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.