Ann Thorac Surg 2005;79:1250-1254
© 2005 The Society of Thoracic Surgeons
Original articles: Cardiovascular
Less-Invasive Surgical Extraction of Problematic or Infected Permanent Transvenous Pacemaker System
Jen-Ping Chang, MDa,
Mien-Cheng Chen, MDb,
G. Bih-Fang Guo, MD, PhDb,
Chiung-Lun Kao, MDc,*
a Department of Thoracic and Cardiovascular Surgery Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
b Department of Cardiology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
c Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
Accepted for publication August 23, 2004.
* Address reprint requests to Dr Kao, Dept of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Chiayi, 6 sec. West, Chia Pu Road, Putzu City, Chiayi Hsien, Taiwan (E-mail: sa11421{at}adm.cgmh.org.tw).
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Abstract
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BACKGROUND: The best management of problematic or infected transvenous permanent pacemaker system is complete surgical or percutaneous intravascular extraction of the pacemaker leads and removal of the generator. We present our experiences in 13 such patients in whom the leads were removed with the less-invasive technique.
METHODS: From 1996 to 2003, 13 patients, from 31 to 83 years of age (mean, 66.9 ± 14.0 years), with problematic or infected transvenous permanent pacemaker systems were referred to our department for surgical treatment. In 6 patients, the original pacemakers were dual-chamber. A subxiphoid pericardiotomy was used as the monitoring port during the ventricular lead extraction. In addition, a right parasternal pericardiotomy through the third intercostal space was used as the monitoring port during the atrial lead extraction.
RESULTS: Pacemaker systems were completely removed in all patients. Three bleeding episodes (23%), including two right atrial tears and one right ventricular rupture, were successfully circumvented through these monitoring ports. Concomitantly, a new epicardial single-chamber device was implanted through the subxiphoid pericardiotomy whenever indicated in 9 patients. All patients recovered and were discharged uneventfully. At a mean follow-up of 24.8 months (range, 1 to 90 months), no recurrent infections were observed.
CONCLUSIONS: A less-invasive technique for explantation of the complete pacemaker system is feasible. This is a reliable method to eradicate infection. Neither cardiopulmonary bypass nor specific intravascular lead extraction devices, such as locking stylets or laser-assisted sheath, are needed.
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Introduction
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The incidence of transvenous pacemaker infection is currently reported to range from 0.02% to 1.5% [1–5]. The generator pocket, the pacing leads, or both may be involved. Eradication of infection associated with pacemakers requires complete removal of the pacemaker system, including the generator and leads [1–5]. Extraction of chronically implanted pacing leads has historically been difficult. Effective tools for percutaneous intravascular extraction of leads have been developed in the past decade, including locking stylets and dilator sheaths, transfemoral snares, retrieval baskets, and the laser-assisted sheath. Although these techniques have achieved fairly stable results, major complications still have been reported [6–8].
Surgical extraction of transvenous permanent pacemaker leads is performed when noninvasive extraction with those intravascular extraction devices is considered to be unsafe or has been unsuccessfully attempted. The traditional surgical approach is by means of a median sternotomy or thoracotomy with inflow occlusion or cardiopulmonary bypass [1–5, 9]. In this report we present our experience with a less-invasive technique for total removal of the infected or problematic transvenous permanent pacemakers, with particular emphasis on the application of the pursestring technique and concomitant new epicardial devices implantation through the monitoring ports.
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Patients and Methods
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Patient Characteristics
Between July 1996 and July 2003, 683 consecutive patients underwent transvenous implantation of a new permanent pacemaker at the Chang Gung Memorial Hospital at Kaohsiung. Seven (1.02%) of the 683 patients and an additional 6 patients who received transvenous pacemaker implantation in other hospitals were referred to our department for treatment of infected or problematic exposed pacemaker systems. There were 10 men and 3 women, ranging in age from 31 to 83 years (mean, 66.9 ± 14 years). Five of the 13 patients were diabetic. Seven patients had pacemakers implanted for complete heart block, 4 patients received units for sick-sinus syndrome, and 2 for heart block of undefined type. Seven patients had been provided with single-chamber pacemakers, and 6 patients had been provided with dual-chamber pacemakers. All the pacemaker leads had been implanted transvenously through the cephalic or subclavian vein, and the pacemaker generators had been positioned above the pectoralis major muscle. The number of previous pacemaker operations, including implantation and revisions, were four in 2 patients, three in 1 patient, two in 2 patients, and one in 8 patients. The average interval between the last pacemaker operation and explantation of the pacemaker system was 39.4 ± 71.4 months (Table 1).
None of the patients showed septic complications, except for fever and mildly elevated white blood cell counts. The presence of significant intracardiac vegetation (>10 mm) on pacemaker leads or tricuspid valve was excluded by deliberative transthoracic or transesophageal echocardiographic examination in all patients. Two patients had infections limited to the pacemaker pocket, and 11 patients had infection of both the pacemaker pocket and the exposed leads with gross purulent discharge. All patients had procedures performed before operation in an attempt either to remove the leads by percutaneous traction or to sterilize the generator pocket site with continuous antibiotic irrigation and repositioning of the exposed pacemaker unit. All patients received at least 2 weeks of parental antibiotics before pacemaker explantation.
Operation
In all patients, both the pacemaker leads and generator were removed regardless of the extent of infection. The manipulation of pacemaker leads and generator were performed at the implantation site by a second surgeon. A longitudinal subxiphoid incision was made, and the pericardium was opened through this incision to expose the diaphragmatic surface of the right ventricle. This incision was used as the monitoring port during ventricular lead extraction. In addition, a right parasternal pericardiotomy through the third intercostal space was used to expose the lateral wall of the right atrium and served as the monitoring port during atrial lead extraction (Fig 1). The sites of the anchored pacemaker lead tips were identified by gentle retraction of the leads, and a pursestring stitch was placed over the related ventricular or atrial wall for management of potential bleeding complication during explantation (Fig 2).
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Fig 1. The longitudinal subxiphoid incision was used as the monitoring port during ventricular lead extraction. An additional right third intercostal transverse parasternal pericardiotomy was used as the monitoring port for atrial lead extraction.
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Fig 2. The site of the anchored pacemaker lead tip (arrowhead) was identified, and a pursestring stitch (arrows) was placed over the related atrial wall for bleeding control during explantation.
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The entire pacing system was explanted transvenously through the original site of implantation by the second surgeon. After removal of the transvenous pacemaker system, the pacemaker pocket was extensively débrided, irrigated, and primarily closed with adequate drainage. Concomitantly, a new epicardial single-chamber device was implanted through the subxiphoid pericardiotomy in 9 patients who preferred to receive a single-stage operation. Two patients received transvenous dual-chamber pacemaker implantation 2 weeks later after complete antibiotic treatment.
Microbiology
In all patients, specimens of infected tissue or swabs from wounds or leads and blood samples were obtained for culture and susceptibility studies. In 8 of the 13 patients, microorganisms were detected. Two patients were infected with Staphylococcus aureus, and Staphylococcus epidermidis, Staphylococcus saprophyticus, Candida albicans, Enterobacter aeruginosa, Propionibacterium acnes, and Pseudomonas aeruginosa were responsible for the infections in the remaining 6 patients.
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Results
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Pacemaker systems were completely removed in all patients. Three bleeding episodes (23%), including two right atrial tears and one right ventricular rupture, were successfully circumvented through these monitoring ports by simply tying the pursestring sutures. No patient had evidence of pulmonary embolism. In 11 patients who still had a pacemaker indication, a new pacing system was implanted (85%). Nine of the 11 patients had new single-chamber epicardial pacemakers implanted concomitantly. The generator pocket was positioned behind the rectus abdominis muscle in these 9 patients. Another 2 patients were provided with temporary epicardial pacemaker support, placed at the time of explantation of the preceding pacing system, and subsequently followed with implantation of the transvenous new dual-chamber systems through the contralateral site after 2 weeks of parenteral antibiotic sterilization.
All patients recovered uneventfully. The follow-up interval ranged from 1 to 90 months (mean, 24.8 ± 27.4 months). One patient (7.7%) without indication for a new pacemaker implantation and infection-free after operation was lost to follow-up at 7 months postoperatively. Two patients (15.4%) died of unrelated causes (hepatoma and renal cell carcinoma) at 21 months and 5 months after operation, respectively. All other patients were alive and free from recurrent infection (Table 2).
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Comment
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Infection, although uncommon, can be the most troublesome of all potential complications after transvenous permanent pacemaker implantation. The incidence of transvenous pacemaker infection is currently reported to range from 0.02% to 1.5% [1–5]. The infection rate at our institute was 1.02% in the 683 transvenous pacemaker implantations during the preceding 7 years. The infection may be limited to the generator pocket and results in skin erosion and generator exposure. It may only involve the leads, or most commonly may include the whole unit, resulting in more serious situations. The vegetations attached to the leads may cause infective endocarditis and, subsequently, promote the development of septicemia and pulmonary embolism.
Infection within the first 8 weeks after implantation probably results from the implant procedure, and infections thereafter could be secondary processes [10–12]. However, some late infections may result from intraoperative contamination [1]. In our patients, 2 of the 13 had suspected infections within 8 weeks after the implantation. Although cultures did not identify any microorganism in these 2 patients, early intervention eradicates the problematic hardware uneventfully. We believe that surgical extraction should not be reserved as a procedure of last resort.
The most common bacteria are those that physiologically colonize the skin, such as the various types of staphylococci, among them S epidermidis and S aureus [1, 4, 5]. In our study, 4 of 8 patients had staphylococci infection, and these findings are consistent with previous observations.
The diagnosis of pacemaker infection is established by the nature of clinical findings such as local inflammatory signs around the pocket, generator exposure, and signs of septicemia. Echocardiography is an important and sensitive tool for detecting vegetations adhering to the leads or tricuspid valve [13]. Either transthoracic or transesophageal echocardiography is strongly recommended before operation because the prognosis and therapeutic strategies for patients who have pacemaker infection with or without large vegetation can be different [1–6, 9]. Extraction of chronically implanted pacing leads has historically been difficult. Effective tools for percutaneous intravascular extraction of leads have been developed in the past decade. Byrd and associates [6] have reported on intravascular techniques for removing problematic or infected leads evolving during a 5-year period. Extraction was attempted using locking stylets and dilator sheaths, transfemoral snares, and retrieval baskets with a 7% rate of incomplete or failed extraction and a 1.4% rate of major complications. Klug and associates [7] have reported their results of using needle's eye snare for femoral approach counteraction in 39 patients with a 12.8% rate of incomplete or failed extraction, two deaths, and one limb ischemia. Moon and associates [8] have used a percutaneous laser-assisted technique for extraction of chronically implanted leads with complete extraction in 88%; however, various vascular injuries were reported. Although these techniques have achieved fairly stable results, major complications have still been inevitable. Most important, these sophisticated tools for percutaneous intravascular extraction of leads are not always available in some developing countries, increasing the needs for sternotomy or open thoracotomy with or without cardiopulmonary bypass even in the rather simple situations, which usually can be managed with a relatively conservative manner like our less-invasive extraction technique advocated in this report.
Classic surgical removal of chronically implanted pacing leads requires the use of the inflow occlusion or partial cardiopulmonary bypass technique when situations such as the presence of large right intracardiac vegetations (>10 mm) arise [1–5, 14, 15]. Recently, Meier-Ewert and associates [16] have reported on the successful transvenous removal of the infected endocardial leads with vegetations ranging in size from 10 mm to 38 mm in 9 patients without affecting survival or length of hospital stay. When considering removal of infected intracardiac leads, the incremental risks of causing either pulmonary embolism or cardiac chamber rupture must be weighed against the technical demands of inflow occlusion and the risk of stroke or systemic inflammatory response associated with cardiopulmonary bypass required for open extraction [17–19]. In our study, no patient had pulmonary embolism perioperatively, and three bleeding complications were successfully circumvented through the monitoring ports by simply tying the pursestring sutures. Hence, considering the safety and effectiveness, our less-invasive technique appears to be an attractive alternative to the classic median sternotomy or open thoracotomy removal of infected leads with or without cardiopulmonary bypass.
In conclusion, our experience, albeit limited to 13 patients who were almost free from vegetation, shows that a less-invasive extraction of infected or problematic transvenous permanent pacemaker system is feasible and safe. Neither cardiopulmonary bypass nor specific intravascular lead extraction devices are needed.
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References
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Abstract
Introduction
