Expert Consensus on Cardiac Implantable Electronic Devices

Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al.
2017 HRS Expert Consensus Statement on Cardiovascular Implantable Electronic Device Lead Management and Extraction. Heart Rhythm 2017;14:e503-e551.

The following are key points to remember from the 2017 HRS expert consensus statement on cardiovascular implantable electronic device (CIED) lead management and extraction:

  1. Currently, most CIEDs use leads that connect the generator to cardiac tissue. Lead management is an important issue given lead failures, generator changes, or in clinical conditions that can potentially directly affect CIEDs such as infection.
  2. A lead model and clinical scenario-specific strategy of increased surveillance and management is recommended for CIED leads that have been identified with higher than expected failure rates.
  3. Leaving the lead in a condition that will permit future extraction and avoids retraction into the vessel is recommended for any lead that is abandoned.
  4. Careful consideration with the patient on the decision on whether to abandon or remove a lead is recommended before the procedure. The risks and benefits of each course of action should be discussed and any decision should take patient preference, comorbidities, future vascular access, and available programming options into account.
  5. In all patients with suspected CIED infection, if antibiotics are going to be prescribed, at least two sets of blood cultures drawn before initiation of antibiotic therapy is recommended to improve the precision and minimize the duration of antibiotic therapy.
  6. Gram stain and culture of generator pocket tissue and the explanted lead(s) are recommended at the time of CIED removal to improve the precision and minimize the duration of antibiotic therapy.
  7. Preprocedure transesophageal echocardiography is recommended in patients with suspected systemic CIED infection to evaluate the absence or size, character, and potential embolic risk of identified vegetations.
  8. Evaluation by physicians with specific expertise in CIED infection and lead extraction is recommended for patients with documented CIED infection.
  9. A complete course of antibiotics based on identification and in vitro susceptibility testing results after CIED removal is recommended in all patients with definite CIED system infection.
  10. Complete device and lead removal is recommended in all patients with definite CIED system infection. Complete removal of epicardial leads and patches is recommended in all patients with confirmed infected fluid (purulence) surrounding the intrathoracic portion of the lead.
  11. Careful consideration of the implications of other implanted devices/hardware is recommended when deciding on appropriateness of CIED removal and for planning treatment strategy and goals.
  12. Lead removal is recommended in patients with clinically significant thromboembolic events attributable to thrombus on a lead or a lead fragment that cannot be treated by other means. Lead removal is recommended in patients with planned stent deployment in a vein already containing a transvenous lead, to avoid entrapment of the lead. Lead removal is recommended in patients with life-threatening arrhythmias secondary to retained leads.
  13. Extraction program and operator-specific information on volume, clinical success rates, and complication rates for lead removal and extraction should be available and discussed with the patient prior to any lead removal procedure.

Clinical Topics: Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Arrhythmias, Cardiac, Comorbidity, Consensus, Echocardiography, Transesophageal, Embolism, Infection, Risk Assessment, Secondary Prevention, Stents, Thrombosis

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