What are the indications for Implantable Cardioverter-Defibrillator (ICD) removal?

Indications for ICD Removal

Complete ICD removal is definitively indicated for all patients with CIED infection, including pocket infection, lead endocarditis, or sepsis, as this is the most effective approach to reduce mortality and morbidity. 1

Primary Indications for ICD Removal

Infection-Related Indications (Class I)

• Device pocket infection - evidenced by:
  • Abscess formation
  • Device erosion
  • Skin adherence
  • Chronic draining sinus 1
• Systemic infection with:
  • Lead and/or valvular endocarditis
  • Sepsis 1
• Occult staphylococcal bacteremia - even without obvious device involvement 1
• Persistent or recurrent bacteremia - particularly with no other identified source 1

Non-Infectious Indications

• Device malfunction requiring replacement when:
  • Battery depletion occurs
  • Lead failure is present
  • System upgrade is necessary 2
• Heart transplantation - device is no longer needed after transplant 3

Timing of ICD Removal in Infections

The European Heart Rhythm Association (EHRA) and Heart Rhythm Society (HRS) guidelines emphasize that device removal should occur without unnecessary delay, ideally within 3 days of diagnosis, as early extraction is associated with lower in-hospital mortality 1.

Management Considerations

Temporary Protection During ICD Removal

• For patients with prior SCA or sustained VA requiring ICD removal (especially due to infection):
  • Wearable cardioverter-defibrillator is reasonable (Class IIa) for temporary protection 1, 4
  • Ensures continued protection from sudden cardiac death during the period between removal and reimplantation

Antibiotic Management

• Duration of antimicrobial therapy:
  • 10-14 days after removal for pocket-site infection
  • At least 14 days for bloodstream infection
  • 4-6 weeks for complicated infection (endocarditis, septic thrombophlebitis, osteomyelitis) 1

Reimplantation Considerations

• Assess continued need for device before reimplantation
• When reimplantation is necessary:
  • Place on contralateral side when possible
  • Consider abdominal placement with tunneled leads if same-side placement is required 1

Special Situations

Contraindications to ICD Removal (Class III)

• Superficial or incisional infection without involvement of the device or leads 1
• Relapsing bloodstream infection due to a source other than the ICD that requires long-term suppressive antibiotics 1

High-Risk Patients

For patients with prohibitive surgical risk:

• Chronic antibiotic suppression may be considered, but:
  • Associated with high relapse rate (18% within 1 year)
  • Poor overall survival (median 1.43 years) 5
  • No reliable clinical predictors of successful salvage have been identified 6

Common Pitfalls and Caveats

1. Delayed recognition of device infection - symptoms can mimic other infections and be overlooked 1

2. Incomplete device removal - all hardware including abandoned leads should be removed to prevent relapse 1

3. Attempted device salvage - studies show high failure rates (58% early failure, 51% late failure among initial survivors) 6

4. Inadequate duration of antibiotics - particularly for complicated infections with endocarditis or persistent bacteremia 1

5. Non-compliance with wearable cardioverter-defibrillator - three sudden deaths occurred in patients not wearing their devices in one study 4

The evidence strongly supports complete system removal for CIED infections, with no reliable clinical factors predicting successful salvage attempts. Delays in device removal are associated with increased mortality and relapse rates.