What are the AHA guidelines for surgical intervention in the treatment of pacemaker infective endocarditis (IE)?

Updated: Jan 03, 2019
  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

The AHA 2010 guideline update on CIED infections and their management recommends complete removal of infected CIED and leads for the following patients: [43]

  • All patients with definite CIED infection, as shown by valvular and/or lead endocarditis or sepsis
  • All patients with CIED pocket infection, as shown by abscess formation, device erosion, skin adherence, or chronic draining sinus without involvement of the transvenous section of the lead system
  • All patients with valvular endocarditis without definite involvement of the lead(s),device, or both

Patients with occult staphylococcal bacteremia

The guideline update states that complete removal is reasonable in patients with persistent occult gram-negative bacteremia despite appropriate antibiotic therapy. [43]

Removal of the device and leads is not indicated in the following cases: [43]

  • A superficial or incisional infection that does not involve the device, leads, or both
  • Relapsing bloodstream infection due to a non-CIED source and for which long-term suppressive antimicrobials are required

After removal of the infected device, placing a temporary transvenous pacer is best. Immediate insertion of a permanent pacemaker at a new site can be safely accomplished.

The AHA 2010 guideline update on CIED infection recommends careful evaluation of each patient to determine if a CIED is still needed. Replacement device implantation should not be ipsilateral to the extraction site. The guideline suggests the contralateral side, the iliac vein, and epicardial implantation as preferred alternative locations. [43]

The AHA 2010 guideline recommends that if blood cultures were positive before the device extraction, blood cultures should be taken after the device removal, and new device placement should be delayed until blood cultures have been negative for at least 72 hours. If valvular infection is present, placement of new transvenous lead should be delayed for at least 14 days after CIED system removal. [43]

In the past, removal of the intracardiac leads that had been in place for several months often necessitated open heart surgery. The use of laser technology to dissolve the pacemaker lead adhesions has proven successful, with a 94% success rate. The risk of dislodging vegetations during removal of infected leads is negligible. Patients whose leads cannot be removed are started on permanent antibiotic suppression. [93, 94]

The AHA 2010 CIED guideline update states that long-term suppressive antimicrobial therapy should be considered for patients with CIED infection who are not candidates for CIED removal. Such therapy should not be administered to patients who are candidates for CIED removal. [43, 95]


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