Complications associated with retained pacemaker leads

Adaptive conductive electrotherapeutic scaffolds for enhanced peripheral nerve regeneration and stimulation

BACKGROUND

While peripheral nerve stimulation (PNS) has shown promise in applications ranging from peripheral nerve regeneration to therapeutic organ stimulation, clinical implementation has been impeded by various technological limitations, including surgical placement, lead migration, and atraumatic removal.

METHODS

We describe the design and validation of a platform technology for nerve regeneration and interfacing: adaptive, conductive, and electrotherapeutic scaffolds (ACESs). ACESs are comprised of an alginate/poly-acrylamide interpenetrating network hydrogel optimized for both open surgical and minimally invasive percutaneous approaches.

FINDINGS

In a rodent model of sciatic nerve repair, ACESs significantly improved motor and sensory recovery (p < 0.05), increased muscle mass (p < 0.05), and increased axonogenesis (p < 0.05). Triggered dissolution of ACESs enabled atraumatic, percutaneous removal of leads at forces significantly lower than controls (p < 0.05). In a porcine model, ultrasound-guided percutaneous placement of leads with an injectable ACES near the femoral and cervical vagus nerves facilitated stimulus conduction at significantly greater lengths than saline controls (p < 0.05).

CONCLUSION

Overall, ACESs facilitated lead placement, stabilization, stimulation, and atraumatic removal, enabling therapeutic PNS as demonstrated in small- and large-animal models.

FUNDING

This work was supported by K. Lisa Yang Center for Bionics at MIT.

Hybrid venous recanalization and cardiac implantable electronic device lead revision procedures: A single-center retrospective analysis of 38 patients

PURPOSE

The purpose of this study was to describe the safety and efficacy of hybrid recanalization procedures in a series of patients with obstructed central veins requiring cardiac implantable electronic device (CIED) revision.

METHODS

Between 2008 and 2016, 38 consecutive patients (24 M; age 60.5 ± 16.2 years; range 25-87 years) with central venous obstruction underwent 42 recanalization interventions performed in conjunction with CIED revision or extraction. Fifty percent of patients (19/38) presented with veno-occlusive symptoms, and 13% (5/38) of patients had CIED leads with an ipsilateral upper extremity dialysis conduit.

RESULTS

Ninety-one percent (38/42) of all procedures resulted in successful recanalization and CIED revision. Twenty-four percent (9/38) of all patients required secondary procedures due to recurrent stenosis, and 78% (7/9) of those requiring secondary procedures had indwelling dialysis conduits and/or clinical symptoms related to venous occlusion before the initial procedure. There were complications in 2 patients related to recanalization, and in 3 related to CIED revision.

CONCLUSIONS

Recanalization of central venous stenosis/occlusion in patients with CIED can be technically challenging but is successful in most patients. Symptomatic patients and those with dialysis conduits often require more aggressive revascularization interventions and may be at increased risk of complication or need for secondary interventions.

Cardiac Implantable Electronic Device Infections: Added Complexity and Suboptimal Outcomes With Previously Abandoned Leads

OBJECTIVES

This study sought to assess the impact of previously abandoned leads on the clinical management of cardiac device infections, notably transvenous lead extraction and subsequent clinical course.

BACKGROUND

The population of patients with cardiac implantable electronic devices continues to grow with a disproportionate increase in device infections, which are invariably life threatening. A potentially complicating issue is the widely practiced strategy of device lead abandonment at the time of system revision, change, or upgrade, which is affecting an increasing number of patients.

METHODS

The study assessed the impact of previously abandoned leads in a prospectively maintained registry of consecutive patients undergoing percutaneous extraction of infected cardiac devices at the Cleveland Clinic between August 1996 and September 2012. The primary clinical endpoint was complete procedural and clinical success defined as the successful removal of the device and all lead material from the vascular space, in the absence of a major complication.

RESULTS

Of 1,386 patients with infected cardiac devices, 323 (23.3%) had previously abandoned leads. Failure to achieve the primary endpoint occurred more frequently in patients with abandoned leads (13.0% vs. 3.7%; p < 0.0001). This was primarily due to retention of lead material (11.5% vs. 2.9%; p < 0.0001), which was associated with poor clinical outcomes including higher rates of 1-month mortality (7.4% vs. 3.5% in those without lead remnants). Lead extraction procedures in patients with previously abandoned leads were longer (p < 0.0001), with longer fluoroscopy times (p < 0.0001), and more likely to require specialized extraction tools (94.4% vs. 81.8%; p < 0.0001) or adjunctive rescue femoral workstations (14.9% vs. 2.9%; p < 0.0001). Procedural complications occurred more frequently in patients with previously abandoned leads (11.5% vs. 5.6%; p = 0.0003), which was true for both major (3.7% vs. 1.4%; p = 0.009) and minor complications (7.7% vs. 4.4%; p = 0.02).

CONCLUSIONS

Previously abandoned leads complicate the management of cardiac device infections, leading to worse clinical outcomes.

Conservative therapy for the management of cardiac implantable electronic device infection

Along with the increased frequency of implantation, the incidence of cardiac implantable electronic device (CIED) infection, which can have serious or fatal complications, has also increased. Although several successful conservative therapies for CIED infection have been reported, retained infected devices remain a source of relapse, which is closely related to a higher mortality rate. Presently, complete hardware removal is initially recommended for infected CIED patients, and indications for conservative therapy, including continuous administration of antibiotics, require careful consideration.

On the other hand, complete removal is not required for superficial or incisional infection at the device pocket if an infection does not involve the device, but the patient should be closely followed for progression to deeper infection, which would require extraction.

A Questionable Indication For ICD Extraction After Successful VT Ablation

Sustained ventricular tachyarrhythmias represent a kind of complication shared by a number of clinical presentations of heart disease, sometimes leading to sudden cardiac death. Many efforts have been made in the fight against such a complication, mainly being represented by the implantable cardioverter defibrillator (ICD). In recent years, catheter ablation has grown as a means to effectively treat patients with sustained ventricular arrhythmias, in the contest of different cardiac substrates. Since carrying an ICD is associated with a potential risk deriving from its possible infective or malfunctioning complications, and given the current effectiveness of lead extraction procedures, it has been thought not to be unreasonable to ask ourselves about how to deal with ICD patients who have been successfully treated by means of ablation of their ventricular arrhythmias. To date, no control data have been published on transvenous lead extraction in the setting of VT ablation. In this paper we will review the current evidence about ICD therapy, catheter ablation of ventricular arrhythmias and lead extraction, trying to outline some considerations about how to face this new clinical issue.

Surgical management of cardiac implantable electronic device infections

PURPOSE

The infection of cardiac implantable electronic devices (CIED) is a serious and potentially lethal complication. The population at risk is growing, as the device implantation is increasing especially in older patients with associated comorbid conditions. Our purpose was to present the management of this complicated surgical condition and to extract the relevant conclusions.

METHODS

During a 3-year period 1,508 CIED were implanted in our hospital. We treated six cases of permanent pacemaker infection with localized pocket infection or endocarditis. In accordance to the recent AHA/ACC guidelines, complete device removal was decided in all cases. The devices were removed under general anaesthesia, with a midline sternotomy, under extracorporeal circulation on the beating heart. Epicardial permanent pacing electrodes were placed on the right atrium and ventricle before the end of the procedure.

RESULTS

The postoperative course of all patients was uncomplicated and after a follow up period of five years no relapse of infection occurred.

CONCLUSIONS

Management protocols that include complete device removal are the only effective measure for the eradication of CIED infections. Although newer technologies have emerged and specialized techniques of percutaneous device removal have been developed, the surgical alternative to these methods can be a safe solution in cases of infected devices.

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

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

Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections

Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices.Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria.The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use of suitable antiseptics in combination with medical devices may further support reduction and prevention of such infections. In addition to reducing the adverse clinical outcomes related with these infections, such reduction may substantially decrease the economic burden caused by device-related infection for health care systems.

Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads

AIMS

The aim of the present study was to describe a 10 years single-centre experience in pacing and defibrillating leads removal using an effective and safe modified mechanical dilatation technique.

METHODS AND RESULTS

We developed a single mechanical dilating sheath extraction technique with multiple venous entry site approaches. We performed a venous entry site approach (VEA) in cases of exposed leads and an alternative transvenous femoral approach (TFA) combined with an internal transjugular approach (ITA) in the presence of very tight binding sites causing failure of VEA extraction or in cases of free-floating leads. We attempted to remove 2062 leads [1825 pacing and 237 implantable cardiac defibrillating (ICD) leads; 1989 exposed at the venous entry site and 73 free-floating] in 1193 consecutive patients. The VEA was effective in 1799 leads, the TFA in 28, and the ITA in 205; in the overall population, we completely removed 2032 leads (98.4%), partially removed 18 (0.9%), and failed to remove 12 leads (0.6%). Major complications were observed in eight patients (0.7%), causing three deaths (0.3%).

CONCLUSION

Mechanical single sheath extraction technique with multiple venous entry site approaches is effective, safe, and with a good cost effective profile for pacing and ICD leads removal.

Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections

OBJECTIVES

We describe the management and outcome of permanent pacemaker (PPM) and implantable cardioverter-defibrillator (ICD) infections in a large cohort of patients seen at a tertiary care facility with expertise in device lead extraction.

BACKGROUND

Infection is a serious complication of PPM and ICD implantation. Optimal care of patients with these cardiac device infections (CDI) is not well defined.

METHODS

A retrospective review of all patients with CDI admitted to Mayo Clinic Rochester between January 1, 1991, and December 31, 2003, was conducted. Demographic and clinical data were collected, and descriptive analysis was performed.

RESULTS

A total of 189 patients met the criteria for CDI (138 PPM, 51 ICD). The median age of the patients was 71.2 years. Generator pocket infection (69%) and device-related endocarditis (23%) were the most common clinical presentations. Coagulase-negative staphylococci and Staphylococcus aureus, in 42% and 29% of cases, respectively, were the leading pathogens for CDI. Most patients (98%) underwent complete device removal. Duration of antibiotic therapy after device removal was based on clinical presentation and causative organism (median duration of 18 days for pocket infection vs. 28 days for endocarditis; 28 days for S. aureus infection vs. 14 days for coagulase-negative staphylococci infection [p < 0.001]). Median follow-up after hospital discharge was 175 days. Ninety-six percent of patients were cured with both complete device removal and antibiotic administration.

CONCLUSIONS

Cure of CDI is achievable in the large majority of patients treated with an aggressive approach of combined antimicrobial treatment and complete device removal. Based on findings of our large retrospective institutional survey and previously published data, we submit proposed management guidelines of CDI.

Laser Lead Extraction: Predictors of Success and Complications

BACKGROUND

Paralleling the rise in pacemaker and defibrillator implantations, lead extraction procedures are increasingly required. Concerns regarding failure and complications remain.

METHODS AND RESULTS

A total of 200 lead extraction procedures were performed at the Montreal Heart Institute between September 2000 and August 2005. In 23 patients, all leads were removed by traction with a locking stylet. A total of 270 leads were extracted using a laser sheath system (Spectranectics, Colorado Springs, CO, USA) in 177 procedures involving 175 patients (74% male), age 62+/-16 years. Procedural indications were: infection 88 (50%), dysfunction 54 (30%), upgrade 21 (12%), and other 14 (8%). Overall, 241 leads (89%) were successfully extracted, 7 (3%) were partially extracted (< or = 4 cm retained), and 22 (8%) were non-extractable. In multivariate analyses, predictors of failed extraction were longer time from implant (OR 1.16 per year, P=0.0001) and history of hypertension (OR 5.2, P=0.0023). Acute complications occurred in 14 of 177 procedures (7.9%): 8 (4.5%) minor and 6 (3.4%) major, with one death. In multivariate analyses, the only predictor of acute complications was laser lead extraction from both right and left sides during the same procedure (OR 9.4, P = 0.0119). In addition, 3 of 10 patients with failed or partially extracted infected systems eventually required open chest explantation because of endocarditis.

CONCLUSION

Most leads not amenable to manual traction may be successfully extracted by a percutaneous laser sheath system. While most complications are minor, major complications including death may occur. Older leads are at higher risk for failed extraction. Endocarditis may ensue if infected leads are incompletely removed.

Surgical lead-preserving procedures for pacemaker pocket infection

BACKGROUND

In the treatment of pacemaker pocket infection, removal of the entire pacing system has been considered necessary to avoid recurrent infection. We report a series of patients treated surgically by our lead-preserving procedures.

METHODS

Between 1990 and 2001, a total of 18 patients underwent one of two types of lead-preserving procedures. Procedure 1 preserves the full length of the lead, and procedure 2 preserves only the distal part of the lead. Signs of bacteremia, endocarditis, or purulent material within the lead insulation preclude application of these procedures in patients with potential or definite pacemaker pocket infection.

RESULTS

Seventeen patients who met the indications for our procedures were discharged 7 to 14 days (8.9 +/- 2.4 days, mean +/- SD) postoperatively without signs of infection and were followed up for a total of 987 patient-months until the close of the study or death without recurrent infection. The remaining 1 patient, who did not meet the indications, suffered reinfection soon after the operation.

CONCLUSIONS

The follow-up data suggest that our lead-preserving procedures should be considered as alternatives to conventional removal of the entire pacing system in cases of pocket infection that meet specific criteria.

Infection of a retained permanent epicardial pacemaker lead

Infection of a retained permanent epicardial pacemaker lead rarely causes mediastinal infection. A 21-month-old boy who had undergone an arterial switch operation at day 6 of life presented with mediastinal infection 3 months after removal of the generator. Removal of the infected pacemaker leads with the inflammatory granuloma was performed under extracorporeal circulation. The mediastinal infection developed from the retained epicardial pacemaker lead infection.

Candida tropicalis pacemaker endocarditis

A rare case of Candida tropicalis pacemaker endocarditis was diagnosed in a 77-year-old male who presented with lethargy. The organism was isolated from cultures of blood and vegetations on the tricuspid valve, interatrial septum and the pacing wire removed at surgery. The postoperative course was stormy and he succumbed to multiorgan failure.

Is there an adverse outcome from abandoned pacing leads?

BACKGROUND

Indications for extraction of an abandoned pacemaker lead (APL) are controversial. The purpose of this study was to determine whether or not APLs should be extracted in the absence of pacemaker-related problems.

METHODS AND RESULTS

We retrospectively reviewed, from 1977 through 1998, all patients with retained, non-functional leads and identified 433-266 males and 167 females. Mean age at initial pacemaker implantation was 68[emsp4 ]years. These patients received a total of 259 atrial and 948 ventricular leads. Of the total of 1,207 leads, 611 became non-functional. A total of 531 non-functional leads were abandoned, of which 18 were later extracted: one APL in 345 patients, two in 78, and three in 10. Indications for new lead placement when non-functional leads were abandoned included capture and/or sensing failure (243), lead recall (177), lead fracture (86), pacing system replacement to the contralateral side (11), accommodating patient growth (5), pacemaker function upgrade (5), replacement with implantable cardioverter defibrillator (ICD, 2), interference with ICD (1), and unknown (1). Complications that were associated with pacemakers were found in 24 patients (5.5%)-pacemaker system infection (8 patients) and venous occlusion at the time of a subsequent procedure of new lead placement when APLs had already been in place (16) which resulted in APL extraction (7) or transfer of the pacemaker system to the contralateral side (9). Neither venous thrombosis nor other complications were found in the remaining 409 patients (94.5%). The incidence of complications was higher in patients with three APLs than in patients with two or fewer APLs (40% vs. 4.7%, P=1x10(-6)), in patients with four or more total lead implantations than in patients with three or fewer total lead implantations (26.2% vs. 0. 6%, P<1x10(-10)), and in patients with three or more procedures of new lead placements than in patients with two or fewer procedures of new lead placements (36.4% vs. 3.9%, P=1x10(-10)). Patients with complications were younger than those without complications both at the time of initial pacemaker implantation (59+/-16 vs. 68+/-17 y, P=0.01) and when non-functional leads were abandoned (63+/-15 vs. 71+/-16 y, P=0.04). Mean numbers of APLs, total leads implanted, and procedures of new lead placement were significantly larger in patients with complications than in those without complications (1.58+/-0.78 vs. 1.2+/-0.44, 4.96+/-1.23 vs. 2.66+/-0.8, and 2.13+/-0.85 vs. 1.25+/-0.53, P=0.03, 4x10(-9) and 4x10(-5), respectively).

CONCLUSIONS

1. With only 5.5% of patients having had pacemaker-related complications, the adverse outcome of APL is small. 2. Clinical clues to the possible occasion for pacemaker-related complications include three or more APLs, four or more total leads, three or more procedures of new lead placement, and a younger age at initial pacemaker implantation. 3. Patients with a large number of APLs, total lead implantations, and procedures of new lead placement should be carefully observed to detect possible pacemaker-associated complications.

Muscle stimulation related to a nonfunctioning epicardial pacemaker electrode

Noninfected retained pacemaker leads produce fewer complications than infected electrodes. Epicardial electrodes are rarely used, thus complications associated with such electrodes are seldom reported. We report a case with muscle stimulation due to a retained epicardial pacemaker electrode.

Intravascular extraction of problematic or infected permanent pacemaker leads: 1994-1996. U.S. Extraction Database, MED Institute

Of the 400,000-500,000 permanent pacemaker leads implanted worldwide each year, around 10% may eventually fail or become infected, becoming potential candidates for removal. Intravascular techniques for removing problematic or infected leads evolved over a 5-year period (1989-1993). This article analyzes results from January 1994 through April 1996, a period during which techniques were fairly stable. Extraction of 3,540 leads from 2,338 patients was attempted at 226 centers. Indications were: infection (27%), nonfunctional or incompatible leads (25%), Accufix or Encore leads (46%), or other causes (2%). Patients were 64+/-17 years of age (range 5-96); 59% were men, 41% women. Leads were implanted 47+/-41 months (maximum 26 years), in the atrium (53%), ventricle (46%), or SVC (1%). Extraction was attempted via the implant vein using locking stylets and dilator sheaths, and/or transfemorally using snares, retrieval baskets, and sheaths. Complete removal was achieved for 93% of leads, partial for 5%, and 2% were not removed. Risk of incomplete or failed extraction increased with implant duration (P<0.0001), less experienced physicians (P<0.0001), ventricular leads (P<0.005), noninfected patients (P<0.0005), and younger patients (P<0.0001). Major complications were reported for 1.4% of patients (<1% at centers with >300 cases), minor for 1.7%. Risk of complications increased with number of leads removed (P<0.005) and with less experienced physicians (P<0.005); risk of major complications was higher for women (P<0.01). Given physician experience, appropriate precautions, and appropriate patient selection, contemporary lead removal techniques allow success with low complication rates.

Assessment of the subclavian vein in patients with transvenous pacemaker leads

Thrombosis of the subclavian vein can occur after the implantation of transvenous pacemaker electrodes. Although this is seldom followed by thromboembolic complications, it can cause problems when replacing the leads. To assess the impact of the pacemaker leads on the subclavian vein, a study using noninvasive duplex sonography was performed on 56 patients at an average of 41 months after the implantation. Forty-three percent of the patients were found to have a normal function of the subclavian vein, 46% developed pathological changes of the vessel wall, and 11% occluded. These changes rarely caused symptoms, and, therefore, had little clinical significance. Moreover, the occlusion rate was found independent of the patient's age, the patient's sex, the number of electrodes, the procedure of implantation, and even the time from implantation. As a result, the clinical diagnosis of occlusion is uncertain. Therefore, duplex sonography is recommended as an easy means of excluding a totally thrombosed subclavian vein prior to replacing pacemaker leads.

Cardiac pacemaker infection: surgical management with and without extracorporeal circulation

BACKGROUND

Pacemaker infections are rare, but serious complications of pacemaker therapy. The generator pocket, the pacing leads, or both may be involved.

METHODS

We report on 12 patients with infected pacemaker systems. Four patients suffered from localized generator pocket infections, 6 had infected leads, and 2 patients had both. Pacemaker systems were completely removed in all patients. When the infection was limited to the generator pocket, the pacemaker system was removed at the original implantation site. Extracorporeal circulation was employed for the explantation of infected pacing leads.

RESULTS

No complications occurred in patients with localized generator pocket infections. One patient with infected leads who was preoperatively already in a serious clinical condition died of septic shock in the early postoperative period; another patient died of pulmonary complications after tricuspid valve replacement 14 months after pacemaker explantation. No recurrent infections were observed.

CONCLUSIONS

Explantation of the complete pacemaker system has proved a reliable method to eradicate infection. Complications have been rare, except in patients in a critically ill state who undergo cardiopulmonary bypass.

The effect of nonisodiametric design on the ease of extracting chronically implanted pacemaker leads

Extracting permanently implanted transvenous pacemaker leads is often difficult because a fibrous sheath tends to trap the lead at various points along its course. Because many leads have bulbous or nonisodiametric portions, extraction may be rendered even more troublesome, because it is difficult to pull the larger portion through the narrow areas of the sheath. Furthermore, forceful extraction may have dire consequences, such as cardiac laceration. A study was undertaken in animals to evaluate the effect of lead isodiametricity on lead extraction. The results show that any increase in the diameter of the lead tip greatly reduces the ease of its removal. Consequently, leads designed to be isodiametric throughout their entire lengths will greatly enhance their removability.

Candida tropicalis multifocal endophthalmitis as the only initial manifestation of pacemaker endocarditis

PURPOSE

To document a case of Candida tropicalis endophthalmitis as the only manifestation of pacemaker endocarditis.

METHODS

We examined a 75-year-old man with diabetes mellitus who was initially examined for bilateral multifocal endophthalmitis complicating endocarditis 2 years after a permanent pacemaker for sick sinus syndrome was implanted.

RESULTS

Transesophageal echocardiography showed a large vegetation with a 3-cm diameter attached to the pacing electrode in the right ventricle. Six consecutive blood cultures grew C tropicalis.

CONCLUSIONS

Ocular involvement, including multifocal endophthalmitis, may occur as the only manifestation of C tropicalis endocarditis, complicating an intravenous permanent pacemaker.

The treatment of septicemia in pacemaker patients

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.

Surgical management of infected permanent transvenous pacemaker systems: ten year experience

BACKGROUND

Between January 1985 and June 1995, more than 1800 consecutive patients underwent implantation of a new permanent cardiac pacemaker at our institution. Thirty-six patients (0.02%) had 45 reinterventions for infected pacemaker systems.

METHODS

in group A, 24 of 27 patients received simultaneous implantation of a new pacemaker. One had reimplantation of the same pacemaker in the same pocket, and two did not require reimplantation. The leads were retained in 19 (70%) of the patients. In group B, nine patients underwent cardiopulmonary bypass or "pursestring" surgery for removal of an infected pacemaker; a new epicardial pacemaker system was simultaneously implanted in seven patients.

RESULTS

Identification of an infectious agent failed in 17 patients (47%), and Staphylococci were found in 15 patients (42%). The time from pacemaker implantation to onset of infection ranged from 1 month to 11 years (mean 31 months; median 19 months) and the time from onset of infection to surgical treatment from 1 month to 7 years (mean 7 months; median 2 months). The mean follow-up time is 74 months (range, 1 month to 10 years; median 5 years). There were 9 reoperations in 3 patients (16%) of group A for recurrent infection of their retained leads ultimately necessitating the use of open cardiac surgery. There was no early death; six patients died late due to unrelated causes.

CONCLUSIONS

Complete removal of all pacemaker leads is recommended; open heart surgery with the use of cardiopulmonary bypass is indicated in selected cases and is effective and safe.

Lead extraction in young patients with and without congenital heart disease using the subclavian approach

Pacemaker lead removal using interlocking stylets and dilator sheaths has greatly reduced the need for major surgical intervention when lead extraction is required. Previous reports have shown the utility of this method in older patients, most of whom have anatomically normal hearts. The purpose of this study is to report the results of this technique in young patients with and without congenital heart disease. There were 13 patients (M:F = 7:6) aged 9-26 years (median 13). Congenital heart disease was present in 8 of 13 patients. A total of 17 leads required removal; they had been implanted for 54 +/- 24 months (range 19-94). Leads were removed from the left subclavian vein (13) or right subclavian vein (4) only. Seventeen of 18 leads were completely removed and one partially retained in the left subclavian vein. New leads were implanted from the same vein in 11 of 13 patients. Interlocking stylets and metal or flexible dilator sheaths were used in all cases except two. There was one surgical complication: a late wound dehiscence, which was easily managed. No patient required a transfusion, and there was no structural damage noted in any patient on the postoperative echocardiogram. We conclude that lead removal using interlocking stylets and dilator sheaths from the subclavian approach is an effective technique that can be used in young patients, including those with congenital heart disease.