Risk of venous occlusion after lead laser extraction preventing future lead implantation

Background Lead laser extraction is a well-established method for removing unwanted leads with low morbidity and mortality. Objective In this observational study, we documented our experience with venous occlusion after lead laser extraction. Methods Retrospective data of patients who underwent lead laser extraction between May 2010 and August 2018 was analyzed. Two subgroups of patients were identified. First group represented patients after lead laser extraction who suffered postoperative venous occlusion. Second group represents patients after lead laser extraction, who has documented patent venous access after lead laser extraction. Results 219 patients underwent percutaneous laser lead extraction. The mean age of patients was 65 ± 14 years. Of these patients, 74% were male. The Most common indication for extraction was Nonfunctional lead (45.2%, n = 99) followed by pocket infection with 33.8% and endocarditis (17.3%). A total number of 447 leads underwent laser extraction. In 7.8% of the patients, lead extraction was partially successful and lead extraction was not successful in only 2.3% of the patients. Only 13 patients developed a documented venous occlusion postoperatively and 26 patients has documented absence of venous occlusion, of whom 17 were under oral anticoagulation. Conclusion Lead laser extraction may lead to venous occlusion, which is mostly asymptomatic but it prevents future lead implantation. The use of oral anticoagulant may prevent postoperative venous occlusion.

Severe pacemaker pocket infection during the COVID-19 pandemic, transvenous lead removal

Introduction: The estimated infection rate after permanent endocardial lead implantation is between 1% and 2%. Pacemaker lead endocarditis is treated with total removal of the infected device and proper antibiotics. In this case report, we present a patient with delayed diagnosis and treatment due to the COVID-19 outbreak. Case Report: An 88-year-old, pacemaker dependent woman with diagnosed pacemaker pocket infection was admitted to the University Cardiovascular institute. The patient had a prolonged follow-up time due to the COVID-19 outbreak. She missed her routine checkup and came to her local hospital when the generator had already protruded completely, to the point where she held it in her own hand. Transthoracic echocardiogram showed possible vegetations on the lead. Transesophageal echocardiography was not performed due to the COVID-19 pandemic. On the day after the admission the patient underwent transvenous removal of the pacemaker lead using a 9 French gauge rotational extraction sheathe (Cook Medical). The extracted lead was covered in a thin layer of vegetations. Further follow-ups showed good recovery with no complications. Conclusions: A case showing delayed treatment of pacemaker pocket infection, due to delayed follow-up time during the COVID-19 pandemic. This patient underwent successful transvenous removal of the infected pacemaker lead, along with adequate antibiotic therapy, which has proven to be the most effective method of treating cardiac device-related endocarditis.

Implantable Cardiac Device Infections Prevalence: Diagnostic and Therapeutic Implications

Background: It has been demonstrated that the use of cardiac implanted electronic devices (CIED) improve mortality and survivability in a variety of patient populations. Nevertheless, CIED related infection is a serious complication characterized by a high rate of mortality and morbidity. Objectives: To evaluate the prevalence of CIED related infections, risk factors, clinical and demographic characteristics, causative organisms, and the management and outcome of patients presented in the Critical Care Department, Cairo University. Methods: A retrospective analysis was conducted in 1871 individuals who had been implanted with a cardiac device with a total number of devices of 1968 and 2270 procedures performed from January 2007 to December 2017. Results: 59 infectious episodes were identified with an estimated incidence of 2.99% of inserted devices and 2.6% of total procedures. The infection rate was considerably higher in patients with multiple procedures than those who had a single procedure (9.27% vs. 1.18%; P<0.001). The individuals with a dual-chamber implantable cardiac defibrillator (ICD) and cardiac resynchronization therapy devices (CRTD) had the highest infection rate of 6.25% & 6.85%, respectively. The rate of pocket infection (PI) and CIED related endocarditis (CDE) was 1.54% & 1.06% of total devices respectively. Numerous risk factors have been found; the most significant of those are diabetes mellitus, recurrent procedures, the device's complexity, and the existence of more than one lead. Gram-positive cocci were the most isolated organisms in all positive cultures (69.23%). Echocardiography revealed lead vegetations and valvular vegetations in 22 patients and 2 patients respectively. In 53 cases (89.83%), the devices were removed; in 41 cases, the entire system was removed; and in 12 cases, only the generator was removed. The mortality rate was found to be 10.17%, having a considerably higher prevalence in CDE individuals than in pocket infection individuals (20.83% vs. 2.86%; P=0.025). Conclusion: In our center, while the rate of CIED implantation continues to increase, the incidence rate of CIED-related infection continues to decline. Until now, the infection burden associated with secondary intervention is still significantly high. The management strategy of selection is to eliminate the entire system for patients presented with infection especially those with CDE. However, the mortality rate is still high.

Cardiac Implantable Electronic Device Infections; Long-Term Outcome after Extraction and Antibiotic Treatment

Background: The aim of the study was to examine the treatment outcome for patients with cardiovascular implantable electronic device (CIED) infections after extraction. Methods: Patients who underwent CIED extractions due to an infection at Karolinska University Hospital 2006–2015 were analyzed. Results: In total, 165 patients were reviewed, 104 (63%) with pocket infection and 61 (37%) with systemic infection. Of the patients with systemic infection, 34 and 25 patients fulfilled the criteria for definite and possible endocarditis, respectively. Complications after extraction occurred only in one patient. Reimplantation was made after a mean of 9.5 days and performed in 81% of those with pocket infection and 44.3% in systemic infection. Infection with the new device occurred in 4.6%. The mean length of hospital stay for patients with pocket infection was 5.7 days, compared to 38.6 days in systemic infection. One-year mortality was 7.7% and 22.2% in pocket infection and systemic infection, respectively. Patients with Staphylococcus aureus infection had a higher mortality. Conclusions: In this study, the majority of the patients had a pocket CIED infection, with a short hospital stay. Patients with a systemic infection, and S. aureus etiology, had a prolonged hospital stay and a higher mortality.

Infections of Port Access Catheters in Children

Background: The most important complication of port access catheters (PAC) compared to peripheral lines is a higher incidence of infections. Objectives: This study investigated the frequency of catheter infection and related factors in Dr. Sheikh Children Hospital (SCH). Methods: This is a retrospective descriptive study at Sheikh children’s hospital, Mashhad, Iran. The data of children with an operation for PAC surgery were gathered from hospital files and completed by calling the parents. The definition of PAC infection was based on clinical signs of catheter infection and any positive blood culture (peripheral or catheter sample) or the resolution of signs of infection after the extraction of the catheter in the absence of positive blood cultures. Results: During six years, 70 children received PAC, all of whom (except five) were followed by telephone calls. Forty percent of them were younger than two years, and 71.4% had malignant disease. Catheter infection occurred in 16 (22.8%) cases. Signs of catheter infection were fever and cellulitis over the port in nine (56%) cases (pocket infection), chills and fever during catheter usage (without port infection) in six (37.5%) cases, and persistent fever in one patient (6.2%). Blood culture was positive in 75% (12 cases) of catheter infections, and the responsible organisms were Gram-negative bacilli (five cases), Coagulase-negative staphylococci (three cases), Candida (three cases), and group B streptococci (GBS). The success rate for “medical therapy per se” was 68% in catheter infections. The catheter was removed in 22 (31.4%) patients, which was due to infection in half of them. The mean time to removal was 15.3 months. Conclusions: The incidence of catheter infection, especially pocket infection, is high in this population, which necessities revision in all procedures of catheter implantation and care.

Incidence of pocket infection during long- term follow- up

Funding Acknowledgements Type of funding sources: None. Introduction Cardiac implantable electronic devices (CIEDs) are being implanted worldwide in increasing numbers, so the incidence of hospitalizations due to their infections is also increasing. Purpose The aim of this study was to analyze the incidence of pocket infection related to the CIED procedure, as well as clinical presentation, diagnostic approach and methods of treatment during long-term follow- up on large cohort of patients. Methods: This was a retrospective, observational, single-center study. We enrolled patients who underwent CIED procedure between January 2011 and December 2015. The CIED procedure included implantation and replacement of the device. Pocket infection is defined as an infection limited to the generator pocket and can be presented from redness, swelling, pain to the skin erosion with exposure of the generator and/or leads. It may also be associated with lead infections and systemic CIED infections and/or infective endocarditis. All patients with CIED infection underwent the same diagnostics: complete blood count and inflammatory markers, pocket swab, three sets of blood cultures and echocardiography. Results: During the observed period 5 969 CIED procedures were performed (anti-bradycardia pacemakers 68.6%; ICD 21.4%; CRT-P/D 10.0%; CIED replacement 26.1%). CIED infection was registered in 41 patients (0.68%), most often after the ICD procedure (59.0%). In 22 patients (53.6%) the infection occurred after primo-implantation. The average time from intervention to infection was 17 ± 7.3 months. The mean follow-up was 52.2 ± 13.4 months. The most common manifestations of infection were redness (68.1%) and swelling (56.0%), then the protrusion of the generator or electrode (41.5%). Pacemaker pocket swabs and wound swabs were positive in 61.1% of samples and coagulase negative staphylococcus was found to be the most prevalent cause of infection (64.2%). The hemoculture test was positive in 10 patients, and the isolated causative agent matched the swab finding. The valvular vegetation was found in 4 patients. Pacemaker removal and surgical wound treatment were performed in all patients. Complete removal of all leads was achieved in 32 patients. In all pacemaker dependent patients and patients with ICD implanted in the secondary prevention of sudden cardiac death, reimplantation of the new device was performed in the same hospitalization on the opposite side. The remaining patients were operated on 3 to 4 weeks after the end of treatment. Conclusions: It has been shown that the risk of pocket infection was low in a large number of patients, during long-term follow-up. The risk was higher in patients with ICD devices, and slightly higher after primo-implantation.