Arrhythmia Management Devices

1031 An 83-year-old woman is referred for lead extraction as a result of pacemaker pocket infection. She has a history of atrial fibrillation and complete heart block after an AV node ablation. A left-sided pacemaker was placed in 2007. One month before admission, she developed urosepsis, followed by an infection of the pacemaker pocket. Blood cultures revealed methicillin-sensitive Staphylococcus aureus. She was admitted to an outside institution where the device was removed, but the leads were left in place after a failed attempt to remove the leads with traction alone. A new single-chamber pacemaker was placed on the right side. On presentation to our institution, the patient appeared quite ill. Physical examination documented congestive heart failure and evidence of pocket infection at sites on both the right and left sides of the chest. Serum chemistry was significant for worsening renal function. A chest x-ray demonstrated a large right pleural effusion. The patient was taken to the hybrid operating room for further management. A transesophageal echocardiogram performed under general anesthesia showed a large pericardial effusion compromising ventricular filling, and a pericardial drain was placed. A temporary pacing wire was placed in the right ventricular apex via a femoral approach. The recently implanted right-sided pacemaker system could then be removed with traction under fluoroscopic guidance. The 2 left-sided leads were extracted with locking stylets and a laser sheath. Both wounds were extensively debrided, and bilateral wound vacuums were placed. An active fixation pacemaker lead was then placed via a right internal jugular approach and connected to a previously used, resterilized pacemaker to provide temporary/permanent right ventricular pacing. Finally, a right-sided chest tube was placed. The patient remained hospitalized for 2 weeks for management of her infected pacemaker sites and sepsis, with her initial care in the intensive care unit and with collaboration with medical teams from cardiology, cardiothoracic surgery, and infectious disease. A new left-sided pacemaker system was subsequently placed, and the patient is doing well after discharge from the hospital. This recent case at our institution highlights many of the challenges encountered in managing patients with cardiac implantable electronic device (CIED) infections. An early diagnosis and knowledge of indications for lead extraction are paramount to patient survival. Equally important is the overall management of the patient, including the procedural approach, pacing requirements, and wound care. Finally, successfully managing these often very complex patients can be done only through a team approach using a hospital’s many resources. These aspects of CIED infection management are discussed in this review.