Abstract
1% of the cases because contemporary small-diameter leads with active-fixation were probably used in the study. These leads are associated with a higher incidence of perforation presenting as a subacute or relatively late clinical problem. 2 One wonders whether lead perforation was classified as lead dislodgement. Long-term lead failure was unusual and consistent with the prevailing recall from one of the manufacturers. Infection Device infection occurred in 30 patients: 18 (60.0%) presented pocket infection, and 12 (40%) presented (40.0%) with systemic infection. The overall incidence of infection was low at 0.68% per procedure-year and was considerably lower for primary implantations. Three procedures are generally associated with a greater risk of infection compared with an initial pacemaker or ICD implantation: (i) CRT where the mechanism is probably related to the longer procedural times and use of multiple leads; (ii) elective device replacement; and (iii) system upgrade or revision. Infection following the procedures listed under (ii) and (iii) probably results from surgical manipulation of the thick fibrotic capsule containing a dormant bacterial colonization from the previous surgery in the absence of any sign of pocket infection. This study confirmed that the above three procedures were indeed associated with a much higher incidence of infection reflecting the general belief that repeat surgery involving the device pocket carries about a five times greater incidence of infection than a new implantation. The 12 patients with systemic infection were transferred to outside centres where all the hardware was extracted. In contrast, the 18 cases of pocket infection underwent extensive surgical revision of the pocket (with debridement and capsulectomy) without the complete removal of all the hardware. The old devices were returned to the revised pocket in 10 patients and new devices were connected to the pre-existing leads in eight patients. Relapse was observed after a median of 5 months in 8 (44%) patients. Then, a new pocket revision was again performed and in three cases, complete removal of the pacing system was
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