Pacemaker pocket infection: Innovative conservative treatment in elderly patients with no signs of systemic infection

Abstract

Background The gold standard to treat cardiovascular implantable electronic devices (CIEDs) infections is the complete system removal. The aim of this retrospective analysis is to assess the feasibility and safety of an alternative conservative surgical system revision approach, to be applied in elderly patients who refused the extraction procedure, in case of no signs of systemic infection. Methods Between May 2009 and January 2019, we performed system revision of 25 patients (15 men and 10 women, median age 81 [IQ: 75‐85] years) with negative blood culture, no signs of vegetation, who experienced CIED infections. Results In all patients the following surgical procedure was applied: the pocket was opened, the wound's necrotic tissue was dissected en bloc; fibrotic tissue was excised. The pocket was washed with hydrogen peroxide and saline solution. The pocket was then closed without implanting the device and left with a continuous infusion of antibiotics and normal saline for 4 days. Subsequently the new generator was implanted, possibly in a different pocket than the previous one. All patients underwent a median follow up of 24 [IQ: 14‐34] months. In 24 patients out of the 25 observed the procedure was safe and effective, except for one patient who needed the extraction. Conclusions The two‐stage surgical revision technique is feasible and safe. It may be considered for elderly patients who refused extraction and presented no signs of systemic infection or in some categories of patients. In case of failure of the procedure, subsequent treatment with complete extraction of the system would not be precluded.

Long-term results of conservative treatment of pacemaker pocket site infections

“…Poller et al, Satsu et al, McGarry et al, and Zheng et al have stated that the negative pressure drainage system is effective for pacemaker pocket site infections in the long term [21,[27][28][29]. In a study of 25 case series by Bisignani et al no recurrence was observed in 24 of the patients during the 24-month follow-up period after local revision, debridement, and reimplantation [23]. A total of 33 patients were included in the study by Cassagneau et al The patients were divided into three groups according to the clinical characteristics of the pocket site.…”

“…In a study by Bisignani et al of 25 cases in the elderly, no systemic infection or blood culture positivity was observed, but 24 of 25 patients had pacemaker pocket site infection with positive culture results. Re-infection was observed in only one patient [23]. According to the 2020 European Cardiac Rhythm Consensus Document, cardiac device infection was accepted if the site of infection was a pacemaker generator or lead protrusion, regardless of the results of the swab cultures [1][2][3][4].…”

“…In a study of 25 case series by Bisignani et al . no recurrence was observed in 24 of the patients during the 24-month follow-up period after local revision, debridement, and reimplantation [ 23 ]. A total of 33 patients were included in the study by Cassagneau et al The patients were divided into three groups according to the clinical characteristics of the pocket site.…”

Long-term survival with pocket-defected permanent pacemaker after conservative management of pacemaker infection

“…Elsewhere, favorable outcomes of conservative treatment were reported in a case of pacemaker pocket infection by a 2-stage surgical revision technique with a continuous infusion of antibiotics. 7 In addition, long-term survival has been reported in cases of conservative treatment consisting of removing infected and necrotic tissue. 8 , 9 Our case is unique because pacemaker leads directly protruded from the chest epidermis owing to complete pocket defection and we were able to achieve long-term survival.…”