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SMITH MACYC, LOVE CHARLESJ. Extraction of Transvenous Pacing and ICD Leads. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:736-52. [DOI: 10.1111/j.1540-8159.2008.01079.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE OF REVIEW Use of electrophysiologic devices (permanent cardiac pacemaker and implantable cardioverter/defibrillator) has been increasing. Infection of these cardiac devices is a devastating complication, and medical treatment alone without device removal is often unsuccessful and frequently leads to infection relapse. This article reviews recent publications that address the diagnosis and management of infected electrophysiologic devices. RECENT FINDINGS Recent studies have shed new light on the incidence, risk factors, management, and outcome of cardiac device infection. Rates of both cardiac device implantation and infection have been increasing, although the rate of increase of cardiac device infection has outdistanced that of implantation and this has had enormous economic and clinical consequences. SUMMARY The large majority of cardiac device infections are likely due to pocket site contamination at the time of device placement. Hematogenous seeding from a distant focus of infection, particularly due to Staphylococcus aureus, can account for late-onset infection. Although no prospective studies have been conducted to date, management with parenteral antibiotics and complete device removal is the current standard of care. Further study is needed to better define optimal diagnostic and management interventions, particularly in patients with bloodstream infection and no local chest wall or echocardiographic evidence of cardiac device infection.
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Affiliation(s)
- Daniel Z Uslan
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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Love CJ, Wilkoff BL, Byrd CL, Belott PH, Brinker JA, Fearnot NE, Friedman RA, Furman S, Goode LB, Hayes DL, Kawanishi DT, Parsonnet V, Reiser C, Van Zandt HJ. Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, training. North American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty. Pacing Clin Electrophysiol 2000; 23:544-51. [PMID: 10793452 DOI: 10.1111/j.1540-8159.2000.tb00845.x] [Citation(s) in RCA: 195] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The procedure of lead removal has recently matured into a definable, teachable art with its own specific tools and techniques. It is now time to recognize and formalize the practice of lead removal according to the current methods of medicine and the health care industry. In addition, since at this time the only prospective scientific study of lead extraction is the PLEXES trial, we suggest that studies relating to the techniques of and indications for lead extraction be designed. Recommendations for a common set of definitions, for a framework of training and reviewing physicians in the art, for general methods of reimbursement, and for consistency among clinical trials have been made. Implementation of these recommendations will require additional effort and cooperation from practicing physicians, medical societies, hospital administrations, and industry.
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Abstract
Extraction of chronically implanted pacing leads involves a thorough understanding of the pathophysiology of lead maturation and the problems that may occur. It also requires specific knowledge of lead construction and the idiosyncrasies of individual lead models. Though we have evolved to use a standardized approach to lead extraction, each patient and lead removal is unique. The operator must be ready to adapt the technique and tools used to the situation at hand. The more experience and the more tools available to the operator, the more likely that there will be a safe and successful outcome to the procedure. Preparation for disaster is mandatory, such that when a complication does occur, one may respond quickly and therefore salvage the patient.
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Affiliation(s)
- C J Love
- Arrhythmia Device Services, Ohio State University, Columbus, USA.
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Feldbaum DM, Brodman RF, Frame R, Camacho MT, Gross J, Ferrick K. Removal of infected pacemaker leads with deep hypothermic circulatory arrest and open surgical exploration of the superior vena cava and innominate veins. Pacing Clin Electrophysiol 1999; 22:962-4. [PMID: 10392398 DOI: 10.1111/j.1540-8159.1999.tb06825.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite the use of transvenous methods for extraction of infected leads, failed attempts may result in retained lead fragments. Retained lead fragments may be a focus of continued infection leading to sepsis. We present two patients in which conversion from cardiopulmonary bypass to hypothermic circulatory arrest allowed direct visualization, using venotomies in the superior vena cava and innominate vein to achieve complete removal of retained pacemaker lead fragments. Use of venotomies in the extracardiac venous system is a technical addition to prior descriptions of lead extraction using deep hypothermia and circulatory arrest.
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Lim AG, Hine KR. Pyrexia and breathlessness in a patient with a cardiac pacemaker. Postgrad Med J 1996; 72:571-3. [PMID: 8949601 PMCID: PMC2398564 DOI: 10.1136/pgmj.72.851.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- A G Lim
- Department of Medicine, St. George's Hospital, London, UK
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Abstract
The authors analyzed the data of seven patients who had undergone open heart surgery because of pacemaker endocarditis in the past 4 years. Repeated surgical interventions on the pacemaker system were found to be the most common predisposing factors. Staphylococcus aureus and Staphylococcus epidermidis were the most common causative organisms. Two-dimensional echocardiography was important in the diagnosis of cases with atypical clinical picture and negative blood cultures. We concluded that: (1) any pacemaker patient with fever should be considered to have a pacemaker endocarditis; (2) all of these patients should be examined by two-dimensional echocardiography; and (3) the total removal of the infected hardware seems to be the only way to achieve complete recovery.
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Affiliation(s)
- A Böhm
- Haynal Imre University of Health Sciences, Department of Medicine, Budapest, Hungary
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Abad C, Manzano JJ, Quintana J, Bolaños J, Manzano JL. Removal of infected dual chambered transvenous pacemaker and implantation of a new epicardial dual chambered device with cardiopulmonary bypass: experience with seven cases. Pacing Clin Electrophysiol 1995; 18:1272-5. [PMID: 7659581 DOI: 10.1111/j.1540-8159.1995.tb06967.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Seven patients with infected transvenous dual chambered pacemakers have undergone removal of the device using cardiopulmonary bypass. There were four women and three men with a mean age of 58 years. Six patients had localized infection in the generator pocket (mean of 4.6 previous unsuccessful operations for surgical sterilization). Four infections were due to Staphylococcus epidermidis, two to Staphylococcus aureus, and one patient presented septicemia caused by Staphylococcus epidermidis and Pseudomonas aeruginosa. The atrial and ventricular transvenous electrodes were removed under direct vision using cardiopulmonary bypass. A new dual chambered epicardial pacemaker was implanted. The procedure was well-tolerated, and all patients are infection free with working pacemakers after a mean follow-up of 25.4 months.
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Affiliation(s)
- C Abad
- Department of Cardio-Vascular Surgery, Hospital NS del Pino, Las Palmas Gran Canaria, Spain
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Colavita PG, Zimmern SH, Gallagher JJ, Fedor JM, Austin WK, Smith HJ. Intravascular extraction of chronic pacemaker leads: efficacy and follow-up. Pacing Clin Electrophysiol 1993; 16:2333-6. [PMID: 7508617 DOI: 10.1111/j.1540-8159.1993.tb02346.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Extraction of chronic pacemaker leads has been recommended for infections, prevention of venous thrombosis, migration, and possible perforation. Success with constant traction techniques has been variable, and the cost and morbidity of open chest surgical procedures are prohibitive. Efficacy of a new system for lead extraction using intravascular techniques was analyzed. The system (Cook Pacemaker) uses a locking stylet, which is secured at the distal electrode by counterclockwise rotation to reinforce the lead and facilitate traction, and dilator sheaths that are used to free the lead from adhesions in the venous system. In a series of 56 patients (ages 19-88) who presented for lead extraction because of erosion (5), infection (14), lead replacement (35), or other (2), 86 leads were extracted. Thirty-two were atrial leads and 54 ventricular; 23 had active fixation and 63 passive. Average duration of implant was 58 +/- 42 months (range 1-264). Eighty-four leads were totally removed and two partially removed. For these two leads, the distal tip was not removed; in both cases the locking stylet was not secured at the distal electrode due to obstruction within the lead. Two patients developed arm edema following the procedure, which resolved with elevation. One patient developed a subclavian thrombosis, which resolved with warfarin anticoagulation. Four patients have expired due to unrelated causes. In conclusion, this intravascular approach for extraction of chronic leads is effective, and the procedure is safe when performed by experienced personnel.
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Frame R, Brodman RF, Furman S, Andrews CA, Gross JN. Surgical removal of infected transvenous pacemaker leads. Pacing Clin Electrophysiol 1993; 16:2343-8. [PMID: 7508619 DOI: 10.1111/j.1540-8159.1993.tb02348.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Infection, though uncommon, can be the most lethal of all potential complications following transvenous pacemaker implantation. Eradication of infection associated with pacemakers requires complete removal of all hardware, including inactive leads. Since 1972, 5,089 patients have had 8,508 pacemaker generators implanted at Montefiore Medical Center. There were 91 infections (1.06%); four of our patients required surgical removal. Nine additional patients were referred for surgical removal of infected transvenous pacemaker leads from other institutions. Surgical methods for removal included use of cardiopulmonary bypass or inflow occlusion. Surgery may be safely used in unstable or elderly patients and should not be reserved as a last resort. This article reviews our surgical experience removing infected pacemaker leads at Montefiore Medical Center.
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Affiliation(s)
- R Frame
- Department of Cardiothoracic Surgery, Montefiore Medical Center, Moses Division, Bronx, New York 10467
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Teno LA, Bestetti RB, Oliveira WM, Zanardi MC, Freitas OC, Cozac EP, Deus DM, Castilho OT. Tricuspid endocarditis: a rare infectious complication of cardiac pacemaker in a patient with Chagas' disease--a case report. Angiology 1993; 44:580-3. [PMID: 8328688 DOI: 10.1177/000331979304400712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Tricuspid endocarditis was diagnosed in a sixty-four-year-old patient with Chagas' disease who had a permanent cardiac pacemaker and whose generator had been replaced five months before an infection in the pocket. The pacing system was replaced by an epicardial one and the patient received antibiotics with good results.
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Affiliation(s)
- L A Teno
- Instituto do Coração da Santa Casa de Ribeirão Preto, Brazil
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Niederhäuser U, von Segesser LK, Carrel TP, Laske A, Bauer E, Schönbeck M, Turina M. Infected endocardial pacemaker electrodes: successful open intracardiac removal. Pacing Clin Electrophysiol 1993; 16:303-8. [PMID: 7680459 DOI: 10.1111/j.1540-8159.1993.tb01581.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED The long-term results after open intracardiac removal of infected pacing electrodes are presented. METHODS Between 1985 and 1990 open intracardiac removal of 19 infected pacing electrodes was performed in seven patients (six male and one female), with a mean age of 56 years. The indications were: persisting bacteremia in three; generator pocket infection in four; endocarditis in one; and ventricular tachycardia caused by retracted electrodes in one. All electrodes were fixed in the right heart and extraction by closed methods failed. Percutaneous catheter techniques were not applied in these seven patients. In five patients two ventricular electrodes had to be removed, and in two patients a single one. A total of seven atrial electrodes were removed in six patients (one electrode each in five patients; two electrodes in one patient). All atrial and two ventricular electrodes could be removed through a pursestring suture without use of a pump oxygenator. For the removal of ten ventricular electrodes in six patients (two electrodes each in four patients; 1 electrode each in two patients) a right-sided atriotomy was necessary with cardiopulmonary bypass (CPB). Simultaneously, five new pacing systems were implanted. RESULTS There were no early or late mortalities. In January 1991, all seven patients are alive and in a mean New York Heart Association Class 1,3 of heart failure after a mean interval of 33 months. In all cases the infection could controlled with a simultaneous antimicrobial chemotherapy and the postoperative period was free of major complications. CONCLUSION Open intracardiac removal of retained pacing electrodes with or without use of CPB is a safe procedure without major complications. It is mandatory for all infected pacing electrodes that cannot be extracted by closed methods.
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Affiliation(s)
- U Niederhäuser
- Clinic for Cardiovascular Surgery, University Hospital, Zürich, Switzerland
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Brodman R, Frame R, Andrews C, Furman S. Removal of infected transvenous leads requiring cardiopulmonary bypass or inflow occlusion. J Thorac Cardiovasc Surg 1992. [DOI: 10.1016/s0022-5223(19)34947-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sisson D, Thomas WP, Woodfield J, Pion PD, Luethy M, DeLellis LA. Permanent transvenous pacemaker implantation in forty dogs. J Vet Intern Med 1991; 5:322-31. [PMID: 1779425 DOI: 10.1111/j.1939-1676.1991.tb03145.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Permanent transvenous cardiac pacemakers were implanted in 40 dogs. Electrocardiographic diagnoses included persistent atrial standstill (3 dogs), sick sinus syndrome (8 dogs), and high-grade second-degree or third-degree atrioventricular (AV) block (29 dogs). Thirteen dogs were alive and well 4 to 42 months after pacemaker implantation (mean, 16.9 months). The mean and median survival times of the 26 dogs that died or were euthanatized during the study were 17.9 months and 13 months, respectively. Most of these dogs succumbed to problems unrelated to the arrhythmia and pacemaker implant. One dog was lost to follow-up. Complications associated with permanent transvenous pacemaker implantation included lead dislodgement, infection, hematoma formation, skeletal muscle stimulation, ventricular arrhythmia, migration of the pulse generator, and skin erosion. Lead dislodgement was the most common complication, occurring in 7 of 9 dogs paced using untined electrode leads and in 6 of 30 dogs paced using tined leads. Lead dislodgement did not occur in the only dog paced using an actively fixed endocardial lead. It was concluded that permanent transvenous cardiac pacing is a feasible, less traumatic alternative to epimyocardial pacing in dogs, but that successful use of this technique requires careful implantation technique and anticipation of the potential complications.
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Affiliation(s)
- D Sisson
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana 61801
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Byrd CL, Schwartz SJ, Hedin N, Beach M. Intravascular techniques for extraction of permanent pacemaker leads. J Thorac Cardiovasc Surg 1991. [DOI: 10.1016/s0022-5223(19)36615-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Myers MR, Parsonnet V, Bernstein AD. Extraction of implanted transvenous pacing leads: a review of a persistent clinical problem. Am Heart J 1991; 121:881-8. [PMID: 2000756 DOI: 10.1016/0002-8703(91)90203-t] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Within a few months of implantation, permanent pacemaker leads become ensheathed in fibrocollagenous tissue. This tissue may anchor the lead so that it is difficult, dangerous, or impossible to remove it. Leads with bulbous or finned tips are particularly resistant to extraction. The risks of applying traction to an entrapped lead include induction of bradycardia or ventricular tachycardia and fibrillation, invagination of the right ventricle, avulsion of the right ventricular myocardium or tricuspid valve, hemopericardium, and cardiac tamponade. Forceful traction may result in uncoiling of the conductor, disruption of the insulation, or complete fracture, leaving an intravascular remnant that may embolize or be a source for thrombosis. Although fixation and abandonment of an inactive chronically implanted lead is frequently appropriate and is known to pose little long-term risk, the retained inactive lead may interact adversely with a new active lead and then increase the risk of venous thrombosis, serve as a potential nidus for infection, or produce spurious electrical sensing signals that may be sensed by the pulse generator. Absolute indications for lead removal are those in which there would be a life-threatening situation if the lead were to remain in situ. In the absence of an absolute indication, the decision to proceed with extraction must be made by weighing the potential for serious morbidity or mortality against risks of the extraction technique. Techniques for lead removal include traction and open cardiotomy operations. When a portion of the lead is intravascular, forceps, snares, baskets, countertraction, or lead-transection devices may be used to retrieve the fragment.
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Affiliation(s)
- M R Myers
- Division of Cardiac Electrophysiology, Huntington Hospital, Pasadena, CA 91105
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Byrd CL, Schwartz SJ, Hedin NB, Goode LB, Fearnot NE, Smith HJ. Intravascular lead extraction using locking stylets and sheaths. Pacing Clin Electrophysiol 1990; 13:1871-5. [PMID: 1704557 DOI: 10.1111/j.1540-8159.1990.tb06906.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chronic lead extraction using intravascular countertraction techniques was studied in patients with over 65 different lead models including passive and active fixation devices. Indications for removal of 115 leads implanted 5 days to 264 months (mean 58 months) in 62 patients (mean 65 years) included septicemia, subcutaneous tissue infection, preerosion, free-floating lead, lead trapped in valve, too many leads, pain, and vein thrombosis. The superior vena cava (SVC) approach was attempted in 101 leads and was successful in 82 attempts (71% of total leads). The inferior vena cava (IVC) approach via the femoral vein was required to extract 14 (12%) leads inaccessible to the SVC approach and the 19 leads that failed the SVC approach (29% of total leads). The SVC procedure includes a sized stylet locked at the tip and telescoping sheaths advanced over the lead to the heart. An IVC procedure includes placement of a 16 F sheath workstation via a femoral vein into the right atrium. A deflection catheter and Dotter snare in an 11 F sheath were advanced through the workstation into the right atrium. The lead was maneuvered into position, snared, and pulled into the workstation. For both the SVC and IVC approaches, the leads were removed by applying traction on the lead and countertraction with the sheaths. In experienced hands, these techniques have proven safe and effective for removing chronic transvenous leads.
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Brodell GK, Castle LW, Maloney JD, Wilkoff BL. Chronic transvenous pacemaker lead removal using a unique, sequential transvenous system. Am J Cardiol 1990; 66:964-6. [PMID: 2220620 DOI: 10.1016/0002-9149(90)90934-s] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Transvenous removal of 43 consecutive chronic pacemaker leads was successful in 28 patients. For leads not removed by traction at the pacemaker connection terminal, a unique locking stylet was advanced through the inner coil lumen and engaged at the tip to allow traction without lead elongation. Leads not extracted with the locking stylet alone had traction maintained on the stylet as sheaths were advanced over the lead to dilate and detach any fibrous tissue adherent to the lead. By applying traction at the pacemaker connection terminal, 2 leads were removed. The locking stylet alone extracted 9 leads. Both the locking stylet and sheaths were necessary to explant 32 leads. There were 15 right atrial and 22 right ventricular leads completely removed. Additionally, 6 right ventricular leads were subtotally removed leaving only the tip in the right ventricular apex. Avulsed myocardium was removed with the lead in 1 patient without sequelae. A subacute hemothorax developed in 1 patient 18 days after discharge requiring drainage, and subclavian vein thrombosis developed in another, which was successfully treated with anticoagulation. Hypotension occurred in 1 patient during final positioning of new leads, which responded to conservative treatment. Chronic pacemaker leads can be reliably removed without thoracotomy. Both a unique locking stylet to allow traction without lead elongation and a sheath to dilate and detach adherent fibrous tissue are needed for consistent success. Recognized complications included myocardial avulsion without sequelae, subacute hemothorax, subclavian vein thrombosis and transient hypotension.
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Affiliation(s)
- G K Brodell
- Cleveland Clinic Foundation, Ohio 44195-5064
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Abstract
With the advent of tined transvenous cardiac pacing leads, the complete extraction of pacing leads in the treatment of an infected cardiac pacing system has become increasingly difficult. A method is described for the extraction of permanent pacing leads from the heart using alligator forceps inserted transvenously through the right internal jugular vein, grasping the lead near its insertion point in the cardiac muscle.
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Affiliation(s)
- J M Kratz
- Department of Surgery, Medical University of South Carolina, Charleston 29425
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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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Cope C, Larrieu AJ, Isaacson CS, Wolk LA, Ghosh SC, Rothkopf B. Transfemoral removal of a chronically implanted pacemaker lead: report of a case. Ann Thorac Surg 1986; 42:329-30. [PMID: 3753082 DOI: 10.1016/s0003-4975(10)62746-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A transfemoral angiographic technique was used to remove a chronically implanted, infected pacemaker wire that could not be withdrawn by using direct traction. The case and a description of the technique are detailed, and the principles of nonsurgical extraction of chronically implanted pacemaker wires are discussed.
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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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Dubernet J, Irarrázaval MJ, Lema G, Maturana G, Urzúa J, Morán S, Navarro M, Fajuri A. Surgical removal of entrapped endocardial leads without using extracorporeal circulation. Pacing Clin Electrophysiol 1985; 8:175-80. [PMID: 2580277 DOI: 10.1111/j.1540-8159.1985.tb05747.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Of 267 patients having a tined endocardial lead implanted from 1978 to December 1983, three (1.1%) developed pulse generator pocket infection. Proper treatment of this complication involves removal of the pulse generator, continued external pacing via the implanted lead, pocket drainage and administration of specific antibiotics until the infected area clears. In two patients, the electrode could not be removed by traction. A sternotomy was performed, the pericardium was opened, the endocardial electrode was located by palpation, and a purse string suture (PSS) was prepared around it on the right ventricular wall. A new myocardial electrode with its corresponding generator was then implanted to reestablish pacing. Through the PSS the myocardium was incised, the distal end of the endocardial lead was exteriorized and severed, and the PSS was tied. The remaining lead was withdrawn proximally and the surgical wounds were closed. The results of this procedure have been been excellent, allowing the removal of the entrapped leads, with continuous pacing and without the need for extracorporeal circulation.
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Byrd CL, Schwartz SJ, Sivina M, Yahr WZ, Greenberg JJ. Technique for the surgical extraction of permanent pacing leads and electrodes. J Thorac Cardiovasc Surg 1985. [DOI: 10.1016/s0022-5223(19)38860-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ramsdale DR, Charles RG, Rowlands DB, Singh SS, Gautam PC, Faragher EB. Antibiotic prophylaxis for pacemaker implantation: a prospective randomized trial. Pacing Clin Electrophysiol 1984; 7:844-9. [PMID: 6207497 DOI: 10.1111/j.1540-8159.1984.tb05626.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Prophylactic antibiotics are frequently prescribed for patients undergoing permanent pacemaker implantation even though data confirming their effectiveness are limited. Five hundred patients requiring elective permanent pacemaker implantation or generator replacement were prospectively randomized either to receive or not receive prophylactic antibiotic treatment at the time of implantation. The implantation site was treated with 10% povidone-iodine solution and 0.5% alcoholic chlorhexidine preoperatively. The wound were inspected for evidence of infection at 3 days and 1, 3, 6 and 12 months postimplantation. Three patients (two receiving prophylactic antibiotics and one no antibiotics) developed pacemaker pocket infection; Staphylococcus aureus was the pathogenic organism in each case (P = 0.56). Eighteen patients developed clinical evidence of superficial wound inflammation requiring antibiotic treatment but not pacemaker removal. Six had received prophylactic antibiotics and 12 had not (P = 0.27). We conclude that pacemaker pocket infection is unusual with careful preoperative skin preparation and close postoperative follow-up. Under these circumstances prophylactic antibiotic treatment is of no practical value.
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DeLeon SY, Bojar R, Koster NK, Ilbawi MN, Munez H, Idriss FS. Recurrent sepsis from retained endocardial electrode in children: successful removal with cardiopulmonary bypass. Pacing Clin Electrophysiol 1984; 7:166-8. [PMID: 6200839 DOI: 10.1111/j.1540-8159.1984.tb04881.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Infection remains a significant problem in patients undergoing permanent cardiac pacemaker implantation, and removal of all components is usually required. The transvenous system carries minimal morbidity at implantation, but the development of infection is more life-threatening than in the epicardial system. Although the evolution of the tined porous endocardial lead reduced the incidence of wire displacement, the development of a serious infection is still a problem and may require major surgery for removal. We experienced this problem in a 15-month-old child who developed recurrent sepsis. Attempts at removal of the retained tined porous electrode through the neck incision proved dangerous and unsuccessful. Removal was carried out using cardiopulmonary bypass and infection was promptly controlled.
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Abstract
To analyze thrombotic complications, we performed brachial phlebographies in 100 consecutive patients (group 1), about 44 months after permanent pacemakers had been installed. Thirty-nine patients showed thrombotic lesions in the veins used to pass the stimulation electrode into the right ventricle. In 10 patients the medical history and in 12 patients clinical symptoms and signs indicated an impairment of venous flow. Fifteen of the 39 patients showed complete occlusion of one venous segment; collateral vessel formation was found dependent on the site and the extent of the occlusion. In the remaining 24 patients only partial occlusion without collateralization was demonstrated. Group 2 comprised 12 patients in whom the pacing lead originally inserted via right-sided veins had been severed and the free distal end left unsecured intraluminally when the second electrode was inserted via the left-sided cephalic vein. In all these patients phlebography about 19 months later revealed thrombotic complications, while 11 presented with clinical symptoms and signs. The incidence of thrombotic complications including segmental occlusion after the application of permanent pacer leads is only one-third of patients with segmental occlusion symptoms. However, since severed leads produce severe symptomatic complications in almost all cases their removal is mandatory.
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Peters R, Wohl B, Fisher M, Carliner N, Plotnick G. Non-operative removal of a tined-tip endocardial pacemaker catheter. Pacing Clin Electrophysiol 1982; 5:129-31. [PMID: 6181465 DOI: 10.1111/j.1540-8159.1982.tb02200.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Bluhm G, Julander I, Levander-Lindgren M, Olin C. Septicaemia and endocarditis--uncommon but serious complications in connection with permanent cardiac pacing. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1982; 16:65-70. [PMID: 7071550 DOI: 10.3109/14017438209100612] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Between 1971 and 1978 septicaemia was observed in 14 patients undergoing permanent pacemaker treatment. The causative microorganisms were: S. aureus (9), S. epidermidis (3), alfa-haemolytic streptococci + P. morganii (1), enterococci (1). In 4 patients, a mural endocarditis of the right atrial wall surrounding the electrode was found at operation or autopsy. The interval between the preceding pacemaker operation and onset of septicaemia varied between 2 days and 23 months (median 2 months). In 5 patients, the last operation before septicaemia was performed because of local infection in the pacemaker pocket or along the electrode. A probable portal of entry was found in 11 patients. The electrode was the origin in 8, the pacemaker pocket in one, and a focus outside the pacemaker system in 2. Of the 6 patients treated with antibiotics alone, 3 were cured, 2 died and one is still on treatment. Eight patients underwent various surgical procedures in addition to the antibiotic treatment. In 4 the electrode was completely removed. In 2 of them cardiotomy during extracorporeal circulation had to be used. All of these patients were cured. In 3 the pacemaker system was partially extracted. Only one of them was cured, one developed osteomyelitis and one died. Based on our experience, we now recommend that all foreign material should be removed, if possible, in the presence of septicaemia and/or endocarditis, and that parenteral antibiotic treatment should be given for at least 6 weeks.
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Abstract
Clinical and morphologic findings are described in a 62 year old woman with "mixed connective tissue disease" who received corticosteroid therapy, and in whom disseminated and fatal Petriellidium boydii infection with right-sided endocarditis developed. The patient was a gardener. The organism is ubiquitous in soil in many part of the United States; therefore, it is likely that the infection was introduced by this means. Endocarditis due to P. boydii has not been reported previously. In the patient described, massive vegetations nearly obliterated the tricuspid valve orifice, encasing a pacemaker catheter which had been inserted eight years earlier. Although never previously isolated from blood cultures, P. boydii was isolated from 11 consecutive blood cultures. P. boydii is a true fungus and has only recently been appreciated as an opportunistic pathogen in a compromised host.
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Saab SB, Jung J, Almond CH. Retention of pacemaker electrode complicated by Serratia marcescens septicemia. J Thorac Cardiovasc Surg 1977. [DOI: 10.1016/s0022-5223(19)39920-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fishbein MC, Tan KS, Beazell JW, Schulman JH, Hirose FM, Criley JM. Cardiac pathology of transvenous pacemakers in dogs. Am Heart J 1977; 93:73-81. [PMID: 318794 DOI: 10.1016/s0002-8703(77)80174-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Transvenous right ventricular pacemaker catheters were implanted in 18 mongrel dogs for periods of 2 to 18 months (average 4.9 months). Heart block was produced in 15 of these dogs by injection of 37 per cent formaldehyde into the interatrial septum. In the other three dogs which served as controls, no heart block was produced and no electrical stimulation was applied to the implanted catheters. After the animals had been put to death, gross and microscopic examination of the hearts revealed four categories of morphological changes: (1) connective tissue sheath formation around the catheters, (2) endocardial papillary thickening, (3) interatrial septal changes, and (4) myocardial damage. Changes 1, 2, and 4 occurred in one or more intracardiac locations in all 18 dogs. Change 3 occurred only in the 15 dogs in which heart block was produced. The most striking histologic findings were areas of cartilagenous metaplasia in endocardium an underlying myocardium and areas of marked cellular proliferation of the endocardial cells both in the endothelium and underlying stroma. Chronic implantation of transvenous intracardiac pacemaker catheters in dogs consistently produces morphologic changes which may interfere with cardiac and pacemaker function and may hinder attempts to remove nonfunctional or unneeded catheter electrodes. The changes observed appear to be related to the presence of foreign material per se and not external electrical stimulation of the heart.
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Abstract
An implanted right ventricular electrode that had become infected and entrapped was removed using continuous traction. Upon removal it was found to be attached to an irregular mass of myocardium 2 to 3 cm long. No unfavorable effects resulted. A new pacemaker was implanted, and the patient has remained well.
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