Introduction: Treating patients with CIED infections is often challenging. In general, the infected device, including all leads, needs to be completely removed before a new CIED can be implanted. Especially in pacemaker-dependent patients, it is often impossible to have a device-free interval to treat the infection. In those cases, the question remains when to implant a new CIED and which bridging strategy to use. Methods: In this single-center retrospective analysis, we included 190 patients who received a complete CIED system extraction between 2013 and 2019 due to device-related infection. We compared three different treatment algorithms. Group 1 (SR) included 89 patients who received system removal only (and delayed re-implantation). Group 2 (EL) consisted of 28 patients who were treated with lead extraction and simultaneous epicardial lead implantation, while the 78 patients in Group 3 (SI) received lead removal with simultaneous contralateral implantation of a new device. We retrospectively analyzed the peri- and postoperative course and one-year follow-up. Results: Patients in the SR and EL groups were significantly older, had more comorbidities and a higher percentage of systemic infection compared to the SI group. We found a comparable high number of successful infection treatments in all groups, with complete lead removal in 95.5%, 96.4%, and 93.2% for the SR, EL, and SI groups, respectively. Lead vegetations were removed in 97.7%, 94.1%, and 100%. Device re-implantation was 100% in the EL and SI groups, whereas in the SR group, only 49.4% of patients received a device re-implantation. At one-year follow-up, the percentage of freedom from infection and pocket irritation was comparable between groups (94.7% SR and EL, 100% SI). We observed no procedure-related mortality, while one-year mortality was 3.4% in the SR, 21.4% in the EL and 4.1% in the SI group. Conclusion: We found comparable success rates regarding device removal, successful infection treatment and perioperative course between groups. However, most likely due to the sicker patient collective with a high number of systemic infections, the one-year mortality was significantly higher in the EL group. Treatment algorithm should be selected due to type, severity, location of infection and comorbidities of the patients.

Abstract Background: We report a 62-year-old patient who received redo-orthotopic Heart transplantation due to worsening severe aortic regurgitation after 19 months of continuous flow LVAD (cf-LVAD) and temporary RVAD support for one month. Case Report: The patient received a heartware LVAD (HVAD) and annuloplasty of the tricuspid valve due to end-stage heart failure (as a consequence of dilated cardiomyopathy) and severe tricuspid regurgitation in addition to right-sided ECMO implantation. Postoperatively due to the inability to wean the implanted ECMO, a temporary RVAD was implanted after which the patient’s condition improved so that it had been explanted later and the patient was discharged after nine-month. In immediate post-operative echo, minimal aortic regurgitation was noted but in the follow-up transthoracic echocardiograms, there was a gradual increase in the severity of aortic regurgitation with worsening both right and left ventricular functions. TAVI was not an option due to unfavourable anatomical issues. That’s why the patient was listed for urgent heart transplantation, performed 19 months after the LVAD implantation. The postoperative course was complicated due to acute renal failure. After recompensation, dialysis, and intensive physiotherapy, the patient could be discharged home after three months. Conclusion: severe aortic regurgitation is a recognizable complication after cf-LVAD implantation which in our case was managed successfully with orthotopic heart transplantation in this high-risk patient.