Cardiovascular Implantable Electronic Device Explantation: What Happens after Device Removal? Perioperative Management of Pocket Infections

Objectives: The incidence of cardiovascular implantable electronic device (CIED) pocket infections is continuously on the rise in recent decades. Since the dawn of new extraction methods most papers solely concentrate on the extraction aspect of CIED infections. Our goal was to focus on the postoperative course, wound management and antibiotic therapy.

Methods: All patients that underwent device extraction with pocket infection between January 2012 and December 2016 were included in this study and were evaluated retrospectively. This includes device infections with lead vegetations. Patients who underwent device extraction without concomitant pocket infection were excluded.

Results: A total of 157 patients (76% male, mean age: 73 ± 12 years) underwent CIED explantation. The most common complication was postoperative bleeding requiring additional surgery (5%). Our initial approach was to insert a vacuum dressing after extraction. However, we observed increased postoperative bleeding, so we changed our strategy by inserting Betaisodona gauze pads. While there was a total reduction of postoperative bleeding (2 incidents with the latter approach, 6 with the former), there was no statistically significance. Other complications include cardiac tamponade (1.2%) and sepsis (1.9%). The total hospital mortality was 3.8% with 6 deaths. Sole pocket infections had a mortality of 1.45%. With the addition of lead vegetations the mortality increased significantly to 27% (3 out of 11 patients, p < 0.0001). Higher preoperative CRP was a statistically significant predictor for hospital mortality (p < 0.0085). Patients with Staphylococcus aureus infections had a statistically significant higher CRP than other pathogens (p < 0.0001 to p < 0.0015) except for Pseudomonas aeruginosa and MRSA. 21% of patients did not receive a new device. Half of the patients did not have a positive wound swab. The detected pathogens were resistant against the initial antibiotic treatment in 29% of the cases. There was no statistical significance between the initial pathogen and secondary wound closure as well as re-implantation of a CIED (with the exception of MRSA compared to sterile wound swabs, 3 cases of MRSA, p < 0.048).

Conclusions: CRP and lead vegetations are statistically significant predictors for intrahospital mortality, while localized pocket infections had low overall mortality. Antibiotic therapy in sterile wound swabs without signs of systemic infections should be reconsidered, since it proved ineffective in 29% of cases.