Diagnosis and management of subcutaneous implantable cardioverter-defibrillator infections based on process mapping

Abstract

Background: Infection is a well-recognized complication of cardiovascular implantable electronic device (CIED) implantation, including the more recently available subcutaneous implantable cardioverter-defibrillator (S-ICD). Although the AHA/ACC/HRS guidelines include recommendations for S-ICD use, currently there are no clinical trial data that address the diagnosis and management of S-ICD infections. Therefore, an expert panel was convened to develop consensus on these topics.

Methods: A process mapping methodology was used to achieve a primary goal - the development of consensus on the diagnosis and management of S-ICD infections. Two face-to-face meetings of panel experts were conducted to recommend useful information to clinicians in individual patient management of S-ICD infections.

Results: Panel consensus of a stepwise approach in the diagnosis and management was developed to provide guidance in individual patient management.

Conclusion: Achieving expert panel consensus by process mapping methodology in S-ICD infection diagnosis and management was attainable, and the results should be helpful in individual patient management.

Keywords: antibiotics; diagnosis; extraction; infection; mapping; subcutaneous implantable cardioverter-defibrillator.

FIGURE 1

Process map for diagnosing and managing an early S‐ICD infection. The steps in diagnosing and managing a possible infection of an implanted S‐ICD are delineated, along with suggestions and quotes from the physician panel during the mapping process. Abbreviations: ABX, antibiotics; CBC, complete blood count; CIED, cardiovascular implantable electronic device; S‐ICD, subcutaneous implantable cardioverter defibrillator; TV‐ICD, transvenous implantable cardioverter defibrillator

FIGURE 2

Examples of infection and non‐infection reactions at S‐ICD implant sites. A, Noninfection localized skin reaction at 5 days post‐implant. B, Same site as in (A) at 14 days. (Photo credit: George Mark, MD, FACC, FHRS, Cooper University Hospital). C, Pocket infection. 36‐year‐old woman with congenital heart disease two weeks postimplant. The superficial infection resolved with oral antibiotics without the need for device removal. (Photo credit: Bridget Loftus, RN, Northwestern Memorial Hospital). D, Pocket infection. 56‐year‐old woman with morbid obesity and heart failure fifteen days postimplant. There were no systemic symptoms. The infection resolved, and the incision healed with local wound care measures without the need for antibiotic therapy or device removal. (Photo credit: Jeremiah Wasserlauf, MD, MS, Northwestern Memorial Hospital). E, Wound dehiscence with negative blood culture and positive wound culture for methicillin‐susceptible Staphylococcus aureus; device explanted four months after implant. Prior TV‐ICD infection with bacteremia and endocarditis followed by device explantation 2 years prior to S‐ICD implant. (Photo credit: Marc A. Miller, MD, Icahn School of Medicine at Mount Sinai)