The Removal, Excision, Sterilization, and Quarantine (RESQ) Method is a Feasible Alternative Treatment for Cardiac Implantable Electronic Device Infections.

Acta Cardiol Sin 2023;39:109-115 Original Article doi: 10.6515/ACS.202301_39(1).20220603C Device Therapy The Removal, Excision, Sterilization, and Quarantine (RESQ) Method is a Feasible Alternative Treatment for Cardiac Implantable Electronic Device Infections Feng-Ching Liao,1,2 Chih-Yin Chien,3,4 Shu-I Lin,1,2,3 Chun-Che Huang,5 Ming-Feng Tsai,2,6 Wei-Ru Chiou,2,7 Po-Lin Lin,8 Jen-Yuan Kuo,1,2 Cheng-Ting Tsai1,2,9 and Ying-Hsiang Lee1,2,9 Background: Current guidelines recommend that all infected cardiac implantable electronic devices (CIEDs) should be removed. However, financial or anatomical concerns can lead to management of infection with simple debridement, as opposed to complete removal. In this observational study, we report the outcomes of our modified procedure for this real-world dilemma. Methods and Results: The Quarantine (RESQ) method is characterized as follows: the removal (R) of all nonessential foreign materials, including old sutures and leads; the excision (E) of all non-viable, chronically inflamed, granulation, or scar tissue; the sterilization (S) of the remaining generator; and the quarantine (Q) of a new pocket in the sub- muscular layer for reimplantation. From a review of electronic medical records, 30 patients were selected and divided into three groups according to the intervention used: RESQ (n = 9) in group A, simple debridement (n = 16) in group B, and guideline-recommended replacement (n = 5) in group C. Patient baseline characteristics were similar between the groups. After analyzing the proportion of patients that were free from infection one year following their respective interventions, we found that group A performed better than group B (100% and 31.2% infection-free, respectively, p = 0.001), and was comparable to group C (both 100% infection-free, p = not applicable). Conclusion: The RESQ method is a feasible and beneficial alternative for selected patients with CIED infections who are unable to receive a generator replacement according to the recommended guideline. Key Words: CIED infection · Lead extraction · Pacemaker · Pocket · RESQ Abbreviations CIEDs E Q R RESQ S Received: September 8, 2021 Accepted: June 3, 2022 1 Cardiovascular Center, MacKay Memorial Hospital, Taipei; 2Department of Medicine, MacKay Medical College, New Taipei City; 3Department of Nursing, MacKay Junior College of Medicine, Nursing, and Management; 4National Taipei University of Nursing and Health Sciences, Taipei; 5Department of Healthcare Administration, I-Shou University, Kaohsiung; 6Division of Plastic Surgery, Department of Surgery, MacKay Memorial Hospital, Taipei; 7Department of Cardiology, Taitung MacKay Memorial Hospital, Taitung; 8Department of Cardiology, Hsinchu MacKay Memorial Hospital, Hsinchu; 9Department of Artificial Intelligence and Medical Application, MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan. Corresponding author: Dr. Ying-Hsiang Lee, Cardiovascular Center, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei 10449, Taiwan. Tel: 886-958015660; E-mail: Cardiac implantable electronic devices Excision Quarantine Removal Removal, excision, sterilization, and quarantine Sterilization INTRODUCTION The widespread use of cardiac implantable electronic device (CIED) therapy in cardiac rhythm disorders has led to a relative increase in the number of complications associated with this treatment.1 Device-related infection 109 Acta Cardiol Sin 2023;39:109-115 Feng-Ching Liao et al. their culture results and data on antibiotic susceptibility, testing in accordance with the current published guidelines. Reimplantation was performed at the discretion of the treating physician. Patients were divided into three groups based on the procedure used to manage their CIED pocket infection. Patients in group A underwent a modified procedure called the RESQ method, which is comprised of four steps: the removal (R) of all non-essential foreign materials, including old sutures and leads; the excision (E) of all non-viable, chronically inflamed, granulation, or scar tissue; the sterilization (S) of the remaining generator; and the quarantine (Q) of a new pocket in the sub-muscular layer for reimplantation. Patients in group B received the traditional surgical method (step E with or without Q), and were treated with open surgical debridement and chronic suppressive antibiotic therapy, without removal of the CIED. Patients in group C underwent removal and contralateral side implantation treatment as per current guidelines. Unlike those in group B, all patients in group A received a new pocket in the sub-muscular layer for reimplantation. They also all retained their original generators, which were completely sterilized and reimplanted in the same location, unlike those in group C, who had new generators implanted on their contralateral side. is one of the most serious complications of CIED therapy, and is associated with significant mortality, morbidity, and financial burden. CIED infections occur via two major mechanisms. The first mechanism is through contamination of the leads or generator during implantation or subsequent manipulation.2 Erosion of the device after intervention may also result in local pocket infection. Contamination and subsequent bacterial colonization can spread along the intravascular parts of the leads, and may progress to systemic infection. The second mechanism of CIED infection occurs through infection of the bloodstream.3 Direct seeding of the leads with bacteria from a distant infection or through entry points such as the skin, mouth, or gastrointestinal and urinary tracts can result in bacteremia. The treatment of such infections has been a main focus of discussion for many years.4-12 Current guidelines recommend that all infected CIEDs be removed; however, the management of infection with simple debridement, as opposed to complete removal, is not uncommon due to anatomical or financial concerns. For the past few years, CIED infections of various severities have been treated at our hospital using a modified procedure called the removal, excision, sterilization, and quarantine (RESQ) method. The purpose of this study was to evaluate any differences in patient characteristics, clinical presentation, and patient outcomes in individuals with CIED infections, following the application of the RESQ method, traditional surgical debridement, or guideline-recommended device removal. Definitions A pocket re-infection was characterized by localized pocket warmth, tenderness, erythema, fluctuance, purulent drainage, wound dehiscence, and erosion of the generator or leads at the site of the CIED. METHODS Patients The participants for this study were selected retrospectively from a registry of patients with CIED infections at MacKay Memorial Hospital. Patients admitted with CIED infections were included in this database from 2012 to 2017. This allowed for a minimum of 24 months unt (...truncated)