"Shift and cover technique": conservative management of complications for the rescue of S-ICD subcutaneous implantable defibrillator systems

BACKGROUND

The risk of complications has been shown to be lower with subcutaneous implantable defibrillator (S-ICD) than with conventional ICDs. Given the low frequency of complications, experience of how to manage them is limited. In this paper, we describe generator- and lead-related complications recorded in a series of S-ICD patients, and we propose our conservative approach to managing them.

METHODS

The study cohort consisted of S-ICD patients who were referred to our institution owing to generator- or lead-related complications requiring surgical intervention. With our "shift and cover" approach, the system component involved is moved from its original position to an alternative, more protected location. In the case of the generator, this involves moving it to an intermuscular pocket. In the case of infections at the parasternal scar, the electrode sleeve is moved away from its original location, stitched, and then covered with the muscular fascia.

RESULTS

Fourteen S-ICD patients were referred to our institution owing to system-related complications. Complications involved the generator in 7 cases (deep pocket infections with erosion, extrusion, or pain), the lead in 5 cases (parasternal infections at the xyphoid incision site), and both the generator and the lead in 2 cases. Complications were managed without completely removing the device and resolved in a single surgical session with no intraoperative complications. During defibrillation testing, the first shock at 65 J was effective in all patients. The shock impedance after revision was significantly lower than that measured during first implantation (59 ± 10 Ohm versus 86 ± 24 Ohm, P = 0.013). In all cases, the cosmetic result was satisfactory. No complications or recurrent infections were reported at the 12-month follow-up visit.

CONCLUSIONS

The proposed conservative approach was successful in managing S-ICD complications. The revision procedure allowed to optimize the system configuration in terms of the defibrillation vector, resulting in lower shock impedance values and better device positioning.

An Alternative to Transvenous Lead Extraction in Selected Patients with CIED Infections—A Retrospective Outcome Study

Cardiac implantable electronic device (CIED) implants are rising in an older, more co-morbid population. The prevalence of CIED infection ranges from 1–4%. Whilst complete extraction of all transvenous hardware is recommended for infected, eroded, or pre-eroding CIEDs, this approach is not without risk and may be unacceptable to some patients. Long-term data on a more conservative strategy is lacking. We report on our experience of conservative management with pocket revision as a primary strategy in carefully selected patients. Method: A retrospective review of all CIED revision procedures was undertaken at a large tertiary center, over a 7-year period, with a mean follow-up timeframe of 39 months. Results: A total of 86 patients underwent 96 revision procedures; 7 patients required further revisions and 13 went on to undergo CIED extraction by the end of the follow-up period. The overall rate of mortality at 12 months was 8.1%, increasing to 24.4% at the end of the follow-up period. Conclusion: Our data provide important outcome information on an alternative strategy to lead extraction in carefully selected patients where the risk of extraction is perceived to be unacceptable. The absence of systemic infection appears to predict better outcomes than previously reported, and over two-thirds of patients remained complication-free at 12 months.

Successful transvenous lead extraction of abandoned lead implanted through persistent left superior vena cava

Persistent left superior vena cava, the most common thoracic venous anomaly, may complicate transvenous lead extraction (TLE). We report a successful case of TLE in a patient with persistent left superior vena cava, despite a long dwelling time and several pocket revisions due to pocket infection. The lead was removed via a hand-powered mechanical extraction sheath, and postoperative complications did not occur. Complicated TLE cases may have a better outcome if performed in a high-volume center with experienced specialists.

Invited Review: Optimal Management of Upper Extremity DVT: Is Venous Thoracic Outlet Syndrome Underrecognized?

BACKGROUND

UEDVT accounts for approximately 10% of all cases of deep vein thrombosis. In the most widely referenced general review of deep vein thrombosis (DVT the American Academy of Chest Physicians essentially recommend that upper extremity DVT (UEDVT) essentially be treated identically to that of lower extremity DVT, with anticoagulation being the default therapy. Unfortunately, the medical literature does not well differentiate between DVT in the arm and the leg, and does not emphasize the effects of the costoclavicular junction (CCJ) and the lack of effect of gravity, to the point where UEDVT due to extrinsic bony compression at the CCJ is classified as "primary."

METHODS

Comprehensive literature review, beginning with both Medline and Google Scholar searches in addition to collected references, then following relevant citations within the initial manuscripts studied. Both surgical and medical journals were explored RESULTS: It is proposed that effort thrombosis be classified as a secondary cause of UEDVT, limiting the definition of primary to that which is truly idiopathic. Other causes of secondary UEDVT include catheter- and pacemaker-related thrombosis (the most common cause, but often asymptomatic), thrombosis related to malignancy and hypercoagulable conditions, and the rare case of thrombosis due to compression of the vein by a focal malignancy or other space-occupying lesion. In true primary UEDVT and in those secondary cases where no mechanical cause is present or can be corrected, anticoagulation remains the treatment of choice, usually for three months or the duration of a needed catheter. However, evidence suggests that many cases of effort thrombosis are likely missed by a too-narrow adherence to this protocol.

CONCLUSIONS

Because proper treatment of effort thrombosis drops the long-term symptomatic status rate from 50% to almost zero and these are healthy patients with a long lifespan ahead, it is proposed that a more aggressive attitude toward thrombolysis be followed in any patient who has a reasonable degree of suspicion for venous thoracic outlet syndrome.

Double Layer Reconstruction of Exposed Cardiac Implantable Electronic Devices in Elderly Patients

Background Elderly patients with multiple comorbidities may not be candidates for cardiac implanted electronic device (CIED) explantation in cases of exposition. Excision of all unhealthy and inflamed scar tissue results in a skin defect that must be covered. Small- to moderate-sized local skin flaps and subpectoral placement of CIEDs have been described in the literature. However, these techniques still could not eliminate the risk of recurrence. In terms of minimizing the recurrence risk, we aim to increase the flap dimensions for getting better circulation and tension-free closure after subpectoral placement. Material and methods Six patients who were operated for a dual-layer reconstruction of exposed cardiac implants between 2017 and 2020 were included in the study. All patients were referred to plastic surgery as soon as the wound biopsy culture results were negative after systemic and topical antibiotic treatment by cardiology department. Results No flap loss or wound dehiscence was seen with a mean duration of 11 months follow-up. Early hematoma was encountered in a patient who was managed with irrigation and drain renewal. One patient developed suture abscess in the second month postoperatively. Knots were removed and wound healed without further intervention. Conclusion Double layer closure of exposed cardiac implants with large breast fasciocutaneous flap after subpectoral placement of pulse generator and leads suggest durable and reliable coverage in elderly patients with multiple comorbidities.

A prospective comparison of four methods for preventing pacemaker pocket infections

This study aims to evaluate four pacemaker pocket cleaning methods for preventing implantation-related infections. This single-center trial prospectively randomized 910 patients undergoing first-time pacemaker implantation or replacement into four pocket cleaning methods: hemocoagulase (group A, n = 228), gentamicin (group B, n = 228), hemocoagulase plus gentamicin (group C, n = 227), and normal saline (group D, n = 227). Before implanting the pacemaker battery, the pockets were cleaned with gauze presoaked in the respective cleaning solutions. Then, these patients were followed up to monitor the occurrence of infections for 1 month after implantation. Twelve implantation-related infections occurred in 910 patients (1.32%): four patients from group A (1.75%), three patients from group B (1.32%), two patients from group C (0.88%), and three patients from group D (1.32%) (P > .05). Furthermore, two patients developed bloodstream infections (0.22%), and both of these patients were associated with pocket infection (one patient was from group A, while the other patient was from group C, respectively). No cases of infective endocarditis occurred. The differences in the number of infections in these study groups were not statistically significant. The application of hemocoagulase, gentamicin, hemocoagulase plus gentamicin, or normal saline on the presoaked gauze before implantation was equally effective in preventing pocket-associated infections.

Pacemaker pocket infection: Innovative conservative treatment in elderly patients with no signs of systemic infection

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.

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

Background

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

Case presentation

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

Conclusions

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

Palliation and Nonextraction Approaches

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.

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

BACKGROUND

Published guidelines mandate complete device removal in cases of cardiovascular implantable electronic device (CIED) infection. Clinical predictors of successful salvage of infected CIEDs have not been defined.

METHODS

Data from the Multicenter Electrophysiologic Device Infection Collaboration, a prospective, observational, multinational cohort study of CIED infection, were used to investigate whether clinical predictors of successful salvage of infected devices could be identified.

RESULTS

Of 433 adult patients with CIED infections, 306 (71%) underwent immediate device explantation. Medical management with device retention and antimicrobial therapy was initially attempted in 127 patients (29%). "Early failure" of attempted salvage occurred in 74 patients (58%) who subsequently underwent device explantation during the index hospitalization. The remaining 53 patients (42%) in the attempted salvage group retained their CIED. Twenty-six (49%) had resolution of CIED infection (successful salvage group) whereas 27 patients (51%) experienced "late" salvage failure. Upon comparing the salvage failure group, early and late (N = 101), to the group experiencing successful salvage of an infected CIED (N = 26), no clinical or laboratory predictors of successful salvage were identified. However, by univariate analysis, coagulase-negative staphylococci as infecting pathogens (P = 0.0439) and the presence of a lead vegetation (P = 0.024) were associated with overall failed salvage.

CONCLUSIONS

In patients with definite CIED infections, clinical and laboratory variables cannot predict successful device salvage. Until new data are forthcoming, device explantation should remain a mandatory and early management intervention in patients with CIED infection in keeping with existing expert guidelines unless medical contraindications exist or patients refuse device removal.

Successful conservative management of a permanent pacemaker pocket infection: a less invasive approach

We present a successful conservative management strategy for a frail elderly patient with a cardiac resynchronisation pacemaker who presented with evidence of an Enterobacter cloacae pacemaker pocket infection. A device washout and debridement procedure was performed, with reburial of the device in a new prepectoral pocket and creation of a closed-loop continuous antibiotic infusion into the infected pacemaker pocket. This was followed by a 6-week course of ambulatory intravenous antibiotic therapy. This conservative management strategy avoided the need for a more invasive and high-risk full device extraction, which the patient clearly stated he did not wish to have. Up-to-date consensus management guidelines recommend extraction of the entire implanted system in this situation; however, in this case we demonstrate an alternative conservative management option, which may be suitable for frail elderly and comorbid patients or for patients who decline device extraction.

Nailed It: Conservative Management of Penetrating Injury and Potential Infection of a Cardiovascular Implantable Electronic Device

A 47-year-old man with a history of ischemic cardiomyopathy and chronic systolic heart failure presented after he inadvertently shot himself in the left upper chest with a pneumatic nail gun, penetrating his implantable cardioverter defibrillator (ICD) generator. The device was noninterrogable, consistent with device failure. A new ICD was attached to the existing right ventricular lead, which showed no evidence of traumatic damage and normal lead parameters on interrogation. Aggressive debridement and antibiotic irrigation of the ICD pocket was performed and an antibacterial envelope was used. Bacterial culture of the ICD pocket grew Bacillus species. The patient completed a course of at least 14 days of oral clindamycin. At follow-up, there were no signs or symptoms of systemic or local wound infection.

Cardiac implantable electronic device infection in patients with end-stage renal disease

INTRODUCTION

Cardiac implantable electronic devices (CIED) are increasingly being used in end-stage renal disease (ESRD) patients. These patients have a high risk of device infection.

OBJECTIVES

To study the optimal management of device infections in patients with ESRD.

METHOD

We used the United States Renal Data System (USRDS) to assess the presence of a CIED and associated comorbidities, risk factors for infection, and mortality following device extraction or medical management in ESRD patients with CIED infection. Univariable, multivariable, and survival analyses were performed using USRDS data from 2005 to 2009.

RESULTS

Of 546,769 patients, 6.4% had CIED and 8.0% of those developed CIED infection. The major risk factors for device infection were black race, temporary dialysis catheter, and body mass index >25. Patients with artificial valves were excluded from the analysis. Only 28.4% of infected CIED were removed. CIED removal was more common in those with congestive heart failure. The median time to death following diagnosis of a CIED infection was 15.7 months versus 9.2 months for those treated via device extraction versus medical-only therapy (hazard ratio: 0.75; 95% confidence interval: 0.68-0.82).

CONCLUSION

Patients with ESRD and infected CIEDs have a poor prognosis. Rates of device extraction are low, but this strategy appears to be associated with modest improvement in survival.

Management of Cardiac Implantable Electronic Device Infection

Despite improved preventive measures, infection associated with the use of cardiac implantable electronic devices (CIEDs) to treat often life-threatening conditions is rising at an average annual rate of almost 5 %. This rise is being driven by the increasing complexity of CIED technology and by the advancing age and co-morbidities of the patients. Although CIED infection is usually suspected based on local signs at the generator pocket site, diagnosis can be challenging in patients presenting no local manifestations or symptoms. Diagnostic methods include microbiological testing and echocardiography, and may be completed by positron emission tomography (PET)/computed tomography (CT) scan in selected cases. CIED infection requires a multidisciplinary approach in view of hardware extraction, targeted antibiotic therapy and reimplantation on an as-needed basis. Antibiotic prophylaxis targeting staphylococcal flora is recommended but the relation of these infections to medical care exposes patients to multi-resistant bacteria. New preventive measures utilising an antibacterial sleeve look promising. Treatment can be started on an empirical basis using an antistaphylococcal agent but must be continued using targeted antibiotic therapy. Crucial questions remain as to the best prevention strategy, optimal duration and timing of antibiotic therapy, and the most effective reimplantation technique.

Extraction of chronically implanted cardiovascular electronic device leads

OPINION STATEMENT

Cardiovascular implantable electronic devices (CIED) are a remarkable success story. These systems are widely used to prevent symptomatic bradycardia, treat malignant tachyarrhythmia, and to restore a more physiologic contraction to a failing left ventricle. Implantation of a CIED usually involves a lifelong commitment to this therapy, which, unfortunately, is not free from complication requiring removal and/or replacement of all or part of the system. The major obstacle to removal of a CIED is the fibrous attachments that develop between a lead and co-existent leads, veins, and the heart. This process increases over time such that, by one year, removal by traction alone may be problematic and, if aggressive, result in complication. Physicians, surgeons, and engineers have refined techniques of percutaneous lead extraction and developed tools, which have facilitated the process, increased success, and lowered the incidence of complication. Extraction may be performed for a variety of indications some of which are unanimously agreed upon while others remain controversial. Proponents of a broadened application of extraction have proffered the concept of 'lead management,' which includes the removal of all leads that are not clinically relevant to the patient. The benefit of this approach would be to limit the risk of future complication, such as venous occlusion or thromboembolism, and to obviate the increase in difficulty of extraction (due to longer implant duration) that might accompany removal should that be required in the future. Intuitively appealing as this approach might be, there is little evidence supporting it, and the extraordinarily large number of patients currently implanted with recalled ICD leads is indicative of the potential impact this practice may have. This review will discuss extraction, its indications, and outcomes.