The clinical presentation of patients
The clinical presentation of patients with CIED pocket infection and those with endovascular infection can vary, but once the diagnosis is made, the management is similar and involves removal of all hardware along with antibiotic therapy [2,7,8,15]. Conservative managements with T-5224 therapy only carries high failure rate and is associated with increased mortality . Removal of the pulse generator and capping the leads should not be performed as the relapse rate of the retained leads is high . CIED removal could be done percutaneously or surgically. Percutaneous extraction has evolved significantly over the years and currently is the method of choice for CIED removal. These procedures are usually safe but could be associated with significant risks including vascular or cardiac perforation leading to major bleeding or tamponade, hemothorax, pulmonary embolism and death . Therefore they should be performed in centers that can provide the clinical skills, expertise, the appropriate equipment, and readily available surgical back up in case of complications. Surgical extraction is usually reserved for patients who already failed percutaneous extraction, or with retained leads not amenable to percutaneous extraction, patients with evidence of valve involvement with endocarditis that requires surgical intervention, presence of infected epicardial leads, or evidence of large vegetations over 2cm in size. Recent data suggest that percutaneous extraction could be done safely even in the presence of vegetations larger than 2cm, however, these cases should be evaluated individually on a case-by-case basis. Many factors other than the vegetation size play a role in the decision-making process including the general condition of the patient, comorbidities, involvement of the tricuspid valve, and the need and timing for reimplanting the CIED. For example, the patient who is pacemaker-dependent with evidence of endovascular infection and intracardiac vegetations represent a clinical dilemma as there will not be a period of “hardware free” to allow the infection to resolve prior to reimplant. These patients could be managed surgically with CIED removal and debridement of the valve and temporary epicardial lead placement to provide pacing followed by endovascular reimplant of a new device, or they can undergo percutaneous removal of CIED and implantation of endovascular temporary pacing lead, followed by surgical implantation of permanent epicardial leads. Extraction strategy should always take into account reimplant strategy and often requires team approach that includes the electrophysiologist, the infectious disease specialist, and the surgeon. While surgical approach could be successful in removing the leads, often times this could not be accomplished due to extensive fibrosis. Cutting both sides of the lead and leaving a remnant of an infected lead should be avoided. These remnants could cause recurrent infection and their extraction can represent a major technical challenge. Therefore these cases require collaboration. If the leads are cut distally at time of surgery, it is important to maintain the proximal portion of the lead in order to perform percutaneous removal of the remnant. Patients with Biventricular pacemakers or defibrillators represent an added challenge when they develop an infection. Upon the removal of the infected device, their hemodynamics can be affected negatively and therefore the operator should anticipate these negative hemodynamic effects and be ready to manage them. These patients require close observation sometimes in intensive care units and often require hemodynamic support medically or using intra-aortic balloon pumps if needed. Whether performed percutaneously or surgically, complete removal of all hardware is critical to effectively treat the infection. Complete removal and debridement of the fibrous scar and necrotic tissue in the device pocket should be performed with minimal disruption of the healthy fat, skin or muscle tissue. Samples of the pocket tissue and lead tips should be sent for gram stain and cultures.