First landmark CIED replacement study of all companies’ cardiac devices provides insight into infection outcomes and prevention


The REPLACE study, sponsored by Biotronik, is the first prospective, multicentre trial to examine a broad range of complications related to replacement of all companies’ cardiovascular implantable electronic devices (CIED) which includes both pacemakers and ICDs (implantable cardiac defibrillators).

The REPLACE study enrolled a total of 1,744 patients in 72 centres located across the United States, dividing them into two cohorts: one undergoing generator (implantable device) replacement only (1,031 patients) and another undergoing generator replacement with a new transvenous lead addition or revision (713 patients). Postoperative wound assessment was completed after three months and six months, with a full 100% of patients having received preoperative antibiotics.

The incidence of overall infection was low at six months, with only 1.3% of patients suffering these complications. Major infections contributed 0.8% to the overall rate. “The systematic collection and adjudication of infectious complications provided a very accurate assessment of the risks of infection,” according to Daniel Z Uslan, Infectious Diseases specialist at the University of California (UCLA), Los Angeles, United States, and lead author of the study. “Patients can be effectively counseled about the risk of infection following CIED replacement.”

The results revealed an intriguing clustering of infections within the study sites. Eighteen per cent of sites (13 of the 72 centres) had patients with infection complications, and six of those 13 sites had an incidence rate of more than 5% of enrolled patients. The patients within these six sites accounted for 14 (64%) of the 22 total infections experienced during the study.

Further investigation of aseptic technique as a potential causal factor revealed that sites experiencing higher infection rates were more likely to use povidone-iodine instead of chlorhexidine for topical antisepsis. Comorbidities, as measured by the Charlson Comorbidity Index (CCI) were also more prevalent in the patient cohorts from these six centres.

Furthermore the study showed patients with infections were more likely to have had postoperative haematomas than those without infection (22.7% versus 0.98%), and patients receiving abdominal generator replacements had higher infection rates. Infection prevention strategies such as postoperative systematic antibiotics were widely used.

“REPLACE was the first study to systematically show the current state of practices for infection prevention for CIED implantation,” said Uslan. “Practices such as postoperative systemic antibiotics were widespread despite a lack of data on their efficacy. While this indicates a commitment to prevent infection among practitioners, it also highlights the need for large randomised trials examining the potential benefits and risks of these practices.”