Ann Thorac Surg 1995;60:704-706
© 1995 The Society of Thoracic Surgeons
Case Report
Importance of Complete System Removal of Infected Cardioverter-Defibrillators
David H. Mull, MD,
Michael A. Wait, MD,
Richard L. Page, MD,
Michael E. Jessen, MD
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, and Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
Accepted for publication March 17, 1995.
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Abstract
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We describe a case of device infection after implantable cardioverter-defibrillator implantation managed by removal of all hardware except a portion of the epicardial sensing electrodes. Recurrent septic complications developed until all residual foreign material was eliminated. Despite anecdotal reports of successful management without device removal, extraction of all hardware components should be considered standard treatment for this complication.
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Introduction
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Device infection is an infrequent but serious complication of implantable cardioverter-defibrillator (ICD) therapy. Conventional management of infection involving a foreign body dictates removal of the foreign material to achieve resolution. However, a large proportion of patients receiving ICDs have severe cardiac dysfunction, multiple medical problems, and extensive prior cardiac surgical procedures, creating a reluctance to remove all hardware when a generator pocket infection occurs. The problem is compounded by the fact that simultaneous involvement of the lead system may be difficult to identify. Several reports have described successful management of device infections where part (or all) of the ICD was left in place [1, 2]. We report a case of device infection that manifested initially as purulence in the generator pocket. The entire device except for a portion of the sensing electrodes was removed, but recurrent septic complications developed and were not eradicated until all foreign material was eliminated.
A 65-year-old man with syncope, episodes of sustained monomorphic ventricular tachycardia, and left main coronary artery disease underwent coronary artery bypass grafting and implantation of an ICD system consisting of two epicardial sensing electrodes in the right ventricular outflow tract, two epicardial patches over the posterolateral left ventricle and right ventricular free wall, and a PCD (Medtronic Inc, Minneapolis, MN) generator in a left abdominal pocket. His postoperative course was complicated by Pseudomonas pneumonia. He recovered and was discharged home. Successful pace-termination of multiple episodes of ventricular tachycardia was documented by postoperative device interrogation.
He returned to the hospital 2 months and again 3 months after operation with fever, malaise, and leukocytosis, and was treated with antibiotics with improvement. He returned again 4 months postoperatively with fever and leukocytosis but no overt signs of wound infection. A gallium scan revealed increased uptake over the generator pocket, with evidence of activity in areas consistent with the patch electrodes (Fig 1
). He subsequently underwent removal of the infected generator, which grew Staphylococcus aureus. At the same time a redo median sternotomy was made with a T extension through the left fifth intercostal space and both epicardial patches were noted to be involved with purulence and were removed. Sensing electrodes were deeply embedded in the heart and were cut off several centimeters from the electrode tips. Because of sternal contamination, all wounds were packed and managed with topical measures for 11 days. He was then returned to operation for debridement, resection of a portion of the inferior sternum, and delayed sternal closure. A random fasciocutaneous flap closed the resection site defect. After 6 weeks of parenteral antibiotics, a new ICD system consisting of an Endotak (Cardiac Pacemakers Inc, St. Paul MN) lead via the left subclavian vein and Cadence (Ventritex, Sunnyvale, CA) generator in a right abdominal pocket was implanted. He was discharged home 6 days later.
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Fig 1. . Gallium scan image obtained 24 hours after intravenous injection of 6 mCi of gallium-67 citrate. This study, performed 4 months after cardioverter-defibrillator implantation, revealed increased uptake over the site of the generator pocket, with additional activity seen near sites of patches or sensing leads.
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At a clinic follow-up 14 months after wound closure, he was noted to have a draining sinus at one margin of his thoracotomy wound. He returned to the operating room where, under fluoroscopy, a sterile probe was passed up the sinus tract, which was found to communicate with the residual sensing electrodes (Fig 2). He then underwent focal sternectomy; the remaining lead fragments were unscrewed from the epicardium, and all residual hardware (of the original system) was removed. The wound was closed primarily and the transvenous device was not removed. After completing a course of antibiotics he was discharged home and remains well with no evidence of local, systemic, or device infection at 6-month follow-up.
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Fig 2. . Anteroposterior chest roentgenogram obtained 14 months after epicardial device removal demonstrating the site of a draining sinus (single arrow), which communicated with the remaining portions of the epicardial sensing electrodes (double arrows).
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Comment
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Implantable cardioverter-defibrillator implantation has become a common procedure, with more than 50,000 devices placed since 1980. Although infection rates as high as 20% have been reported [3], most large series describe an incidence of infection of about 2% [1, 4, 5]. Although many cases are obvious, clinical presentation can be subtle. In these situations, imaging studies such as gallium scans [6] or computed tomography [7] may be helpful. As in this case, the gallium scan may also suggest infection on the sensing electrodes or patches, a finding that may be missed with indium-111 leukocyte scans [8].
The present case also illustrates the importance of complete removal of all components when the diagnosis of infection is made. Even relatively small portions of retained epicardial sensing electrodes led to persistent problems over an 18-month period. Apparent successful management of device infection has been reported with local irrigation only [2] or with removal of the generator only [1]. However, many patients with less-than-complete extraction have required subsequent operative removal [5] or have died with evidence of undrained purulence in the patch components [8]. With the proliferation of nonthoracotomy devices, endocardial lead extraction may also be advisable, although in our patient no communicating infection with the transvenous ICD was identified and this device was retained. At present, complete removal of all components represents the preferred strategy for management of infected cardioverter-defibrillators.
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Footnotes
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Address reprint requests to Dr Jessen, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 75235-8879.
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References
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- Siclari F, Klein H, Troster HJ, Borst HG. Infectious complications after AICD implantation [Abstract]. PACE 1990;13:547.
- Taylor RL, Cohen DJ, Widman LE, Chilton RJ, O'Rourke RA. Infection of an implantable cardioverter defibrillator: management without removal of the device in selected cases. PACE 1990;13:1352–5.[Medline]
- Barbola J, Denes P, Ezri MD, Hauser RG, Serry C, Goldin MD. The automatic implantable cardioverter defibrillator. Clinical experience, complications and follow-up in 25 patients. Arch Intern Med 1988;148:70–6.[Abstract/Free Full Text]
- Winkle RA, Mead RH, Ruder MA, et al. Long-term outcome with the automatic implantable cardioverter-defibrillator. J Am Coll Cardiol 1989;13:1353–61.[Abstract]
- Wunderly D, Maloney J, Edel T, McHenry M, McCarthy PM. Infections in implantable cardioverter defibrillator patients. PACE 1990;13:1360–4.[Medline]
- Kelly PA, Wallace S, Tucker B, et al. Postoperative infection with the automatic implantable cardioverter defibrillator: clinical presentation and use of the gallium scan in diagnosis. PACE 1988;11:1220–5.[Medline]
- Almassi GH, Olinger GN, Troup PJ, Chapman PD, Goodman LR. Delayed infection of the automatic implantable cardioverter-defibrillator. Current recognition and management. J Thorac Cardiovasc Surg 1988;95:908–11.[Abstract]
- Bakker PFA, Hauer RNW, Wever EFD. Infections involving implanted cardioverter defibrillator devices. PACE 1992;15:654–8.
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Abstract
Introduction
