Diagnostic & Surgical Procedures

CIED recipients can safely undergo any type of surgical procedure. The feasibility of major surgery is indeed dependent on the severity of structural heart disease and of any other coexistent morbidity.
The management of the CIED to avoid dangerous EMI, and the prevention of bacteraemia (entry of pathogens into the blood circulation) are the two pivotal concerns of surgical and invasive diagnostic procedures.

EMI avoidance: this task can be safely accomplished following a specific protocol that is suggested by any centre that runs a CIED follow-up program.

Prevention of infections on the CIED system

Lead Infection.

Lead Infection. No definite answer is available in medical literature about the role of concurrent infections or bacteraemia related to surgical/diagnostic procedures and the risk of infective colonization of implanted CIED leads. Nonetheless, in centres involved in the treatment of CIED-related endocarditis, a minority of patients report such procedures in the months preceding the onset of lead infection.

Thus, it is currently believed that, in situations at risk of bacteraemia, a policy similar to that adopted for prosthetic heart valve recipients ought to be used: antibiotic prophylaxis during the period at risk of bacteraemia.
In the absence of allergic drug reaction, the risk of antibiotic prophylaxis is really negligible compared to the complications related to lead infection.

Procedures that might predispose to bacteraemia:

  • Dental surgery
  • Endoscopical diagnostic procedures (respiratory, gastro-intestinal, and urinary-genital tract), especially if concomitant biopsy/endoscopical surgery is performed
  • Minimally-invasive surgery (usually carried out in day-surgery regimen)
  • Chronic illness of soft tissues, frequently as a consequence of trauma, complications of diabetes or of peripheral vascular disease, or associated to skin burns, malignancy, dermatologic or infectious illnesses.

CIED Pocket infection.

The occurrence of pocket infection is 2 to 4-fold higher after device replacement compared to device implantation, and ranges from 0.5% to 4% in the medical literature. This is the reason why device replacement should not be minimised, but instead ought to be regarded as a very important procedure. Pocket infection is more frequent when concomitant lead addition/revision procedures are needed at replacement. These observations highlight the importance of device longevity as a mean to prevent infections, and make the demand for rechargeable batteries from CIED recipients a very sensitive issue. End of energy supply is nowadays the only reason for repeated surgery.

Indeed, technologically innovative and helpful algorithms have been downloaded into CIEDs since the end of the ‘90s, hence CIED circuitry upgrade can be achieved by telemetry without any need for surgery.