Introduction
The use of cardiac implantable electronic devices (CIED) has been an essential and indispensable therapy option for patients with symptomatic cardiac arrhythmias or a high risk of sudden cardiac death (SCD) for over 60 years. Unfortunately, for most patients, the initial implantation of such a device implicates repeated revision procedures. Ideally, these should be limited to only pulse generator-replacement due to battery depletion. However, additional revision or correction surgeries do occur, originating in technical problems of the implanted systems or in infections. The predominant local infections are pocket infections, which often occur shortly after a device replacement, or those caused by percutaneous perforation of pulse generator or electrode components (1-3). Aside from local symptoms, like pain, swelling and tenderness, these infections pose a high risk for systemic seeding into the bloodstream. The transmission of the infection along the implanted electrodes is particularly feared, as it can lead to life-threatening endocarditis, which can be fatal in 35% of cases if left untreated (4,5). A similar vital threat can also arise from a primary hematogenous bacteremia with superinfection of the implanted device components. Biofilm-forming bacteria such as staphylococci, streptococci or pseudomonas are especially feared in this context (6). This often leads to septic vegetations on the intravascular parts of the leads, which can, on one hand trigger septic emboli and serve as a retreat for bacteria under a protective layer of biofilm during antibiotic therapy on the other. For these reasons, the timely and aggressive treatment of intracardiac infections is essential, as cardiac structures such as heart valves or myocardial tissue can be irreversibly destroyed if left untreated. Based on these findings, international and national professional societies recommend prompt and complete removal of intracardiac devices with a Class I recommendation in cases of proven infections. (11-15).
However, a CIED cannot always be easily removed. In addition to technical and anatomical imponderabilities, the further strategy must be carefully evaluated and planned, especially in pacemaker-dependent patients (16,17). In addition, there is still no uniform recommendation among experts regarding the timing of the re-implantation of a necessary system (12-19). Therefore, various approaches arise in clinical practice, which can be reduced to three established variants: The first and most commonly performed treatment option is system re-implantation after complete system removal (SR) with a time delay of 4-6 weeks under antibiotic therapy and after exclusion of an ongoing infection (18,19). This strategy is limited by the requirement of an adequate intrinsic cardiac rhythm. In case of pacemaker dependency, as a second option, simultaneous implantation of an epicardial pacing lead through an additional left lateral thoracotomy (system removal and implantation of an epicardial pacing lead - EL) can be performed during removal of the infected system. This is then connected to a subcutaneously implanted ”sacrificial pacemaker” and ensures continued stimulation (18). Alternatively, temporary percutaneous transvenous “sacrificial electrodes” can also be placed (18,19). In both cases, implantation of a definitive system is performed in a second scheduled procedure after successful antibiotic therapy (18,19). The third and final therapeutic option is a simultaneous implantation of a permanent system from the contralateral side after removal of the infected system (System removal and contralateral implantation of a new device - SI). Thus, uninterrupted full device therapy is possible - but with the remaining risk of re-infection, for example, via contact infections or continued hematogenous bacterial dissemination.
The decision for one of the described procedures is usually based on the clinical experience of the treating physicians, as there are no comparative studies or follow-up data on the outcome of these procedures in the currently available literature (13,19). For this reason, we retrospectively analyzed all patients treated in our hospital between 2013 and 2019 who received a CIED removal/extraction due to device infection. We searched for differences in the pre-existing conditions of the patient groups in a retrospective analysis of the treatment pathways in order to evaluate the clinical decisions made. We further analyzed whether peri- and postoperative differences in the treatment courses during the hospital stay could be shown. Finally, we investigated the one-year follow-up data of the 3 treatment strategies, in order to compare possible outcome differences between the treatment pathways.