Expedited and safe discharge path for extraction patients utilizing a temporary permanent pacemaker

Key Findings.

• ▪Temporary permanent pacing can be a standard bridge for postextraction after cardiac implantable electronic device infection.
• ▪It is safe to discharge patients to home with a temporary permanent pacemaker while awaiting reimplantation of a permanent device.
• ▪Close outpatient monitoring after discharge with a temporary permanent pacemaker is critical to ensure patient safety.

One of the most concerning complications from a long-term cardiac implantable electronic device (CIED) implant is the risk of infection. Studies have shown a direct correlation between infection risk and duration of the implant.¹ Management includes removal of the generator and leads with adjunct antibiotic therapy.² Duration of antibiotic therapy varies and can continue for weeks to months after extraction. Historically, managing patients who require longer durations of antibiotic therapy and are pacemaker dependent has been challenging. While temporary transvenous pacing systems (TVPs) can be placed as a short-term option, they are not durable or reliable for long-term use. However, active-fixation pacing leads with externalized pacemaker pulse generators, or temporary permanent pacemakers (TPPM), are an ideal alternative. TPPMs allow increased and early patient mobility with optimal stability and reliability. This can provide a safe route for discharge for patients who need long-term antibiotics, which results in decreased length of hospital stay and overall cost savings.

We reviewed data from patients who underwent CEID extraction between July 2012 and October 2021 at Oregon Health and Science University. Patients selected were pacemaker dependent and underwent extraction of their complete CIED system secondary to systemic infection or localized pocket infection. The TPPM was placed via the right internal jugular vein, in all patients, with the lead anchored to the neck using a suture sleeve and the pacemaker generator secured with a Tegaderm dressing (3M). These patients were ultimately discharged with a TPPM. Data were collected from a prospective, Institutional Review Board–approved, clinical and research database. Patient demographics are shown (Table 1). Twelve pacemaker-dependent patients were included with a median age of 71 years. Three patients had implantable cardioverter-defibrillators and 9 had pacemakers. Nine patients had systemic infection and 3 had a localized pocket infection. TPPMs were placed in 11 patients for complete heart block and in 1 for sinus node dysfunction.

Table 1.

Demographics

Age, y	71 (53-82)
Sex
Female	4
Male	8
Device
Pacemaker	9
ICD	3
Indication
Complete heart block	11
SA node dysfunction	1
Comorbidities
Coronary artery disease	6
Heart failure	5
Diabetes mellitus	5
Chronic obstructive pulmonary disease	4
Infection
Systemic	9
Local	3

Values are median (range) or n.

ICD = implantable cardioverter-defibrillator; SA = sinoatrial.

All 12 patients were discharged with TPPMs. The mean length of hospitalization was 12 days. Follow-up for all patients occurred, on average, 5 days postdischarge. The total duration patients had their TPPM ranged from 6 to 153 days, with a mean of 36 days. Patients had weekly device interrogations and dressing changes in the device clinic. Stable device parameters were noted with each visit, and no complications were reported by patients or providers during these follow-up visits. After completion of antibiotic therapy and confirmation of infection clearance, all patients underwent successful outpatient reimplantation of a new permanent CIED.

As management of CEID infection typically requires removal of the permanent device, consideration must be given to ongoing management postextraction in the setting of complete heart block or significant sinus node dysfunction. In many situations, long-term antibiotic use is necessary and reimplantation of a permanent device cannot be performed immediately. Therefore, a sustainable temporary pacing strategy is necessary. While placement of a TVP is common, this is not a durable solution given limited mobility and the need for continuous inpatient monitoring. Several studies have evaluated the safety and efficacy of TPPM placement.^3,4 However, data on outcomes in patients who were discharged with a TPPM are limited.³

For patients who require pacing following CEID extraction, TPPMs can provide early mobility, hospital discharge, and thus presumably significant cost savings. Chihrin and colleagues⁵ compared and concluded that the cost of active-fixation leads vs TVPs provided a greater cost savings at just 18 hours. All 12 patients in our study underwent placement of a TPPM post–CIED extraction and had early mobility, were able to safely discharge from the hospital, and had no reported complications. Patients were able to go about their daily activities, including 1 patient who had his driver’s license renewed with his TPPM in place.

Placement of a TPPM is an attractive option for pacemaker-dependent patients who require long-term antibiotic therapy post–CIED extraction and are awaiting reimplantation of a permanent device. With early mobility and a stable pacing system, discharging patients with TPPMs allows for antibiotics to be administered at home, facilitates earlier discharge, and opens hospital beds, all of which lend to a decrease in healthcare costs. In addition, TPPMs relieve the pressure for reimplantation of a permanent device as soon as possible, allowing providers to ensure that this occurs only after the infection has been adequately treated.