Postoperative Wound Management Following Pacemaker and Defibrillator Implantation
© 2025 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates.
EP LAB DIGEST. 2025;25(7):6.
Bradley P Knight, MD, FACC, FHRS
Dear Readers,
Preoperative intravenous (IV) antibiotics (ABX) have been shown to reduce infections in patients undergoing implantation of a cardiac implantable electrical device (CIED). Infusion of antibiotics within 1 hour of the incision is now standard of care and is a common hospital quality metric. As discussed in my November 2018 editorial, cefazolin is a better preoperative ABX than vancomycin.1 When a patient who is scheduled for an elective CIED implantation reports a penicillin allergy, there is still a high likelihood that the patient can safely receive cefazolin. If the patient reports that the allergic reaction was a rash or other minor reaction, then cefazolin can be given safely. When the patient has experienced an IgE-mediated reaction such as angioedema or anaphylaxis, consider referral to an allergist to perform skin testing and desensitization if necessary.
In addition to preoperative ABX, many patients are also prescribed postoperative ABX after CIED implantation. This varies from predischarge IV administration to several days of oral ABX. Decades ago, it was routine to prescribe oral cephazolin for a week after implantation of a pacemaker. However, several studies including the PADIT trial2 have failed to show any benefit from postoperative ABX, and now societal guidelines recommend against their use.
But what is the role of surgical dressings to prevent surgical site infections (SSIs)? At the 2025 Heart Rhythm Society Scientific Sessions in San Diego, a satellite symposium titled “SSI Prevention and Postoperative Wound Management Following CIED Surgery,” sponsored by Convatec, was held on April 25. Speakers included Drs Charles Love, Theofanie Mela, and Peter Belott. During the symposium, a poll asked audience members how long they typically advised their patients to wait before showering in order to avoid getting the surgical dressing wet. The responses were widely divergent, ranging from 1 day to 1 week. In our EP program, patients are still told to not shower for 1 week after CIED implantation. Following the poll, speakers discussed the value of a silver-impregnated surgical dressing (AQUACEL Ag Advantage, Convatec) to reduce the risk of SSIs and allow patients to shower sooner.
There are data that this surgical dressing with a special formulation kills a broad spectrum of bacteria within the dressing, including antibiotic-resistant microorganisms, for up to 1 week.3 According to the company, the dressings feature 2 technologies working synergistically to manage the key local barriers to wound healing—exudate, infection, and bioburden.4 In addition, the dressing is occlusive, so patients can shower immediately after being discharged from the hospital. In a prospective, randomized, controlled study,5 a total of 240 patients undergoing minimally invasive total knee arthroplasty were randomized to receive either the AQUACEL Ag or a standard dressing. In this study, there was a significant reduction in the incidence of superficial SSI (0.8%, 95% CI, 0.00-2.48) in the study group compared to 8.3% (95% CI, 3.32-13.3) in the control group (P = 0.01). There were no differences in blister and deep/organ-space SSIs between the 2 groups. Multivariate analysis revealed that AQUACEL Ag Surgical dressing was an independent risk factor for reduction of SSI (odds ratio: 0.07, 95% CI, 0.01-0.58; P = 0.01). The study group had longer wear times (5.2 ± 0.7 versus 1.7 ± 0.4 days; P < 0.0001) and a lower number of dressing changes (1.0 ± 0.2 versus 3.6 ± 1.3 times; P < 0.0001). Increased patient satisfaction (P < 0.0001) was also noted. The dressings come in various sizes and cost about $25.00.
Although the risk of CIED infections is low in the current era, it is not zero and can lead to sepsis and device removal, which may be devastating for patients. It is overdue for electrophysiologists to adopt modern surgical dressings for patients undergoing CIED implantation, if they have not already done so.
Disclosures: Dr Knight reports payment or honoraria from Convatec for a lecture. He has served as a paid consultant to Medtronic and was an investigator in the PULSED AF trial. In addition, he has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AltaThera, AtriCure, Baylis Medical, Biosense Webster, Biotronik, Boston Scientific, CVRx, Philips, and Sanofi; he has no equity or ownership in any of these companies.
References
1. Knight BP, Pre-incision strategies for penicillin allergies. EP Lab Digest. 2018;18(11):4.
2. Krahn AD, Longtin Y, Philippon F, et al. Prevention of arrhythmia device infection trial: the PADIT trial. J Am Coll Cardiol. 2018;72(24):3098-3109. doi:10.1016/j.jacc.2018.09.068
3. Said J, Walker M, Parsons D, Stapleton P, Beezer AE, Gaisford S. An in vitro test of the efficacy of an anti-biofilm wound dressing. Int J Pharm. 2014;474(1-2):177-181. doi:10.1016/j.ijpharm.2014.08.034
4. Advanced wound care solutions. Convatec. Accessed June 17, 2025. https://www.convatec.com/advanced-wound-care/
5. Kuo FC, Chen B, Lee MS, Yen SH, Wang JW. AQUACEL® Ag surgical dressing reduces surgical site infection and improves patient satisfaction in minimally invasive total knee arthroplasty: a prospective, randomized, controlled study. Biomed Res Int. 2017;2017:1262108. doi:10.1155/2017/1262108
