Complete system explantation versus conservative treatment in patients with infections of Implantable Cardioverter Defibrillators

Introduction Device infection is a life-threatening complication in patients with Implantable Cardioverter defibrillator (ICD). Therefore, current guidelines recommend complete system explantation of infected devices (Class I B recommendation). However, complete system removal may be associated with an increased risk of mortality due to the complexity of implanted devices or the frailty of affected patients. Less invasive strategies, such as partial removal of the device, wound revision with device relocation or lifelong antibiotic therapy may be alternatives to system explantation. Aim of the study was to investigate the long-term outcome of patients with ICD-device infection who were assigned either to a system explantation strategy or alternative less invasive strategies (conservative strategy: no removal, only generator removal, wound revision, device relocation, only antibiotic therapy). Methods A total of 86 consecutive ICD patients from a prospective single-centre ICD-registry who developed a device infection between 2013 and June 2024 were analyzed. For all patients, the strategy of complete removal or conservative therapy was determined by a heart team. Results Patients in the conservative group were 9 years older, more often frail, and more frequently had pocket infections (Table 1). The estimated survival rate was similar in both groups (Figure 1). In a multivariate analysis adjusted for age, gender, EF, staph aureus and pocket infection, conservative treatment strategy was not associated with an increased mortality (HR 2.06, 95% CI 0.71 – 6.02). During follow-up, nearly half of the patients (45%) of the conservative group had a relapse of ICD infection or chronic wound infection compared to 6% of patients treated with complete removal strategy (p < 0.001). Conclusion In patients with ICD device infection, conservative strategy is associated with a 7fold increased recurrence rate of device infection or chronic wound infection compared to a complete removal strategy but not with increased mortality. Thus, in selected patients with ICD infection and high surgical risk, a conservative treatment strategy may present a therapeutic alternative to complete removal.Table 1Figure 1