Surgical removal of infected transvenous pacemaker leads

Anesthetic Considerations in the Electrophysiology Laboratory: A Comprehensive Review

Catheter ablation procedures for arrhythmias or implantation and/or extraction of cardiac pacemakers can present many clinical challenges. It is imperative that there is clear communication and understanding between the anesthesiologist and electrophysiologist during the perioperative period regarding the mode of ventilation, hemodynamic considerations, and various procedural complications. This article provides a comprehensive narrative review of the anesthetic techniques and considerations for catheter ablation procedures, ventilatory modes using techniques such as high-frequency jet ventilation, and strategies such as esophageal deviation and luminal temperature monitoring to decrease the risk of esophageal injury during catheter ablation. Various hemodynamic considerations, such as the intraprocedural triaging of cardiac tamponade and fluid administration during catheter ablation, also are discussed. Finally, this review briefly highlights the early research findings on pulse-field ablation, a new and evolving ablation modality.

Surgical Management of Cardiac Implantable Electronic Device Complications in Patients Unsuitable for Transvenous Lead Extraction

BACKGROUND

Although surgical approaches for infected or failing cardiac implantable electronic device (CIED) leads are more invasive than transvenous approaches, they are still required for patients considered unsuitable for transvenous procedures. In this study, surgical management with transvenous equipment for CIED complications was examined in patients unsuitable for transvenous lead extraction.

METHODS AND RESULTS

We retrospectively examined 152 consecutive patients who underwent CIED extraction between April 2009 and December 2021 at the Department of Cardiovascular Surgery, Nippon Medical School. Nine patients (5.9%; mean [±SD] age 61.7±16.7 years) who underwent open heart surgery were identified as unsuitable for the isolated transvenous approach. CIED types included 5 pacemakers and 4 implantable cardioverter-defibrillators; the mean [±SD] lead age was 19.5±7.0 years. Indications for surgical management according to Heart Rhythm Society guidelines included failed prior to transvenous CIED extraction (n=6), intracardiac vegetation (n=2), and severe lead adhesion (n=1). Transvenous CIED extraction tools were used in all patients during or before surgery. Additional surgical procedures with CIED extraction included epicardial lead implantation (n=4) and tricuspid valve repair (n=3). All patients were discharged; during the follow-up period (mean 5.7±3.7 years), only 1 patient died (non-cardiac cause).

CONCLUSIONS

Surgical procedures and transvenous extraction tools were combined in the removal strategy for efficacious surgical management of CIED leads. Intensive surgical procedures were safely performed in patients unsuitable for transvenous extraction.

Leadless Cardiac Pacemaker Implantation After Lead Extraction in Patients With Severe Device Infection

BACKGROUND

Conventional pacemaker therapy is limited by short- and long-term complications, most notably device infection. Transcatheter pacing systems (TPS) may be beneficial in this kind of patients as they eliminate the need for a device pocket and leads and thus may reduce the risk of re-infection.

METHODS

We assessed a novel procedure in 6 patients with severe device infection who were pacemaker dependent. After lead extraction a single chamber TPS was implanted into the right ventricle.

RESULTS

Of the 6 patients who underwent lead extraction due to severe device infection at our institution, 3 were diagnosed with a pocket infection only, whereas the other 3 showed symptoms of both pocket and lead infection. Successful lead extraction and TPS implantation was accomplished in all patients. Four patients were bridged with a temporary pacemaker between 2 hours and 2 days after lead extraction, whereas 2 patients had the TPS implanted during the same procedure just before traditional pacemaker system removal. All patients stayed free of infection during the follow-up period of 12 weeks. An additional positron emission tomography scan was performed in each patient and indicated no signs of an infection around the TPS.

CONCLUSION

Transcather pacemaker implantation was safe and feasible in 6 patients and did not result in re-infection even if implanted before removal of the infected pacemaker system within the same procedure. Therefore, implantation of a TPS may be an option for patients with severe device infection, especially in those with blocked venous access or who are pacemaker dependent.

Surgical management of superior vena cava syndrome following pacemaker lead infection: a case report and review of the literature

Superior vena cava (SVC) syndrome is a known but rare complication of pacemaker lead implantation, accounting for approximately less than 0.5% of cases. Its pathophysiology is due to either infection or endothelial mechanical stress, causing inflammation and fibrosis leading to thrombosis, and therefore stenosis of the SVC. Due to the various risks including thrombo-embolic complications and the need to provide symptomatic relief, medical and surgical interventions are sought early. We present the case of a 48-year Caucasian male who presented with localised swelling and pain at the site of pacemaker implantation. Inflammatory markers were normal, but diagnostic imaging revealed three masses along the pacemaker lead passage. A surgical approach using cardiopulmonary bypass and circulatory arrest was used to remove the vegetations. Culture from the vegetations showed Staphylococcus epidermidis. The technique presented here allowed for safe and effective removal of both the thrombus and infected pacing leads, with excellent exposure and minimal post-procedure complications.

Clinical manifestations of lead-dependent infective endocarditis: analysis of 414 cases

It is important to identify clinical manifestations of lead-dependent infective endocarditis (LDIE), as it begins insidiously with the slow development of nonspecific symptoms. Clinical data from 414 patients with the diagnosis of LDIE according to Modified Duke Lead Criteria (MDLC) were analyzed. Patients with LDIE had been identified in a population of 1,426 subjects submitted to transvenous lead extraction (TLE) in the Reference Clinical Cardiology Center in Lublin between 2006 and 2013. The symptoms of LDIE and pocket infection were detected in 62.1 % of patients. The mean duration of LDIE symptoms prior to referral for TLE was 6.7 months. Fever and shivers were found in 55.3 % of patients, and pulmonary infections in 24.9 %. Vegetations were detected in 67.6 % of patients, and positive cultures of blood, lead, and pocket in 34.5, 46.4, and 30.0 %, respectively. The most common pathogens in all type cultures were coagulase-negative staphylococci (CNS), with Staphylococcus epidermidis domination; the second most common organism was Staphylococcus aureus. 76.3 % of patients were treated with empirical antibiotic therapy before hospitalization due to TLE. In the laboratory tests, the mean white blood cell count was 9,671 ± 5,212/μl, mean erythrocyte sedimentation rate 43 mm, C-reactive protein (CRP) 46.3 mg/dl ± 61, and procalcitonin 1.57 ± 4.4 ng/ml. The multivariate analysis showed that the probability of LDIE increased with increasing CRP. The diagnosis of LDIE based on MDLC may be challenging because of a relatively low sensitivity of major criteria, which is associated with early antibiotic therapy and low usefulness of minor criteria. The important clinical symptoms of LDIE include fever with shivering and recurrent pulmonary infections. The most specific pathogens were Staphylococcus epidermidis and Staphylococcus aureus. Laboratory tests most frequently revealed normal white blood cell count, relatively rarely elevated procalcitonin level, and significantly increased erythrocyte sedimentation rate (ESR) and CRP. This constellation of signs should prompt a more thorough search for LDIE.

FDG-PET in cardiac infections

Cardiac infections include a group of conditions involving the heart muscle, the pericardium, or the endocardial surface of the heart. Infections can extend to prosthetic material or the leads in case of the implantation of devices. Despite their relative low incidence, these conditions that are associated with high morbidity and mortality involve a relevant burden of diagnostic workup. Early diagnosis is crucial for adequate management of patient, as early treatment improves the prognosis; unfortunately, the clinical manifestations are often nonspecific. Accurate and timely diagnosis typically requires the correlation of imaging findings with laboratory data. (18)F-FDG-PET is a well-established imaging modality for the diagnosis and management of malignancies, and evidence is also increasing regarding its value for assessing infectious and inflammatory diseases. This article summarizes published evidence on the usefulness of (18)F-FDG-PET for the diagnosis of cardiac infections, mainly focused on endocarditis and cardiovascular device infections. Nevertheless, the diagnostic potential of (18)F-FDG-PET in patients with pericarditis and myocarditis is also briefly reviewed, considering the most likely future advances and new perspectives that the use of PET/magnetic resonance would open in the diagnosis of such conditions.

Legal aspects in implantable defibrillator extraction

At the Institute of Legal Medicine in Chieti, a case of iatrogenic superior vena cava perforation was observed during laser extraction of an infected biventricular implantable cardiac defibrillator. The presentation of this particular case represented a starting point for studying the occurrence of similar complications in literature, since their knowledge and understanding should induce resolution of any organisation problems, aid in increasing physicians' training and impose the availability of cardiac surgeons during such operations.

Reuse of pacemakers: comparison of short and long-term performance

BACKGROUND

In developing economies, there are patients in whom pacemaker implantation is delayed because they cannot afford one. Reused devices have been a solution. To address concerns about safety, a cohort of consecutive patients implanted with a reused pacemaker was compared with a control group.

METHODS AND RESULTS

A cohort of 603 consecutive patients from 2000 to 2010 was studied in an ambispective noninferiority study. The study group patients (n=307) received resterilized pacemakers, and the control group patients (n=296) received a new pacemaker. A combined end point of 3 major outcomes-unexpected battery depletion, infection, and device dysfunction-was analyzed. A total of 85 pacemakers had to be explanted, 31 in the control group (10.5%) and 54 in the study group (17.6%; relative risk, 1.68; 95% confidence interval, 1.1-2.5; P=0.02). Forty-three reached the primary end point, 16 in the control group (5.5%) and 27 in the study group (7.2%; relative risk, 1.3; 95% confidence interval, 0.70-2.45; P=0.794). In terms of individual outcomes, 5 new pacemakers (1.7%) and 11 resterilized pacemakers (3.6%) had unexpected battery depletion (relative risk, 2.12; 95% confidence interval, 0.75-6; P=0.116); 3.7% new pacemakers and 3.2% reused pacemakers had a procedure-related infection (relative risk, 0.87; 95% confidence interval, 0.38-2.03; P=0.46); and 1 pacemaker in the study group malfunctioned.

CONCLUSIONS

Pacemaker reuse is feasible and safe and is a viable option for patient with bradyarrhythmias. Other than the expected shorter battery life, reuse of pacemaker generators is not inferior to the use of new devices.

Safety and cost-effectiveness of same day permanent pacemaker implantation

An overnight stay after permanent pacemaker implantation has major cost implications for healthcare systems. Same day pacing could be effective in alleviating this. We evaluated our elective same day pacing practice to determine safety and cost-effectiveness. A total of 780 patients were scheduled for elective new permanent pacemaker implantation as a same day procedure at the University Hospital, North Staffordshire, from April 2001 to December 2006. The mean age +/- SEM of the cohort was 73.8 +/- 0.4 years (464 men and 316 women). Single-chamber devices were implanted in 272 (27 atrial and 245 ventricular) and dual chamber in 508 patients. Vascular access was by the subclavian vein in 431 patients and the cephalic vein in 349. Preimplant intravenous antibiotics were administered to 28% and perioperative antibiotics to the remainder; all patients received oral antibiotics after implantation. Of the 780 patients, 41 (5.3%) required an in-hospital stay after implantation because of hematoma formation in 12, pneumothorax in 3, social reasons for 7, observation at the physicians request but no complication for 13, angina in 3, arrhythmia in 1, and warfarin therapy in 2. Immediate complications (<24 hours) occurred in 6 patients and early complications (>24 hours to 6 weeks) developed in 17. Of the 780 patients, 94 had died at mean follow-up of 2.4 +/- 0.1 years; none were related to pacemaker implantation. An overnight stay at our hospital costs pound203.60 ( approximately US$305). From November 2005 to November 2006, 109 patients underwent same day implantation, resulting in a cost saving of pound22,192.40 ( approximately US$34,500). In conclusion, same day permanent pacemaker implantation was feasible, safe, and cost-effective. It was associated with a low prevalence of complications and only a few patients required an overnight stay.

Percutaneous pacemaker and implantable cardioverter-defibrillator lead extraction in 100 patients with intracardiac vegetations defined by transesophageal echocardiogram

OBJECTIVES

We describe the feasibility, safety, and clinical outcomes of percutaneous lead extraction in patients at a tertiary care center who had intracardiac vegetations identified by transesophageal echocardiogram.

BACKGROUND

Infection in the presence of intracardiac devices is a problem of considerable morbidity and mortality. Patients with intracardiac vegetations are at high risk for complications related to extraction and protracted clinical courses. Historically, lead extraction in this cohort has been managed by surgical thoracotomy.

METHODS

We analyzed percutaneous lead extractions performed from January 1991 to September 2007 in infected patients with echocardiographic evidence of intracardiac vegetations, followed by a descriptive and statistical analysis.

RESULTS

A total of 984 patients underwent extraction of 1,838 leads; local or systemic infection occurred in 480 patients. One hundred patients had intracardiac vegetations identified by transesophageal echocardiogram, and all underwent percutaneous lead extraction (215 leads). Mean age was 67 years. Median extraction time was 3 min per lead; median implant duration was 34 months. During the index hospitalization, a new device was implanted in 54 patients at a median of 7 days after extraction. Post-operative 30-day mortality was 10%; no deaths were related directly to the extraction procedure.

CONCLUSIONS

Patients with intracardiac vegetations identified on transesophageal echocardiogram can safely undergo complete device extraction using standard percutaneous lead extraction techniques. Permanent devices can safely be reimplanted provided blood cultures remain sterile. The presence of intracardiac vegetations identifies a subset of patients at increased risk for complications and early mortality from systemic infection despite device extraction and appropriate antimicrobial therapy.

Risk Factors for Mortality in Patients With Cardiac Device-Related Infection

Background— Because of the increased use of pacemakers and implantable cardioverter defibrillators, infection has become a complication with significant morbidity and mortality. Data on risk factors for mortality in patients with cardiac-device related infection are limited. We evaluated the prognostic significance of key clinical and echocardiographic variables in a large retrospective population of patients with cardiac-device related infection.

Methods and Results— Two hundred ten patients with cardiac-device related infection were identified at the University of Michigan between 1995 and 2006. Data were abstracted on key clinical and echocardiographic variables, treatment strategy, and 6-month outcomes. We used multivariable Cox proportional hazards models to examine clinical and echocardiographic variables that were associated with 6-month mortality. Mean age for our study population was 63�17 years, and 72 (44%) were women. All-cause 6-month mortality was 18% (n=37). Independent variables associated with death were systemic embolization (hazard ratio 7.11; 95% CI 2.74 to 18.48), moderate or severe tricuspid regurgitation (hazard ratio 4.24; 95% CI 1.84 to 9.75), abnormal right ventricular function (hazard ratio 3.59; 95% CI 1.57 to 8.24), and abnormal renal function (hazard ratio 2.98; 95% CI 1.17 to 7.59). Size and mobility of cardiac device vegetations were not independently associated with mortality.

Conclusions— We identified several clinical and echocardiographic variables that identify patients with cardiac-device related infection who are at high-risk for mortality and may benefit from more aggressive evaluation.

Pacemaker infection secondary to burkholderia pseudomallei

Infection is a relatively rare but devastating complication of intracardiac device implantation. Burkholderia pseudomallei is the organism which causes melioidosis, an endemic and lethal infection in the tropics. We describe a case of pacemaker infection secondary to Burkholderia pseudomallei, which was treated by explantation of the device and appropriate antimicrobial therapy.

Pacemaker Endocarditis in Patients with Prosthetic Valve Replacements: Case Trilogy and Literature Review

Infective endocarditis is not uncommon in patients with both a permanent pacemaker system and a prosthetic valve. No guidelines exist to aid management. The recommendations for pacemaker infective endocarditis alone are limited and contradictory. We present a case trilogy and literature review that highlights these shortcomings and the challenges facing physicians. Complete extraction of the infected pacemaker system is essential. The timing of extraction, duration of antibiotic therapy, and timing of reimplantation are all controversial. The presence of a concomitant prosthetic valve exacerbates these dilemmas further.

Extracción de electrodos de marcapasos y desfibrilador mediante técnicas percutáneas

INTRODUCTION AND OBJECTIVES

There is an increasing need for endocardial pacing and defibrillators leads to be removed. However, the procedure can be complex and it is not risk-free. We reviewed our experience between April 1989 and June 2006 with the percutaneous extraction of leads.

METHODS

In total, 314 electrodes were extracted from 187 patients. The leads had been implanted over an average period of 69.16 months (range 0.11-234.6 months, median 60.25 months). Some 115 were atrial leads, 196 were ventricular, and three were in the coronary veins; of these, 78 had been abandoned in the vascular bed.

RESULTS

Indications for removal were infection (26.1%), dysfunction (22.9%), erosion (25%), endocarditis (20.7%), and bacteremia (2.7%). Overall, 58.8% of patients were referred from other departments. In 96.8%, the electrodes were completely removed. Simple traction was used in 23.4%, and countertraction techniques (with and without radiofrequency current support) were used in 60.7%. For abandoned leads, a biopsy clamp was used in combination with countertraction (4.3%) or a femoral approach with a snare (10.1%). A sternotomy was required in three of the 10 patients with remaining electrode fragments. The complication rate was 4.6% (with major complications in 2.5%). Complications were associated with age < 60 years (odds ratio [OR]=5.38, 95% confidence interval [CI] 1.07-27.23), the presence of endocarditis (OR=4.97: 95%CI, 1.04-23.70), and right side implantation (OR=17.09; 95% CI, 2.15-135.70).

CONCLUSIONS

In the majority of cases, pacing and defibrillator leads can be removed without difficulty using modern extraction techniques. However, because there is a risk of complications during extraction, even though it is low, the procedure should be carried out in specialized centers with surgical facilities.

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.

Intravascular Device Infections

Intravascular devices such as pacemakers, implantable cardioverter-defibrillators (ICDs), left ventricular assist devices (LVADs), and prosthetic vascular grafts are life-saving therapies for patients with malignant arrhythmias, heart failure, and various vascular diseases. As indications for their use have increased, so has the prevalence of infectious complications associated with these devices. We present a review of the clinical literature on the epidemiology, diagnosis, and management of infectious complications of these intravascular devices. Most intravascular device infections are thought to result from skin flora contamination during implantation. Infection of the subcutaneous portion of the device can subsequently track to deeper intravascular tissues. Infection that involves the intravascular or intracardiac portion of these devices carries a high morbidity and mortality. Despite appropriate antibiotic therapy, cure of infection is frequently possible only with device removal. Well-designed placebo-controlled, randomized studies evaluating antimicrobial therapy for treatment of intravascular device infections are lacking. In the absence of better information, authorities recommend antibiotics targeted toward cultured organisms for approximately 4 to 6 weeks and device removal.

Outcome after complete percutaneous removal of infected pacemaker systems and implantable cardiac defibrillators

The mortality of retained, infected pacemaker systems is high. We assessed the safety and rate of relapse of infection after complete percutaneous removal of leads of infected pacemaker systems. None of the 40 subjects experienced procedure-related mortality and there were no cases of relapse after a median duration of follow up of 8 years (range, 3 months to 12 years). Procedure-related complications and other adverse events during therapy are reported. Percutaneous removal of infected pacemakers in conjunction with appropriate antibiotic therapy is safe and effective.

Cardiac device infections: getting to the heart of the matter

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.

Pacemaker Lead Endocarditis Caused by Staphylococcus Hominis

Infective endocarditis related to pacemaker is a rare but serious condition in permanent venous tracing. A 65-year-old man was admitted to the hospital with high fever and chills. A DDD pacemaker had been implanted via the right subclavian vein because of sick sinus syndrome 6 years earlier. Transesophageal echocardiogram identified an oscillating round hyperechoic mass with a stalk near the tricuspid valve. Blood cultures grew Staphylococcus hominis. The patient was treated with antibiotics and operated on after the acute phase of the illness had subsided. We hereby report a case of lead endocarditis caused by S. hominis in a patient with pacemaker, which has been rarely reported in the English literature.

Klebsiella Pneumoniae: A Rare Cause of Device-Associated Endocarditis

Intravascular infections involving implanted pacemakers and defibrillators are being seen with increasing frequency. This report describes a case of intravascular infection of an implanted defibrillator with Klebsiella pneumoniae, an unusual pathogen for pacemaker or defibrillator infection.

Successful removal of an infected pacemaker lead using cardiopulmonary bypass in an 89-year-old patient

We report the case of an 89-year-old patient suffering from endocarditis with septicemia caused by a growth on a pacemaker lead. The entire pacemaker system was successfully removed using cardiopulmonary bypass. Although the patient was an octogenarian in poor condition with a systemic infection, an aggressive operation with careful perioperative management gave a good clinical result. As far as we know, this is the oldest patient in whom a pacemaker system has been removed using cardiopulmonary bypass.

Antibiotic Prophylaxis with a Single Dose of Cefazolin During Pacemaker Implantation: Incidence of Long-Term Infective Complications

OBJECTIVE

Systemic and localized infections related to permanent pacemaker implantation are not common, but are serious and potentially life-threatening complications. The aims of this prospective observational study were: (1) to assess the safety and long-term efficacy of a simplified scheme of antibiotic prophylaxis, and (2) to identify the predictors of long-term infective complications, in patients undergoing pacemaker implantation or replacement.

METHODS AND RESULTS

From October 1998 to July 2001, 852 patients (mean age 77.0 +/- 9.2 years; 474 men) who underwent new permanent pacemaker implantation (69.6%) or pulse generator replacement (30.4%) received a mini-bag of 2 g of cefazolin diluted in 50 mL of saline solution, administered intravenously in 20 minutes before the beginning of the procedure. Early (within 2 months of implantation) and late major and minor infective complications were recorded. During the earlier phase, minor complications were observed in 9 patients (1%). During the long-term phase of the surveillance (mean 25.6 +/- 11.0 months, range 12-55 months) major infective complications were observed in 6 patients (0.7%). On multivariate analysis, no clinical or procedural variable predicted the occurrence of long-term infective complications.

CONCLUSIONS

Our data indicate the safety and efficacy of a single, intravenous 2 g dose of cefazolin in preventing infective complications related to pacemaker implantation or replacement. No clinical or procedural variable predicted the occurrence of long-term infective complications.

Less-Invasive Surgical Extraction of Problematic or Infected Permanent Transvenous Pacemaker System

BACKGROUND

The best management of problematic or infected transvenous permanent pacemaker system is complete surgical or percutaneous intravascular extraction of the pacemaker leads and removal of the generator. We present our experiences in 13 such patients in whom the leads were removed with the less-invasive technique.

METHODS

From 1996 to 2003, 13 patients, from 31 to 83 years of age (mean, 66.9 +/- 14.0 years), with problematic or infected transvenous permanent pacemaker systems were referred to our department for surgical treatment. In 6 patients, the original pacemakers were dual-chamber. A subxiphoid pericardiotomy was used as the monitoring port during the ventricular lead extraction. In addition, a right parasternal pericardiotomy through the third intercostal space was used as the monitoring port during the atrial lead extraction.

RESULTS

Pacemaker systems were completely removed in all patients. Three bleeding episodes (23%), including two right atrial tears and one right ventricular rupture, were successfully circumvented through these monitoring ports. Concomitantly, a new epicardial single-chamber device was implanted through the subxiphoid pericardiotomy whenever indicated in 9 patients. All patients recovered and were discharged uneventfully. At a mean follow-up of 24.8 months (range, 1 to 90 months), no recurrent infections were observed.

CONCLUSIONS

A less-invasive technique for explantation of the complete pacemaker system is feasible. This is a reliable method to eradicate infection. Neither cardiopulmonary bypass nor specific intravascular lead extraction devices, such as locking stylets or laser-assisted sheath, are needed.

Bacteremia caused by late-infected pacemaker lead--a case report

A 73-year-old man with bradycardia and atrial fibrillation underwent implantation of a transvenous pacemaker system on the left anterior chest wall in 1995. Six years later, he was admitted for bacteremia from coagulase-negative Staphylococcus. Repeated treatment employing antibiotic therapy was ineffective. The infected electrode was removed under cardiopulmonary bypass. His electrode had become firmly encased with fibrous tissue within the right ventricle and atrium. It was removed under direct vision during complete cardiac arrest. The postoperative course was uneventful and there has been no recurrence after 1 year.

Pacemaker lead infection secondary to Haemophilus parainfluenzae

Cardiac device infections are a rare complication of pacing and defibrillator therapy. The number of implanted devices will likely continue to rise with increasing implantation of the cardioverter defibrillator and cardiac resynchronization devices. This report describes a case of an uncommon pathogen for device-associated endocarditis.

Pacemaker lead infection in young patients

Transvenous pacing has become widespread in the pediatric population, but related pacemaker lead infection in young patients has rarely been reported. To determine prevalence and optimal management of pacemaker lead infection in children and young adults, the authors reviewed their pacing database including 4476 patients who previously had pacemaker implantations from 1975 to 2001. A pacemaker was implanted in 304 patients under the age of 40. Of these patients 217 of them had congenital heart disease: 108 with structural defect, 109 without (mainly complete AV blocks). Among patients with congenital heart disease, 12 developed a pacemaker lead infection (5.5%, 6 patients with structural defect, 6 without). This incidence was significantly higher than in patients < 40 years at first implantation without congenital heart disease (2.3%) and in > 40-year-old patients(1.2%, P < 0.001). However, the number of reinterventions at the pulse generator site was higher in patients having had their first implantation before the age of 40. In patients with structural cardiac defect: two died after surgical lead extraction and one died before the scheduled lead extraction. The three remaining patients had successful surgical (n = 1) or percutaneous (n = 2) lead extractions. In patients without structural cardiac defect successful percutaneous extraction (5/6) or surgical extraction (1/6 with vegetation > 25 mm) was performed. One patient with percutaneous extraction developed chronic cor pulmonale during follow-up. One infection recurred in one patient with structural cardiac defect although complete removal of the pacing material had been performed. The prevalence of pacemaker lead infection is higher in younger patients, perhaps in part due to a higher number of procedures at the pacemaker site than in the general population of patients with a pacemaker. Patients with structural cardiac defect who underwent surgical lead removal were at high risk for death. Patients with percutaneous lead extraction may develop cor pulmonale.

Infections of intracardiac devices

Intracardiac devices are increasingly used to correct hemodynamically dysfunctional valves and electrophysiologic abnormalities. These devices become infected at relatively low rates. Nevertheless, when these low rates are applied to widely used devices, significant numbers of infections result. Additionally, these infections have been associated with high degrees of morbidity and high mortality rates. This article reviews the epidemiology, microbiology, clinical presentation, and medical as well as surgical therapy of intracardiac device infections.

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.

Prolonged low-dose thrombolytic therapy: a novel adjunctive strategy in the management of an infected right atrial thrombus

An 81-year-old man presented with a large, infected right atrial thrombus that was refractory to anticoagulants and several courses of antibiotics. The risk of surgical removal of the thrombus, which was associated with a pacemaker electrode, was considered prohibitive. The patient was treated for 7 days with low-dose (40 mg/day) tissue-type plasminogen activator (t-PA). Hemostatic monitoring during infusion revealed (1) a plasma t-PA antigen that was approximately 5% of that achieved during short-course t-PA for acute myocardial infarction, (2) biochemical evidence of prolonged clot lysis, and (3) no significant depletion of fibrinogen or plasminogen. Nearly complete dissolution of the thrombus was observed. His bacteremia was eradicated by intravenous penicillin despite the presence of the pacemaker lead. This case highlights the benefits of combined antibiotic and thrombolytic therapy and documents for the first time the response of the human hemostatic system to prolonged t-PA infusion and the plasma t-PA levels attained when thrombolytic therapy is administered in this manner. Prolonged courses of fibrinolytic agents may be a good alternative to surgical intervention in selected patients with infected, right-sided intracardiac thrombi.

Infections of intracardiac devices

Intracardiac devices are increasingly used to correct hemodynamically dysfunctional valves and electrophysiologic abnormalities. These devices become infected at relatively low rates. Nevertheless, when these low rates are applied to widely used devices, significant numbers of infections result. Additionally, these infections have been associated with high degrees of morbidity and high mortality rates. This article reviews the epidemiology, microbiology, clinical presentation, and medical as well as surgical therapy of intracardiac device infections.

Pacemaker endocarditis: approach for lead extraction in endocarditis with large vegetations

We present the case of a patient with vegetations on a pacing lead from a pacemaker implanted 13 years previously. A new surgical technique for removal of infected leads was developed to avoid the increased risk of septic pulmonary embolism. The electrode with vegetations was removed without cardiopulmonary bypass using the direct surgical approach described.

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

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.

[Secondary infections after pacemaker implantation]

INTRODUCTION

Infectious complications following pacemaker implantation are not common but may be particularly severe. Localized wound infections at the site of implantation have been reported in 0.5% of the cases in the most recent series, with an average of about 2%. The incidence of septicemia and infectious endocarditis is lower, about 0.5% of the cases. The operator's experience, the duration of the procedure and repeat procedures are considered to be predisposing factors.

CURRENT KNOWLEDGE AND KEY POINTS

The main cause of these infections has been recently demonstrated to be local contamination during implantation. The commonest causal organism is Staphylococcus (75 to 92% of the cases), Staphylococcus aureus being the cause of acute infections (less than 6 weeks), whereas Staphylococcus epidermidis is associated with cases of secondary infection (more than 2 months). The usual clinical presentation is infection at the site of the pacemaker but other forms such as abscess, endocarditis, rejection of the implanted material, septic emboli or phlebitis have been described. The diagnosis is confirmed by local and systemic biological investigations and by echocardiography (especially transesophageal echocardiography) in cases of right heart endocarditis. There are two axes of treatment: bactericidal double antibiotherapy and surgical ablation of the infected material either percutaneously or by cardiotomy.

FUTURE PROSPECTS AND PROJECTS

A recent meta-analysis supported the role of systematic, preoperative, prophylactic antibiotic therapy in the prevention of these complications. These data should be confirmed by suitably powered clinical trials.

Current concepts in extraction of transvenous pacing and ICD leads

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.

Removal of infected pacemaker leads with deep hypothermic circulatory arrest and open surgical exploration of the superior vena cava and innominate veins

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.

Extraction of pacemaker and implantable cardioverter defibrillator leads

The common reasons for removal of pacing and defibrillator leads are infection, malfunction, or design defects such as fracture of J wires in Teletronics Accufix leads (Telectronics Pacing, Englewood, CO), which impose considerable risk for cardiac morbidity and mortality. Chronically implanted leads are fixed to the myocardium by fibrous tissue. Fibrous scar tissue may also encase the lead along its course. Furthermore, fragility of the lead and its tendency to break when extraction force is applied to overcome resistance imparted by the scar tissue add to the challenge of lead extraction. Thus, the extraction of chronically implanted leads is an important issue. Until a few years ago, the only methods available for the removal of chronically implanted leads were traction on the proximal segment of the lead and cardiac surgery. New techniques were developed to extract the leads by a transvenous approach using locking stylets, sheaths, snares, and retrieval baskets. Lead extraction using intravascular countertraction methods has since evolved as a specialty of its own. Progress has also been made in developing other system, such as Excimer laser energy for lead extraction. In this article, we discuss principles, techniques, and experience with these methods of extraction of chronic pacemaker and defibrillator leads.

Late complications following permanent pacemaker implantation or elective unit replacement

OBJECTIVE

To determine the rate of late complications following first implantation or elective unit replacement of a permanent pacemaker system.

DESIGN

Analysis of pacemaker data and complications prospectively acquired on a computerised database. Complications were studied over an 11 year period from January 1984 to December 1994.

SETTING

Tertiary referral cardiothoracic centre.

PATIENTS

Records of 2621 patients were analysed retrospectively.

MAIN OUTCOME MEASURES

Complications requiring repeat procedures occurring more than six weeks after pacemaker implantation or elective unit replacement.

RESULTS

The overall rate of late complications was significantly lower after first implantation of a permanent pacemaker (34 cases, complication rate 1.4%, 95% confidence interval 0.9% to 1.9%) than after elective unit replacement (16 cases, complication rate 6.5% (3.3% to 9.7%). There were 20 cases of erosion, 18 infections, five electrode problems, and seven miscellaneous problems. Complications were more common with inexperienced operators (18.9% (6.0% to 31.8%)) than with experienced operators (0.9% (0.3% to 1.5%).

CONCLUSIONS

The incidence of late complications following pacemaker implantation is low and compares favourably with early complication rates. The majority are caused by erosion and infection. Patients who have undergone elective unit replacement are at particular risk.