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J Thorac Cardiovasc Surg 1997;113:121-129
© 1997 Mosby, Inc.

SURGERY FOR ACQUIRED HEART DISEASE

THE TREATMENT OF PATIENTS WITH INFECTED IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEMS

Sean O'Nunain, MB, Irving Perez, MD, Marc Roelke, MD, Stefan Osswald, MD, Brian A. McGovern, MD, D. Ross Brooks, MD, David F. Torchiana, MD, Gus J. Vlahakes, MD, Jeremy Ruskin, MD, Hasan Garan, MD, From the Department of Surgery (Cardiac Surgical Unit) and the Department of Medicine (Cardiac Unit), Harvard Medical School and the Massachusetts General Hospital, Boston, Mass.

Received for publication Jan. 15, 1996 Revisions requested March 19, 1996 Revisions received June 17, 1996 Accepted for publication July 8, 1996 Address for reprints: Gus J. Vlahakes, MD, Cardiac Surgical Unit, Massachusetts General Hospital, 55 Fruit St., EDR105, Boston, MA 02114-2696.

Abstract

Objective: The purpose of this study was to evaluate the treatment of patients with infected implantable cardioverter-defibrillator systems. Methods: Retrospective analysis was done of the cases of 21 patients treated for implantable cardioverter-defibrillator infection during an 11-year period. Results: Of 723 cardioverter-defibrillator implantations (550 primary implants, 173 replacements), nine (1.2%) were complicated by early postoperative device-related infections. Late infections developed in two patients 19 and 22 months, respectively, after implantation. Ten other patients were transferred to our institution for treatment of cardioverter-defibrillator infection. The time from implantation to overt infection was 2.2 ± 1.3 months, excluding the two late infections. The responsible organisms were Staphylococcus aureus (9), Staphylococcus epidermidis (6), Streptococcus hemolyticus (1), gram-negative bacteria (3), Candida albicans (1), and Corynebacterium (1). All patients were treated with intravenous antibiotic drugs. Total system removal was done in 15 patients and partial removal in 2; in 4, the cardioverter-defibrillator system was not explanted. There were no perioperative deaths. A new implantable cardioverter-defibrillator system was reimplanted in 7 patients after 2 to 6 weeks of antibiotic therapy. Ten patients were treated without reimplantation (2 arrhythmia operation, 8 antiarrhythmic drugs). Four patients (3 patients without explantation and 1 with partial system removal) were treated with maintenance long-term antibiotic therapy. During a mean follow-up of 21 ± 2.8 months, no patient had clinical recurrence of infection. One patient treated with antiarrhythmic drugs without system reimplantation died suddenly. Conclusions: Infections that involve implantable cardioverter-defibrillator systems can be safely managed by removing the entire system with reimplantation after intravenous antibiotic therapy. In selected patients in whom the risk for system explantation is high and anticipated life expectancy is short, long-term antibiotic therapy to suppress low-virulence infections may represent an acceptable alternative.

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