[Percutaneous lead extraction. Complications and their management]

Infection remediation after septic device extractions: analysis of three treatment strategies including a 1-year follow-up

Introduction

In CIED infections, all device material needs to be removed. But, especially in pacemaker-dependent patients it is often not possible to realize a device-free interval for infection remediation. In those patients, different treatment options are available, however the ideal solution needs still to be defined.

Methods

This retrospective analysis includes 190 patients undergoing CIED extractions due to infection. Three different treatment algorithms were analyzed: Group 1 included 89 patients with system removal only (System removal group). In Group 2, 28 patients received an epicardial electrode during extraction procedure (Epicardial lead group) while 78 patients in group 3 (contralateral reimplantation group) received implantation of a new system contralaterally during extraction procedure. We analyzed peri- and postoperative data as well as 1-year outcomes of the three groups.

Results

Patients in the system removal and epicardial lead groups were significantly older, had more comorbidities, and suffered more frequently from systemic infections than those in contralateral reimplantation group. Lead extraction procedures had comparable success rates: 95.5%, 96.4%, and 93.2% of complete lead removal in the System removal, Epicardial Lead, Contralateral re-implantation group respectively. Device reimplantation was performed in all patients in Epicardial lead and Contralateral reimplantation group, whereas only 49.4% in System removal group received device re-implantation. At 1-year follow-up, freedom from infection and absence of pocket irritation were comparable for all groups (94.7% Contralateral reimplantation group and Epicardial lead group, 100% System removal group). No procedure-related mortality was observed, whereas 1-year mortality was 3.4% in System removal group, 4.1% in Contralateral re-implantation group and 21.4% in Epicardial lead group (p < 0.001).

Conclusion

In patients with CIED infection, systems should be removed completely and reimplanted after infection remediation. In pacemaker-dependent patients, simultaneous contralateral CIED re-implantation or epicardial lead placement may be performed, depending on route, severity and location of infection.

Recurrent Bacteremia After Heart Transplantation Due to Abandoned Lead Fragment in an Anonymous Vein-A Case Report

Heart transplantation (HTx) represents the "gold standard" in end-stage heart failure therapy. Due to their severe heart failure and for prevention of sudden cardiac death, the majority of patients presenting for HTx will have a history of an implanted cardioverter-defibrillator (ICD). Usually, within the scope of HTx, all cardiac-implanted electronic device components are removed. In rare cases these efforts fail and some material remains. The abandoned lead fragments can cause serious complications. The case presented herein involves a patient with recurrent bacteremia after successful HTx originating from an abandoned and infected lead fragment. In 2016, a 64-year-old man received a donor heart transplant due to end-stage heart failure. Unfortunately, during the procedure, not all components of an ICD implanted in 2007 could be removed. An initially event-free period was followed by recurrent fever attacks and staphylococcal bacteremia was diagnosed. After an extensive search, the source of the bacteremia was identified by positron emission tomography-computed tomography (PET-CT), and percutaneous extraction of the abandoned and infected ICD lead fragment was scheduled. The fragment was extracted using a minimally invasive approach via percutaneous femoral vein access. The patient was discharged 3 days later, with no further complications. This case highlights the need for conscientious and complete removal of foreign material in the HTx setting. Difficult-to-diagnose sources of infection could be reliably identified by PET-CT. When required, extraction of the foreign body should be done using a minimally invasive approach.