For patients indicated for primary or secondary prevention implantable cardioverter defibrillators (ICDs) without bradycardia pacing or cardiac resynchronization therapy (CRT), shared decision-making is recommended to select between transvenous and non-vascular devices. Specifically, subcutaneous ICDs (S-ICDs) are advised for those with inadequate vascular access, high infection risk, or prior device infections. Epicardial ICDs (EV-ICDs) are reasonable alternatives, especially where avoiding transvenous leads is beneficial, such as in younger patients. Leadless pacing devices are suitable for patients requiring bradycardia support, with shared decision-making emphasized.
In infection management, obtaining blood cultures before antibiotics and utilizing echocardiography (TTE/TEE) and advanced imaging like FDG-PET/CT enhances diagnosis. Complete device removal is recommended for pocket infections and systemic infections involving pathogens like S. aureus, with early removal preferable. For persistent bacteremia or endocarditis, removing the device reduces relapse risk. Antibiotic therapy should be tailored based on pathogen identification, with a typical course lasting 4-6 weeks post-extraction. In cases where device removal isn’t feasible, long-term suppressive antibiotics may be considered.
Lead management includes prioritizing removal over abandonment when benefits outweigh risks, particularly for malfunctioning or advisory leads. Vascular access management involves utilizing upper extremity veins (axillary/cephalic) to reduce complications like pneumothorax. Lead extraction procedures should be performed by experienced teams with appropriate equipment, under imaging guidance, with protocols for managing complications such as vascular injury or tamponade.
Reimplantation timing should be individualized, especially for pacemaker-dependent patients, with temporary pacing strategies during infection treatment. Prevention strategies include preoperative antibiotics and antibacterial envelopes in high-risk cases. For patients with tricuspid valve disease or undergoing MRI, specific considerations for lead removal or device management are outlined. Overall, multidisciplinary approaches, careful procedural planning, and patient-centered discussions are emphasized across all aspects of device therapy and management.
Reference:
2026 HRS Cardiovascular Implantable Electronic Device Lead Management and Extraction Guidelines – CIED Guideline Summary – Guideline Central. (n.d.). https://www.guidelinecentral.com/guideline/10599/
