Background The recommended management of cardiac implantable electronic device (CIED) infection is complete system extraction. There are limited clinical data on the optimal time for device re-implantation. A small series reported good results with simultaneous contralateral implantation. We evaluated this approach in our institution for patients without signs of systemic sepsis. We present clinical outcomes and completeness of extraction.
Methods The clinical records of all patients undergoing lead extraction in our institution since January 2008 were reviewed.
Results 68 patients underwent CIED extraction for infection during this time period (see Abstract 151 table 1). In 34 cases, the device was removed with simple traction, 9 with locking stylet, 22 with locking stylet and laser sheath, 1 with locking stylet and mechanical sheath and 2 with femoral snare. There was complete hardware removal in 64 cases (94%). One patient with lead related endocarditis required a subsequent surgical procedure to remove a lead fragment and in 4 other patients who had erosion, pocket infection or threatened erosion, a small fragment of lead remained. 18/68 patients were re-implanted with a new device on the contralateral side on the same day as the extraction. 28/68 patients received a new device between 1 and 227 days later and 22/68 have not undergone reimplantation. An active fixation bipolar TPW (temporary pacing wire) was used in 6 patients for a mean 7.8±2.7 days. 3 patients had a further device related procedure during a mean follow-up of 445±304 days: 1 lead reposition, 1 pocket washout and 1 extraction. Of the 2 procedures carried out for recurrent infection, 1 was managed with a TPW for 7 days prior to reimplantation and 1 underwent reimplantation at 14 days without TPW. In addition, the patient requiring pocket washout had a fragment of lead remaining following their initial extraction.
Conclusion We report low rates of recurrent infections following CIED extraction. None of the 18 individuals simultaneously re-implanted with a new device on the contralateral side needed any further procedures during the follow-up period. This approach may be appropriate, particularly in pacing dependant patients who would otherwise require a TPW with its associated risks. In those individuals who required a TPW, the risk of recurrent infection in our series was 17% despite our use of an active fixation pacing lead and externalised pulse generator which has a lower reported complication rate. Only one of the 4 patients with a residual lead fragment required re-intervention for recurrent infection. This provides some supportive evidence that in patients with high surgical risk and pocket abnormalities, if fragments of lead may remain, the patient may be treated conservatively and monitored for signs of recurrent CIED infection.
- Cardiac implantable electronic device
- lead extraction