once cardiovascular implantable electronic device ( cied ) infections encroach on a pulse generator pocket , the standard recommended treatment is removal of all the devices including the pulse generator and intravascular electrode(s).1 - 3 ) if the electrodes are not removed , the recurrence rate of local or systemic infection is extraordinarily high due to remnant hardwares.1)2)4 - 8 ) although electrode removal may be easy for recent cied implantations , it may be difficult in patients whose electrodes have been fixed with tight fibrosis following implantations performed several months or years earlier . although many percutaneous devices have been developed to remove such immobile electrodes , these procedures involve significant risks including cardiac tamponade , hemothorax , pulmonary embolism , lead migration and death , even with experienced surgeons.4 - 8 ) when percutaneous removal of cied system is impossible , open heart surgery should be performed to remove immobile electrodes but this surgery poses considerable risks . occasionally , electrode removal is impossible because the medical condition of the patient is unsuitable for a risky operation or the procedure is refused by a patient.9 ) global experience on the management of patients with a remnant intravascular electrode in cied infection is limited . we describe a patient who refused percutaneous or surgical removal of an intravascular electrode and was treated effectively by repositioning the electrode to a safer area between the pectoralis major and minor muscles without relapse into local or systemic infection for 12 months . this is the first report of a successful repositioning of electrode procedure to our knowledge . although this is not a standard type of management for this condition , it can be considered a secondary treatment in these cases , since it addresses the needs of patients who have refused to remove remnant electrodes . a 45-year - old male visited the out - patient department ( opd ) with the primary complaint of skin erosion and pus discharge from a former implantable cardioverter - defibrillator ( icd ) pocket . he had been engaged in christian missionary work in novosibersk , russia for the last 15 years and had a medical history of emergency surgery at a hospital in novosibersk in may 1999 for primary closure of a stab injury , which penetrated the right ventricular free wall . he then suffered from dyspnea on exertion ( new york heart association functional class ii ) , palpitation and dizziness . the palpitation attacks developed and terminated suddenly , usually appearing once a month and lasting for a duration of 20 minutes to two hours . sometimes they were relieved by deep inspiration and accompanied by chest discomfort , nausea and dizziness . later on , palpitation attacks appeared more than once a day and loss of consciousness eventually developed after march 2004 . the patient visited the opd on 15th june 2004 , with a primary complaint of recurrent syncope . two - dimensional echocardiography and a treadmill test revealed no evidence of organic heart disease . holter monitoring showed non - sustained but symptomatic ventricular tachycardia ( vt ) with dizziness and lightheadedness . during an electrophysiological study , rapid ventricular pacing could easily and reproducibly induce vt , which sometimes degenerated into ventricular fibrillation ( vf ) with a syncope and hemodynamic compromise . another session of electrophysiological study was performed with continuous intravascular infusion of an anti - arrhythmic agent , procainamide , without suppression of vt / vf induction . a single coil ventricular electrode was inserted into the apex of the right ventricle through a right subclavian puncture . the left upper chest area could not be used because there were previous operative scars and fibrosis ( fig . an icd pulse generator was inserted subcutaneously at the right anterior chest without complication on 12th july 2004 . frequency of sustained or non - sustained vt attack decreased after oral medication with amiodarone and only five vt attacks were recorded between 2005 and 2008 . all the attacks were successfully and appropriately converted to sinus rhythm and over the last year there were no vt / vf attacks . the patient experienced blunt trauma at the area of the icd pocket with a broomstick in may 2009 when he slipped on an icy road . the icd pocket was swollen with hematoma , and the icd pulse generator began to displace downward . the skin over the lower lateral angle of the pulse generator was thinning , and the pulse generator was exposed in july 2009 . although he self - sterilized the wound in russia , pus discharge appeared two weeks after the erosion . fever and other signs of systemic toxicity were absent and the patient presented with vague symptoms such as anorexia , fatigue , malaise and decreased functional capacity . a small cutaneous erosion with percutaneous exposure of the generator and pus discharge were evident upon inspection ( fig . 1 ) . three sets of blood culture were obtained , but he did not develop any appreciable fever over 38.3. empiric vancomycin was initiated after the third set of blood culture . the generator was removed , meticulous debridement was performed , and cultures were obtained from the electrode tips and the pocket - site tissue . the causative organism did not grow in all cultures and therefore , systemic vancomycin was continued for 14 days . the second exploration , five days after the removal of the generator , revealed improved local infection and consequently , little debridement was required . follow - up transthoracic and transesophageal echocardiography ( tee ) showed no evidence of infective endocarditis . the patient refused to remove the intravascular electrode after we explained the risks and benefits of open heart surgery to remove the electrode . the third exploration of the wound was done 10 days after the first exploration , and the wound was clear enough to be closed . the tips of the electrode were carefully displaced apart from the infected site , repositioned between the pectoralis major and minor muscles , and the skin was closed using a local flap without complication ( fig . he also refused a second icd implantation and was recommended to take oral amiodarone for the time being . he was discharged three days after wound closure , and visited the opd daily for wound care . regular opd follow - up showed no recurrence of infection symptoms over the next 12 months . in addition , biomarkers , such as white blood cell count and differential count , erythrocyte sedimentation rate and c - reactive protein were normal . recently an american heart association ( aha ) committee updated the guidelines on cied infections and their management.10 ) according to the guidelines , complete removal of all hardware , regardless of location ( subcutaneous , transvenous or epicardial ) , is the recommended treatment for patients with established cied infection because relapse rates of infection due to retained hardware are high.1)2)4 - 8 ) established management for patients with cied infections who are not candidates for device removal either by percutaneous or surgical methods has not been established . often , these patients have a limited life expectancy or have refused device removal.9)10 ) long - term antimicrobial suppressive therapy such as oral antibiotics for one to two years or more may be used in selected patients , but little is known about relapse rates , resistant organisms , safety profiles , patient compliance and financial expenses.9 ) in this case , we did not try long - term antibiotic treatment . intravenous antibiotics were administered for 14 days while the patient was in the hospital and oral antibiotics were also administered for 10 more days after discharge ( until the stitches were removed ) . the length of time that antibiotics should be continued still needs to be resolved . according to aha recommendations , blood cultures should be performed in every patient with suspected cied infection . for patients with negative cultures like the patient discussed in this study , 10 - 14 days of antibiotics should be sufficient . for patients with positive cultures or prior antibiotic treatment , tee is a useful test . for patients with negative tee and non - s . aureus infection , 14 days of antibiotic treatment is sufficient . for patients with s. aureus infection , two to four weeks of antibiotic treatment if vegetation is present in any of the cardiac valves , aha guidelines for treatment of infective endocarditis should be followed . if complicated vegetation is found in intravascular leads , four to six weeks of antibiotic treatment are required . realistically , an infected generator pocket will not close in a short period , and antibiotics should be continued until the stitches are removed . a challenging issue is whether a new cied is mandatory in patients who have had all hardware removed . in this case , a new icd implantation could not be performed because , contrary to medical advice , the patient refused the implantation . although there were no vt / vf episodes for the past year , he had five episodes of symptomatic vt / vf over the previous five years , and he definitely needed a new icd implantation . a new , transvenous device implantation should not be done in an ipsilateral chest with cied infection.10 ) moreover , this patient had a remnant intravascular electrode through the right subclavian vein and an ipsilateral transvenous procedure might spread local infection directly into the blood stream . he also had previous emergency open - heart surgery scars on the anterior mid - chest , left lower chest , and at the left upper chest area where a new icd should be placed ( fig . the only option for a new icd in this patient was epicardial icd with general anesthesia and open chest surgery . therefore , he decided not to have a new icd and to take long - term oral amiodarone . but in most patients with cied infection , each patient should be re - evaluated to determine whether a new cied is necessary . one third to one half of patients in some study will not require a new cied placement.2 ) another challenging issue is at what time a new cied should be implanted in patients with cied infection . the optimal timing of device replacement is unknown . if the infection is confined to the pocket , replacement after 72 hours of negative blood culture is generally accepted however , if there is valve vegetation , implantation of a new cied should be delayed 14 days from the first negative blood culture.2)5)11 ) higher mortality is reported in patients with confirmed endocarditis and in those treated without device removal.11 - 15 ) all - cause mortality at six months with cied infection was shown to be 18% , and variables associated with increased risk were systemic embolization , moderate to severe tricuspid regurgitation , abnormal right ventricular function and abnormal renal function.16 ) prevention of cied infection is vital . parenteral antibiotic prophylaxis , antiseptic preparation of the surgical site , a sterile technique , prevention of hematoma through meticulous bleeding control , irrigation with antimicrobial - containing solution for pocket cleansing , use of monofilament suture in the subcutaneous layer , pressure dressing for 12 to 24 hours after skin closure , and early follow - up after discharge all reduced cied infection.10)17)18 ) also , special attention should be paid to patients at greater risk of cied infection . these risk factors include 1 ) renal dysfunction , 2 ) immunosuppression ( corticosteroid use ) , 3 ) oral anticoagulation , 4 ) coexisting illness , 5 ) periprocedural factors ( failure to administrate prophylactic antibiotic ) , 6 ) device revision - replacement , 7 ) operator experience , 8) the amount of indwelling hardware , and 9 ) the microbiology of the infectious organism.13)18 - 25 ) limited data on cied infections are available in korea . choi et al.26 ) reported a long - term follow - up of 440 patients with permanent pacemaker implantation and only six cied infections were reported . all the infections developed shortly after the implantation , and there were no difficulties in removing the entire cied system . after the first icd implantation in korea , there was only one available icd follow - up report on 28 patients , and the icd infection did not appear.27)28 ) in korea , cied infection may increase because cied implantation , revision / replacement , and implantation in patients with medical illness are increasing . morbidity , mortality and cost are substantial in the treatment of cied infection and the prevention of infection is of primary importance in cied implantation . although the clinical course and pathophysiology of late - onset ( six months after cied implantation ) cied infections are not known , all devices should be removed in patients with established cied . therefore , the treatment shown in this case should not be generalized and only considered as an auxiliary method in exceptional conditions such as very old age , severe co - morbidity , limited life expectancy , or refusal by a patient .
treatments of choice for cardiac implantable electronic device ( cied ) infections are the removal of the entire cied system , control of infection , and new device implantation . 
 occasionally , a complete cied removal can not be performed for several reasons , such as very old age , severe comobidity , limited life expectancy , or refusal by a patient . 
 we encountered a male patient who developed traumatic cied infection five years after cardioverter - defibrillator implantation . 
 an intravenous electrode could not be removed by a simple transvenous extraction procedure , and he refused surgical removal of the remnant electrode . 
 after control of local infection , the tips of the electrode were separated and buried between muscles , and the wound was closed with a local flap . cied infection did not recur for 12 months even without relying on long - term antimicrobial treatment .