Early Versus Delayed Lead Extraction in Patients With Infected Cardiovascular Implantable Electronic Devices

Introduction: Infection of cardiovascular-implantable electronic devices (CIED) is a serious complication. Systemic antibiotic therapy is considered ineffective, justifying the current guidelines proposing total CEID and lead extraction. Objective: To evaluate the safety and efficacy of continuous in-situ-targeted, ultra-high concentration of antibiotics (CITA) in CIED infections limited to the subcutaneous pocket. Methods: Infected CIED were treated with CITA, delivered to the CIED pocket following minimally invasive surgery (MIS). The CIED were submerged in a 10 2 -10 3 minimal inhibition concentration (MIC) solution of vancomycin and/or gentamicin as per daily conventional dosing. Serum antibiotic levels were regulated by adjusting the concentration and flow of pocket irrigation. CIED salvage rate was assessed. Results: A total of 937 and 481serum assays of vancomycin and gentamicin, respectively, from 83 infected CIED was evaluated (Figure). Target antibiotic serum levels were obtained at 12-48 hours. Median treatment was 8 days (IQR 5,12). Parallel intravenous (IV) vancomycin treatment was applied in 6 (7%) infections. Vancomycin serum levels exceeded a trough limit of 20μg/ml in 20 (2.1%) assays, of which 19/20 received parallel IV treatment. No peak gentamicin levels were recorded. Gentamicin exceeded trough serum level reaching 2-3μg/ml in 80 (16.6%), reached potentially toxic levels of 3-5μg/ml in 33 (6.9%), and exceeded 5μg/ml in 10 (2.1%) assays. CITA resulted in a 1-year salvage of 71 (86%) CIED. Treatment failed in 12 infections, resulting in 8 uneventful total CIED extractions. The 30-day mortality rate was 2.4%. Conclusions: CITA provided ultra-high pocket antibiotic levels, with its safety confirmed by systemic level assays. CITA combined with MIS enabled salvage of 86% of infected CIED. The CITA-MIS approach may serve as an initial therapeutic option prior to the extraction of locally infected CIED, especially in high-risk patients.

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EFFICACY AND FEASIBILITY OF CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICES LEAD EXTRACTION IN ELDERLY PATIENTS

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(12)60710-4 ◽

2012 ◽

Vol 59 (13) ◽

pp. E709

Author(s):

Michio Nagashima ◽

Yoshimori An ◽

Kenji Ando ◽

Yoshimitsu Soga ◽

Masakiyo Nobuyoshi

Keyword(s):

Elderly Patients ◽

Electronic Devices ◽

Lead Extraction ◽

Cardiovascular Implantable Electronic Devices

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Anesthetic Management of Laser Lead Extraction for Cardiovascular Implantable Electronic Devices

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1177/1089253217728581 ◽

2017 ◽

Vol 21 (4) ◽

pp. 302-311 ◽

Cited By ~ 1

Author(s):

Meena Bhatia ◽

Payam Safavi-Naeini ◽

Mehdi Razavi ◽

Charles D. Collard ◽

Daniel A. Tolpin ◽

...

Keyword(s):

Anesthetic Management ◽

Electronic Devices ◽

Cardiac Resynchronization ◽

Lead Extraction ◽

Lead Removal ◽

Implantable Cardioverter Defibrillators ◽

Cardiovascular Implantable Electronic Devices ◽

Number Of Patients ◽

Cardioverter Defibrillators

Cardiovascular implantable electronic devices (CIEDs) play a significant role in the modern management of cardiovascular disease. CIEDs include implantable pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. These devices improve the quality of life of their recipients and help reduce the incidence of sudden cardiac death. Traditionally, CIEDs have been reliant on the use of transvenous endocardial leads to directly connect with the heart. Over time, these endovascular leads may become endothelialized rendering removal extremely difficult. As the indications for CIEDs expands and with the continuing evolution of these devices, the number of patients requiring explantation for device recall, malfunction, and infection continues to increase. In this manuscript, we review the most common CIEDs, the indications and process of lead removal/device explantation, potential complications associated with the procedure and the anesthetic management of these patients.

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Transvenous Lead Extraction of Cardiac Implantable Electronic Devices Indications, Complications and Outcome: An Egyptian Two Years' Experience

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2019.415 ◽

2019 ◽

Vol 7 (15) ◽

pp. 2447-2451

Author(s):

Ibrahim El-Zoghby ◽

Amr Nawar ◽

Mohamed Soliman ◽

Mahmoud Kenawy ◽

Khaled Hussien ◽

...

Keyword(s):

Electronic Devices ◽

Lead Extraction ◽

Extraction Techniques ◽

Factors Associated ◽

Cardiac Implantable Electronic Devices ◽

Cardiovascular Implantable Electronic Devices ◽

Permanent Pace ◽

Pace Maker ◽

Locking Stylet ◽

Manual Traction

BACKGROUND: The growing needs to extract cardiovascular implantable electronic devices warrants the need to improve the outcome and prevent complications. AIM: This study aims to analyse the findings and identify factors associated with complications of Percutaneous Transvenous Lead Extraction in the Critical Care Department, Cairo University. METHODS: We studied 52 candidates for Percutaneous Transvenous Lead extraction of a Permanent Pace Maker (PPM) regarding extraction indications, comorbidities, device type, complications and outcome. Extraction was first attempted by simple manual traction using regular non-locking stylet and if failed, locking stylet, and evolution dilator sheath were used. RESULTS: We extracted 110 leads with a mean lead age of 4.67 ± 3.6 years. The most common extraction indication was an infection (71.15%). Indications correlated significantly with comorbidities (p = 0.024), the most common being Diabetes Mellitus (40.38%). Simple traction was successful in 31 % of the leads, while 69% were extracted using locking stylet and evolution dilator sheath. The method of lead extraction correlated significantly with lead age (P ≤ 0.001). Complications were significantly higher with extraction by evolution dilator sheaths than by simple traction (P = 0.003) and in older patients (P = 0.008). Complications also correlated significantly with extractions indications (p = 0.012), type of PPM (P = 0.037), number of extracted leads (P = 0.041), and lead age (p= 0.011). CONCLUSION: Among the studied variables, extraction indications particularly infection, was the only preventable factor significantly associated with complications. While focusing on preventable factors, improving, implantation and extraction techniques should also be addressed.

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