Incomplete extraction, sterilization using antibiotic envelope and contralateral pacemaker implantation for elderly patients with pocket infection

Introduction: CIED infection rates are increasing worldwide. Current guidelines recommend on complete removal of all hardware in case of infection. Elderly patients with old leads are at increased risk for complication during lead extraction. Here, we describe a less invasive approach for these patients.

Methods and results: Two nonagenarian patients presented with device pocket infection more than 10 years after the implantation. Both patients were completely dependent on ventricular pacing. There were no systemic signs of infection including lack of fever, negative blood cultures, normal CRP levels and leukocyte count and negative transesophageal echocardiography. The patients first underwent device implantation in the contralateral side, followed by incomplete extraction in the same procedure. The procedure in the infected side included removal of the old device, careful debridement of the pocket, removal of old sutures, and saline and antibiotic wash. The old leads were cut up to 5 cm from the point of insertion to the axillary vein, and the remaining part was put in an antibiotic envelope (TYRX, Medtronic). Cultures from the infected device and the pocket were positive in both cases and the patients received 2-4 weeks of appropriate antibiotic therapy at home. Mean procedural time was 90 minutes. During mean follow-up of 20 months, the patients were free of recurrence.

Conclusion: In elderly patients with local device infection, a less invasive approach of partial removal and contralateral implantation can be successfully done, avoiding the risk of major complication associated with lead extraction.