What are the criteria for removal of an Implantable Cardioverter-Defibrillator (ICD)?

Criteria for ICD Removal

Complete device and lead removal is mandatory for all patients with definite ICD infection (valvular/lead endocarditis or sepsis), pocket infection (abscess, erosion, skin adherence, chronic draining sinus), valvular endocarditis without definite lead involvement, or occult staphylococcal bacteremia. 1

Infectious Indications (Class I Recommendations)

Definite ICD Infection

• Valvular and/or lead endocarditis confirmed by transesophageal echocardiography showing vegetations 1
• Sepsis with positive blood cultures and no other identified source 1

Pocket Infection

Complete removal is required when any of the following are present: 1

• Abscess formation at the generator site
• Device erosion through the skin
• Skin adherence to the device
• Chronic draining sinus tract
• Purulent drainage from the pocket

Bacteremia-Related Criteria

• Occult staphylococcal bacteremia (S. aureus or coagulase-negative staphylococci) without other identified source 1
• Relapsing Gram-negative bacteremia despite appropriate antibiotics with no other defined focus 1
• Persistent Gram-negative bacteremia despite appropriate antibiotics with no other source identified 1
• Valvular endocarditis even without definite lead involvement 1

High-Risk Bacteremia Scenarios

ICD removal should be strongly considered when S. aureus bacteremia occurs with: 1

• Relapsing bacteremia after appropriate antibiotic therapy
• No other identified source for bacteremia
• Bacteremia persisting >24 hours
• Presence of a prosthetic cardiac valve
• Bacteremia within 3 months of device placement

Important caveat: Gram-negative bacteremia alone without relapse or persistence does NOT require ICD removal, as infection is unlikely in this scenario. 1

Non-Infectious Indications

End-of-Life Care (Class I Recommendations)

• ICD shock therapy deactivation (not removal) is appropriate when consistent with patient goals and preferences in: 1
  • Refractory heart failure symptoms
  • Refractory sustained ventricular arrhythmias
  • Terminal illness from other causes
• Patients should be informed at implantation and during advance care planning that shock therapy can be deactivated at any time 1

Device Malfunction or Upgrade

• Non-infectious device complications requiring replacement
• Critical point: Do NOT obtain routine microbiological cultures during removal for non-infectious reasons, as contamination frequently yields false-positive results that lead to inappropriate antibiotic use 1

Situations Where Removal is NOT Indicated (Class III)

• Superficial or incisional infection without device/lead involvement 1
• Relapsing bloodstream infection from a source other than the ICD requiring long-term suppressive antibiotics 1
• Isolated Gram-negative bacteremia without relapse or persistence 1

Post-Removal Management Algorithm

Antimicrobial Therapy Duration

• Pocket infection only: 10-14 days after device removal 1
• Bloodstream infection: At least 14 days after device removal 1
• Complicated infection (endocarditis, septic thrombophlebitis, osteomyelitis, or persistent bacteremia): 4-6 weeks 1

Timing of Reimplantation

Before reimplanting, assess whether the patient still requires device therapy—one-third to one-half of patients may not need reimplantation due to resolved indications. 1

Blood culture requirements: 1

• Repeat blood cultures must be negative for at least 72 hours before new device placement
• For valvular infection: delay reimplantation for at least 14 days after first negative blood culture 1

Site selection: 1

• Reimplant on the contralateral side whenever possible to avoid relapsing infection
• Alternative sites include iliac vein or epicardial placement if contralateral approach not feasible

Bridging Strategy for Pacing-Dependent Patients

• Wearable cardioverter-defibrillator is reasonable for patients with history of sudden cardiac arrest or sustained ventricular arrhythmia requiring temporary ICD removal due to infection (Class IIa) 1, 2
• Active-fixation leads connected to external pacing generators can serve as a bridge until reimplantation 1

Common Pitfalls

• Attempting conservative management with antibiotics alone results in 100% relapse rates and must be avoided 3, 4
• Incomplete lead removal significantly increases risk of recurrent infection—all leads must be extracted, not just the generator 3, 4
• Premature reimplantation before adequate blood culture clearance leads to treatment failure 1
• Underestimating infection extent—apparent pocket infections may involve leads or endocardium, requiring transesophageal echocardiography for complete evaluation 3
• Obtaining cultures during non-infectious removals leads to false-positive results and inappropriate management 1