Salvage of Exposed or Infected Cardiac Electrical Devices Pocket Revision and Relocation

                                                                      Purpose

            The treatment of infected or exposed cardiac pacing and defibrillator devices is evolving. The long standing and widely accepted treatment calls for removal of leads and the electrical device^1,2,3 , with subsequent replacement on the opposite side of the chest.  Success in resolving infection is 98% but lead extraction carries a 0.5-1% mortality rate.  We assess whether pocket revision and relocation is a reasonable surgical procedure that allows salvage of exposed or infected cardiac electrical devices.

Methods

            Nineteen consecutive patients with cardiac electrical devices and clinical concern for infection were studied retrospectively.  One patient was subsequently excluded since he received a heart transplant with device and lead removal 2 months post salvage.  The patients presented with at least one of the following signs - severely atrophic skin,  perforated skin, clinical evidence of infection. The patients were divided into 4 study groups – 1) Atrophic skin, intraoperative cultures negative, 2) Atrophic skin, intraoperative cultures positive, 3) Perforated skin, exposed hardware, no macroscopic pus, 4) Perforated skin, exposed hardware, macroscopic pus.  All 18 patients were treated with aggressive surgical resection of the entire lining of the device pocket, and relocation of the pocket to a new supramuscular or submuscular pocket on the same side of the chest.  All patients received a minimum of 4 weeks of antibiotics postoperatively. 

Results

            15 of the 18 cardiac electrical devices were salvaged.  The results for the specific study groups follow:

Study group                        Number salvaged                        Average follow up (months)

1                                    3/3                                                73 (55-96)

2                                    5/6                                                31 (6-76)

3                                    5/5                                                28 (7-61)

4                                    2/4                                                49 (33-62)

            The 3 patients who were not salvaged developed recurrent infection.  They were treated with device and lead removal (ave. 8 months) and subsequent successful replacement (100%) on the opposite side of the chest. 

Conclusion

            Aggressive pocket lining excision and device relocation is an appropriate procedure for infected or exposed cardiac electrical devices or leads.  Patients with macroscopic pus had a salvage rate of 50%.  All other groups combined had a salvage rate of 92%.  Patients with atrophic skin overlying the device should be treated.  6/9 patients with atrophic skin had positive cultures from the device pocket. 

1. Sohail    J Am Coll Cardiol 49:1851, 2007.
2. Margey   Europace 12:64, 2010.
3. Johansen   Eur Heart J 2011 (Epub).