Cardiac implantable electronic device (CIED) infection with pocket erosion or exposed hardware is generally considered a definite system contamination, for which major societies recommend complete device extraction. However, a minority of patients present with highly focal pocket ulceration, negative microbiology, and no systemic features of infection, yet face prohibitive risks with transvenous lead extraction. We report two such patients: a middle-aged man with longstanding ICD leads and a frail older woman with CRT-D and a tip-down sleeve–related focal ulcer, both without clinical, laboratory, or echocardiographic evidence of infection. Each underwent excision of the ulcerated segment, exploration of the original pocket, relocation of the generator to an adjacent pocket with better soft tissue coverage, and placement in a TYRX™ absorbable antibacterial envelope as a prophylactic adjunct. Both patients had uneventful recoveries and remained free of local or systemic infections during the 10- and 32-month follow-up, respectively. These cases illustrate that in exceptional scenarios that meet stringent clinical and microbiological criteria and involve disproportionate extraction risk, conservative salvage with debridement, adjacent pocket relocation, and antibacterial envelope use may be considered but should not be viewed as an alternative to guideline-directed extraction for proven or suspected CIED infection.
Keywords: Cardiac implantable electronic device infection; Defibrillator pocket erosion; TYRX antibacterial envelope; Conservative pocket revision; Case report
