Salvage of focally infected implantable cardioverter-defibrillator system by in situ hardware sterilization

Introduction Cardiovascular implantable electronic device (CIED)-related infections have increased in frequency over the past 2 decades out of proportion to the rise in device implantations. This has occurred despite an improvement in technology, which includes smaller device profiles, improvement in battery life, prepectoral systems, and greater operator experience. Much of what is driving this trend is the greater implantation rate of implantable cardiac defibrillators (ICD), which are more likely to become infected than permanent pacemakers, possibly owing to greater surface area for bacterial adherence. The current recommended treatment for CIED infection includes the removal of all hardware, including subcutaneous and transvenous components. This is true even in the setting of a localized pocket infection without signs of systemic infection. Complete removal of all components, including the device generator and leads, is required owing to high infection relapse rates when retained hardware is in place. Percutaneous lead extraction has become the preferred method for removal of CIED hardware, which often requires the use of laser sheath technology extraction systems or mechanical telescopic sheaths. Extraction of chronic pacemaker and ICD leads involves small but serious potential risks, including cardiac tamponade, hemothorax, pulmonary embolism, lead migration, vascular laceration, and death, even in experienced hands. The performance of these procedures has generally been limited to centers with the appropriate facilities and training in order to minimize procedural risks and be able to initiate an immediate surgical rescue in the event of a complication.