Epicardial Cardiac Rhythm Devices for Dialysis Patients: Minimizing the Risk of Infection and Preserving Central Veins

Abstract

Transvenous leads of cardiac rhythm devices (CRDs) are known to cause central stenosis and are vulnerable to contamination during hemodialysis access-related bacteremia. In this retrospective study, nine consecutive chronic hemodialysis patients with transvenous CRD infection due to dialysis access-related bacteremia and recurrent central stenosis are presented. Four patients with tunneled hemodialysis catheters (TDCs) and three with arteriovenous grafts experienced access-related bacteremia that spread to the transvenous CRD. Two patients required repeated angioplasty procedures (less than 3 months apart) for central venous stenosis. Transvenous CRD was removed and replaced with an epicardial system in all. One patient with TDC switched to peritoneal dialysis and did not experience infection of the epicardial system despite two episodes of peritonitis. The remaining TDC (n=3) and graft patients (n=3) received a new TDC after the resolution of bacteremia. While all six experienced on average 1.5 episodes of catheter-related bacteremia (average follow-up = 14.5 months), none developed infection of the epicardial system. The patients with central stenosis have required only one angioplasty each for the past 8 and 6 months. To the best of our knowledge this is the first study to suggest that an epicardial approach might be a preferred method over transvenous leads for chronic hemodialysis patients.

Vascular Access Sites for Acute Renal Replacement in Intensive Care Units

“…After neck movements, oral secretions may contaminate the dressing. Another potential problem associated with temporary catheterization is vein stenosis (18), particularly when the jugular site is chosen in the presence of pacemaker leads (19). After colonization of the central catheter, the pacemaker leads can also become infected (20).…”

Cardiac implantable electronic devices in end-stage renal disease patients: preservation of central venous circulation

“…Recently published preliminary information lends validity to the epicardial approach in HD patients. In this study, the development of CIED infection and central stenosis were markedly reduced after the endocardial devices were removed and replaced with epicardial CIEDs [31]. Bardy et al reported recently that subcutaneous ICD consistently detected and converted spontaneous and induced VF [36].…”

“…Repeated cannulation of arteriovenous fistulas and the use of tunneled catheters for HD are potential sources for bacteremia in this population. The intravascular location of the CIEDs makes the leads vulnerable to bacterial seeding during HD [31]. In recent years, we have also observed an evolution of implantation techniques of epicardial and subcutaneous CIEDs, making it accessible to patients in whom the traditional transvenous implantation could be associated with high complication rates [32][33][34][35][36].…”

“…For these reasons, the transvenous route has become the most frequently used method for implantation of CIEDs. However, the use of the transvenous CIEDs can be associated with significant complications in chronic HD patients including central venous stenosis, tricuspid regurgitation (TR), and device infection [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31].…”

Central Venous Stenosis after Hemodialysis: Case Reports and Relationships to Catheters and Cardiac Implantable Devices

“…Most studies comparing the value of epicardial versus transvenous CIED lead placement have been conducted in patients from the general population in whom transvenous leads had been removed because of infection. Efficacy and mortality were usually equal in both groups [19, 20]. However, placement requires cardiothoracic surgery, which is an expensive procedure.…”