of Literature. Ann Plast Surg 2019; 81:340-343. [PMID: 29781854 DOI: 10.1097/sap.0000000000001474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
| | | | - Roger A Freedman
- Cardiovascular Medicine University of Utah Health Sciences Center Salt Lake City, UT
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3
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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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Suarez K, Banchs JE. A Review of Temporary Permanent Pacemakers and a Comparison with Conventional Temporary Pacemakers. J Innov Card Rhythm Manag 2019; 10:3652-3661. [PMID: 32477730 PMCID: PMC7252718 DOI: 10.19102/icrm.2019.100506] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022] Open
Abstract
Temporary cardiac pacing is commonly used in patients with life-threatening bradycardia and serves as a bridge to implantation of a permanent pacemaker (PPM). For years, passive fixation leads have been used for this purpose, offering the advantage of that they can be placed at bedside. The downside, however, is that patients must remain on telemetry and bed rest until lead removal due to the risk of displacement and failure to capture. Even then, the latter cannot always be prevented. Temporary cardiac pacing with passive fixation leads has also been related to a higher incidence of infection and venous thrombosis, delayed recovery, and increased length of stay. Thus, over the last couple of decades, pacemaker leads with an active fixation mechanism have become increasingly used. This is known as a temporary PPM (TPPM) approach, which carries a very low risk of lead dislodgement and allows patients to ambulate, among other advantages. Here, we performed a review of the literature on the use of TPPMs and their advantages over temporary pacemakers with passive fixation leads and in order to evaluate the advantages and disadvantages of active and passive fixation leads in temporary cardiac pacing. Most articles found were case reports and case series, with few prospective studies. We excluded documents such as editorials and image case reports that provided little to no useful information for the final analysis. The literature search was performed in PubMed, Google Scholar, and other databases and articles written in English and Spanish were considered. Articles were screened up to January 2017. The search keywords used were "temporary permanent pacemaker," "external permanent pacemaker," "active fixation lead," "explantable pacemaker," "hybrid pacing," "temporary permanent generator," "prolonged temporary transvenous pacing," and "semipermanent pacemaker." A total of 24 studies with 770 patients were ultimately included in our review. The age group was primarily above the sixth decade of life, with the exception of one that included pediatric patients. Indications for pacing included device infection, sick sinus syndrome, atrioventricular block, ventricular tachycardia, and bradyarrhythmias associated with systemic illness. The duration of TPPM usage varied from a few days up to 336 days. A total of 18 (2.3%) TPPM-related infections were reported, in which the duration of TPPM use was less than 30 days in at least 15 patients. Loss of capture was documented in only eight patients (1.0%). Complication rates varied from 0% to 30%, with the highest event rates being present in studies that used femoral venous access. In conclusion, although no high-quality studies were identified in our literature search, we found the data retrieved suggest the association of overall favorable outcomes with the use of TPPMs. Device placement and removal typically involve a simple procedure, although fluoroscopy, usually applied in the cardiac catheterization laboratory, is necessary for implantation, which could represent an additional risk in a patient who is already hemodynamically unstable. When possible, a screw-in-lead pacemaker should be used for temporary pacing.
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Affiliation(s)
- Keith Suarez
- Section of Electrophysiology & Pacing, Division of Cardiology, Department of Medicine, Baylor Scott & White Temple Memorial Hospital, Baylor Scott & White Health, Dallas, TX, USA
| | - Javier E Banchs
- Section of Electrophysiology & Pacing, Division of Cardiology, Department of Medicine, Baylor Scott & White Temple Memorial Hospital, Baylor Scott & White Health, Dallas, TX, USA
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5
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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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Salvage of focally infected implantable cardioverter-defibrillator system by in situ hardware sterilization. HeartRhythm Case Rep 2017; 3:431-435. [PMID: 28948149 PMCID: PMC5601326 DOI: 10.1016/j.hrcr.2017.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Sharobaro VI, Gavrilov AG, Manturova NE. [Intraoperative disinfection, sterilization and repeated use of infected titanium implant in treatment of scalp radial ulcer with recurrent meningioma]. Khirurgiia (Mosk) 2017. [PMID: 28638017 DOI: 10.17116/hirurgia2017665-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- V I Sharobaro
- N.I. Pirogov Russian National Research Medical University
| | - A G Gavrilov
- N.N. Burdenko Institute of Neurosurgery, Moscow, Russia
| | - N E Manturova
- N.I. Pirogov Russian National Research Medical University
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Safe and Simplified Salvage Technique for Exposed Implantable Cardiac Electronic Devices under Local Anesthesia. Arch Plast Surg 2017; 44:42-47. [PMID: 28194346 PMCID: PMC5300922 DOI: 10.5999/aps.2017.44.1.42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 11/08/2022] Open
Abstract
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.
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10
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Lopez JA. Conservative management of infected pacemaker and implantable defibrillator sites with a closed antimicrobial irrigation system. ACTA ACUST UNITED AC 2012; 15:541-5. [DOI: 10.1093/europace/eus317] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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11
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Damm S. Intraoperative anaphylaxis associated with bacitracin irrigation. Am J Health Syst Pharm 2011; 68:323-7. [DOI: 10.2146/ajhp090238] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Suzanne Damm
- Via Christi Health, 929 North Saint Francis, Wichita, KS 67214
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12
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Castberg T. Complications from the pacemaker pocket. Prophylaxis, treatment and results. ACTA MEDICA SCANDINAVICA. SUPPLEMENTUM 2009; 596:51-4. [PMID: 1070225 DOI: 10.1111/j.0954-6820.1976.tb08379.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
281 patients who had permanent pacemaker implanted between 1961--73 have been checked at 4 month intervals over a period of 1 to 13 years. Complications from the pacemaker pocket comprises haematoma, skin necrosis, infection of the pocket, allergic reaction to the pulse generator, pacemaker twiddlers syndrome, and muscle contractions. The causes for and treatment of 11 cases with haematoma, skin necrosis or infection are dealt with in detail.
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Nandyala R, Parsonnet V. One Stage Side-to-Side Replacement of Infected Pulse Generators and Leads. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:393-6. [PMID: 16650268 DOI: 10.1111/j.1540-8159.2006.00359.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Infected and contaminated cardiac pulse generators and leads must be removed entirely in order to effect a cure. We have shown through our experience with 68 consecutive cases that explantation of the offending system and replacement of a new device on the opposite side can be safely accomplished in one sitting--a side-to-side replacement--as long as there is appropriate case selection. There were no early or late infections of the new operative site.
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Affiliation(s)
- Ramavathi Nandyala
- Pacemaker and Defibrillator Evaluation Center at Newark Beth Israel Medical Center, Newark, New Jersey 07112, USA
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15
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Lee JH, Geha AS, Rattehalli NM, Cmolik BL, Johnson NJ, Biblo LA, Carlson MD, Waldo AL. Salvage of infected ICDs: management without removal. Pacing Clin Electrophysiol 1996; 19:437-42. [PMID: 8848391 DOI: 10.1111/j.1540-8159.1996.tb06514.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
During the 7-year period from August 1986 to December 1993, 242 patients with malignant ventricular arrhythmias underwent 242 ICD implantations and 50 subcutaneous generator changes. Wound infections developed in 5 patients (1.7%): in 3 cases, after primary implantation (3/242 [1.2%]); and in 2 following a generator change (2/50 [4.0%]). This difference was not statistically significant. Infection developed at the generator pocket and became clinically manifest between 6 weeks and 40 months, postoperatively. Our treatment approach with the first patient consisted of simple debridement of the pocket and reimplantation of the existing generator. This led to recurrence, and the generator was safely explanted. In the remaining four patients, our approach has been that of local treatment, with wide debridement of the pocket, and placement of a closed irrigation system with continuous irrigation with a bacitracin, polymyxin, neomycin solution, and culture-specific antibiotic therapy. We have successfully controlled the infection and salvaged the generator with this approach in all four patients, who are all alive and well at a mean follow-up of 25.0 +/- 17.3 months with no recurrence. The good results obtained in these patients suggest that the concept of total explanation of the infected ICD should be reassessed.
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Affiliation(s)
- J H Lee
- Division of Cardiothoracic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Griffith MJ, Mounsey JP, Bexton RS, Holden MP. Mechanical, but not infective, pacemaker erosion may be successfully managed by re-implantation of pacemakers. BRITISH HEART JOURNAL 1994; 71:202-5. [PMID: 8130034 PMCID: PMC483647 DOI: 10.1136/hrt.71.2.202] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE When a pacemaker box causes erosion it is usually removed and a new pacemaker implanted at a contralateral site. In this study when there was no evidence of systemic infection an attempt was made to clean and reimplant the same pacemaker in the same site. RESULTS Over 10 years 62 patients had pacemaker reimplantation. In 18 patients the procedure was repeated a second time. Reimplantation was successful after at least six months follow up in 38 patients (61%): in nine two attempts had been made. Mean hospital stay for all patients was 21.3 days; for patients in whom the procedure was successful it was 12.5 days and for those in whom it was unsuccessful it was 35.4 days. 31 (82%) of the 38 patients in whom reimplantation was successful had no bacterial growth from wound swabs from 17/24 (71%) patients in whom reimplantation was unsuccessful (p < 0.001). Bacteria were grown from swabs from 7/8 patients with a protruding wire compared with 9/23 patients with a protruding pacemaker (p = 0.05). Thin patients and those who were older were more likely to have successful reimplantation: neither association reached statistical significance. A clinical impression of infection was not helpful. If re-implantation had been attempted only in the patients with negative wound swabs or intact skin the success rate would have been 74% at a cost of 5010 pounds per patient compared with a cost of 6509 pounds per patient for explantation and a reimplantation of a new contralateral pacemaker. CONCLUSION These data support the hypothesis that pacemaker erosion is caused by primary infection or by a non-infective process (probably mechanical pressure). Pacemaker erosion that is not caused by infection can be successfully managed by ipsilateral reimplantation and this approach saves money.
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Affiliation(s)
- M J Griffith
- Cardiac Department, Freeman Hospital, Newcastle upon Tyne
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Kassanoff AH, Levin CB, Wyndham CR, Mills LJ. Implantable cardioverter defibrillator infection causing constrictive pericarditis. Chest 1992; 102:960-3. [PMID: 1516435 DOI: 10.1378/chest.102.3.960] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A case of severe constrictive pericarditis resulting from an indolent Pseudomonas aeruginosa infection of the automatic internal cardiac defibrillator is described. Total explanation of the device was attempted after nine months but was unsuccessful because of dense adhesions under the patch electrodes. The patient subsequently developed clinical and hemodynamic findings of constrictive pericarditis and a second desperate attempt to remove the patches resulted in operative death. Diagnostic modalities for detecting infection of the AICD are reviewed. As soon as there is infection involving any component, the entire lead system and pulse generator should be removed.
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Affiliation(s)
- A H Kassanoff
- Department of Medicine, Presbyterian Hospital of Dallas
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Taylor RL, Cohen DJ, Widman LE, Chilton RJ, O'Rourke RA. Infection of an implantable cardioverter defibrillator: management without removal of the device in selected cases. Pacing Clin Electrophysiol 1990; 13:1352-5. [PMID: 1701884 DOI: 10.1111/j.1540-8159.1990.tb04005.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A case is presented in which an implantable cardioverter defibrillator (ICD) became infected in the abdominal wall pocket 5 weeks following implantation. There was no evidence clinically or by computed tomographic scan suggesting mediastinal extension of the infection. The infection was treated successfully by debriding the abdominal wall pocket followed by a combination of pocket irrigation with antibiotic solution, parenteral antibiotics, and long-term oral antibiotics. This conservative therapy was successful and avoided removal of the device.
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Affiliation(s)
- R L Taylor
- Division of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio
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Har-Shai Y, Amikam S, Ramon Y, Kahir G, Hirshowitz B. The management of exposed cardiac pacemaker pulse generator and electrode using restricted local surgical interventions; subcapsular relocation and vertical-to-horizontal bow transposition techniques. BRITISH JOURNAL OF PLASTIC SURGERY 1990; 43:307-11. [PMID: 2350636 DOI: 10.1016/0007-1226(90)90077-d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This paper describes an approach to the treatment of exposed pacemaker generator and electrode. Local infection is controlled by the administration of systemic antibiotics and topical antibacterial solutions. Because the generator and lead are enveloped by an inert synthetic coating, it is possible to eradicate an infection without their removal if it is due to a weak opportunist pathogen fully sensitive to antibiotics. Thereafter, subcapsular relocation of the exposed generator or vertical-to-horizontal transposition of the exteriorised lead is carried out. These surgical interventions are designed to overcome the vertical force which tends to cause the extrusion of the pacing hardware.
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Affiliation(s)
- Y Har-Shai
- Department of Plastic Surgery, Rambam Medical Center, Israel Institute of Technology, Haifa
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20
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Heimberger TS, Duma RJ. Infections of Prosthetic Heart Valves and Cardiac Pacemakers. Infect Dis Clin North Am 1989. [DOI: 10.1016/s0891-5520(20)30260-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hong-Barco P, O'Toole J, Gerber ML, Domat I, Moquin M, Jackson SC. Endocarditis due to six entrapped pacemaker leads and concomitant recurrent coronary arteriosclerosis. Ann Thorac Surg 1988; 46:97-9. [PMID: 2981002 DOI: 10.1016/s0003-4975(10)65863-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A case of endocarditis associated with six entrapped endocardial pacer leads is presented. Because of many failed attempts at removing them by conservative measures, cardiopulmonary bypass was needed; concomitant redo coronary bypass grafts were done. To our knowledge, this represents a unique case, the like of which has not been reported previously. Salient features of management are discussed.
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Affiliation(s)
- P Hong-Barco
- Division of Cardiovascular Surgery, Shadyside Hospital, Pittsburgh, PA
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22
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Hurst LN, Evans HB, Windle B, Klein GJ. The salvage of infected cardiac pacemaker pockets using a closed irrigation system. Pacing Clin Electrophysiol 1986; 9:785-92. [PMID: 2432481 DOI: 10.1111/j.1540-8159.1986.tb06628.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Over a period of 71 months, 19 patients were treated for infected or eroded permanent pacemaker pockets. All cases were treated with local debridement and insertion of a closed irrigation system using a solution of tyloxapol and tobramycin. Successful eradicaiton of the infection, without complete replacement of the pacemaker system, was achieved in all cases.
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Mansour KA, Kauten JR, Hatcher CR. Management of the infected pacemaker: explantation, sterilization, and reimplantation. Ann Thorac Surg 1985; 40:617-9. [PMID: 4074010 DOI: 10.1016/s0003-4975(10)60360-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
From January, 1970, through December, 1984, nineteen infected or eroded pacemaker units were reimplanted in 17 patients. Characteristics of the patients, types of infecting organisms, surgical management, and complications are described. Optimal treatment of the infected generator pocket requires explantation of the generator unit with utilization of the in situ leads for pacing by an external-demand pacemaker unit. The generator unit is sterilized, and new leads are placed with relocation of the pocket. The old leads are then removed. This technique has been used safely and with excellent results for the past fourteen years.
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Bluhm G, Jacobson B, Ransjö U. Antibiotic prophylaxis in pacemaker surgery: a prospective trial with local or systemic administration of antibiotics at generator replacements. Pacing Clin Electrophysiol 1985; 8:661-70. [PMID: 2414747 DOI: 10.1111/j.1540-8159.1985.tb05878.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Beder SD, Hanisch DG, Cohen MH, Van Heeckeren D, Ankeney JL, Riemenschneider TA. Cardiac pacing in children: a 15-year experience. Am Heart J 1985; 109:152-6. [PMID: 3966313 DOI: 10.1016/0002-8703(85)90427-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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26
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Peters G, Saborowski F, Locci R, Pulverer G. Investigations on staphylococcal infection of transvenous endocardial pacemaker electrodes. Am Heart J 1984; 108:359-65. [PMID: 6464972 DOI: 10.1016/0002-8703(84)90625-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Infections of pacemaker electrodes and/or aggregate pockets are usually caused by staphylococci, primarily Staphylococcus epidermidis. From in vitro experiments it can be demonstrated that staphylococci are able to adhere to the plastic electrode sheath, to multiply there, and to form microcolonies. Furthermore, the staphylococci produce a slimy amorphous substance with which they are completely covered after a 24-hour incubation. No difference was noticed between the in vitro experiment situation and that occurring in pacemaker infection in humans. This slimy material may be responsible for the maintenance of the infection and the protection of the enclosed bacterial cells against natural host defense mechanisms and antibiotic treatment.
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Madigan NP, Curtis JJ, Sanfelippo JF, Murphy TJ. Difficulty of extraction of chronically implanted tined ventricular endocardial leads. J Am Coll Cardiol 1984; 3:724-31. [PMID: 6693644 DOI: 10.1016/s0735-1097(84)80248-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The dislodgment rate of permanent pacing ventricular and atrial endocardial leads has significantly decreased with the incorporation of tines as a fixation device. In contrast, transvenous manual extraction of chronically implanted endocardial leads is, at times, clinically indicated, particularly when pacemaker system infection is present. The success rate of such extraction attempts for ventricular endocardial leads over the past 5 years was reviewed. Extraction was usually successful (six of seven attempts) in patients with silicone rubber nontined (or short-tined) older ventricular endocardial leads (Group A). However, in patients with newer urethane long-tined ventricular endocardial leads (Group B), extraction was unsuccessful in three of four attempts. Because of entrapment of the distal electrode tip in the right ventricular apex, manual traction of these leads resulted in permanent conductor material stretching with resultant urethane insulator material breakage in the region of the joints with proximal and distal electrodes. The one successful extraction in Group B was technically difficult and appeared to create a significant risk of intracardiac lead separation. This experience indicates that with improved pacemaker lead design decreased lead dislodgment has been obtained at the cost of increased difficulty of ventricular endocardial lead extraction. Such difficulty should be anticipated when a clinical decision is made to attempt to extract the new urethane long-tined ventricular leads.
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Choo MH, Holmes DR, Gersh BJ, Maloney JD, Merideth J, Pluth JR, Trusty J. Permanent pacemaker infections: characterization and management. Am J Cardiol 1981; 48:559-64. [PMID: 7270461 DOI: 10.1016/0002-9149(81)90088-6] [Citation(s) in RCA: 137] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
From January 1974 to June 1980, a total of 46 patients were treated for infections involving permanent pacing systems. Demographic characteristics, types of infecting organisms, specific clinical features, significance of an infected foreign body and various medical and surgical treatment methods are described. Likely infecting organisms depend on the mode of presentation and the time course of the infection. Optimal treatment for the large majority of patients requires removal of the entire infected pacing system. In a subgroup of patients, a short course of antibiotic therapy followed by one stage surgery involving implantation of a new pacing system and concurrent explanation of the infected pacemaker was used safely with excellent results.
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Abstract
The records of 1,235 consecutive patients treated with long-term pacing by the endocardial route between 1964 and 1977 were analyzed to determine the incidence, mechanism, course and treatment of septicemia. Septicemia developed in 12 patients (1 percent), and Staphylococcus aureus was isolated from the blood culture in 10. All patients were treated with the usual prolonged course of bactericidal drugs. Treatment was successful in only two of the seven patients whose endocardial pacing system was left in place; in three of the seven the septicemia recurred, necessitating removal of the endocardial system, and two of these patients died. In the remaining four patients the endocardial wire was promptly withdrawn, with use of a thoracotomy when necessary, and an epicardial system inserted; all of these patients survived. This is the treatment of choice.
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Abstract
Five patients who had infected cardiac pacemakers with epicardial electrodes have been managed by exteriorization of the pulse generator and placement of an endocardial unit. In each case the remaining electrode leads where detached from the myocardium and removed by simple traction, avoiding a surgical procedure. In 4 patients, sets of cables had been sutured to the myocardium through an anterior thoracotomy, in some instances using Teflon pledgets as buttresses. In one of these procedures a pericostal suture had been used to secure the leads from the thoracic cavity against the ribs. The remaining patient had received a subxiphoid pacemaker also implanted with sutures. This is a consecutive series, and we have had no failures so far. All pulse generator units were bipolar and located beneath either the pectoral or the rectus muscle. All of them were functioning properly when infection was diagnosed. This procedure constitutes an alternative method of management when more conservative techniques, such as closed irrigation and debridement, cannot be utilized.
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