A 78-year old male patient with a left-sided superior vena cava presented with systemic device infection and atrial fibrillation. Transvenous lead extraction was successfully performed. Due to a previously difficult endovascular left-ventricular (LV) lead implantation and pacemaker dependency, an epicardial LV-lead was implanted via minimally-invasive left-lateral thoracotomy. Simultaneously, due to AF, left-atrial appendage closure using an epicardial clip was performed through the same access. The patient was discharged with a wearable defibrillator and scheduled for a CRT-D upgrade eight weeks later. An implantation of new transvenous RV- and RA lead was performed and the existing left-ventricular epicardial lead was used.

Introduction: Treating patients with CIED infections is often challenging. In general, the infected device, including all leads, needs to be completely removed before a new CIED can be implanted. Especially in pacemaker-dependent patients, it is often impossible to have a device-free interval to treat the infection. In those cases, the question remains when to implant a new CIED and which bridging strategy to use. Methods: In this single-center retrospective analysis, we included 190 patients who received a complete CIED system extraction between 2013 and 2019 due to device-related infection. We compared three different treatment algorithms. Group 1 (SR) included 89 patients who received system removal only (and delayed re-implantation). Group 2 (EL) consisted of 28 patients who were treated with lead extraction and simultaneous epicardial lead implantation, while the 78 patients in Group 3 (SI) received lead removal with simultaneous contralateral implantation of a new device. We retrospectively analyzed the peri- and postoperative course and one-year follow-up. Results: Patients in the SR and EL groups were significantly older, had more comorbidities and a higher percentage of systemic infection compared to the SI group. We found a comparable high number of successful infection treatments in all groups, with complete lead removal in 95.5%, 96.4%, and 93.2% for the SR, EL, and SI groups, respectively. Lead vegetations were removed in 97.7%, 94.1%, and 100%. Device re-implantation was 100% in the EL and SI groups, whereas in the SR group, only 49.4% of patients received a device re-implantation. At one-year follow-up, the percentage of freedom from infection and pocket irritation was comparable between groups (94.7% SR and EL, 100% SI). We observed no procedure-related mortality, while one-year mortality was 3.4% in the SR, 21.4% in the EL and 4.1% in the SI group. Conclusion: We found comparable success rates regarding device removal, successful infection treatment and perioperative course between groups. However, most likely due to the sicker patient collective with a high number of systemic infections, the one-year mortality was significantly higher in the EL group. Treatment algorithm should be selected due to type, severity, location of infection and comorbidities of the patients.