Complete Pocket Resection with Regional Flap Closure for Treatment of Cardiac Implantable Device Infections

Abstract

Background: Cardiac implantable electronic device infections are associated with substantial morbidity and mortality. There are varied recommendations in the literature about treatment of the wound after extraction of all hardware, but only conservative, time-consuming approaches such as open packing and negative-pressure therapy along with a long interval before reimplanting any hardware have generally been recommended for the treatment. 1 – 4 Methods: A retrospective review was performed of 42 patients treated at Jersey Shore University Medical Center for implantable cardioverter defibrillator and permanent pacemaker infections between July 2010 and April 2018 with an aggressive, multidisciplinary approach utilizing an invasive cardiologist and a plastic surgeon. Clinical and demographic data were collected, and a descriptive analysis was conducted. Results: A total of 42 patients, with a median age of 76 years, were selected for our treatment of pacemaker pocket infection. Patients underwent removal of all hardware followed by debridement and flap closure of the wound soon after extraction. Reimplantation was performed when indicated typically within a week after initial extraction and typically on the contralateral side. There were no reports of reinfection and no mortality in all 42 patients treated. Conclusion: We found that the aggressive removal of all hardware and excisional debridement of the entire capsule followed by flap coverage and closure of the wound allowed for a shortened interval to reimplantation with no ipsilateral or contralateral infections during the follow-up period.

Outcomes of chlorhexidine lavage without capsulectomy versus complete capsulectomy after lead extraction for the treatment of cardiac implantable electronic device infection

“…Nevertheless, the appropriate management strategy for the generator pocket and the wound has not been established based on solid evidence 5 . This knowledge gap has led to many protocols, including the use of costly therapies with unproven clinical benefits 20,21 …”

“…5 This knowledge gap has led to many protocols, including the use of costly therapies with unproven clinical benefits. 20,21 Total capsulectomy has been proposed to achieve resolution of the infection and is currently used by approximately 58%-76% of centers, with no distinction made in current guidelines regarding the type of infection (i.e., pocket infection vs. bacteremia/endocarditis). 7,8 Furthermore, there is insufficient evidence to support its routine use, and capsulectomy is an arduous procedure associated with a significant risk of hematoma formation and the occasional need for pocket revision to control the bleeding.…”

Outcomes of Chlorhexidine Scrubbing without Capsulectomy vs. Complete Capsulectomy After Lead Extraction for the Treatment of Cardiac Implantable Device Infection

“…(5) This knowledge gap has led to many protocols, including the use of costly therapies with unproven clinical benefits. (20,21) Total capsulectomy has been proposed to achieve resolution of the infection and is currently used by approximately 58-76% of centers, with no distinction made in current guidelines regarding the type of infection (i.e., pocket infection vs. bacteremia/endocarditis).…”

Early modified primary closure for treatment of cardiac implantable electronic device pocket infections

“…There was one case of re‐infection and two cases of hematoma, one of which required re‐exploration. In another series of 42 patients, debridement followed by pectoralis major muscle flap either at the time of device removal/extraction or a staged procedure has been described as an alternative to NPWT 10 . Early, standard primary closure using multiple layers of sutures was used in this study after the flap for closure over a temporary drain.…”

“…In another series of 42 patients, debridement followed by pectoralis major muscle flap either at the time of device removal/extraction or a staged procedure has been described as an alternative to NPWT. 10 Early, standard primary closure using multiple layers of sutures was used in this study after the flap for closure over a temporary drain. There was no reported re-infection; however, the length of stay was not reported in this study.…”