Timing of ICD Removal in Infected Devices
When an ICD infection is diagnosed, complete device and lead removal should occur without unnecessary delay—ideally within 3 days of diagnosis—as early extraction is associated with lower in-hospital mortality. 1
Immediate Removal Indications
Complete device and lead removal is mandatory for the following scenarios and should not be delayed regardless of antimicrobial therapy initiation 1, 2:
- Definite ICD infection including valvular/lead endocarditis or sepsis 1, 2
- Pocket infection with abscess formation, device erosion, skin adherence, chronic draining sinus, or purulent drainage 1, 2
- Valvular endocarditis even without definite lead involvement 1, 2
- Occult staphylococcal bacteremia without other identified source 1, 2
- Persistent or relapsing Gram-negative bacteremia despite appropriate antibiotics with no other defined focus 1, 2
The American Heart Association emphasizes that antimicrobial therapy is adjunctive only, and complete device removal should not be delayed regardless of when antibiotics are started 1.
Timing of Reimplantation After Removal
The timing of new device placement depends critically on the type and extent of infection 1:
For Pocket Infection Only (No Bacteremia)
- Blood cultures must be negative for at least 72 hours before new device placement 1, 2
- Reimplantation can proceed once this criterion is met 1
For Bloodstream Infection Without Valvular Involvement
- Blood cultures must be negative for at least 72 hours after device removal 1, 2
- Median time to reimplantation: 13 days for bacteremic patients versus 7 days for non-bacteremic patients 1
- Pathogen-specific timing: median 7 days for coagulase-negative staphylococci versus 12 days for S. aureus 1
For Valvular Infection (Lead or Valve Vegetations)
- Delay reimplantation for at least 14 days after the first negative blood culture 1, 2
- This extended period allows for adequate treatment of endocarditis 1
For Sustained Bacteremia Despite Removal
- If blood cultures remain positive for ≥24 hours after device removal despite appropriate antibiotics, delay reimplantation until cultures are negative and complete at least 4 weeks of parenteral therapy 1
Critical Reimplantation Principles
The replacement device must NOT be implanted ipsilateral to the extraction site 1. Preferred alternative locations include 1:
- Contralateral side (most preferred) 2
- Iliac vein approach
- Epicardial implantation
Bridging Strategies for Device-Dependent Patients
For pacemaker-dependent patients who cannot be discharged with temporary pacing 1:
- Active-fixation leads connected to external pacing generators serve as a bridge until reimplantation 1, 2
- This approach permits earlier mobilization and reduces risks of lead dislocation, severe bradycardia, and local infection 1
For patients with history of sudden cardiac arrest or sustained ventricular arrhythmia 2:
- Wearable cardioverter-defibrillator is reasonable during the waiting period (Class IIa recommendation) 2
Reassessment of Device Need
Before any reimplantation, carefully evaluate whether the patient still requires device therapy 1, 2. One-third to one-half of patients may not need a new device due to 1, 2:
- Reversal of pathological processes that precipitated initial implantation
- Changing clinical circumstances
- Lack of appropriate clinical indication initially
Common Pitfalls to Avoid
- Do not attempt simultaneous contralateral device exchange at the time of infected device removal—this approach lacks sufficient evidence and is not recommended for routine use despite one center's reported success 1
- Do not use long-term suppressive antibiotics as an alternative to device removal in candidates for extraction (Class III recommendation) 1
- Do not delay extraction for completion of antibiotic courses—removal should proceed promptly once infection is diagnosed 1
- Do not reimplant on the same side—this significantly increases risk of relapsing infection 1