Complete removal as a routine treatment for any cardiovascular implantable electronic device-associated infection

Objective: Pacemaker and implantable cardioverter defibrillator lead endocarditis mandates removal of all foreign material. In supposedly limited (pocket) infections, such a radical approach is still controversial. Thus, some patients are potentially exposed to persistent and recurrent infection because of retained material. Procedural risks and the success of eradicating infection were examined if involvement of the complete system was assumed in any cardiovascular implantable electronic device infection and complete removal was thus mandatory. Methods: A 12-year experience with 192 consecutive cases of bacterial pacemaker (152) or defibrillator (40) infections is presented. Complete removal of all prosthetic material was always aimed for. This was followed by antibiotic treatment for 4 to 6 weeks under temporary pacing if required, and then the new system was implanted. A total of 104 parameters concerning patient characteristics and operative and postoperative treatment were examined for their influence on outcome. Results: Infection was eradicated in 92.8% of patients. Recurrence was predominantly caused by failure to remove all prosthetic material (P <. 001). If the protocol was strictly followed, infection was eradicated in 97.4% of patients. Conversely, 71.4% of patients with retained material showed recurrence. Further risk factors were poor dental hygiene and evidence of chronic subclinical infection. Morbidity and mortality of the interventional and open procedures were low. Open lead extraction was performed primarily in 34 patients (17.7%) and secondarily in 3 patients (1.9%). Temporary pacing and long-term antibiotic treatment were well tolerated. Conclusions: Complete removal of prosthetic material in any cardiovascular implantable electronic device infection is safe and associated with low morbidity and mortality. Success of eradicating infection is high if all system components are removed. Temporary pacing in dependent patients may be performed safely on an outpatient basis. (J Thorac Cardiovasc Surg 2011;142:1482-90)