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Background: Transvenous lead extraction (TLE) for cardiovascular implantable electronic device (CIED)‐related infections has increased. The incidence of TLE in nonagenarians is low, with limited reports outlining the outcomes of this procedure. Therefore, in this study, we aimed to clarify the outcomes of TLE in nonagenarians. Methods: Patients with TLE treated at our hospital between 2014 and 2023 were retrospectively examined; patient characteristics, device type, indications, procedures, complications, and clinical data of nonagenarians were analyzed. Results: Of 12 patients with 24 leads (active fixation lead, n = 11; passive fixation lead, n = 13) who underwent TLE, the indication for TLE was infection (pocket infection, n = 8; sepsis, n = 4). Methicillin‐resistant Staphylococcus epidermidis was the most frequently identified causative agent (n = 4). The median patient age was 91 years; five patients were female. The median lead dwell time was 9 years. Excimer laser sheath (16 leads), mechanical sheath (five leads), Evolution RL (one lead), and manual traction (two leads) were employed in TLE. The procedure was successful in all patients, and only one had a minor complication. Six patients required CIED re‐implantation, and leadless pacemakers were selected for five patients. The 30‐day mortality after TLE was 0%. Conclusion: TLE can be safely performed in nonagenarians. The decision to perform TLE should not be based on old age alone; the suitability of removing infected CIEDs should be determined based on each patient's condition. [ABSTRACT FROM AUTHOR]

Background: Transvenous lead removal (TLR) is associated with increased mortality and morbidity. This study sought to evaluate the impact of TLR on in-hospital mortality and outcomes in patients with and without CIED infection. Methods: From January 1, 2017, to December 31, 2020, we utilized the nationally representative, all-payer, Nationwide Readmissions Database to assess patients who underwent TLR. We categorized TLR as indicated for infection, if the patient had a diagnosis of bacteremia, sepsis, or endocarditis during the initial admission. Conversely, if none of these conditions were present, TLR was considered sterile. The impact of infective vs sterile indications of TLR on mortality and major adverse events was studied. Results: Out of the total 25,144 patients who underwent TLR, 14,030 (55.8%) received TLR based on sterile indications, while 11,114 (44.2%) received TLR due to device infection, with 40.5% having systemic infection and 59.5% having isolated pocket infection. TLR due to infective indications was associated with a significant in-hospital mortality (5.59% vs 1.13%; OR = 5.16; 95% CI 4.33–6.16; p < 0.001). Moreover, when compared with sterile indications, TLR performed due to device infection was associated with a considerable risk of thromboembolic events including pulmonary embolism and stroke (OR = 3.80; 95% CI 3.23–4.47, p < 0.001). However, there was no significant difference in the conversion to open heart surgery (1.72% vs. 1.47%, p < 0.111), and infection was not an independent predictor of cardiac (OR = 1.12; 95% CI 0.97–1.29) or vascular complications (OR = 1.12; 95% CI 0.73–1.72) between the two groups. Conclusion: Higher in-hospital mortality and rates of thromboembolic events associated with TLR resulting from infective indications may warrant further pursuing this diagnosis in patients. [ABSTRACT FROM AUTHOR]

Introduction: Transvenous lead extractions (TLEs) for cardiac implantable electronic device complications often encounter difficulties with strong adhesions to the myocardium or vessels. In this report, we introduce a novel "Four‐Stage Rocket" technique for effective TLE in cases where conventional methods fail. Methods and Results: Two challenging cases where conventional TLE methods failed were treated using a combination of four devices: Needle's Eye Snare, Agilis NxT Steerable Introducer, GlideLight Laser sheath, and GORE® DrySeal Flex Introducer sheath, employed via the inferior vena cava. The "Four‐Stage Rocket" technique successfully detached firmly adhered leads near the tricuspid valve annulus, where the traditional superior vena cava approach was inadequate. Conclusion: The "Four‐Stage Rocket" technique offers a potential alternative in complex TLE cases, aligning the laser direction with the adhesion detachment and reducing the tissue damage risk. [ABSTRACT FROM AUTHOR]

We present a complex case of cardiac implantable electronic device infection and extraction in the setting of bacteremia, large lead vegetation, and patent foramen ovale. Following a comprehensive preprocedural workup including transesophageal echocardiogram and computed tomography lead extraction protocol, in addition to the involvement of multiple subspecialties, an open chest approach to extraction was deemed a safer option for eradication of the patient's infection. Despite percutaneous techniques having evolved as the preferred extraction method during the last few decades, this case demonstrates the importance of a thorough evaluation at an experienced center to determine the need for open chest extraction. [ABSTRACT FROM AUTHOR]

The subclavian vein is typically used in cardiovascular implantable electronic device (CIED) implantations. External stress on the subclavian vein can lead to lead‐related complications. There are several causes of this stress, such as frequent upper extremity movements or external injury. Venous thoracic outlet syndrome (TOS) can also become the cause of external lead stress. However, the diagnosis of venous TOS can be challenging because subclavian venography can appear normal at first glance. We present a unique case of a device infection in a patient with venous TOS. A careful observation of the imaging studies is vital for diagnosing venous TOS and a leadless pacemaker implantation could be an alternative therapeutic option. [ABSTRACT FROM AUTHOR]

Background and Aims Bloodstream infection (BSI) of any cause may lead to device infection in cardiac implantable electronic device (CIED) patients. Aiming for a better understanding of the diagnostic approach, treatment, and outcome, patients with an implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy and defibrillator (CRT-D) hospitalized with BSI were investigated. Methods This is a single-centre, retrospective, cohort analysis including consecutive ICD/CRT-D patients implanted between 2012 and 2021. These patients were screened against a list of all hospitalized patients having positive blood cultures consistent with diagnosed infection in any department of a local public hospital. Results The total cohort consisted of 515 patients. Over a median follow-up of 59 months (interquartile range 31–87 months), there were 47 BSI episodes in 36 patients. The majority of patients with BSI (92%) was admitted to non-cardiology units, and in 25 episodes (53%), no cardiac imaging was performed. Nearly all patients (85%) were treated with short-term antibiotics, whereas chronic antibiotic suppression therapy (n = 4) and system extraction (n = 3) were less frequent. Patients with BSI had a nearly seven-fold higher rate (hazard ratio 6.7, 95% confidence interval 3.9–11.2; P <.001) of all-cause mortality. Conclusions Diagnostic workup of defibrillator patients with BSI admitted to a non-cardiology unit is often insufficient to characterize lead-related endocarditis. The high mortality rate in these patients with BSI may relate to underdiagnosis and consequently late/absence of system removal. Efforts to increase an interdisciplinary approach and greater use of cardiac imaging are necessary for timely diagnosis and adequate treatment. [ABSTRACT FROM AUTHOR]

Previous retrospective studies suggest a good diagnostic performance of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET)/computed tomography (CT) in left ventricular assist device (LVAD) infections. Our aim was to prospectively evaluate the role of PET/CT in the characterization and impact on clinical management of LVAD infections. A total of 40 patients (aged 58 [53-62] years) with suspected LVAD infection and 5 controls (aged 69 [64-71] years) underwent 18F-FDG-PET/CT. Four LVAD components were evaluated: exit site and subcutaneous driveline (peripheral), pump pocket, and outflow graft. The location with maximal uptake was considered the presumed site of infection. Infection was confirmed by positive culture (exit site or blood) and/or surgical findings. Visual uptake was present in 40 patients (100%) in the infection group vs 4 (80%) control subjects. For each individual component, the presence of uptake was more frequent in the infection than in the control group. The location of maximal uptake was most frequently the pump pocket (48%) in the infection group and the peripheral components (75%) in the control group. Maximum standard uptake values (SUV max) were higher in the infection than in the control group: SUV max (average all components): 6.9 (5.1-8.5) vs 3.8 (3.7-4.3), p = 0.002; SUV max (location of maximal uptake): 10.6 ± 4.0 vs 5.4 ± 1.9, p = 0.01. Pump pocket infections were more frequent in patients with bacteremia than without bacteremia (79% vs 31%, p = 0.011). Pseudomonas (32%) and methicillin-susceptible Staphylococcus aureus (29%) were the most frequent pathogens and were associated with pump pocket infections, while Staphylococcus epidermis (11%) was associated with peripheral infections. PET/CT affected the clinical management of 83% of patients with infection, resulting in surgical debridement (8%), pump exchange (13%), and upgrade in the transplant listing status (10%), leading to 8% of urgent transplants. 18F-FDG-PET/CT enables the diagnosis and characterization of the extent of LVAD infections, which can significantly affect the clinical management of these patients. [Display omitted] [ABSTRACT FROM AUTHOR]

BackgroundPatients with progressive chronic kidney disease (CKD) are at higher risk of infections and complications from cardiac implantable electronic devices (CIED). In patients with a primary or secondary prophylactic indication, implantable cardiac defibrillators (ICD) can prevent sudden cardiac deaths (SCD). We retrospectively compared transvenous-ICD (TV-ICD) and intermuscularly implanted subcutaneous-ICD (S-ICD) associated infections and complication rates together with hospitalizations in recipients with stage 4 kidney disease.MethodsWe retrospectively analyzed 70 patients from six German centers with stage 4 CKD who received either a prophylactic TV-ICD with a single right ventricular lead, 49 patients, or a S-ICD, 21 patients. Follow-Ups (FU) were performed bi-annually.ResultsThe TV-ICD patients were significantly older. This group had more patients with a history of atrial arrhythmias and more were prescribed anti-arrhythmic medication compared with the S-ICD group. There were no significant differences for other baseline characteristics. The median and interquartile range of FU durations were 55.2 (57.6–69.3) months. During FU, patients with a TV-ICD system experienced significantly more device associated infections (n = 8, 16.3% vs. n = 0; p

Transvenous lead extraction has been increasingly recognized as a safe and effective method of lead extraction, but there are only few references for extracting leads migrating outside the heart. We present a successful extraction of a fractured pacemaker lead from the spermatic vein using several approaches and multiple tools.

71-year-old male with history of obstructive sleep apnea presented with persistent drainage from the surgical incision site over the recently implanted hypoglossal nerve stimulator. Wound cultures from device pocket identified the pathogen as Turicella otitidis. Clinical course included treatment with broad-spectrum intravenous antibiotics and device explantation. This case is the first known T. otitidis device associated infection.

Infection is the most dreaded complication of cardiac implantable electronic devices (CIEDs), particularly in patients undergoing high-risk procedures (eg, generator change, device upgrade, lead/pocket revision). The purpose of this study was to describe the impact of chlorhexidine gluconate (CHG) pocket lavage in high-risk procedures. Patients from a prospective multicenter registry undergoing high-risk procedures were included. CHG lavage was performed by irrigating the generator pocket with 20 cc of 2% CHG without alcohol followed by and normal saline (NS) irrigation. Only NS irrigation was performed in the comparison group. The primary efficacy outcome was CIED-related infection at 12 months. The primary safety outcome was any CHG-associated adverse event. The secondary outcome was CIED infection during long-term follow-up. Propensity score matching (PSM) analysis was performed for the primary efficacy outcome. A total of 1504 patients were included. At 12-month follow-up, the primary efficacy outcome occurred in 4 of 904 CHG (0.4%) and 14 of 600 NS (2.3%) subjects (log-rank P =.005). On multivariate analysis, the use of CHG irrigation was associated with a lower risk of infection at 1-year follow-up (Cox proportional hazard ratio [HR] 0.138; 95% confidence interval [CI] 0.04–0.45; P =.001). This effect persisted during long-term follow-up. PSM demonstrated a significant reduction in CIED-related infection for the CHG group (0.2% vs 2.5%; Cox proportional HR 0.08; 95% CI 0.01–0.59; P =.014). No adverse events were associated with the use of CHG. CHG lavage during high-risk procedures was associated with a reduction in CIED-related infections without any adverse events reported. The benefits of CHG lavage were observed even during long-term follow up and in PSM analysis. [Display omitted] [ABSTRACT FROM AUTHOR]

BackgroundCardiac Implantable Electronic Device infections increase short- and long-term mortality, along with healthcare costs. Leadless pacemakers (PM) were developed to overcome pocket- and minimize lead-related complications in selected high-risk patients. Recent advancements enable leadless devices to mechanically detect atrial activity, facilitating atrioventricular (AV) synchronous stimulation.Case summaryA 90-year-old woman, implanted with a dual-chamber pacemaker eight years ago due to sinus node dysfunction, presented with syncope. A diagnosis of complete AV block, in the setting of ventricular lead dysfunction was made. Due to a high risk of infection, the patient was implanted with a leadless PM capable of maintaining AV synchrony in VDD mode (MICRA™ model MC1AVR1). The transvenous PM was programmed to AAI-R mode to drive the atria, which, in turn, triggered the leadless PM to stimulate the ventricles. At six month follow-up, the AV synchrony rate was 85%.ConclusionThe combination of classic atrial pacing with leadless ventricular stimulation can be used in high-risk patients to reduce the risk of complications, in the setting of ventricular lead dysfunction. In this manner, AV synchrony can be maintained, improving hemodynamic parameters and quality of life. Low sinus rate variability at rest is essential to achieve a high AV synchrony rate in such cases.

Background: The gold standard for the treatment of cardiac implantable electronic devices (CIEDs)-related infection and lead malfunction is transvenous lead extraction (TLE). To date, the risk of mortality directly related to TLE procedures is relatively low, but data on post-procedural and long-term mortality are limited, even more in the aging population. Methods: Consecutive patients with CIEDs who underwent TLE were retrospectively studied. The primary outcome was the endpoint of death, considering independent predictors of long-term clinical outcomes in the TLE aging population comparing patients with and without infection. Results: One hundred nineteen patients (male 77%; median age 76 years) were included in the analysis. Eighty-two patients (69%) documented infection, and thirty-seven (31%) were extracted for a different reason. Infected patients were older (80 vs. 68 years, p-value > 0.001) with more implanted catheters (p-value < 0.001). At the last follow-up (FU) available (median FU 4.1 years), mortality reached 37% of the patient population, showing a statistically significant difference between infected versus non-infected groups. At univariable analysis, age at TLE, atrial fibrillation, and anemia remained significant correlates of mortality; at multivariable analysis, only patients with anemia and atrial fibrillation have a 2.3-fold (HR 2.34; CI 1.16–4.75) and a 2.5-fold (HR 2.46; CI 1.33–4.54) increased rate of death, respectively. Conclusion: Our long-term data showed that aging patients who underwent TLE for CIED-related infection exhibit a high mortality risk during a long-term follow-up, potentially leading to a rapid and effective procedural approach in this patient population. [ABSTRACT FROM AUTHOR]

This special article is the fifth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors would like to thank the Editor-in-Chief, Dr Kaplan, the Associate Editor-in-Chief, Dr Augoustides, and the editorial board for the opportunity to author this series, which summarizes the key research papers in the electrophysiology (EP) field relevant to cardiothoracic and vascular anesthesiologists. These articles are shaping perioperative EP procedures and practices, such as pulsed-field ablation, cryoablation for first-line treatment for atrial fibrillation, advancements in conduction system pacing, safety issues related to smartphones and cardiac implantable electronic devices, and alterations in EP workflow as the world emerges from the COVID-19 pandemic. Special emphasis is placed on the implications of these advancements for the anesthetic care of patients undergoing EP procedures. [ABSTRACT FROM AUTHOR]

Patent foramen ovale device closure is rarely associated with complications. This case report is believed to be the first description of a patient with infective endocarditis of a patent foramen ovale closure device presenting as glomerulonephritis. This article serves to educate as to this rare device complication and its unusual presentation. (Level of Difficulty: Intermediate.)

The rate of transvenous lead extraction (TLE) due to cardiac implantable electronic device (CIED) infection continues to rise. CIED infections are associated with significant morbidity and mortality. Temporary pacing in patients with active CIED infections after TLE can be challenging. Leadless pacing has emerged as an alternative approach in this patient population. The purpose of this study was to describe the outcomes of a strategy using concomitant leadless pacemaker implantation and TLE in patients with active infections and ongoing pacing requirements. This study involved all leadless pacemaker implantation procedures performed during TLE between June 2018 and September 2022 in the setting of active infection. Demographic characteristics, procedural details, and clinical outcomes were analyzed. The study included 86 patients with indications for ongoing pacing, 60 (70%) men with mean age 77.4 ± 10.5 years, who underwent TLE and concomitant leadless pacemaker implantation in the setting of active infection. There were no procedure-related complications. Sixty-five patients (76%) had evidence of bacteremia, 80% of whom were discharged to complete their antimicrobial treatment. During a median follow-up of 163 days (interquartile range 57–403 days), there were no recurrent infections. Of the 25 deaths (29%) during the study period, 22 (88%) were unrelated to the initial infection. Nine deceased patients (36%) had methicillin-resistant Staphylococcus aureus or Candida infections, 3 of whom had persistent infection despite TLE. Leadless pacing is a safe and efficacious approach for the management of patients with pacing requirements that undergo CIED extraction in the setting of active infection. [ABSTRACT FROM AUTHOR]

Cardiac positron emission tomography (PET) imaging has established themselves firmly as excellent and reliable functional imaging modalities in assessment of the spectrum of coronary artery disease. With the explosion of technology advances and the dream of flow quantification now a reality, the value of PET is now well realized. Cardiac PET has proved itself as precise imaging modality that provides functional imaging of the heart in addition to anatomical imaging. It has established itself as one of the best available techniques for evaluation of myocardial viability. Hybrid PET/computed tomography provides simultaneous integration of coronary anatomy and function with myocardial perfusion and metabolism, thereby improving characterization of the dysfunctional area and chronic coronary artery disease. The availability of quantitative myocardial blood flow evaluation with PET provides additional prognostic information and increases diagnostic accuracy in the management of patients with coronary artery disease. Hybrid imaging seems to hold immense potential in optimizing management of cardiovascular diseases and furthering clinical research. [ABSTRACT FROM AUTHOR]

Aims In patients with infections of cardiac implantable electronic devices (CIEDs), the identification of causative pathogens is complicated by biofilm formations and previous antibiotic therapy. In this work, the impact of an additional fluorescence in situ hybridization (FISH), in combination with polymerase chain reaction and sequencing (FISHseq) was investigated. Methods and results In 36 patients with CIED infections, FISHseq of explanted devices was performed and compared with standard microbiological cultivation of preoperative and intraoperative samples. The mean age was 61.9 (±16.2) years; 25 (69.4%) were males. Most patients (62.9%) had heart failure with reduced ejection fraction. Infections occurred as endoplastits (n = 26), isolated local generator pocket infection (n = 8), or both (n = 2); CIED included cardiac resynchronization therapy defibrillator (n = 17), implantable cardioverter defibrillator (n = 11), and pacemaker (n = 8) devices. The overall positive FISHseq detection rate was 97%. Intraoperatively, pathogens were isolated in 42 vs. 53% in standard cultivation vs. FISHseq, respectively. In 16 of 17 FISHseq-negative patients, the nucleic acid strain DAPI (4′,6-diamidino-2-phenylindole) indicated inactive microorganisms, which were partially organized in biofilms (n = 4) or microcolonies (n = 2). In 13 patients in whom no pathogen was identified preoperatively, standard cultivation and FISHseq identified pathogens in 3 (23%) vs. 8 (62%), respectively. For the confirmation of preoperatively known bacteria, a combined approach was most efficient. Conclusion Fluorescence in situ hybridization sequencing is a valuable tool to detect causative microorganisms in CIED infections. The combination of FISHseq with preoperative cultivation showed the highest efficacy in detecting pathogens. Additional cultivation of intraoperative tissue samples or swabs yielded more confirmation of pathogens known from preoperative culture. [ABSTRACT FROM AUTHOR]

Introduction: Transesophageal echocardiography (TEE) is recommended to rule out endocarditis in patients with cardiac implantable electronic devices (CIED). A lead‐based echodensity (LBE), however, is often found on TEE in patients with a CIED and may not represent an infection. We sought to evaluate the predictors, characteristics, and clinical significance of LBEs seen on TEE in patients with a CIED. Methods: Patients with a CIED were retrospectively identified from a database using International Classification of Diseases (ICD)‐9/ICD‐10 codes and were cross‐matched with Current Procedural Terminology codes for a TEE. Clinical and follow‐up data were collected. A blinded echo board‐certified cardiologist reviewed all TEEs. Results: Out of the 231 patients in the cohort, 191 had TEE performed for a noninfection‐related indication while 40 TEEs were part of an endocarditis workup. A total of 50 LBEs were identified, and a majority were in the noninfection cohort. Systemic anticoagulant use in the noninfection cohort was associated with a decreased odds of having LBE on TEE (odds ratio [OR] of 0.23 [95% confidence interval [CI]: 0.06–0.60, p =.003]). Lead dwell time in the noninfection cohort was associated with an increased odds of having LBE on TEE (OR 1.21 (95% CI: 1.04–1.39, p =.009]). Conclusion: In our cohort of patients who had TEE for noninfection indications we found that systemic anticoagulant use is associated with fewer LBEs on TEEs, suggesting possible thrombin fibrin composition of LBE. [ABSTRACT FROM AUTHOR]

Aims The safety and efficacy of leadless intracardiac-permanent pacemaker (L-PM) have been demonstrated in multiple clinical trials, but data on comparisons with conventional transvenous-permanent pacemaker (T-PM) collected in a consecutive, prospective fashion are limited. The aim of this analysis was to compare the rate and the nature of device-related complications between patients undergoing L-PM vs. T-PM implantation. Methods and results Prospective, multicentre, observational project enrolling consecutive patients who underwent L-PM or T-PM implantation. The rate and nature of device-related complications were analysed and compared between the two groups. Individual 1:1 propensity matching of baseline characteristics was performed. A total of 2669 (n = 665 L-PM) patients were included and followed for a median of 39 months, L-PM patients were on average older and had more co-morbidities. The risk of device-related complications at 12 months was significantly lower in the L-PM group (0.5% vs. 1.9%, P = 0.009). Propensity matching yielded 442 matched pairs. In the matched cohort, L-PM patients trended toward having a lower risk of overall device-related complications (P = 0.129), had a similar risk of early complications (≤30 days) (P = 1.000), and had a significantly lower risk of late complications (>30 days) (P = 0.031). All complications observed in L-PM group were early. Most (75.0%) of complications observed in T-PM group were lead- or pocket-related. Conclusion In this analysis, the risk of device-related complications associated with L-PM implantation tended to be lower than that of T-PM. Specifically, the risk of early complications was similar in two types of PMs, while the risk of late complications was significantly lower for L-PM than T-PM. [ABSTRACT FROM AUTHOR]

Background: Cardiac implantable electronic device (CIED) implantation is on the rise, accompanied by an increase in its inevitable complications such as different types of CIED infections that require further therapy and potential device extraction. Ensuring efficacy and safety remains paramount in transvenous lead extraction (TLE), given the complex nature of the procedure. The purpose of this study is to assess the outcomes of relatively low-cost mechanical TLE, including mid-term clinical follow-up, and to develop a predictive model for post-TLE survival. This study included all consecutive patients admitted for TLE at two tertiary medical centers between 2016 and 2021. Baseline characteristics, TLE procedure details complications occurring during and/or after the procedure and follow-up outcomes were collected., Results: During the 5-year period, 100 consecutive patients underwent TLE. The mean age of the subjects was 61 ± 3 years. The average time from lead implantation to TLE was 69.34 ± 9.36 months, with a total of 216 leads extracted. The most common indication for TLE was infection observed in 87% of subjects with pocket infection seen in the majority (84%). Complete clinical success was achieved in 98% of patients, with major complications occurred in 5% of cases and only one case of peri-procedural death. Proposed experimental model showed that near 50% of the patients will live less than 73.29 months., Conclusion: TLE demonstrated a high level of safety with low mortality and morbidity rates. Using low cost widely available mechanical tools is useful for treating CIED-related infections., Competing Interests: Declarations. Ethical approval and consent to participate: Following approval from the local ethics committee (Tehran University of Medical Sciences), with the ethical code IR.TUMS.IKHC.REC.1399.212. Informed consent was obtained from all patients who entered this study. The authors state that they have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. Meanwhile, informed written consent has been obtained from the participants who participated in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Safety and efficacy of leadless pacemakers (L-PM) have been demonstrated in multiple clinical trials, but real-world data on patient selection, implantation technique, and peri-procedural patient management in a clinical practice setting are lacking. Consecutive patients undergoing L-PM implantation in 14 Italian centers were followed in a prospective, multicentre, observational project. Data on baseline patient characteristics, clinical indications, implantation procedure, and peri-procedural patient management were collected. The rate and nature of device-related complications were also recorded. A total of 782 L-PM patients (68.4% male, 75.6 ± 12.4 years) were included in the analysis. The main patients-related reason leading to the choice of implanting a L-PM rather than a conventional PM was the high-risk of device infection (29.5% of cases). The implantation success rate was 99.2%. The median duration of the procedure was 46 min. In 90% of patients the device was implanted in the septum. Of patients on oral anticoagulant therapy (OAT) (n = 498) the implantation procedure was performed without interrupting (17.5%) or transiently interrupting OAT without heparin bridging (60.6%). During a median follow-up of 20 months major device-related complications occurred in 7 patients (0.9%): vascular access-site complications in 3 patients, device malfunction in 2 patients, pericardial effusion/cardiac tamponade in one patient, device migration in one patient. In the real world setting of Italian clinical practice L-PM is often reserved for patients at high-risk of infection. The implantation success rate was very high and the risk of major complications was low. Peri-procedural management of OAT was consistent with available scientific evidence. • Leadless pacemaker is often reserved for patients at high-risk of infection. • Electrical parameters are optimal and remain stable during follow-up. • The rate of major device-related complications is low. • Peri-procedural management of OAT was consistent with available scientific evidence. [ABSTRACT FROM AUTHOR]

Background: Although infections are a significant potential complication among patients undergoing left ventricular assist device (LVAD) implantation, standardized surgical infection prophylaxis (SIP) regimens are not well defined. At Montefiore Medical Center, a 4‐drug SIP regimen containing fluconazole, ciprofloxacin, rifampin, and vancomycin was previously utilized. In January 2020, the antimicrobial stewardship program implemented a 2‐drug SIP regimen of vancomycin and cefazolin to limit exposure to broad‐spectrum antibiotics. This study evaluated LVAD‐associated infection rates prior to and following the SIP revision. Methods: A retrospective review of patients who underwent LVAD implantation from 1/2018 to 4/2021 was performed. Infections were classified using the International Society for Heart and Lung Transplantation definitions. Infection rates at 2 weeks, 30 days, and 90 days post‐implantation in the 4‐drug SIP regimen (1/2018‐12/2019) and the 2‐drug SIP regimen (1/2020 to 4/2021) were compared. Results: A total of 71 patients were included. The number of patients with LVAD‐associated infections (including surgical site infections) was not significantly different in either SIP group at 2 weeks (9% vs. 4%, p =.64), 30 days (9% vs. 11%, p =.99), or 90 days (19% vs. 14%, p =.75). There was no statistically significant difference in 30 or 90‐day mortality. LVAD‐associated gram‐negative (7% vs. 7%; p >.99) and fungal (5% vs. 0%; p =.51) infections were uncommon. The most common organism isolated was Staphylococcus aureus, and the most common type of infection was pneumonia in both SIP groups. Conclusion: No significant difference in LVAD‐associated infections or infection‐related mortality was observed with de‐escalation of perioperative antibiotics. Additional studies with larger sample sizes are needed to endorse the findings of this study. [ABSTRACT FROM AUTHOR]

The article focuses on cases of potential allergic or inflammatory reactions to the TYRX antibacterial envelope used in cardiac implantable electronic devices (CIEDs). The cases involve purulent discharge, absence of systemic infection, healthy tissue appearance, and negative cultures. Topics discussed include the prevalence of such reactions, clinical presentations, and the need for differentiation from infection to guide appropriate management.

Introduction: The skin overlying cardiovascular implantable electronic devices (CIEDs) sometimes becomes very thin after implantations, which could cause a device erosion. The factors related to the skin thickness of device pockets have not been elucidated. This study aimed to evaluate the skin thickness of CIED pockets and search for the factors associated with the thickness. Methods: Seventeen skin thickness points around the CIED pocket were measured through ultrasonography in each patient. Results: A total of 101 patients (76 ± 11 years, 26 female) were enrolled. The median duration from the implantation to the examination was 95 months (quartile: 52.5–147.5). The median skin thickness overlying the device was 4.1 mm (3.3–5.9). Patients with heart failure and malignancy had thinner skin overlying the CIED than those without. A significant correlation existed between skin thickness and body mass index (BMI), hemoglobin, serum creatinine, estimated glomerular filtration rate (eGFR), and left ventricular ejection fraction. In contrast, age, gender, and device size did not exhibit a significant correlation with skin thickness. A multivariate logistic regression analysis revealed that chronic heart failure and a decrease in the eGFR and BMI were independent predictive factors of "very thin (≦3.3 mm)" skin of the CIED pocket late after an implantation. Conclusion: Aside from a low BMI, the comorbidities (low hemoglobin, heart failure, and renal dysfunction) had a stronger impact on the skin thickness overlying the device than the device size. A careful observation of the device pocket should be performed in patients with those risk factors. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular implantable electronic device (CIED) infections are associated with increased mortality and morbidity.Objective: This study sought to evaluate the impact of early vs delayed transvenous lead removal (TLR) on in-hospital mortality and outcomes in patients with CIED infection.Methods: Using the nationally representative, all payer, Nationwide Readmissions Database, we evaluated patients undergoing TLR for CIED infection between January 1, 2016, and December 31, 2018. The timing of TLR was determined on the basis of hospitalization days after the initial admission for CIED infection. The impact of early (≤7 days) vs delayed (>7 days) TLR on mortality and major adverse events was studied.Results: Of the 12,999 patients who underwent TLR for CIED infection, 8834 (68%) underwent early TLR and 4165 (32%) underwent delayed TLR. Delayed TLR was associated with a significant increase in in-hospital mortality (8.3% vs 3.5%; adjusted odds ratio 1.70; 95% confidence interval 1.43-2.03; P < .001). Subgroup analysis of patients with CIED infection and systemic infection showed that delayed TLR in patients with systemic infection was associated with a higher rate of in-hospital mortality compared with early TLR (10.4% vs 7.5%; adjusted odds ratio 1.24; 95% confidence interval 1.04-1.49; P < .019). Delayed TLR was also associated with significantly higher adjusted odds of major adverse events and postprocedural length of stay.Conclusion: These data suggest that delayed TLR in patients with CIED infection is associated with increased in-hospital mortality and major adverse events, especially in patients with systemic infection. [ABSTRACT FROM AUTHOR]

Competing Interests: Disclosures The authors have no conflicts of interest to disclose.

Pantoea Agglomerans is an environmental gram-negative aerobic bacillus in the Enterobacteriaceae family. Typically, it is not responsible for infections in humans. We present the case of an immunocompetent patient who developed Pantoea Agglomerans bacteremia, Cardiovascular Implantable Electronic Device (CIED)-related endocarditis, and cholecystitis following a cat scratch. Following this case, we performed a review of the available literature regarding Pantoea Agglomerans. Overall, infections in humans are very well-treated with few strains of Pantoea Agglomerans demonstrating resistance to antimicrobial therapy. Learning objective: Recognize uncommon bacterial etiologies of endocarditis and review treatment modalities for Pantoea infections.

Purpose of Review: Repeat anti-incontinence surgery presents a challenging clinical entity due to altered anatomy and potentially impaired tissue health due to previous dissection, radiation, or infection. This document seeks to explore the etiologies leading to recurrent incontinence after primary intervention, outline a systematic approach to the evaluation of such patients, and explore our approach to the management of the most common scenarios. Recent Findings: For patients with a prior artificial urinary sphincter (AUS), repeat surgery may be required due to atrophy, mechanical malfunction, or infection/erosion. We use a transcorporal technique for added tissue bulk in the setting of revision for urethral atrophy, a technique which was found to have significantly lower revision and cuff erosion rates while preserving erectile function. Recent studies demonstrate that both cuff downsizing and repositioning are associated with incontinence failure and downsizing has an additional statistically significant risk of mechanical failure. New strategies seeking to avoid such surgical revisions pursue urethral capsulotomy to restore urethral caliber. Summary: In the case of atrophy and mechanical malfunction, complete device exchange is typically performed if the initial implantation was performed within 3 years. When erosion is encountered, explantation of all components is performed, with consideration for a delayed reimplantation which can be technically challenging. In patients with persistent or recurrent urinary incontinence after male urethral sling placement, limited data is available. From the series available, AUS placement after a sling provides excellent outcomes. [ABSTRACT FROM AUTHOR]

Complete removal of cardiac implantable electronic devices (CIEDs) is recommended in patients with CIED infections, including both systemic and localized pocket infection. The aim of the study was to provide an up-to-date and comprehensive assessment of evidence relating to the effect of complete CIED extraction in patients with a CIED infection. We performed a systematic review and meta-analysis of studies reporting short- and mid-term outcomes in patients who had a device infection or infective endocarditis (IE) and underwent complete removal of the cardiac device (generator and leads) compared to those who received conservative therapy (no removal, partial removal, local antibiotic infiltration or isolated antibiotic therapy). The primary outcome was reinfection/relapse. Secondary outcomes were short-term (30-day/in-hospital) and mid-term (mean follow-up: 43.0 months) mortality. Random effects model was performed. Thirty-two studies met the criteria for inclusion in the final analysis. Patients with complete CIED extraction (n = 905) exhibited a lower rate of relapse/re-infection compared to patients (n = 195) with a conservative treatment approach (n = 195, OR 0.02, 95%CI 0.01–0.06, p < 0.0001, mean-follow-up: 16.1 months). Additionally, these patients displayed a lower short- (OR 0.40, 95%CI 0.23–0.69, p = 0.01) and mid-term (OR 0.52, 95%CI 0.34–0.78, p = 0.002) mortality. The analysis indicates that patients with a CIED infection who undergo complete CIED extraction exhibit a lower rate of relapse/re-infection. Additionally, a lower short- and mid-term mortality is observed, although it is acknowledged that this outcome may be influenced by treatment allocation bias. • Patients with a CIED infection who undergo complete CIED extraction for management exhibit a lower rate of relapse/re-infection. • Furthermore, there is a observed decrease in short- and mid-term mortality, though it's recognized that treatment allocation bias might influence this outcome. • It's important for colleagues to recognize that opting for conservative management increases the risk of relapse or reinfection. [ABSTRACT FROM AUTHOR]

Cardiac devices are frequently used in different cardiovascular conditions for the purpose of morbidity or mortality prevention. These include cardiac implantable electronic devices (CIED) like permanent pacemakers and implantable cardiac defibrillators, ventricular assistance devices (VADs), left atrial appendage occlusion (LAAO) devices like the Watchman™, atrial and ventricular septal occluders like the Amplatzer™, among others. In the past years, there has been an increase in the development of these devices as a result of a rise in the number of indications for implantation, paired with the aging and more medically complex patient population. This has led to an increase in the incidence of cardiac device-related infections, one of the most feared and serious complications which is associated with significant morbidity, mortality and financial burden. Accurate diagnosis of cardiac device-related infections is essential given the management implications which often involve removal of the infected device, removal of other prosthetic material and long-term antimicrobial therapy. Clinical and laboratory data are useful diagnostic tools but multimodality imaging is often necessary. The recently published 2020 European Heart Rhythm Association International Consensus document, which is endorsed by many expert societies, has recommended the use of multimodality imaging for the diagnosis of CIED infections. (1) This allows better disease characterization by identifying abnormal fluid collections and guiding aspiration for both diagnostic and therapeutic purposes (i.e. soft tissue ultrasound and computed tomography), evaluation for local extent of disease (i.e. transesophageal echocardiogram to evaluate for concomitant infective endocarditis), embolic manifestation of disease (i.e. computed tomography and magnetic resonance imaging) and metabolic tissue characterization (positron emission tomography and tagged white blood cell scan). (2) In addition, computed tomography (CT) allows for pre-procedural planning which has shown to be associated with better procedural outcomes.

Patients who have undergone cardiac surgery using prosthetic devices have an increased risk of developing prosthetic device-related infection and mediastinitis. However, accurate diagnosis of prosthetic device-related infection can be difficult to evaluate and treat with antibiotic therapy alone. In recent years, 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) has made promising contributions to detect infective endocarditis, pacemaker infections, or other inflammations. Nevertheless, 18F-FDG PET-CT for congenital heart disease (CHD) with device infection has been sparsely reported. We present an infantile girl diagnosed with pulmonary atresia with a ventricular septal defect who underwent replacement of the right ventricle-to-pulmonary artery (RV-PA) conduit for improvement cyanosis. She developed high fever and was diagnosed with mediastinitis and bacteremia by Pseudomonas aeruginosa (P. aeruginosa) on postoperative day 4. Mediastinal drainage and 6 weeks of antibiotic therapy improved her condition, but bacteremia flared up on postoperative day 56. Despite a long course of antibiotic therapy, she had two more recurrences of bacteremia with the detection of P. aeruginosa. Echocardiography and chest contrast CT showed no evidence of vegetation and mediastinitis. On postoperative day 115, 18F-FDG PET-CT revealed an accumulation on the RV-PA conduit (SUV max 3.4). Finally, she developed an infectious ventricular pseudo-aneurysm on postoperative day 129 and underwent aneurysm removal and RV-PA conduit replacement on postoperative day 136. Our case showed the importance of 18F-FDG PET-CT for diagnosing specific localization of prosthetic device-related infection which is hard to detect using other imaging techniques. It can be a useful diagnostic tool for infantile patients with CHD with cardiac prosthetic devices and improve subsequent clinical treatments.

Objective: Wound dehiscence (WD) has been reported as a complication in 0.3% of cardiac implantable electronic device (CIED) procedures. Stapling has not previously been reported as a treatment modality for WD. Presently described is the experience of a single center with WD and its management. Methods: A retrospective chart review of all patients who underwent CIED implantation between 2009 and 2016, a total of 759 devices, was performed. Results: There were a total of 11 (1.4%) patients with WD. The majority 9/11 patients were female, 5 of 11 (45.5%) had diabetes, and 2 of the 11 patients were immunocompromised due to recent chemotherapy. WD occurred in 6 patients after generator change, in 2 patients after a biventricular device upgrade, in 1 patient after biventricular implantable cardioverter defibrillator (ICD) implantation, in 1 patient after dual-chamber pacemaker implantation, and in 1 patient after subcutaneous ICD implantation. The median time of WD was 6 weeks post procedure (range: 1–20 weeks). In all of the patients, wound stapling was performed under sterile conditions after administering intravenous narcotic analgesics. Eight patients received intravenous antibiotics and all patients received at least 2 weeks of oral antibiotics. Blood cultures were negative in 8/11 (72.7%) patients. However, the wound cultures in 5 patients were positive. The staples were removed in a median of 16 days (range: 9–36 days). All of these patients were successfully treated with stapling and none of the devices required extraction. Conclusion: Stapling under sterile conditions may be an acceptable treatment strategy to manage WD after device implantation. This can be performed as an outpatient procedure and can help avoid unnecessary device extraction.

Background: Short duration, antimicrobial prophylaxis that includes antistaphylococcal activity is recommended at the time of left ventricular assist device (LVAD) implantation to reduce infection‐related complications. There continues to be wide variability in surgical infection prophylaxis (SIP) regimens among implantation centers. The aim of this study is to characterize current SIP regimens at different LVAD centers. Methods: A survey study was conducted from 26 September 2017 to 25 October 2017. Surveys were distributed electronically to LVAD coordinators and infectious diseases specialists at 75 US medical centers identified as having an LVAD program. Data collection included information about antimicrobial selection, duration, Staphylococcus aureus screening, and decolonization procedures. Results: We received 29 survey responses. The majority of surveys were completed by infectious diseases physicians (72.4% [21 out of 29]). Most responding centers reported LVAD programs established for greater than 10 years (20 out of 29 [69%]). Cardiac transplantation was performed in 28 out of 29 (96%) centers. Of centers reporting a defined SIP regimen for non‐penicillin allergic patients (96% [28 out of 29]), 17.9% (5 out of 28) reported a four‐drug regimen, 35.7% (10 out of 28) reported a three‐drug regimen, and 46.4% (13 out of 28) reported a two‐drug regimen, while no centers reported a single‐drug regimen. Empiric fluconazole was common (50% [14 out of 28]) and 96.4% (27 out of 28) of regimens included vancomycin. Duration of antimicrobial prophylaxis (24 hours to 5 days), S. aureus screening, decolonization procedures, and alterations due to drug allergies varied across participating centers. Conclusions: Our survey results indicate wide variation in SIP regimens among participating LVAD centers. These results highlight the need for studies evaluating the implications of SIP regimens, and whether clinical factors that prolong antimicrobial duration impact postoperative infection rates. [ABSTRACT FROM AUTHOR]

Background The Attain Stability Quadripolar 4798 lead is a relatively new quadripolar active fixation coronary sinus (CS) lead. No cases of extraction of a chronically implanted 4798 lead have been published to date. Case summary A 52-year-old man with a history of previous cardiac resynchronization therapy pacemaker (CRT-P) insertion and atrioventricular node ablation presented to our institution with a pocket infection 69 weeks after implantation. Directed intravenous antibiotic therapy was commenced and an extraction was performed the following day. Extraction of the right atrial and right ventricular leads was simple and achieved with gentle manual traction. Extraction of the CS lead was more difficult. Significant traction was required due to the formation of adhesions inside the CS but extraction of the lead was eventually successful without complication. Specialized extraction equipment was not required. A new contralateral CRT-P device was implanted, and the patient was discharged home. He remains well at 3 months of follow-up. Discussion We present the first case of extraction of a chronically implanted active fixation Attain Stability Quadripolar lead. Our experience demonstrates that this has been performed successfully without specialist tools and with preservation of the CS branch. Significant adhesion was noted at the site of active fixation, however. Potential difficulty with this lead's extraction should therefore be considered when contemplating its use. [ABSTRACT FROM AUTHOR]

Introduction: Subcutaneous defibrillator (S-ICD) is the latest development in the clinically available devices for sudden cardiac death prevention. Experience from pivotal trials and post-marketing studies has proven the feasibility and safety of S-ICD. Extra-cardiac location of S-ICD obviates the need for transvenous leads which translates into lower incidence of lead-related complications and systemic infections. This is a review on peri-procedural interventions to minimize complications associated with S-ICD during implant and follow-up.Areas Covered: This paper will highlight the results of pertinent studies related to perioperative management of S-ICD and review the approaches to minimize the risk of complications such as hematoma at the pulse generator location, unsuccessful defibrillation due to suboptimal S-ICD lead and generator position, postoperative pain, inappropriate shocks due to T wave oversensing and interaction with concomitant cardiac implantable devices. An extensive literature search was performed to identify the relevant articles.Expert Commentary: The use of S-ICD is expanding, and the published results suggest a preferential use of such devices for younger patients and those with a potential risk of infection from intravascular devices. The perioperative management of S-ICD has significantly evolved during a decade of experience. Contemporary experience suggests that these procedures are associated with minimal complications. [ABSTRACT FROM AUTHOR]

Aims: Patients with infective endocarditis (IE) frequently have cardiac implantable electronic devices (CIEDs). Here, we aim to define the clinical profile and prognostic factors of IE in these patients.Methods and Results: Infective endocarditis cases were prospectively identified in the Spanish National Endocarditis Registry. From 3996 IE, 708 (17.7%) had a CIED and 424 CIED-related IE (lead vegetation). Patients with a CIED were older (68 ± 11 vs. 73 ± 8 years); had more comorbidities {pulmonary disease [176 (24.8%) vs. 545 (16.7%)], renal disease [239 (33.8%) vs. 740 (22.7%)], diabetes [248 (35.0%) vs. 867 (26.6%)], and heart failure [348 (49.2%) vs. 978 (29.9%)]}; and fewer complications {intracardiac destruction [106 (15%) vs. 1077 (33.1%)], heart failure [215 (30.3%) vs. 1340 (41.1%)], embolism [107 (15.1%) vs. 714 (21.9%)], and neurological involvement [77 (10.8%) vs. 702 (21.5%)]} (all P-values <0.001) in comparison to subjects without a CIED. In-hospital mortality was similar in patients with and without CIED [171 (24.2%) vs. 881 (27.0%), P = 0.82]. In subjects with a CIED, CIED-related IE was independently associated with in-hospital survival: odds ratio (OR) 0.4 [95% confidence interval (CI) 0.3-0.7, P = 0.001]. Surgery was independently associated with in-hospital survival in CIED-related IE: OR 0.4 (95% CI 0.2-0.7, P = 0.004); but not in subjects with valve IE and no CIED lead involvement: OR 0.9 (95% CI 0.5-1.7, P = 0.77).Conclusion: Over a sixth of IE patients have a CIED. This group of patients is older, with more comorbidities and fewer IE-related complications in comparison to subjects without a CIED. In-hospital mortality was similar in patients with and without a CIED. [ABSTRACT FROM AUTHOR]

Introduction: The need for transvenous lead extractions due to cardiac implantable electronic device (CIED)‐related infections continues to rise. Current guidelines recommend complete device removal in the setting of an active infection, which can be challenging in pacemaker‐dependent patients. Methods: We retrospectively reviewed all leadless pacemaker implants between January 2018 and November 2019 and identified a subset of patients who had undergone a concomitant CIED extraction in the setting of an active infection. Baseline characteristics, procedural details, and clinical follow‐ups were recorded. Results: Seventeen patients received a leadless pacemaker during the same procedure as the CIED extraction. There were no procedural complications. All patients were being treated for an active CIED infection at the time of the procedure. Fourteen patients (82.4%) were completely pacemaker‐dependent and four patients (23.5%) had positive blood cultures at the time of the leadless pacemaker implantation. During a median follow‐up of 143 days (interquartile range: 57, 181 days), there were no recurrent infections. Conclusion: Simultaneous leadless pacemaker implantation and CIED extraction are safe and feasible in the setting of an active infection. This strategy may be particularly useful in patients that are pacemaker‐dependent. [ABSTRACT FROM AUTHOR]

Abstract An 86‐year‐old woman suffering from repeated methicillin‐resistant Staphylococcus aureus (MRSA) bacteremia underwent percutaneous lead extraction using an excimer laser. Since negative blood cultures were confirmed three times after lead extraction under intravenous infusion of anti‐MRSA drugs, a Micra transcatheter pacing system (Micra TPS) was implanted 7 days after the lead extraction. Although infusion of anti‐MRSA drugs was continued for 5 weeks, MRSA was isolated in four separate samples of blood cultures 3 weeks after the discontinuation of the anti‐MRSA therapy. The micra TPS was successfully retrieved using a steerable sheath and snare at 8 weeks after implantation.

Aims: The safety of pacemaker reuse has been proven by numerous studies in the last two decades. With the exception of one research paper, the safety of reuse of implantable cardioverter‐defibrillators has not been properly investigated. Our aim was to establish whether resterilized implantable cardioverter‐defibrillators are as safe as new devices in relation to functionality and infection rates. Methods: All the patients (n = 271) implanted with a new or a donated, used implantable cardioverter‐defibrillator (ICD) at the Institute of Cardiovascular Disease Timisoara Romania between January 2001 and December 2012 were included in the study. The patients had class I indication for ICD implantation. One hundred fifty‐seven patients received reused ICDs and 114 patients received new ICDs. Complications were defined as infections that required reintervention, device malfunction, and replacements due to untimely or unexpected battery depletion. Results: Complications occurred in 4.38% of the patients in the new ICD group and in 1.91% of the reused ICD group. The difference was not considered statistically significant (odds ratio 0.28, 95% confidence interval 0.04‐1.82, P = .18). Conclusion: According to our data, properly verified and resterilized ICDs are as safe as new devices, when risk of infection or malfunction rates are assessed. Due to the high costs of new ICDs, their safe reuse has profound humanitarian and financial implications. [ABSTRACT FROM AUTHOR]