How to treat infected pacemaker leads in very elderly patients

Infection of pacemaker leads is one of the difficult problems after implantation, especially in elderly patients. Three octogenarians were referred to our hospital due to infection of pacemaker leads which had been resistant to antibiotic treatments. The patients were 81 approximately 88 years old including 1 male and 2 females. Primary implantation of pacemaker had been performed 9 months approximately 16 years before and infection had started 7 months approximately 7 years before. The infected leads were partially resected in an 88-year-old woman who had serious dementia and poor nutrition status. The infected leads were completely removed under cardiopulmonary bypass (on-beating) in an 81-year-old woman who had undergone 3 previous surgical treatments. The infected lead was partially removed in an 82-year-old man, but infection was not perfectly controlled. Therefore, the lead was completely removed under cardiopulmonary bypass with cardiac arrest. In conclusion, complete removal of the whole pacemaker system is desirable, while palliative surgery might be an option for very elderly patients with high risks.     

Total removal of infected pacemaker lead with cardiopulmonary bypass; report of a case

The incidence of infection after pacemaker implant has been reported to occur rarely but it's one of the severe complication. Pacemaker lead sometimes imbedded in the right atrial and ventricular wall, and it seemed to be difficult to remove the pacemaker lead by closed techniques. The optimal treatment is total removal generator and pacing lead, therefore, it is necessary to remove with cardiopulmonary bypass. Septicemia caused by infections retained pacemaker lead developed in an 87-year-old man. Following antibiotic therapy, the lead was successfully removed by cardiotomy on cardiopulmonary bypass. Total removal with cardiopulmonary bypass would be recommended.     

Removal of methicillin-resistant staphylococcus aureus infected pacemaker leads under cardiopulmonary bypass: report of a case

A 71-year-old man, who underwent an intravenous pacemaker implantation previously, suffered from fever and local infection of the generator pocket. A blood culture showed positive for methicillin-resistant staphylococcus aureus (MRSA). He underwent removal of total pacemaker system under cardiopulmonary bypass support successfully. Two leads were tightly adhered to the right atrial free wall, tricuspid valve and right ventricular trabeculation. Postoperative course was uneventful with administration of antibiotics for 5 weeks. Removal under cardiopulmonary bypass is considered to be an effective procedure for treatment of patients with infected pacemaker lead.     

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.     

MRSA septicemia caused by an infected pacemaker lead: a case report with a review of Japanese literatures

A 50-year-old woman was admitted to our hospital because of MRSA septicemia caused by a contaminated permanent pacemaker lead. A pacemaker system was successfully removed under cardiopulmonary bypass support. Postoperative antibiotics was administered for 7 weeks. Total removal of a pacemaker system under cardiopulmonary bypass support is the treatment of choice in a case with pacemaker infection associated with MRSA septicemia.     

A case report of total removal of infected pacemaker with cardiopulmonary bypass

A successful removal of infected pacemaker with septicemia, pre-DIC state, and pneumonia is reported. A 44-year-old man received transvenous permanent pacemaker implantation through right subclavian region at 42 years of age. Two years and 3 months after implantation an abscess formed around the generator. Since incision and drainage were not effective, the generator was removed after 2 months (another pacemaker was reimplanted at the opposite side), and the initial pacing lead was cut after 3 months of initiation of the infection. But wound healing was not obtained and high fever-up occurred. Arterial blood culture showed septicemia caused by Staphylococcus aureus. He also suffered pre-DIC state and pneumonia. The end of the cut lead had fallen into the right ventricle. After general condition was recovered, the residual lead and the reimplanted pacemaker system were extirpated under cardiopulmonary bypass. And at the same time a new pacemaker system was implanted again. He was in good postoperative course, and he is up and well 8 months after operation.     

Removal of infected pacemaker lead through sternotomy without cardiopulmonary bypass

A 66-year-old man, who had undergone DDD pacemaker implantation for complete A-V block two years ago, was admitted because of endocarditis with septicemia and renal failure. His blood culture revealed Staphylococcus aureus. We tried to remove the infected cardiac pacemaker lead. But we failed to remove the atrial lead because it was strongly adhered with the right atrial appendage. Antibiotic therapy was ineffective. In the last resort, we operated through median sternotomy three months after the initial infectious episode. In intraoperative inspection, we found it difficult to remove the lead by traction because of atrial residual lead sticking out of the right atrial appendage. We applied a purse string suture on the right appendage and obtained successful removal of infected lead without the cardiopulmonary bypass. His postoperative course has been uneventful. He is totally asymptomatic and doing well up to now. In case of such local infection, we conclude that all transvenous leads should be removed and recommend a simultaneous implantation of the epicardial pacemaker system.     

Removal of retained transvenous pacemaker electrodes under cardiopulmonary bypass

A case of breakage and removal of a retained transvenous pacemaker electrode is described. A 22-year-old woman with complete A-V block underwent implantation of a transvenous pacemaker system on the left anterior chest wall in 1989. Three years later, a new generator was implanted on the right chest wall because of local infection of the pacemaker pockets. The old electrodes could not be removed and were left in place. Beginning in 1995, the patient complained of anterior chest pain. A chest roentgenogram revealed that one of the pacemaker electrodes had broken at the right costoclavicular ligament and a fragment was floating in the superior vena vava. The retained electrodes were removed under totl cardiopulmonary bypass. These electrodes had become firmly encased with fibrous tissue within the right ventricle and atrium, but they were easily removed under direct vision duting complete cardiac arrest. The postoperative course was uneventful and the patients had no further complaint.     

Tricuspid valve plasty associated with removal of an infected pacemaker lead: report of a case

We performed tricuspid valve plasty in a 72-year-old woman with pacemaker lead infection and septicemia. All the infected pacemaker system was removed under cardiopulmonary bypass. Because of advanced adhesion and infection, we needed partial resection and plasty of the tricuspid valve. Postoperative echocardiography revealed only mild tricuspid regurgitation and the recurrence of infection has been avoided. Our technique of valve plasty was useful in a patient with advanced infection of both pacemaker leads and tricuspid valve leaflets.     

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.     

Fractured inferior vena cava filter strut presenting as a penetrating foreign body in the right ventricle: report of a case

Migration of a fractured strut of an inferior vena cava (IVC) filter to the heart is a rare complication. We report the case of a 40-year-old woman who had this complication eight months after infrarenal IVC filter placement. She presented with chest pain. The broken arm of the IVC filter had migrated to the heart and penetrated the free wall of the right ventricle. It was removed successfully by cardiac surgery without the aid of cardiopulmonary bypass.     

Removal of infected pacemaker leads under extracorporeal circulation

We report 3 cases of removal of infected pacemaker leads under extracorporeal circulation. The infections occurred 12, 29, and 58 months after the implantations. A skin ulcer was at first formed over the pacemaker; then the pacemaker itself became infected. The right atrium was incised, and the infected leads were pulled out. The ventricular leads adhered to the tricuspid valve, the chordae tendineae and the endocardia. A lead tip could easily be extirpated with sharp scissors. Two cases underwent implantation of myocardial electrodes; the new generators were implanted below the fascia of the rectus abdominis muscle. In the other case, a pacemaker was implanted transvenously because an appropriate epicardial pacing site could not be found. Case infected by methicillin-resistant Staphylococcus aureus (MRSA) died from mediastinitis a month after the operation. The others did not have a recrudescence of their infections. Removal of the leads under extracorporeal circulation is an invasive but sure procedure to extirpate.     

Sudden death under successful medical management of sick sinus syndrome after cardiac pacing discontinuation

Bacterial infection is a serious complication of permanent pacemaker implantation. A 52-year-old woman with sick sinus syndrome and vasospastic angina developed pacemaker infection 4 years after implantation, with methicillin-resistant Staphylococcus aureus detected in arterial blood cultures. We treated the septicemia with antibiotics and removed the infected pacemaker. We treated sick sinus syndrome with intravenous nitroglycerin followed by oral maintenance isosorbide mononitrate. After cardiac pacing was discontinued following removal of the infected permanent pacemaker, the patient remained well, until her sudden death 3.5 years later. Although the precise cause of death was not clear, we suspected sick sinus syndrome or vasospastic angina, and now consider the outcome may have been more favorable if we had reimplanted a permanent pacemaker before she died.     

Ventricular tachycardia associated with transmyocardial migration of an epicardial pacing wire

A 66-year-old man who had undergone a three-vessel coronary artery bypass grafting (CABG) procedure 3 years previously presented with ventricular tachycardia (VT) and cardiac arrest. Echocardiography demonstrated a wire coursing through the right ventricle into the pulmonary artery. The wire was removed with a snare and confirmed to be an epicardial temporary pacing wire placed during the CABG operation. We suspect that the epicardial pacing wire eroded through the right atrium and migrated into the right ventricle, contributing to the VT. Complications due to temporary epicardial pacing wires placed during CABG are discussed.     

Left ventricular pacing site-timing optimization during biventricular pacing using a multi-electrode patch

A 71-year-old man with class IV congestive heart failure and an infected pacemaker/implantable cardioverter defibrillator (ICD) underwent median sternotomy for removal of endocardial leads with a 15-mm vegetation. Cardiac output during biventricular pacing was optimized with an aortic flow probe, a multi-electrode left ventricular patch, and a randomized protocol assessing 54 combinations of pacing site and right ventricle-left ventricle delay. Results that were assessed with response surface methodology determined permanent epicardial lead position and timing. The difference between the best and worst site-timing combinations altered cardiac index by nearly 70%. This experience demonstrates potential importance of the epicardial approach to site-timing optimization for biventricular pacing.     

Successful management of multiple permanent pacemaker complications – infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis

A 59 year old man underwent mechanical tricuspid valve replacement and removal of pacemaker generator along with 4 pacemaker leads for pacemaker endocarditis and superior vena cava obstruction after an earlier percutaneous extraction had to be abandoned, 13 years ago, due to cardiac arrest, accompanied by silent, unsuspected right atrial perforation and exteriorisation of lead. Postoperative course was complicated by tricuspid valve thrombosis and secondary pulmonary embolism requiring TPA thrombolysis which was instantly successful. A review of literature of pacemaker endocarditis and tricuspid thrombosis along with the relevant management strategies is presented. We believe this case report is unusual on account of non operative management of right atrial lead perforation following an unsuccessful attempt at percutaneous removal of right sided infected pacemaker leads and the incidental discovery of the perforated lead 13 years later at sternotomy, presentation of pacemaker endocarditis with a massive load of vegetations along the entire pacemaker lead tract in superior vena cava, right atrial endocardium, tricuspid valve and right ventricular endocardium, leading to a functional and structural SVC obstruction, requirement of an unusually large dose of warfarin postoperatively occasioned, in all probability, by antibiotic drug interactions, presentation of tricuspid prosthetic valve thrombosis uniquely as vasovagal syncope and isolated hypoxia and near instantaneous resolution of tricuspid prosthetic valve thrombosis with Alteplase thrombolysis.     

Total removal of infected pacemaker lead under cardiopulmonary bypass in a case of endocarditis, bacteremia and lung abscess

A 60-year-old man, who had undergone implantation of a transvenous pacemaker system on the left chest wall for sick sinus syndrome 19 years ago, was admitted because of endocarditis with septicemia and lung abscess 2 months after reimplantation of the generator. His blood culture revealed Staphylococcus aureus. Following debridement of the infected pacemaker pocket and antibiotics therapy, we tried to remove the pacemaker system under cardiopulmonary bypass 1 month after admission. In intraoperative inspection, the electrodes had become firmly encased with fibrous tissue within the tricuspid valve and the right ventricle. After the operation, antibiotic therapy was performed for 4 weeks. His postoperative course was uneventful. Patients with pacemaker infection should undergo aggressive total removal of the pacemaker system, particularly incase with endocarditis and bacteremia.     

Superior vena cava thrombosis after intravascular AICD lead extraction: a case report

Pacemaker lead extraction has been shown to be an effective and safe treatment in the case of infected per-manent pacemaker leads. However, it can lead to potentially serious complications, usually occurring during the ex-traction procedure. This report describes a case of a 74-year-old male with a persistent superior vena cava thrombo-sis related to an infected permanent pacemaker lead transvenous extraction. Clinical and surgical management are discussed.     

Surgical Management of Infected Permanent Transvenous Pacemaker Systems: Ten Year Experience

A bstract 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.     

Infected implantable cardioverter-defibrillator lead extraction under deep hypothermic circulatory arrest; report of a case

We performed infected implantable cardioverter-defibrillator lead extraction under deep hypothermic circulatory arrest in a 58-year-old man. Venogram during the implantation of the lead had revealed complete obstruction of the innominate vein. Preoperative trans-esophageal ecocardiogram revealed intracardiac vegetation with a diameter of 20×13 mm. Because of advanced adhesion and large vegetation, we performed lead extraction under cardiopulmonary bypass. The leads were adherent to the wall of the superior vena cava( SVC) and the innominate vein and could not be extracted. So we converted to deep hypothermic circulatory arrest. We performed venotomy in the SVC and the innominate vein to achieve complete visualization. The leads were extracted under direct vision. Postoperative course was uneventful without recurrence. Extraction of implantable devices is highly recommended when infection occurs. When adhesion of the lead is suspected, safe extraction can be performed by venotomy of the innominate vein under deep hypothermic circulatory arrest.