Management of the infected pacemaker: explantation, sterilization, and reimplantation

From January, 1970, through December, 1984, nineteen infected or eroded pacemaker units were reimplanted in 17 patients. Characteristics of the patients, types of infecting organisms, surgical management, and complications are described. Optimal treatment of the infected generator pocket requires explantation of the generator unit with utilization of the in situ leads for pacing by an external-demand pacemaker unit. The generator unit is sterilized, and new leads are placed with relocation of the pocket. The old leads are then removed. This technique has been used safely and with excellent results for the past fourteen years.     

Update on infections involving permanent pacemakers. Characterization and management

From January, 1974, to December, 1983, 75 patients with infections related to permanent pacemakers were successfully treated. Demographic characterization, mode of presentation, types of infecting organisms, potential predisposing factors, significance of a retained infected pacemaker lead, and various medical and surgical treatment methods were analyzed. Likely infecting organisms depended on the mode of presentation and the time of the infection. Dermatologic diseases accounted for a significant number of secondary infections. Removal of the entire infected pacing system was required for eradication of infection in 74 of 75 patients. In 31 patients, the infected system was removed at the same time that the new system was implanted. In 26 patients, a two-stage procedure was used that included a period of temporary pacing between explantation of the old system and implantation of the new. No difference in complications or incidence of reinfection was found between these two groups. Infections occurring within 2 weeks after operation accounted for 15% of the cases. In these patients, Staphylococcus aureus was the most common organism. In patients with later infections, Staphylococcus epidermidis was the most common.     

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.     

Pacemaker dependent patients with device infection—a modified approach

A modified surgical concept for temporary cardiac pacing in pacemaker dependent patients requiring total removal of infected devices is presented. Proximal to the infected pocket a permanent bipolar pacing lead is placed transcutaneously into the ipsilateral subclavian or jugular vein. The lead is placed in the right ventricle and fixed into the skin using the suture sleeve. Pacing is established by connecting an external pacing generator. Subsequently the infected device can be removed completely. After wound dressing the externalized lead is connected to a permanent VVI-pacemaker allowing for prolonged temporary pacing.     

A novel technique for removal of permanent pacemaker leads

We removed from 4 patients pacemaker leads that had migrated or become infected. Case 1: A 62-year-old man developed uncontrollable infection of the pacing leads. Case 2: A 78-year-old man, whose infected pacemaker was removed, had a second one implanted in the contralateral side; the pacing lead infection from the first procedure, however, was uncontrollable. Case 3: A 56-year-old woman presented with dyspnea and hepatomegaly subsequent to the second implantation of a pacemaker; the pacing leads from the first procedure caused severe stenosis in both the superior and inferior vena cavae. Case 4: A 60-year-old woman had a ruptured and migrated pacing lead in the right ventricle. We operated using a cardiopulmonary bypass and a specially designed plastic tube for removal of the leads. Although Case 2 required reconstruction of the vena cavae, all patients recovered. When removal of pacing leads is necessary, it should be done as soon as possible with cardiopulmonary bypass.     

Laser-assist during extraction of chronically implanted pacemaker and defibrillator leads

Background. Extraction of chronically implanted pacing and defibrillator leads has historically been difficult, occasionally requiring open surgical procedures. The purpose of this study was to evaluate the efficacy, safety, and potential need for percutaneous laser-assisted sheath techniques for extraction of chronically implanted leads.

Methods. From January 1999 to August 2001, 128 consecutive patients underwent extraction of 229 leads (138 pacing, 91 defibrillator) in the operating room 61 ± 44 (mean ± standard deviation) months after implantation. Common indications included erosion or pocket infection (41%), lead dysfunction (30%), and sepsis (13%).

Results. Laser techniques were used for 56% ± 4% (104 of 186) of long-term (implanted for more than 1 year) leads, compared with only 16% ± 6% (7 of 43) of short-term (implanted for less than 1 year) leads (p < 0.001). For infected leads, laser was used in 53% ± 5% (49 of 92) with erosion or pocket infections, compared with only 3% ± 4% (1 of 29) with sepsis (p < 0.001). Extraction was complete in 88%, near complete (retained tip) in 10%, and incomplete in 2%. Two patients required a later percutaneous femoral venous approach to remove mobile retained segments, but no patients required cardiac surgery for extraction. Complications included sternotomy for subclavian vein injury (1), chest tube for caval perforation (1), innominate vein thrombosis (1), and partial clavicle removal for subclavian vein repair (2). There were no procedure-related deaths.

Conclusions. Laser-assisted lead extraction is safe, but it is best performed in the operating room; it should be available for long-term leads, except when they are grossly infected, producing sepsis. Laser techniques have essentially eliminated the need for open surgical removal of retained leads.     

Removal of infected pacemaker leads using lead removal kit (Cook Pacemaker Corporation)]

A new technique for effective removal of chronic transvenous pacemaker lead was developed to address the need for explantation of eroded and infected lead (Lead Removal Kit, Cook Pacemaker Corporation). This Kit consists of a stylet for locking at the distal tip of the lead and a sheath for separating adhering fibrous tissue. Successful removal of 3 leads in 2 patients using this kit was reported.     

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.     

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.     

An inordinate elevation in pacing threshold after myocardial electrode implantation

An inordinate elevation in pacing threshold beyond a maximal output of the pulse generator was observed in 4 patients during the acute interval following permanent pacemaker implantation using a myocardial electrode. Pacemaker implantation was performed in these patients (9 months, 11 months, 5 years and 32 years of age) for the treatment of brady-arrhythmias (complete A-V block or atrial fibrillation) developed following open heart surgery. In two infants, hypopotassemia caused transient pacing failure due to an increase in threshold over 5 volt. In other two patients, threshold increased to levels more than 10 volt within 36 and 12 days probably due to unsuitable pacing site, and then the pulse generators were removed. It is important to measure threshold periodically after permanent pacemaker implantation and to consider the possibility of an inordinate elevation in threshold.     

Salvage of exposed implantable cardiac electrical devices and lead systems with pocket change and local flap coverage

Erosion and exposure of pacemaker (PPM) and implantable cardiac defibrillator (ICD) devices are potentially dire complications, which have classically required the removal of the entire generator and lead systems. This study evaluates a series of cases wherein debridement, irrigation, pocket change, and local flap coverage were used for the successful salvage of indwelling leads after exposure and infection of implantable cardiac defibrillator devices. Patients with skin erosion, infection, and/or exposure of prepectoral infraclavicular cardiac defibrillator devices were treated over a 23-month period between June 2004 and April 2006. The surgical technique involved wide excision of the exposure site with a rhombic incision pattern, followed by removal of the generator unit and complete debridement of the peridevice capsule. Subclavian atrioventricular (AV) leads were preserved. The pocket was irrigated with antibiotic solution. A new pocket plane was selected and developed, and a new generator unit was implanted. A rhombic flap was developed and transposed to achieve tension-free closure over closed suction drains. Data were reviewed retrospectively. Six patients were treated, all male, mean age 66 years (range, 50 to 83 years). All patients presented with "new" exposure of the implantable generator within 48 hours. None demonstrated gross purulence, sepsis, or endocarditis. Initial gram stain was negative for bacteria in all cases, 1 (17%) grew sensitive Staphylococcus epidermidis species. Mean follow-up is 22 months (range, 8 to 31 months). One patient (17%) developed a hematoma, successfully treated by aspiration. Five patients (83%) were treated successfully, with no wound dehiscence, generator or lead exposure, or recurrence of infection. One patient (17%) developed drainage and exposure at a separate site (AV lead) at 10 months postoperative and required generator and lead explantation and site change to the contralateral anterior chest wall. In conclusion, in the absence of sepsis or gross infection, skin excision, pocket change, generator change with lead preservation, closed-suction drainage, and flap coverage for tension-free closure should be considered in the treatment of early ICD and PPM exposure.     

New site for pacemaker generators in children

Bipolar pacemaker implantation was performed in three children, aged 5, 6 and 9 years. The two epimyocardial fishhook pacing electrodes were inserted through different incisions. After resection of the anterior part of the 5th and 6th rib, the generator was placed into a pocket with the posterior wall resulting from the remaining periostium/perichondrium and the anterior wall consisting of the isolated intercostal and pectoral muscle. The leads were brought in extrapleurally and connected to the generator. The operations were conducted without perioperative and late postoperative complications.     

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.     

Arteriovenous dialysis access-associated transvenous pacemaker infection

Pacemaker (PM), implantable cardioverter defibrillator and cardiac resynchronization therapy devices also provide support to chronic hemodialysis patients with cardiac rhythm abnormalities. However, these devices can get infected. In general, device infection is either primary or metastatic spread from a distant source. Arteriovenous grafts are commonly used to provide dialysis therapy. Compared to a fistula an arteriovenous graft runs a higher risk of infection. In this analysis, we report 2 chronic hemodialysis patients who have been successfully receiving dialysis through an arteriovenous graft for approximately 2 years. Both had had a PM device for about the same duration. Access infection necessitated surgical removal of the arteriovenous graft in these patients. However, due to bacteremia (methicillin-resistant Staphylococcal aureus (MRSA)), infection spread to involve the transvenous PM leads in both patients. In 1 patient the infection also involved the PM pocket. Lead and wound culture confirmed MRSA in both patients. PM device and leads were removed in both patients. After the resolution of bacteremia, both patients received an epicardial pacemaker. None of the patients had valvular endocarditis. While dialysis was provided with a catheter, an arteriovenous fistula was planned. In conclusion, contamination of the transvenous PM device can occur due to hematogenous spread of infection from an infected arteriovenous graft. Epicardial instead of a transvenous PM might be the better option for such patients to provide long-term cardiac rhythm support.     

Management of Infected Implantable Cardiac Defibrillators

Background. The implantable cardiac defibrillator (ICD) was introduced clinically in 1980 for the management of ventricular arrhythmias.

Methods. From January 31, 1989, through May 29, 1996, 329 ICD devices were implanted at Allegheny University Hospital, Hahnemann Division, Philadelphia, Pennsylvania. All device-related infections were examined.

Results. Fifteen patients (5%) experienced infection of the generator component of the ICD. There were 14 male and 1 female patients with a mean age of 62 years (range, 38 to 79 years). All infections involved the generator with or without other component involvement. Complete removal of the system was performed in 7 patients, partial removal in 5, and the entire system was left intact in 3. In 4 patients (27%), further procedures were performed to remove additional infection. Three patients (20%) died during the hospital stay.

Conclusions. Infection of ICD devices is a devastating event. We favor complete removal of the ICD generator and all the components when possible. Partial removal of the ICD unit (ie, generator only) is reserved for patients in whom the risk of complete removal is too high and infection is confined to the generator only.     

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.     

Vesical pacing in patients with overactive bladder: technique and results

OBJECTIVES: A recent study has demonstrated that the electric activity of the overactive bladder (OAB) is 'dysrhythmic'. The cause was attributed to a disordered vesical pacemaker which discharges these waves. In a subsequent study, the dysrhythmic waves have been 'normalized' by vesical pacing and the optimal parameters which are required to achieve normalization have been defined. We investigated the hypothesis that vesical pacing of the OAB might improve not only the vesical electric activity but also the symptoms. METHODS: Vesical pacing was used in 9 patients (age 39.2 +/- 10.3; 5 women, 4 men) with OAB. Under anesthesia, the pacemaker was implanted in an inguinal subcutaneous pocket and connected to 2 pacing electrodes implanted into the vesical vault. The normalization of the waves was tested by 2 recording electrodes which were temporarily applied to the vesical wall and removed post-testing. The pacemaker was then programmed for home pacing to be activated at given times. RESULTS: Vesical pacing effected normalization of the dysrhythmic electric waves with disappearance of the OAB symptoms in 7 patients and failed in 2. Vesical pacing was abandoned in 3/7 patients after a few months following the spontaneous disappearance of the symptoms. CONCLUSIONS: Vesical pacing has normalized the dysrhythmic electric activity and suppressed the symptoms of the OAB in 77.7% of patients. The pacemaker was removed in 5 patients: 2 failures and 3 after spontaneous waves normalization. No complications were encountered. Vesical pacing is suggested as a treatment for OAB when commonly used therapeutic modalities have failed.     

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.     

Wound Complications and Treatment of the Infected Implantable Cardioverter Defibrillator Generator

A bstract Since 1980, the automatic implantable cardioverter defibrillator (ICD) has evolved as effective therapy for prevention of sudden cardiac death following documented sustained ventricular tachycardia or fibrillation. During a 5-year period, 412 ICD devices were implanted at the University of Michigan Hospitals with a wound complication rate of 4.1%. In this group, there were 13 infections, 3 erosions of the generator pocket, and 1 wound hematoma. Of the 16 patients with infection or erosion, 12 patients were treated with a rectus abdominis muscle flap closure and 4 with ICD generator removal. In 83% (n = 12) of the muscle flap patients, the wound healed uneventfully. Preoperative chest CT scanning was found to be helpful in identifying probable infection of the epicardial leads. In these cases, all hardware had to be removed to achieve resolution of the infection. We concluded that rectus abdominis muscle flaps were helpful in salvaging infected or exposed ICD generators in the absence of infected epicardial leads.