Treatment of Infected Cardiac Implantable Electronic Devices

Abstract

With their rising benefits, cardiac implantable electronic devices (CIEDs) such as pacemakers and left ventricular assist devices (LVADs) have witnessed a sharp rise in use over the past 50 years. As indications for use broaden, so too does their widespread employment with its attendant rise of CIED infections. Such large numbers of infections have inspired various algorithms mandating treatment. Early diagnosis of inciting organisms is crucial to tailoring appropriate antibiotic and or antifungal treatment. In addition, surgical debridement and explant of the device have been a longstanding modality of care. More novel therapies focus on salvage of the device by way of serial washouts and instilling drug-eluting antibiotic impregnated beads into the wound. The wound is then serially debrided until clean and closed. This technique is better suited to patients whose device cannot be removed, patients who are poor candidates for cardiac surgery, or patients who have failed conventional prior treatments.

Keywords: antibiotic beads; cardiac implantable electronic devices; infection; left ventricular devices; salvage therapy.

Fig. 1

An 82-year-old man with an exposed pacemaker with necrotic skin.

Fig. 2

(A) A 46-year-old woman with a hematoma. (B) Evacuation of hematoma and changing of generator. (C) Four months postoperative.

Fig. 3

The microbiology of pacemaker infections.

Fig. 4

Algorithm used for treatment of all patients. Repeated débridement and bead exchange were typically performed every 1 to 2 weeks until results of surgical-site cultures were negative or until other definitive endpoints were reached (i.e., device removal, transplantation, or death).

Fig. 5

(A–C) Patient undergoing coverage of salvaged left ventricular assist devices (LVAD) drive line using the anterior rectus sheath. (D, E) Placement of antibiotic beads for salvage of LVAD.