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Questions:<\/b><\/p>\n <\/p>\n Response:<\/b><\/p>\n James Fang, MD<\/b><\/a><\/p>\n July 24, 2013<\/i><\/p>\n 1. The appearance is strongly indicative of some type of infection, although atypical for a bacterial process. A reader has suggested a parasitic infection, which is an interesting possibility. Benign processes are almost uniformly serosanguinous; this appearance is quite different. The lack of systemic signs and symptoms does not dissuade me from strongly considering infection; many cardiac device infections do not result in systemic illness.<\/p>\n 2. With the device in hand, I would ask that Gram stain and cultures be performed from the device. Blood cultures should be done as well. The entire device should be sent to pathology; a sample of the thickened capsule should also be sent for pathology review. I would consider explanting the just-implanted device, as that would be much easier to do now than later. His arrhythmic risk could be covered with use of a LifeVest\u00a0(see\u00a0Chung MK et al., JACC 2010; 56:194<\/a>). The original indication for the ICD and whether there have been events in the interim are not clear but would affect the decision about whether to use a LifeVest.<\/p>\n 3. I think the risk for a localized infection is significant but needs confirmation.<\/p>\n 4. The\u00a02010 AHA Update on Cardiovascular Implantable Device Infections<\/a>\u00a0is an excellent resource for all physicians who care for such patients. The take-home message is to have a high level of suspicion and to treat aggressively.<\/p>\n <\/p>\n Follow-Up:<\/b><\/p>\n Westby G. Fisher, MD,<\/a> and Edward Janszen Schloss, MD<\/a><\/p>\n July 31, 2013<\/i><\/p>\n Gram stain of the debris showed no white cells or organisms. The capsule was removed in its entirety. Cultures of the pocket capsule tissue, blood cultures, and cultures of the fluid all came back showing no growth. The patient had been on warfarin (and later rivaroxaban) for his atrial fibrillation.<\/p>\n Of course, at the time of the procedure, the culture results were not known. So the new ICD pocket was re-draped and prepped, and the wound was opened to find the tunneled 0074 ICD lead’s tie-down sleeve. This was released, the lead was cut and capped, and the distal portion was withdrawn back to the abdominal pocket to prevent a “wick” extending from the abdominal wound to the new ICD system. The new ICD wound was re-closed.<\/p>\n The abdominal would was irrigated with antibiotic saline solution and closed primarily, and a Jackson-Pratt drain was placed to remove dead space and prevent seroma formation. The antibiotic was expanded to vancomycin only (from cefazolin), continued for 3 days, and then discontinued when the Jackson-Pratt drain was removed.<\/p>\n The patient was seen by an ID specialist, who agreed that stopping antibiotics and observing was the best scenario. The patient was seen in follow-up 10 days later and has done well.<\/p>\n\n