Process mapping strategies to prevent subcutaneous implantable cardioverter-defibrillator infections

Abstract

Background: Infection remains a major complication of cardiac implantable electronic devices and can lead to significant morbidity and mortality. Implantable devices that avoid transvenous leads, such as the subcutaneous implantable cardioverter-defibrillator (S-ICD), can reduce the risk of serious infection-related complications, such as bloodstream infection and infective endocarditis. While the 2017 AHA/ACC/HRS guidelines include recommendations for S-ICD use for patients at high risk of infection, currently, there are no clinical trial data that address best practices for the prevention of S-ICD infections. Therefore, an expert panel was convened to develop a consensus on these topics.

Methods: An expert process mapping methodology was used to achieve consensus on the appropriate steps to minimize or prevent S-ICD infections. Two face-to-face meetings of high-volume S-ICD implanters and an infectious diseases specialist, with expertise in cardiovascular implantable electronic device infections, were conducted to develop consensus on useful strategies pre-, peri-, and postimplant to reduce S-ICD infection risk.

Results: Expert panel consensus on recommended steps for patient preparation, S-ICD implantation, and postoperative management was developed to provide guidance in individual patient management.

Conclusion: Achieving expert panel consensus by process mapping methodology for S-ICD infection prevention was attainable, and the results should be helpful to clinicians in adopting interventions to minimize risks of S-ICD infection.

Keywords: antibiotic prophylaxis; antibiotics; defibrillator; infection; mapping; prevention; subcutaneous implantable cardioverter-defibrillator; surgical site infection.

Figure 1

Overview of the steps for preventing subcutaneous implantable cardioverter‐defibrillator infections

Figure 2

Preoperative techniques: Illustrative example of prepping and draping. (A) Initial preparation with markings of the skin prior to prepping. (B) Skin after preparation with chlorohexidine. (C) Large area of surgical exposure.

Figure 3

Examples of wound closures. (A) Subcutaneous layer closure using 2‐0 vycril. Note the perfect hemostasis. (B) Subcutaneous layer completed (note the borders are well approximated and no tension on the skin. (C) Subcuticular layer closure using 4‐0 sutures.